complications of cataract surgery

1. Tpa chhangte
Complications of Cataract
Surgery

2. INTRODUCTION
 The no of blindness from cataract is increasing by approx
1 million /year and the no of operable cataract eyes with a
VA < 6/60 is increasing by 4-5 million /year
 Cataract surgery is one of the most commonly performed
surgeries in the world, with over 1 million performed per
year in the United States alone.
 Approximately 10 million cataract operations are
performed each year in the world, with rates varying from
100 to 6000 CSR
 Economically well developed countries usually perform b/w
4000 and 6000 CSR
 India has dramatically increased its CSR in the last 10
years from less than 1500 to a figure of around 3000 today
 Middle income countries – Latin America, parts of Asia 500
and 2000 CSR
 Most of Africa, china and poorer countries of Asia < 500
CSRVISION 2020: THE CATARACT CHALLENGE; Community Eye Health. 2000; 13(34): 17-19.
PMCID: PMC 1705965

3.  AIMS OF MODERN CATARACT SURGERY
 Restoration of vision to meet the pt’s needs
 Achievement of the desired refractive outcome
 Improvement in quality of life
 Ensuring patient safety and satisfaction
Cataract Surgery Guidelines; September 2010; Scientific Department; The Royal colle
;17 Cornwall Terrace; Regent’s Park; London NW1 4QW

4. CATARACT SURGERY
OUTCOMES
WHO STANDARDS
 POOR OUTCOME
- < 20/200 best corrected
- <5% at two months
 BORDERLINE OUTCOME
- < 20/60 – 20/200
 GOOD OUTCOME
- 20/60 + best corrected
- > 90% at two months

5. CAUSE OF POOR OUTCOMES
 SELECTION
- Pre-existing eye disease
 SURGERY
- Surgical complications
 SPECTACLES
- Failure to correct post-op refractive error

6. Editorial;Cataract Complications;Community Eye Health Journal(International Centr
volume 21/issue 65/March 2008
<20/200 SPECTA
CLES
SELECTI
ON
SURGER
Y
INDIA(hy
derabad)
21.4% 21% 29% 50%
APEDS study in Hyderabad, S. India

7. WORST OUTCOME more likely if:
 Illiterate
 Poor
 Female
 Rural
 ICCE
 Recent surgery
APEDS data from South India

8. IMPROVING OUTCOMES
 5 S
 SELECTION
 STERILITY
 SOFT EYE
 SAFE SURGERY
 SPECTACLES
 SEQUELAE (post-operative complications)

9. COMPLICATIONS OF CATARACT
SURGERY
 Intraoperative Complications
 Postoperative Complications
 Early (within first few days to 4
weeks)
Late (after 1 month to years)
Intra Ocular Lens related

10. INTRAOPERATIVE
COMPLICATIONS
 Block related
 SR related
 Conjunctiva related
 Wound related
 Capsulotomy related
 Hydro related
 Iris related
 Nucleus related
 I/A related
 IOL insertion related
 Closure related

11. BLOCK RELATED
COMPLICATIONS
 Retrobulbar haemorrhage
 Globe perforation
 Central spread of anaesthetic
 Retinal vascular occlusion
 Optic nerve trauma
 Optic atrophy
 Oculocardiac reflex
 Subconjunctival haemorrhage
 Spontaneous dislocation of lens

12. RETROBULBAR
HAEMORRHAGE
 Predisposing factors: vascular or hematologic ds;
syst. therapy with aspirin or anticoagulants
 Venous  spread slowly, limited
 Arterial 
- rapid & taut orbital swelling
- marked proptosis with immobility of the globe
- elevated IOP
- inability to separate eyelids
- massive ecchymosis of the lids and conjunctiva
 INCIDENCE: 1 – 3 %
 Late – optic atrophy

13. MANAGEMENT
 Lateral Canthotoomy
 Digital pressure (moderate to vigorous)
 Osmotic diuresis (IV mannitol 0.5 to 1.0 gm/kg)
 Anterior paracentesis (controversial)
 Postpone sx otherwise bleeding of venous origin
controlled by digital pressure, no proptosis and
eyelids easily separated
 Surgery can usually be performed after 2-4 days
later, preferably under GA

