LENS AND CATARACT :

COMPLICATIONS OF CATARACT SURGERY

AAO READING KBR

HIKBAN FIQHI K.
Capsular Opacification and Contraction
Posterior Capsule Opacification
• The most common late complication of cataract surgery by means of
ECCE or phacoemulsification is posterior capsule opacification (PCO).
• Contracture of a continuous curvilinear capsulorrhexis may occlude
the visual axis because of anterior capsule fibrosis and phimosis.
• Posterior or anterior capsule opacification is amenable to treatment
by intraocular peeling or polishing of the capsule or by means of
Nd:YAG laser capsulotomy.
• Capsular opacification stems from the continued viability of lens epithelial cells
that remain after removal of the nucleus and cortex. Opaque secondary
membranes are formed by proliferating lens epithelial cells, fibroblastic
metaplasia, and collagen deposition.
• Lens epithelial cells proliferate in several patterns.
• If the epithelial cells migrate out of the capsular bag, translucent globular masses
resembling fish eggs (Elschnig pearls) form on the edge of the capsular opening.
These pearls can fill the pupil or remain hidden behind the iris.
• Histologic examination shows that these “fish eggs”, identical to those
proliferating within the capsule of a Soemmering ring but usually lacking a
basement membrane. If the epithelial cells migrate across the anterior or
posterior capsule, they may cause capsular wrinkling and opacification.
• Significantly, the lens epithelial cells are capable of undergoing metaplasia with
conversion to myofibroblasts. These cells can produce a matrix of fibrous and
basement membrane collagen. Contraction of this collagen matrix causes
wrinkles in the posterior capsule, with resultant distortion of vision and glare.
• The reported incidence of PCO varies widely but has been diminishing with current IOL
design and placement. Older studies report that the frequency of Nd:YAG laser
capsulotomy varies between 3% and 53% within 3 years of cataract surgery. More recent
clinical series with a 3- to 5-year follow-up of cases with either hydrophobic acrylic or
silicone square-edge design show PCO rates between 0% and 4.7%.
• Factors :
1. age of the patient
2. history of intraocular inflammation
3. presence of pseudoexfoliation syndrome
4. size of the anterior capsulorrhexis
5. quality of the cortical cleanup
6. capsular fixation of the implant
7. design of the lens implant
8. modification of the lens surface
9. presence of intraocular silicone oil
Anterior Capsule Fibrosis and Phimosis

