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1. COMPLICATION OF
CATARACT SURGERY
MADE BY : SWATI PANARA
FROM : BHARTIMAIYA COLLEGE OF OPTOMETRY
2nd YEAR 4th SEMESTER

2. TYPES
PREOPRATIVE COMPLICATION
OPERATIVE COMPLICATION
EARLY POSTOPERATIVE
COMPLICATION
LATE POSTOPERATIVE
COMPLICATION
IOL RELATED COMPLICATION

3. PREOPERATIVE COMPLICATION
ANXIETY
NAUSEA & GASTRITIS
ALLERGIC CONJUNCTIVITIS
CORNEAL ABRASION
LOCAL ANAESTHESIA

4. • 1 ANXIETY : due to fear & apprehension of
operation. Anxiolytic drugs such as diazepam 2 to
5 mg at bed time usually alleviate such
symptoms.
• 2 NAUSEA & GASTRITIS : due to preoperative
medicines such as acetazolamide &/or glycerol.
• Oral antacids & omission of further dose of such
medicines usually relieve the symptoms

5. ALLERGIC CONJUNCTIVITIS
• It is irritative.
• It may occur in some patients due to
preoperative topical antibiotic drops.
• Postponing the operation for 2 days along
with withdrawal of such drugs required.

6. CORNEAL ABRASION
• due to inadvertent injury during schiotz
tonometry.
• Patching with antibiotic ointment for a day
and postponement of operation for 2 days is
required.

7. COMPLICATION DUE TO LOCAL
ANAESTHESIA
• (1) Retrobulbar haemorrhage may occur due
to retrobulbar block.
• Immediate pressure bandage after instilling
one drop of 2% pilocarpine and postponement
of operation for a week is advised.

8. • (2) Oculocardiac reflex, which manifests as
bradycardia and/or cardiac arrhythmia, has also
been observed due to retrobulbar block.
• An intravenous injection of atropine is helpful.
• (3) Perforation of globe may also occur
sometimes.
• To prevent such catastrophy, gentle injection with
blunt-tipped needle is recommended. Further,
peribulbar anaesthesia may be preferred over
retrobulbar block.

9. • (4) Subconjunctival haemorrhage is a minor
complication observed frequently, and does
not need much attention.
• (5) Spontaneous dislocation of lens in vitreous
has also been reported during vigorous ocular
massage after retrobulbar block.
• The operation should be postponed.

10. OPERATIVE COMPLICATION
• SUPERIOR RECTUS MUSCLE LACERATION
• EXCESSIVE BLEEDING
• INCISION RELATED COMPLICATION
• INJURY TO THE CORNEA , IRIS & LENS
• ANTERIOR CAPSULORHEXIS
• POSTERIOR CAPSULAR RUPTURE
• VITREOUS LOSS
• ZONULAR DEHISCENE
• NUCLEAR DROP IN TO THE VITREOUS CAVITY
• POSTERIOR LOSS OF LENS FRAGMENT
• EXPULSIVE CHOROIDAL HAEMORRHAGE
• SUPRACHOROIDAL HAEMORRHAGE

11. (1) Superior rectus muscle laceration and/or
haematoma, may occur while applying the bridle
suture.
• Usually no treatment is required.
(2). Excessive bleeding may be encountered during
the preparation of conjunctival flap or during
incision into the anterior chamber. Bleeding
vessels may be gently cauterized.

12. • 3. Incision related complications depend upon
the type of cataract surgery being performed.
• i. In conventional ECCE there may occur irregular
incision.
• In manual SICS and phacoemulsification following
complications may occur while making the self-
sealing tunnel incision.
• Button holing of anterior wall of tunnel can occur
because of superficial dissection of the scleral
flap (Fig. 8.27B).

13. A, correct incision;
B, Buttonholing of anterior wall of the tunnel;

14. • Premature entry into the anterior chamber can
occur because of deep dissection (Fig. 8.27C).
• Once this is detected, dissection in that area
should be stopped and a new dissection
started at a lesser depth at the other end of
the tunnel.
•
C, Premature entry into the anterior chamber

15. • Scleral disinsertion can occur due to very deep
groove incision.
• In it there occurs complete separation of
inferior sclera from the sclera superior to the
incision (Fig. 8.27D).
• Scleral disinsertion needs to be managed by
radial sutures.

16. • 4. Injury to the cornea (Descement's
detachment), iris and lens may occur when
anterior chamber is entered with a sharp-tipped
instrument such as keratome or a piece of razor
blade.
• A gentle handling with proper hypotony reduces
the incidence of such inadvertent injuries.
• 5. Iris injury and iridodialysis (tear of iris from
root) may occur inadvertently during intraocular
manipulation.