14. GLOBE PERFORATION
 Predisposing factors: Increased AL, posterio
staphyloma, severe enophthalmos, previous
scleral buckling procedure and repeated
retrobulbar injections
 MOST frequently in elongated myopic eyes and in
deep set eyes
 1 in a series of 12,000 cases (peribulbar and
retrobulbar)
 Acute Hypotony, poor red reflex, “poking through
sensation”
marked pain at the site of perforation
 Extreme ocular firmness if the anesthetic is

15.  MANAGEMENT
 Indirect ophthalmoscopy to determine the
involved region of retina
 CARRY ON if the lens prevents visualization of
the perforation
 If there is DENSE VH, cancel the SX and the pt
refered to vitreoretinal surgeon

16. CENTRAL SPREAD OF LOCAL
ANAESTHETIC
 Subdural space of optic nerve to the chiasma, and into
the subarachnoid space surrounding pons and midbrain
 1 case in 350 to 500 cases
 Onset of any of the following
- mental confusion
- loss of contact with the patient
- signs of extraocular paresis or amaurosis of C/L eye
- Shivering bordering on convulsive behavior, nausea or
vomitting,
- sudden swings in Cardiovascular signs
- dyspnoea & respiratory depression
- usually contralateral pupil is dilated with absent light
reflex
 Mx : Cardiopulmonary resuscitation
- avoid deep orbital depth injection

17. ANAESTHETIC INDUCED
STRABISMUS
 IR is m/c injured muscle, resulting in post-op
veritical diplopia
 Disappears after the muscle heals
 Replaced in older individuals by progressive
contracture of the muscle  reversal of direction
of diplopia
 Muscle contracture most often affects IR muscle
but also SR, IO & LR muscles
 Mx: Surgery
 Other causes of postoperative
strabismus/diplopia:
- TED, myasthenia, CN palsy, Prolonged vision
deprivation by cataract and anisophoria, marked
anisometropia

18. POSOPERATIVE PTOSIS
 Multifactorial
 Already unhealthy LPS aponeurosis,
degenerative conditions and disinsertion in the
tarsal plate
 Dehiscence and rarefaction of LPS aponeurosis
 This may be caused not only by dissection of
local anesthetic, but may also be associated with
injury from lid speculum or a SR bridle suture
 Surgical repair should be delayed until a stable
state has been reached

19. SUPERIOR RECTUS RELATED
GLOBE PERFORATION
 Sudden hypotony, appearance of vitreous under
the conjunctiva or muscle and vitreous
haemorrhage
 UNNOTICED (if very small perforation) 
recognized post operatively by presence of
localized choroidal hmg, RD or postoperative
hypotony associated with a VH
MANAGEMENT
 IMMEDIATE T/T and postponement of Sx
 For prevention, use round bodied needle and
direct away from globe and apply bridle suture
only after visual confirmation of the tissue held by
the SR forceps

20. CONJUNCTIVAL DISSECTION
 SUBCONJUNCTIVAL HAEMORRHAGE
 STRINKAGE OF SCLERAL TISSUE
 CONJUNCTIVAL TEAR

21. SUBCONJUNCTIVAL
HAEMORRHAGE
 NO CONSEQUENCE other than rendering
visualization of the wound problematic and
possible alarm to the patient
Mx
 Light directed cautery

22. STRINKAGE OF SCLERAL
TISSUE
 HEAVY AND BLIND CAUTERY
 Strinkage of scleral tissue may induce significant
astigmatism

23. CONJUNCTIVAL TEAR
 At the site it is held for globe fixation
 While dissecting the tunnel in SICS or phaco by
blunt instruments (necessitate the use of too
much force)

24. WOUND RELATED
COMPLICATIONS
COMPLICATIONS can arise as a result of
errors in the
 SITE (1.5 – 3 mm from limbus)
 DEPTH (1/3 to half thickness sclera)
 LENGTH
 WIDTH
 SHAPE (straight, convex or concave)