• Capsular fibrosis is associated with clouding of the anterior capsule. If

a substantial portion of the IOL optic is covered by the opaque
anterior capsule, including portions exposed through the undilated
pupil, the patient may become symptomatic.
• Symptoms may include glare, especially at night due to physiologic
mydriasis in darkness, or a perception that vision has become cloudy
or hazy. The term capsular phimosis is used to describe the
postoperative contraction of the anterior capsule opening as a result
of circumferential fibrosis.
• Phimosis produces symptoms similar and often more pronounced than
those of fibrosis itself and may cause stress on the zonular fibers or
decentration of an IOL optic.
• Anterior capsule contraction and fibrosis occur more frequently with
smaller capsulorrhexis openings, in patients with underlying
pseudoexfoliation syndrome, and in other situations with abnormal or
asymmetric zonular support (eg, penetrating or blunt trauma, Marfan
syndrome, or surgical trauma).
• Anterior capsule contraction may contribute to late
pseudophakodonesis or in-the-bag IOL subluxation due to stress on the
zonular apparatus.
• Capsular phimosis can be treated with several radial Nd:YAG anterior
capsulotomies to release the annular contraction, reduce the traction
on the zonular fibers, and enlarge the anterior capsule opening
• This procedure is performed in a fashion similar to Nd:YAG laser
posterior capsulotomy
• In general, the anterior capsule tissue or a fibrotic ring is tougher and
thus requires more laser power than does the posterior capsule.
Nd:YAG Laser Capsulotomi
• Use of the Nd:YAG laser is now a standard procedure for the
treatment of secondary opacification of the posterior capsule or
contraction of the anterior capsule.
• Alternatively, intraocular surgical cleaning of the capsule may be
performed during the course of concurrent anterior segment surgery
• If possible, posterior capsulotomy should be delayed until there is
adequate apposition and fusion of the anterior and posterior capsule
peripheral to the lens optic to reduce the possibility of vitreous
prolapse around the IOL and into the anterior chamber.
Indications :
• visual acuity symptomatically decreased as a result of PCO
• a hazy posterior capsule preventing the clear view of the ocular
fundus required for diagnostic or therapeutic purposes
• monocular diplopia, a Maddox rod–like effect, or glare caused by
wrinkling of the posterior capsule
• contraction of anterior capsulotomy (capsular phimosis)
• capsular block syndrome
Contraindications :
• inadequate visualization of the posterior capsule
• a patient who is unable to remain still or hold fixation during the
procedure
• active intraocular inflammation
• uncontrolled glaucoma
• high risk of retinal detachment
• suspected CME
Complications :
• transient or long-term elevated IOP
• retinal detachment
• CME
• Hyphema
• damage to or dislocation of the IOL
• corneal edema
• corneal abrasions.
• Transient elevation of IOP occurs in a significant number of patients,
with pressure levels peaking 2–3 hours after surgery.
• This elevation is likely due to obstruction of the outflow pathways by
debris scattered by the laser treatment.
• It is more common in eyes with vitreous prolapse, those without in-
the-bag fixation of the IOL, or those with preexisting glaucoma.
• Such elevation responds quickly to topical glaucoma medications,
which can be continued for 3–5 days following the procedure.
• For any type of laser capsular surgery, many surgeons prescribe
prophylactic preoperative and postoperative ocular hypotensive
medications (α-adrenergic agonist or β-blocker drops), as well as
either topical corticosteroids or NSAIDs to reduce the risk of
postprocedure IOP spikes, inflammation, and CME.
• Nd:YAG laser capsulotomy may increase the risk of retinal
detachment; the reported incidence is 0%–3.6%. Approximately 50%–
75% of the retinal detachments following cataract extraction occur
within 1 year of surgery or within 6 months of capsulotomy, often in
association with a posterior vitreous detachment (PVD).
• In many cases, it is difficult to ascertain whether the retinal
detachment is related to the capsulotomy or to the cataract surgery
itself or whether it is simply a consequence of a naturally occurring
PVD.
• Factors that increase the risk of retinal detachment following Nd:YAG
capsulotomy
1. Axial myopia
2. male sex
3. young age,
4. Trauma
5. vitreous prolapse
6. a family history of retinal detachment
7. preexisting vitreoretinal pathology
• All patients at increased risk of retinal detachment should be instructed to
promptly report any new symptoms suggesting a PVD or retinal tear. CME
can occur following Nd:YAG capsulotomy. In patients with a history of
CME, or in high-risk patients such as those with diabetic retinopathy, the
prophylactic use of topical corticosteroids or NSAIDs may be beneficial.
 Hemorrhage
Systemic Anticoagulation
• A large, prospective cohort study did not show an increased risk of hemorrhagic
complications in patients on anticoagulant or antiplatelet therapy during
cataract surgery. In addition, no increase in the risk of medical complications
was observed when such therapy was temporarily discontinued for surgery.
• This result contrasts with earlier reports suggesting that anticoagulation
increases the risk of suprachoroidal effusion and hemorrhage, and with more
recent reports that cessation of anticoagulation therapy carries significant risks
of thromboembolic complications.
• In general, patients undergoing cataract surgery with topical or sub-Tenon
anesthesia do not require cessation of anticoagulant therapy. If the surgeon is
considering discontinuation of anticoagulants, consultation with the patient’s
primary care physician is recommended.
Retrobulbar Hemorrhage
• Retrobulbar hemorrhages are more common with retrobulbar
anesthetic injections than with peribulbar injections, and they may
vary in intensity. These hemorrhages have become rare with the
declining use of retrobulbar injections for cataract surgery. Reports
estimate the incidence of significant retrobulbar hemorrhage after
retrobulbar injection to be 0.44%–0.74%.
• Venous retrobulbar hemorrhages are usually self-limited and tend to
spread slowly. They often do not require treatment.
• Arterial retrobulbar hemorrhages occur more rapidly and are
associated with taut orbital swelling, marked proptosis, elevated IOP,
reduced mobility of the globe, and massive ecchymosis of the eyelids
and conjunctiva. This type of retrobulbar hemorrhage causes an
increase in orbital volume and associated orbital pressure, which can
restrict the vascular supply to the globe.
• Ophthalmologists can often make the diagnosis of retrobulbar
hemorrhage by observing the rapid onset of eyelid and conjunctival
ecchymosis and tightening of the orbit.
• The diagnosis can be confirmed by tonometry revealing elevated IOP.
Direct ophthalmoscopy may reveal pulsation or occlusion of the
central retinal artery in severe cases.
• Treatment of acute retrobulbar hemorrhage consists of maneuvers to
lower the intraocular and orbital pressure as quickly as possible.
These may include digital massage, intravenous osmotic agents,
aqueous suppressants, lateral canthotomy and cantholysis, localized
conjunctival peritomy (to allow egress of blood), and occasionally
anterior chamber paracentesis.
• The planned surgery should be postponed until the IOP and mobility
of the globe and eyelids are normal. To reduce the risk of a recurrent
retrobulbar hemorrhage, it may be advisable to use another form of
anesthesia for the second attempt at surgery.
• In addition to retrobulbar hemorrhage, potential complications of
retrobulbar injections include central retinal artery occlusion,
ischemic optic neuropathy, toxic neuropathy or myopathy, diplopia,
ptosis, and inadvertent subdural injections with possible CNS
depression and apnea. Ischemic complications are more common if
epinephrine is used in the anesthetic.
Hyphema
• Hyphema in the immediate postoperative period usually originates from the
incision or the iris.
• It is commonly mild and resolves spontaneously.
• The risk of hyphema is greater in patients with :
1. pseudoexfoliation syndrome
2. anterior segment neovascularization
3. Fuchs heterochromic uveitis
4. vascular tufts at the pupillary margin.
• Resolution may take longer if vitreous is mixed with the blood.
• The two major complications from prolonged hyphema are elevated IOP and
corneal blood staining. IOP should be monitored closely and initially treated
medically, although it may be difficult to control if the blood is mixed with the OVD
used during the procedure.
• Surgical evacuation is occasionally necessary.
• Hyphema occurring months to years after surgery is usually the result
of incision vascularization or erosion of vascular tissue in the iris or
ciliary body by an IOL haptic or optic edge.
• Argon laser photocoagulation of the bleeding vessel, often performed
through a goniolens, may stop the bleeding or prevent rebleeding.
• To reduce the risk of continued or recurrent bleeding, antiplatelet or
anticoagulation therapy may be withheld, if medically possible, until
the hyphema resolves.
• Occasionally, it is necessary to reposition or exchange an IOL that
comes in contact with iris or angle structures and results in recurrent
intraocular hemorrhage.
Suprachoroidal Effusion or Hemorrhage
• Suprachoroidal effusion with or without suprachoroidal hemorrhage
usually occurs intraoperatively, but may also occur later in cases with
prolonged postoperative hypotony.
• Suprachoroidal effusion typically presents as a forward prolapse of
ocular structures, including iris, lens diaphragm, and vitreous
• Clinically, suprachoroidal effusion may be difficult to differentiate from
suprachoroidal hemorrhage.
• Patient agitation and pain followed by an extremely firm globe suggest
suprachoroidal hemorrhage.
• Both complications are more common in the presence of associated
hypertension, arteriosclerotic cardiovascular disease, tachycardia,
obesity, high myopia, glaucoma, advanced age, nanophthalmos,
choroidal hemangioma associated with Sturge-Weber syndrome, or
chronic ocular inflammation.
• Suprachoroidal effusion may be a precursor to suprachoroidal
hemorrhage. Exudation of fluid from choroidal vasculature ultimately
stretches veins or arteries that supply the choroid after coursing
through the sclera.
• Alternatively, suprachoroidal hemorrhage may represent a
spontaneous rupture of choroidal vasculature, particularly in patients
with underlying systemic vascular disease.
Expulsive Suprachoroidal Hemorrhage