17. • 6. Complications related to anterior capsulorhexis. Continuous curvilinear
capsulorhexis (CCC) is the preferred technique for opening the anterior capsule for
SICS and phacoemulsification. Following complications may occur:
• Escaping capsulorhexis i.e., capsulorhexis moves peripherally and may extend to
the equator or posterior capsule.
• Small capsulorhexis. It predisposes to posterior capsular tear and nuclear drop
during hydrodissection.
• It also predisposes to occurrence of zonular deshiscence. Therefore, a small sized
capsulorhexis should always be enlarged by 2 or 3 relaxing incisions before
proceeding further.
• Very large capsulorhexis may cause problems for in the bag placement of IOL.
• Eccentric capsulorhexis can lead to IOL decentration at a later stage.

18. Small Capsulorhexis

19. • 7. Posterior capsular rupture (PCR).
• It is a dreaded complication during extra capsular
cataract extraction.
• In manual SICS and phacoemulsification PCR is even
more feared because it can lead to nuclear drop into
the vitreous.
• The PCR can occur in following situations:
• During forceful hydrodissection,
• By direct injury with some instrument such as
• Sinskey's hook, chopper or phacotip, and
• During cortex aspiration

20. • (8) Zonular dehiscence- during nucleus
prolapse into the anterior chamber in manual
SICS.
• (9) Vitreous loss.- occur following accidental
rupture of post. Capsule during any technique
of ECCE.

21. zonular dehiscence

22. • To decrease vitreous volume: Preoperative use of
hyperosmotic agents like 20 percent mannitol or oral
glycerol is suggested.
• To decrease aqueous volume: Preoperatively
acetazolamide 500 mg orally should be used and
adequate ocular massage should be carried out
digitally after injecting local anaesthesia.
• To decrease orbital volume adequate ocular massage
and orbital compression by use of superpinky, Honan's
ball, or 30 mm of Hg pressure by paediatric
sphygmomanometer should be carried out.

23. • Better ocular akinesia and anaesthesia decrease
the chances of pressure from eye muscle.
• Minimizing the external pressure on eyeball by
not using eye speculum, reducing pull on bridle
suture and overall gentle handling during surgery.
• Use of Flieringa ring to prevent collapse of sclera
especially in myopic patients decreases the
incidence of vitreous loss.

24. • When IOP is high in spite of all above
measures and operation cannot be
postponed, in that situation a planned
posterior-sclerotomy with drainage of vitreous
from pars plana will prevent rupture of the
anterior hyaloid face and vitreous loss.

25. • (10) Nuclear drop into the vitreous cavity. – it
occurs phacoemulsification , less frequently
with manual SICS.
• It is a dreadful complication which occur due
to sudden & large PCR.
Management.- ant. Vitrectomy & cortical
clean up.

26. • (11) Post. Loss of lens fragments- into the
vitreous cavity may occur after PCR or zonular
dehiscence during phaco.
- Result in glaucoma, chronic, uveitis, chronic
CME, RD.
- Management.- pars plana Vitrectomy &
removal of nuclear fragment.

27. • (12) Expulsive choroidal haemorrhage.-
• It is one of the most dramatic and serious complications of
cataract surgery.
• It usually occurs in hypertensive and patients with
arteriosclerotic changes.
• It may occur during operation or during immediate
postoperative period.
• Its incidence was high in ICCE and conventional ECCE but
has decreased markedly with valvular incision of manual
SICS and phaco emulsification technique.
- Characterized by spontaneous gaping of the wound followed
by expulsion of the lens, vitreous, retina, uvea, & finally a gush
of bright red blood.

28. EARLY POSTOPERATIVE COMPLICATION
HYPHAEMA
IRIS PROLAPSE
STRIATE KERATOPATHY
FLAT ANTERIOR CHAMBER
POSTOPERATIVE ANTERIOR UVEITIS
TOXIC ANTERIOR SEGMENT SYNDROME
BACTERIAL ENDOPHTHALMITIS

29. • (1) Hyphaema – collection of blood in ant.
Chamber may occur from conjunctival or
scleral vessels due to minor ocular trauma.
• Treatment. Most Hyphaema absorb
spontaneously and thus need no treatment.
Sometimes hyphaema may be large and
associated with rise in IOP.

30. Hyphaema
 Early / Late
 Early: Immediate postoperative period
 Origin: Incision / Iris
 Mild resolves spontaneously
 Mixed with blood / viscoelastic – resolution
longer
 Late: Months / years after surgery
 Origin: wound vascularization / erosion of
vascular tissue by lens implant

31. Hyphema

32. • (2) Iris prolapse – by inadequate suturing of the
incision after ICCE & conventional ECCE.
• This complication is not known with manual SICS
and phacoemulsification technique.
• Management: A small prolapse of less than 24
hours duration may be reposited back and wound
sutured.
• A large prolapse of long duration needs
abscission and suturing of wound.

33. Iris prolapse

34. • (3) Striate keratopathy.- by mild corneal oedema
with descement's fold is a common complication
observed during immediate postoperative period.
- Due to endothelial damage during surgery.
• Management : Mild striate keratopathy usually
disappears spontaneously within a week.
Moderate to severe keratopathy may be treated
by instillation of hypertonic saline drops (5%
sodium chloride) along with steroids.