25. WOUND RELATED COMPLICATIONS
CONTD/-
1. IRIS PROLAPSE
 d/t VERY POSTERIOR INTERNAL INCISION IN ECCE
 d/t Premature entry into AC without adequate tunnel length in
CORNEA
 d/t VERY LARGE or very Close to limbus or VERY deep wound
 Also by Positive vitreous pressure
 MX
 Replace the prolapsed tissue with iris repositor or viscoelastic
 Wound length can be reduced with a suture; iridectomy may
help
 RELEASE SR bridle; Reducing vitreous trust by bolus
hyperosmotic agents
 A WIRE VECTIS OR LENS GLIDE should be used for nucleus
delivery if iris prolapse is present

26. WOUND RELATED COMPLICATIONS
CONTD/-
DESCEMET’S MEMBRANE DETACHMENT
 Entry into AC with blunt instruments (blades or
keratomes)
 AVOID TANGENTIAL ENTRY OF SCISSORS in
ECCE
MANAGEMENT
 If limited, proceed with sx and tamponade the
membrane with a LARGE AIR BUBBLE at the end
of the procedure
 IF LARGE, reposit into place with a LARGE AIR
BUBBLE or isoexpansile mixture of air and SF6
(1.5:1)

27. WOUND RELATED COMPLICATIONS
CONTD/-
Endothelial damage/corneal edema
 Inadequate length of incision
 Inadequate length of valcular wounds (SICS AND
PHACO)
ASTIGMATIC SHIFT
 More sutures if too large incision
EXCESSIVE MOVEMENT OF THE EYE
 WITH HANDPIECE MOVMENT If incision is too small
 May also limits proper irrigation by compressing the
sleeve of probe tip if incision is too small
 Also problems in IOL implantation

28. WOUND RELATED COMPLICATIONS
CONTD/-
Shallowing of AC
 Too large incision due to incisional leakage
 Apply suture to prevent this
BLEEDING
 FROM SCLERAL PERFORATING VESSELS
 Adequate cautery of episcleral vessles before
starting the dissection
FAILED SELF SEALING TUNNEL
 SMALL width

29. WOUND RELATED COMPLICATIONS
CONTD/-
Button Holing
 Too superficial incision and too thin anterior flap
(less depth of incision)
 Start the incision at proper depth & maintain the
correct direction of the crescent
MX
 DEEPEN the incision and make a fresh tunnel at
a deeper plane
 Make a tunnel AT A DIFFERENT SITE

30. WOUND RELATED COMPLICATIONS
CONTD/-
PREMATURE ENTRY INTO AC
 tOO DEEP a plane during dissection of a tunnel
 It will leads to problems with iris tissue
DISINSERTION OF THE SCLERA
 A VERY DEEP INCISION
 The inferior sclera disinserts from the anterior
wound
 It results in LARGE ATR SHIFT postoperatively
 MX
 Suture the tunnel with raidal sutures to appose
the two edges of the floor

31. WOUND RELATED COMPLICATIONS
CONTD/-
INJURY TO CILIARY BODY AND
PROLAPSE
 By a very deep wound
 Repair the incision
A Deeper dissection is also associated with
increased incidence of postoperative hyphaema

32. WOUND RELATED COMPLICATIONS
CONTD/-
SIDE PORT RELATED
 BLEEDING if made in vascular area
 Repeated shallowing if large side port made
 Injury to iris and lens if sudden entry made
 Descemet’s detachment from using a blunt
instrument

33. COMPLICATIONS RELATED TO
ANTERIOR
CAPSULOTOMY
CAN OPENER CAPSULOTOMY
UNEQUAL CAPSULAR FLAPS
 THESE flaps have a tendency to be aspirated
into I/A cannula
 TEAR TOWARDS THE ZONULES
 By vigorous tension on entrapped tags during
cortical aspiration
if goes unnoticed, a large PCR can occur rapidly
or
sometimes the whole capsular bag may be
aspirated
 Use of multiple fine punctures (upto 30-40 in Nos)
eliminates capsular flaps

