Complications of Cataract Surgery

Cataract surgery has a very high success rate (over 95 percent), but complications occur and the outcome depends on early recognition.

• Intraoperative: posterior capsule rupture and vitreous loss (about 1 to 3 percent), anterior capsule tear (radial extension), zonular dialysis, nucleus or lens fragment drop, iris trauma and intraoperative floppy iris syndrome (alpha blockers such as tamsulosin), corneal burn (wound thermal injury), Descemet membrane detachment, suprachoroidal haemorrhage (about 0.03 percent), retrobulbar haemorrhage (anaesthesia), and wrong intraocular lens.
• Early postoperative (first weeks): corneal oedema, raised intraocular pressure, wound leak and shallow chamber, iris prolapse, hyphaema, toxic anterior segment syndrome, endophthalmitis, intraocular lens malposition, anterior uveitis.
• Late: cystoid macular oedema, posterior capsule opacification, retinal detachment, bullous keratopathy, intraocular lens dislocation, glaucoma, chronic inflammation, and dysphotopsia.

• Posterior capsule rupture: sudden deepening of the chamber, loss of fundus red reflex, nucleus tilting, vitreous prolapse.
• Suprachoroidal haemorrhage: sudden pain, shallow chamber, firm eye, loss of red reflex, expulsion of contents.
• Toxic anterior segment syndrome: severe sterile inflammation within 12 to 48 hours with diffuse corneal oedema, fibrin and hypopyon, with limbus-to-limbus oedema, but pain is milder and vitreous is clear (distinguished from infection).
• Early wound leak: low pressure, positive Seidel test, shallow chamber.
• Cystoid macular oedema: reduced vision at 4 to 12 weeks, with central thickening.
• Retinal detachment: flashes, floaters, field loss.

• Slit lamp (wound integrity with fluorescein and Seidel, anterior chamber depth, cells and flare, intraocular lens position, vitreous in chamber, corneal clarity).
• Intraocular pressure; B-scan ultrasound if the view is poor (retained fragments, choroidal haemorrhage, retinal detachment).
• Macular optical coherence tomography.
• Aqueous and vitreous tap for cultures and polymerase chain reaction when infection is suspected.

• Posterior capsule rupture and vitreous loss: stop phaco, avoid enlarging the tear, fill with dispersive viscoelastic, remove prolapsed vitreous with a vitrector using low flow and cut first technique; triamcinolone 4 mg/0.1 mL staining of vitreous; removal of retained cortex and nucleus; place a three piece lens in the sulcus, optic capture, or defer the lens; ensure wound closure with 10-0 nylon and no vitreous at the wound.
• Dropped nucleus: avoid chasing it; perform anterior vitrectomy, place a sulcus lens if possible, and refer for pars plana vitrectomy within 1 to 2 weeks.
• Suprachoroidal haemorrhage: close the wound immediately, give intravenous mannitol 20 percent, topical and oral steroids, aqueous suppressants, and drainage via sclerotomy at 7 to 14 days when clot liquefies.
• Raised pressure: acetazolamide 250 to 500 mg, timolol 0.5 percent, brimonidine 0.2 percent, dorzolamide 2 percent, and release of viscoelastic through paracentesis when retained.
• Wound leak: bandage contact lens, aqueous suppressants, or suturing the wound with 10-0 nylon.
• Corneal oedema: hypertonic saline 5 percent four times daily and topical steroid; persistent oedema needs endothelial keratoplasty.
• Toxic anterior segment syndrome: intensive topical prednisolone acetate 1 percent every hour, with later tapering, and review of sterilisation of instruments and irrigating solutions.
• Endophthalmitis: same day vitreous and aqueous tap, then intravitreal vancomycin 1 mg in 0.1 mL plus ceftazidime 2.25 mg in 0.1 mL, with vitrectomy if vision is light perception only or worse.
• Cystoid macular oedema: nepafenac 0.1 percent three times daily plus prednisolone acetate 1 percent four times daily for 6 to 12 weeks, then sub-Tenon triamcinolone 40 mg if it persists.
• Posterior capsule opacification: Nd:YAG laser capsulotomy at least 3 months after surgery, with apraclonidine 1 percent before and after the laser.
• Retinal detachment: urgent vitrectomy or scleral buckle.
• Prevention: preoperative povidone iodine 5 percent, intracameral cefuroxime 1 mg in 0.1 mL, careful risk assessment (small pupil, pseudoexfoliation, dense nucleus, tamsulosin), and appropriately experienced surgeon.