Management of Surgical Complications

Intraoperative Complications - Oops Moments!

• Posterior Capsular Rupture (PCR):

  • Signs: Sudden anterior chamber (AC) deepening, pupil snap/ovalization, vitreous in AC/wound, nucleus/fragment drop.
  • Management: Recognize! Stop phaco. Anterior vitrectomy (low flow, high cut rate). IOL: sulcus (if support), ACIOL, iris-claw, or scleral-fixated.

• Expulsive Suprachoroidal Hemorrhage (ESH):

  • Signs: Sudden ↑IOP, shallow/flat AC, iris prolapse, firm globe, dark choroidal mound, loss of red reflex.
  • Management: Close wound STAT! Posterior sclerotomies (2, inferotemporal & inferonasal). IV Mannitol 20%. Systemic steroids.
  • ⚠️ Risks: Elderly, glaucoma, atherosclerosis, high myopia, aphakia, vitrectomized eye.

⭐ In PCR with vitreous loss, meticulous anterior vitrectomy is key to prevent postoperative cystoid macular edema (CME) and retinal detachment (RD).

Early Postoperative Complications - Early Alarms

• Endophthalmitis: Acute onset (typically 2-7 days). Severe pain, ↓vision, hypopyon, vitritis. Rx: Intravitreal antibiotics (e.g., Vancomycin + Ceftazidime), +/- Pars Plana Vitrectomy (PPV).
• Toxic Anterior Segment Syndrome (TASS): Onset 12-48 hours. Sterile inflammation. ↓Vision, diffuse "limbus-to-limbus" corneal edema, anterior chamber reaction, NO vitritis. Rx: Intensive topical steroids.
• Wound Leak: Shallow anterior chamber, positive Seidel test, hypotony. Rx: Pressure patch, bandage contact lens (BCL), resuturing.
• Elevated Intraocular Pressure (↑IOP): Causes: Retained viscoelastic, inflammation, pupillary block. Rx: Topical anti-glaucoma medications, AC paracentesis if very high.
• Corneal Edema: Causes: Surgical trauma, TASS, ↑IOP. Rx: Topical hypertonic saline, steroids (if inflammatory).

⭐ TASS typically presents 12-48 hours post-surgery with diffuse "limbus-to-limbus" corneal edema and is a sterile, non-infectious inflammation (NO vitritis), distinguishing it from endophthalmitis.

Late Postoperative Complications - Delayed Dramas

• Posterior Capsular Opacification (PCO): Most common. Lens epithelial cell (LEC) proliferation (Elschnig pearls).
  • Sx: ↓ Vision, glare.
  • Rx: Nd:YAG laser capsulotomy.
• Cystoid Macular Edema (CME) / Irvine-Gass Syndrome: Weeks-months post-op. Inflammatory perifoveal capillary leakage.
  • OCT: Petalloid pattern, foveal thickening.
  • Rx: Topical NSAIDs, steroids.
• Suture Issues: Loose/broken sutures → irritation, astigmatism, infection. Rx: Removal.
• Late-onset Endophthalmitis: Months-years. Low-virulence organisms (e.g., P. acnes). Chronic uveitis.
• Corneal Decompensation (Pseudophakic Bullous Keratopathy - PBK): Endothelial cell loss. Corneal edema.
• Secondary Glaucoma: Steroid-induced, pupillary block.

⭐ PCO, or "after-cataract", is the leading cause for Nd:YAG laser capsulotomy following cataract surgery.

IOL-Related Complications - Lens Lamentations

• IOL Malposition: Decentration, tilt, subluxation, dislocation (anterior/posterior chamber, vitreous).
• IOL Opacification: Glistenings (microvacuoles), subsurface nanoglistenings, calcification, snowflake degeneration.
• Corneal Decompensation: Pseudophakic Bullous Keratopathy (PBK) from endothelial cell loss.
• UGH Syndrome: Uveitis, Glaucoma, Hyphema; due to IOL chafing iris/ciliary body.
• Cystoid Macular Edema (CME): Irvine-Gass Syndrome, peak 4-6 weeks post-op.
• Refractive Surprise: Error in biometry, formula, or IOL placement.
• Posterior Capsular Opacification (PCO): Most common; Elschnig pearls, Soemmering ring.

  ⭐ PCO, the most common late complication after cataract surgery, is treated with Nd:YAG laser capsulotomy, often 3-6 months+ post-op.

High‑Yield Points - ⚡ Biggest Takeaways

• Post-operative endophthalmitis: Requires immediate intravitreal antibiotics (e.g., vancomycin + ceftazidime); vitrectomy if vision is PL or worse.
• TASS (Toxic Anterior Segment Syndrome): Sterile inflammation within 12-48 hours post-op, responds well to intensive topical steroids.
• Suprachoroidal hemorrhage: Characterized by sudden severe pain, ↑IOP, and loss of red reflex; manage with immediate wound closure.
• Shallow anterior chamber (post-trabeculectomy): Key causes include wound leak, pupillary block, or malignant glaucoma.
• Cystoid Macular Edema (CME) (Irvine-Gass syndrome): Primary treatment involves topical NSAIDs and steroids.
• Dropped nucleus/IOL: Management involves pars plana vitrectomy and fragment/IOL removal by a vitreoretinal surgeon.
• Expulsive choroidal hemorrhage: An acute, severe complication requiring prompt surgical closure of the globe.