34. COMPLICATIONS RELATED TO ANTERIOR CAPSULOTOMY
contd/-
CONTINUOUS CURVILINEAR CAPSULORRHEXIS
1. RHEXIS ESCAPE
 Inadvertent perpendicular peripheral extension into the
zonular area
 More common if the AC is shallow or there is +ve pressure on
the globe
 Ant. bowing of the ant capsule encourages the tear to ‘run
downhill’
 MX
 Deepen AC and flatten the ant capsule by injecting liberal amt
of VISCO into AC
 Change over to forceps if initially cystitome was being used
(Forceps ensure a safer and firmer hold)
 Alternatively, a very curved micdroscissors is used or
 STARTING A NEW RHEXIS in another position working in
opp direction attempting to join the first rhexis at the escape
point
 In the event that the progress is blocked by one or more

35. ‘Capsulorrhexis escape’ – Management
A. escape noticed during rhexis; B – Direction of force
changed to resume circular tear; C – Conversion to Can-
opener capsulotomy

36. COMPLICATIONS RELATED TO ANTERIOR
CAPSULOTOMY contd/-
2. SMALL RHEXIS
 PROBLEMS in subincisional I/A in phaco
 May later cause CAPSULAR BAG CONTRACTION
 In case of SICS, luxation of nucleus into AC is dificult
(and unsafe)
 It places excessive stress on the zonules
ZONULAR DIALYSIS and AVULSION OF BAG into AC
MX
 Give RELAXING INCISIONs or
 Enlarge the rhexis by continuing a spiral tear initiated in
the existing rhexis

37. COMPLICATIONS RELATED TO ANTERIOR
CAPSULOTOMY contd/-
3. LARGE RHEXIS
 It may l/t PREMATURE PROLAPSE OF THE
NUCLEUS into the AC
 Difficulty in IOL PLACEMENT in the bag
4. ECCENTRIC RHEXIS
 It may l/t dECENTRATION of the IOL

38. COMPLICATIONS DURING
HYDROPROCEDURES
 1. PERIPHERAL EXTENSION OF NOTCHES
/RADIAL TEARS
 By vigorous injection of large amount of fluid
PERIPHERAL EXTENSION OF NOTCHES OR
RADIAL TEARS
PCR and VL Occasionally POST.
DISLOCATION
OF THE NUCLEUS
 Intact rhexis is more resistant
 More in Mature or HMSC or Hard nuclear
cataracts

39. COMPLICATIONS DURING HYDROPROCEDURES
contd/
2. POSTERIOR POLAR CATARACT
 Avoid hydrodissection as there may be a
preexisting PC defect
Tendency to enlarge b/c of the hydrostatic
pressure of the fluid wave
Dislocation of nucleus into the vitreous cavity
 Only HYDRODELINEATION is to be performed in
these cases

40. COMPLICATIONS DURING HYDROPROCEDURES
contd/
3. INADEQUATE HYDRODISSECTION
Corticocapsular adhesions
no free rotation of the nucleus
Transmitted force to the zonules if too much force
used
Zonular dehiscence
 Repeat hydro carefully from another site

41. GENERAL PRINCIPLES FOR
HYDRODISSECTION
 It should be carried as fast as possible
 A small amount of fluid should be used
 No of injections should be minimal
 Bag should be decompressed by taping the
nucleus before every injection
 Amount of cannula stays in the AC must be
minimal
 Nucleus should be loosened as much as possible
and as musch as possible of the capsule and
superficial cortex separated from the inner layers

42. COMPLICATIONS RELATED TO IRIS AND
THE PUPIL
1. IRIS PROLAPSE
 MAINLY due to improper wound construction as has
been described
2. SMALL PUPIL
 Inability to dilate due to intrinsic pathology
(pseudoexfoliation, senile miosis, diabetes, old uveitis
with Post synechiae, Chronic ACG, chronic miotic
usage etc) or intraoperative iris manipulations
DIFFICULTY IN CAPSULORHEXIS,
HYDROPROCEDURES
NUCLEUS PROLAPSE AND DELIVERY, CORTICAL
CLEAN UP AND IOL IMPLANTATION