35. FLAT ANTERIOR CHAMBER
 Shallow or flat anterior chamber
 Wound leak
 Choroidal detachment or hemorrhage
 Pupillary block
 Ciliary block

36. WOUND LEAK
It Is associated with hypotony.
It is diagnosed by Seidel's test.
• In this test, a drop of fluorescein is instilled into the lower
fornix and patient is asked to blink to spread the dye
evenly.
• The incision is then examined with slit lamp using cobalt-
blue filter.
• At the site of leakage, fluorescein will be diluted by
aqueous. In most cases wound leak is cured within 4 days
with pressure bandage and oral acetazolamide.
• If the condition persists, injection of air in the anterior
chamber and resuturing of the leaking wound should be
carried out.

37. • CILIOCHOROIDAL DETACHMENT : It may or
may not be associated with wound leak.
• In most cases choroidal detachment is cured
within 4 days with pressure bandage and use
of oral acetazolamide.
• PUPIL BLOCK : Pupil block due to vitreous
bulge after ICCE leads to formation of iris
bombe and shallowing of anterior chamber.

38. • (5) Postoperative anterior uveitis can be
induced by instrumental trauma, undue
handling of uveal tissue, reaction to residual
cortex or chemical reaction induced by
viscoelastics, pilocarpine etc.
• Management includes more aggressive use of
topical steroids, cycloplegics.

39. • Bacterial endophthalmitis- dreadful
complication with an incidence 0.2 to 0.5%.
- Sorce of infection- contaminated solution,
instruments, surgeon’s hands, pt’s own flora
from conjunctiva, eyelids, & air-borne
bacteria.
- Sign & symptom : ocular pain , diminished of
vision , corneal oedema

41. Signs of mild endophthalmitis
• Mild pain and visual loss
• Anterior chamber cells
• Small hypopyon
• Fundus visible with indirect
ophthalmoscope

42. LATE POSTOPERATIVE COMPLICATION
• CYSTOID MACULAR OEDEMA
• DELAYED CHRONIC POSTOPERATIVE
ENDOPHTHALMITIS
• PSEUDOPHAKIC BULLOUS KERATOPATHY
• RETINAL DETACHMENT
• EPITHELIAL INGROWTH
• FIBROUS DOWNGROWTH
• AFTER CATARACT
• GLAUCOMA

43. • CME- collection of fluid in the form of cystic
loculi in the henle’s layer of macula is a
frequent complication of cataract Surgery.
- On fundoscopy it gives a honeycomb
appearance.
- On FA- typical flower petal patterns due to
leakage of dye from perifoveal capillaries.

44. FFA

45. • Delayed chronic postoperative
endophthalmitis is caused when an organism
of low virulence becomes trapped within the
capsular bag.
• It has an onset ranging from 4 weeks to years
(mean 9 months) postoperatively.

46. • Delayed chronic postoperative
endophthalmities-

47. • Pseudophakic bullous keratopathy(PBK)-
postoperative corneal oedema produced by
surgical or chemical insult to a healthy or
compromised corneal endothelium.

48. RETINAL DETACHMENT
• This serious postoperative complication is,
fortunately, rare but is more common in
myopic (shortsighted) patients after intra
operative complications.

49. • Epithelial ingrowth- rarely conjunctival
epithelial cells may invade the ant. Chamber
through a defect in the incision.

50. • Fibrous down growth- into the ant. Chamber
may occur very rarely when the cataract
wound apposition is not perfect.
- May cause secondary glaucoma, phthisis
bulbi.

51. • After cataract- (secondary cataract)
• “It is the opacity persists or develop after ECCE.”
• TYPES : Present as thickened post. Capsule or
dense membranous after cataract.
• Soemmering’s ring –thick ring of after cataract
formed behind the iris, enclosed between the
two layers of capsule.
• Elshning’s pearls- vasculated sub capsular
epithelial cells are clustered like soap bubbles
along the post. Capsule.

52. After cataract- (secondary cataract) (PCO)

53. A, dense membranous; B, Soemmering's ring; C, Elschnig's pearls.

54. Capsule or dense membranous Elshning’s pearls-
Soemmering’ ring

55. ILO RELATED COMPLICATION
MALPOSITION OF IOL
PUPILLARY CAPTURE
OF THE IOL
TOXIC ANTERIOR
SEGMENT SYNDROME

56. • Complications like-
• CME, corneal endothelial damage, uveitis, secondary
glaucoma are seen.
• UGH syndrome- uveitis, glaucoma. Hyphema. Occur
with rigid ACIOL.
• Pupillary capture of the IOL - postoperative iritis
• Toxic lens syndrome- uveal inflammation excited by
either ethylene gas used for sterilising IOLs or by the
lens materials

57. • Malposotion of IOL – decentration,
subluxation, & dislocation.
• Sun-set syndrome- infer. Subluxation of IOL
• Sun- rise syndrome-sup. Subluxation of IOL
• Lost lens syndrome- IOL into the vitreous
cavity
• Windshield wiper syndrome- IOL is places
vertically in the sulcus.