• Expulsive suprachoroidal hemorrhage, a rare but serious condition,

generally occurs intraoperatively. The hemorrhage usually presents as
a sudden increase in IOP accompanied by acute onset of pain and the
following :
1. darkening of the red reflex
2. incision gape
3. iris prolapse
4. expulsion of the lens, vitreous, and bright red blood
• The instant this condition is recognized, the surgeon must close the
incision with sutures or digital pressure. Prolapsed vitreous should be
excised and uveal tissue, reposited. After the wound is securely
closed, the surgeon may consider posterior sclerotomies.
• Drainage of suprachoroidal blood may be achieved by performing
sclerotomies in one or more quadrants, 5–7 mm posterior to the
limbus. Elevated IOP serves both to stop bleeding and to expel
suprachoroidal blood.
• It may be necessary to repeat the drainage procedure 7 days or more
after an expulsive hemorrhage in cases of residual suprachoroidal
blood that threatens ocular integrity or vision. These procedures may
lower dangerously elevated IOPs but they carry some risk that
bleeding will recur.
• If the incision can be closed without posterior sclerotomies, more
rapid tamponade of the bleeding vessel can be achieved. Most
surgeons would then terminate the operation and observe for 7–14
days to allow clotting and liquefaction of the hemorrhage, while
managing elevated IOP medically.
• Referral to a vitreoretinal surgeon for management and subsequent
drainage of choroidal hemorrhage should be considered.
Delayed Suprachoroidal Hemorrhage
• Delayed suprachoroidal hemorrhage may occur in the early
postoperative period, presenting with sudden onset of pain, loss of
vision, and shallowing of the anterior chamber.
• Predisposing factors for postoperative choroidal hemorrhage or effusion
include :
1. prolonged hypotony
2. wound leak
3. unrecognized scleral perforation
4. Trauma
5. Uveitis
6. Cyclodialysis
7. excessive filtration.
• This condition is far more common after glaucoma filtering
procedures than routine cataract surgery and may also arise following
laser photocoagulation or cryotherapy.
• If the incision remains intact and the IOP can be controlled medically,
limited suprachoroidal hemorrhage may be observed and frequently
will resolve spontaneously.
• If the incision is not intact, surgical revision may be sufficient to allow
the hemorrhage to resolve.
• Medical management consists of systemic corticosteroids, topical and
oral ocular hypotensive agents for elevated IOP, topical cycloplegia,
and close observation.
• Surgical drainage of the suprachoroidal space is indicated if there is a
flat anterior chamber, medically uncontrolled glaucoma, or persistent
or adherent (kissing) choroidal detachments.
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