43. COMPLICATIONS RELATED TO IRIS AND THE
PUPIL contd/
2. SMALL PUPIL
MANAGEMENT
 1. INTRACAMERAL LIDOCAINE and
ADRENALINE
 2. VISCOMYDRIASIS
 3. POSTERIOR SYNECHIOLYSIS
- will increase the pupil size by 1-2mm; done in a
viscoelastic filled chamber with a blunt tipped
spatula under the pupillary plane and swept 360
deg + intracameral adrenaline( will further
increase)

44.  4. PUPILLARY STRECHING
- With the help of two SINSKEY HOOKS or
LESTER LENS MANIPULATORS
- MANEUVER is performed from 3 o’clock – 9
o’clock position and then 90 deg away along the
6 o’clock – 12 o’clock positions
- Mydriasis obtained depends on residual
elasticity of the iris
Pupillary streching
A. in the axis of the wound B. 90 deg away

45.  5. MULTIPLE SPHINCTEROTOMIES
 6-8 mini sphicterotomies 0.5 – 0.7 mm in length
performed in a viscoelastic tampnaded
environment ( to – bleeding)
all round the pupillary margins with LONG
ARMED VANNAS SCISSORS
 Will result in good mydriasis and very acceptable
postoperative appearance
Multiple sphincterotomy
Using microscissors, 8 mini-sphincterotomies
are performed, resulting in acceptable
pupillary aperture

46.  5. FOUR IRIS HOOKS
 4 iris hooks inserted from stab incisions at the
limbus
 Hitched under the pupil margin and pulled taut
with silicone buttons
Use of Iris Hooks in rigid pupils
A- retractors in place, B- if the paracentesis incisions a
high, iris gets folded towards the cornea, C- if paracen
too low, iris gets bunched up, D- correct placement

47.  6. SMALL IRIDECTOMY AND PERFORM
IRIDOTOMY
 Creation of small iridectomy in the periphery near
incision
Perform a RADIAL IRIDITOMY through this with
microscissors
10-0 prolene to reconstruct the pupil or leave as
such
(double armed BV-100 needle on a 2 inch 10-0
Prolene suture)

48. COMPLICATIONS RELATED TO IRIS AND THE
PUPIL contd/
3. INTRAOPERATIVE MIOSIS
 Prevented by using 1:1,000,000 adrenaline in the
infusion fluid or using eye drop ketorolac
preoperatively 15 minutes interval
 If occurs at the capsulotomy stage, a can opener
capsulotomy can still be completed with ease
 But if difficulty encountered in completion of rhexis,
convert into can-opener capsulotomy
 Hydrodissection must be performed with utmost care
especially if edge of rhexis is not visible OTHERWISE
PERFORM ECCE
 In case of phaco, it’s better to use an AC technique or
the nucleus fracture with the cross technique
 Aspiration of cortex is best done with a BIMANUAL
TECHNIQUE

49. COMPLICATIONS DURING NUCLEAR
MANAGEMENT
 1. VITREOUS LOSS, PCR AND POSTERIOR
DISLOCATION
 VL During nuclear extraction is usually caused by a too
much pressure on a wound that is too tight
 Presence of LOOSe ZONULES
 INADEQUATE SPACE below nucleus during delivery
with vectis
PCR --------- > VL
 Capsulorrhexis ---> more difficult to extract nucleus
Small rhexis --- > INADVERTENT OR TOTAL LENS
DISLOCATION may occur or
POSTERIOR DISLOCATION OF LENS
(Sinking nucleus posteriorly)

50.  MANAGEMENT
 Enlarge the WOUND (ECCE/SICS)
 Make adequate space between capsule and
nucleus with VISCO
 Give RELAXING CUTS when doing an
ECCE/SICS with a rhexis
 In case of POSTERIOR DISLOCATION OF
LENS, NUCLEUS should be immediately
supported with a lens loop, elevated anteriorly
and delivered out
 Do appropriate ANTERIOR VITRECTOMY in+nce
of VL

51. COMPLICATIONS DURING NUCLEAR
MANAGEMENT contd/
2. ZONULAR DEHISCENCE
 Seen commonly in beginners in SICS
 Happens when TOO MUCH FORCE is applied during
nuclear rotation and delivery into AC
 A Freely rotating nucleus not prolapsing into AC
A TILTING NUCLEUS towards the side or
VITREOUS in AC
MANAGEMENT
 TO PREVENT this, pressure should not be applied
POSTERIORLY, BUT more in the HORIZONTAL
PLANE
 Depends on +nce and extent of VL

52.  MANAGEMENT
ZONULAR DEHISCENCE
UNDISTURBED VITREOUS VITREOUS in AC
No Vitreous in AC
AUTOMATED VITRECTOMY
OR MANUAL ANTERIOR VITRECTOMY
INCREASE THE SIZE OF
INCISION IN PHACO/SICS
ENLARGE CAPSULOTOMY & GENTLY DO HYDRO
Deliver nucleus into AC with minimal force
(so as not to increase area of dehiscence
NUCLEUS DELIVERY with vectis
I/A with low flow
IOL IMPLANTATION AWAY from area of dehiscence
SMALL LARGE
CONVERT TO ECC
DELIVER
NUCLEUS
FREE AC OF VITREOU
IOL IMPLANTATION
into the SULCUS OR
SCLERAL FIXATION

53. COMPLICATIONS DURING NUCLEAR MANAGEMENT
contd/
 3. TEARS IN POSTERIOR CAPSULE (PCR)
DURING NUCLEAR MANAGEMENT IN PHACO
 This can occur any stage
 Prevent undue and repeated shallowing of AC
 Never release the footswitch(position O) WHILE
THE PROBE or any instrument is in the AC
 Exercise caution while IN THE PERIPHERY or
when using SHARP INSTRUMENTS
 AVOID USE OF FORCE if nucleus does not
rotate
 Do not exert any LATERAL or TORSIONAL
FORCE in +nce of defect --- > ENLARGEMENT

54. Posterior capsular rupture with nuclear
fragment in AC
Small rent with intact hyaloid face. The
second instrument supports the nuclear
fragment & brings it to the phaco tip

55.  MANAGEMENT
PCR
+NCE of Nuclear materials
Deliver nuclear fragments out of AC (
ALWAYS USE LENS LOOP OR VECTIS
NO PRESSURE TO EXPRESS THE
NUCLEUS
ENSURE NO POSTERIOR DISLOCATION
Use VISCO below nucleus TO TAMPONADE
the VITREOUS
SINKING NUCLEAR FRAGMENTS
NEVER CHASE WITH VECTIS OR
PHACO PROBE
USE SUPPORT OF POST LEVITATION IF SINKING is
Use VISCO to float up the nucleus OR
ANTERIOR VITRECTOMY
WHEREVER DOUBT exists, use help o
VR surgeon rather than being AGGRES
Clear AC of Vitreous and cortical matter
Automated vitrectomy handpiece or
manual I/A (dry ) and Wck cell-scissors vitrectomy
SMALLPCR LARGE PCR
IOL IN BAG
SULCUS IMPLANTATION OR SCLERAL FIXA
OR ACIOL

56. Use of wire vectis to remove partially
emulsified nucleus
Wound is enlarged to 10mm, viscoelastic is
injected and vectis placed beneath the
nucleus for removal

57. COMPLICATIONS DURING NUCLEAR
MANAGEMENT contd/
 4. DISLOCATION OF NUCLEUS (PART OR
WHOLE)
 This is a disaster in the true sense and must be
managed likewiseFragments consisting of % or more of lens should be removed
Pars Plana vitrectomy and removal of fragment

58. COMPLICATIONS DURING NUCLEAR
MANAGEMENT contd/
 5. INADVERTENT IRIDODIALYSIS
 More common when the lens loop is being used
to deliver nucleus in the +nce of small pupil
 The 6 o’clock pupillary edge can get caught b/w
nucleus and the loop and be pulled out creating a
large ‘IRIDODIALYSIS’
 Superior iris can also be caught with the nucleus
in the wound and be pulled out

59. COMPLICATIONS DURING NUCLEAR
MANAGEMENT contd/
 MANAGEMENT
 VISCOELASTIC TAMPONADE immediately to
prevent bleeding
Rest of sx carried out as planned yet with
difficulty due to floppy iris tissue
 At the end of surgery, repair with 10-0 prolene
sutures b/w the torn iris root and posterior scleral
lip of the wound or
at a later date using McCannel sutures

60. COMPLICATIONS DURING NUCLEAR
MANAGEMENT contd/
 6. DAMAGE TO CORNEAL ENDOTHELIUM
 More common with large HARD NUCLEAR
CATARACTS
 Inadvertent touch with INSTRUMENTS
 INADEQUATE INCISION SIZE AND
INCONSTANT VIGILANCE as to the position of
instruments in the AC
 MANAGEMENT
 Protect the endotheium with VISCO during
nucleus delivery
 Make adequate incision size and CONTANT
VIGILANCE asto the position of instruments in

61. COMPLICATIONS DURING CORTICAL
ASPIRATION
 1. RETAINED LENS MATERIAL
 Usually found in cases with operative difficulty
- small pupil
- small rhexis
- PCR
- subincisional cortex in SICS
 if little amount
 If larger amount

62. COMPLICATIONS DURING CORTICAL ASPIRATION
CONTD/
MANAGEMENT
 Avoid BLIND ASPIRATION but ‘Water jetting’ technique
with irrigation only
 If automated I/A is being used, retract the iris with another
instrument for better visualisation
 Better leave a small amount rather than risk of PCR in
pursuit of perfect cortical clean up
Retained lens materials may
be aspirated after 3-4 weeks of
observation if found to cause
problems
Till that time medical control
of complications is tried
Use of instrument through side
port to assist in I/A in the
presence of small pupil

63. COMPLICATIONS DURING CORTICAL ASPIRATION
contd/
 2. POSTERIOR CAPSULAR DEHISCENCE
 Most commonly during cortical aspiration in ECCE and
SICS as compared to PHACO (where it is more common
during nucleus management)
 Predisposing factors: Large capsular tags
Positive vitreous pressure
 CHARACTERISTICS
- Sudden appearance of abnormally good
flow
- deepening of AC
- alteration of AC fluidics
- defect itself is visible
 Usually the tear occurs when part of the posterior
capsule is aspirated into the aspiration port (recognized
as striae radiating from the part caught and demands
immediate reversal of flow to release the capsule)

64. COMPLICATIONS DURING CORTICAL ASPIRATION
contd/
 MANAGEMENT
 POSTERIOR CAPSULE DEHISCENCE
SMALL &
INTACT VITREOUS FACE
REMOVE REMAINING CORTEX
USE MANUAL I/A for precise control of flow
Safer to leave a little cortex when position or size
of rent does not allow complete removal
RUPTURED HYALOID SURFACE
VITRECTOMY WITH AUTOMATED CUTTE
(to prevent traction on the retina and vitreou
when aspiration is performed)

65. Posterior capsular rupture & Its management
A - Posterior capsule rupture; B - Vitreous loss; C - Coaxial infusion can
hydrate vitreous, and, D - cause vitreomacular interface disturbance;
E - Bimanual vitrectomy with separate infusion & cutting; F- Vitreous
must be cleared from the AC Capsular bag and just behind the posterior
capsule without disturbing the main vitreous body

66. COMPLICATIONS DURING CORTICAL ASPIRATION
contd/
 3. POSITIVE VITREOUS PRESSURE
 More so in ECCE
 SIGNS: bulging posterior capsule
Shallowing of AC
Iris Prolapse
 Usually due to: Pressure on the globe from speculum
or SR bridle
- unreconized RBH
- suprachoroidal haemorrhage
- simply inadequate massage after the
regional block

67. COMPLICATIONS DURING CORTICAL
ASPIRATION contd/
 MANAGEMENT
 Release the bridle suture,
 readjust the speculum and inject viscoelastic to
deepen the chamber.
 Raise height of the irrigation bottler
 Intravenous mannitol ( 0.5 – 1 gm/kg)helps in
reducing vitreous volume
 Partially closing the chamber with 2-3 sutures
before I/A
 Vitreous aspiration through pars plana with 18 G
needle can be considered in refractory
circumstances

68. COMPLICATIONS DURING IOL
PLACEMENT
 Most surgeons aim to implant the IOL in the bag
and IOL power calculations are done accordingly
1. INADVERTENT SULCUS PLACEMENT
 most common complication, esp with can-opener
technique
 Results in post –operative refractive error
2. TILT
 One haptic in the bag and the other in the sulcus

69. COMPLICATIONS DURING IOL PLACEMENT contd/
 3. DECENTERED IOLS
 Encountered more commonly with improper
placement of IOLs or
with co-existence of PCR or zonular dialysis
 MANAGEMENT
MINIMAL APHAKIC PART
VISUAL AXIS CONVERED
NO TREATMENT
DECENTERED IOLS
LARGE SUBLUXATION
REPOSITION
REMOVAL OF IOL &
REPLACEMENT WITH ACIOL OR SCLERAL FIXAT

70. COMPLICATIONS DURING IOL PLACEMENT contd/
 4. POSTERIOR DISLOCATION OF THE IOL
 Implantation of IOL in +nce of LITTLE
CAPSULAR SUPPORT
 IOL are inert and generally do not cause
problems
 May l/t RD, VH, uveitis and chr. CMO
 MANAGEMENT
 Should be followedIOL in VISUAL AXIS
FIBROUS PROLIFERATION WITH
BANDS DEVELOPING IN
VITREOUS
RISK OF RD
REMOVAL THROUGH PPV
REPOSITIONING or exchange of IOL depending on extent of capsular su

71. COMPLICATION RELATED TO WOUND
CLOSURE
 Aim during wound closure is to minimize INDUCED
ASTIGMATISM
 Each surgeon must determine which suturing
technique will provide the best results in his or her
hands
 GENERAL PRINCIPLES:
- take sufficient depth of tissue in each bite
- EQUIDISTANT spacing
- ADEQUATE No of sutures
- Tissue approximation WITHOUT FORCE
(including the floor of tunnel with such incisions)
- BURY THE KNOTS to avoid irritation

79. HAEMORRHAGE
 Bleeding from vessels in the scleral bed
 From iris vessels if iridectomy performed or iridodialysis
produced
 Temporal incisions tend to bleed more than superior
incisions
 Clot formation may interfere with surgical maneuvers
such as capsulorhexis
MANAGEMENT
 Irrigate IMMEDIATELY before it passes through zonules
into the vitreous cavity
 Depress the posterior lip of the wound
 Viscoelastic substance by tamponading the bleeding site
 Air bubble will oftenstop the bleeding

80. SUPRACHOROIDAL
HAEMORRHAGE
 SHOULD BE DIFFERENTIATED FROM
EXPULSIVE HAEMORRHAGE
 0.04% with phacoemulsification
 “Dark mass posteriorly that obscures part of the
red fundus reflex”
 Usually venous in origin; and often associated
with hypotony accompanying intraocular surgery
 More common when a vitrectomy is necessary
due to PCR

81. MANAGEMENT
 SOME are SELF LIMITIN  continue Sx
 If Globe becomes firm, perform posterior
sclerotomy to drain the choroidal haemorrhage

82. EXPULSIVE CHOROIDAL
HAEMORRAHGE
 ½ OF all expulsive haemorrhage
 Most frightening and seious complications of
cataract surgery
 Vail refered to it as the “bete noire of the
ophthalmic surgeon”
 Mostly from short posterior ciliary arteries
 Factors associated:- Arterial hypertension,
Generalized arteriosclerosis, Elevated IOP,
Necrosis of intraocular arterioles, Local vascular
sclerosis, High degree of myopia, Vascular
fragility, Polycythemia, Precipitious fall in IOP as a
result of surgical decompression, Operative loss
of vitreous, Congestion of choroid, Hypotension,
Diabetes

83. CLINICAL FINDINGS

84. IRIDODIALYSIS
 During enlargement of incision, during iridotomies
or during insertion of phaco tip or I/A tip in high
pressure eyes
 During deliveries of nucleus by wire vectis
MANAGEMENT
 If excessive, it should be sutured with 10- 0 Nylon
or polypropylene sutures
 If repair is left for postoperative period, a
technique described by McCannel