Complications of Cataract Surgery

Intraoperative Complications - Surgery Slip-ups

• Wound Issues:
  • Poor construction (leak, astigmatism), thermal burn.
  • Descemet's Membrane Detachment (DMD): Instrument trauma.
  • Iris Prolapse: Poor wound apposition, ↑IOP.
• Capsular Events:
  • Posterior Capsular Rupture (PCR): High risk: vitreous loss, dropped nucleus/IOL.
  • Zonular Dialysis: Weak zonules (pseudoexfoliation); IOL instability.
  • Argentinian Flag Sign: Anterior capsular tear extension (intumescent cataracts).
• Nucleus/Cortex Problems:
  • Dropped Nucleus/Fragments: May need PPV (pars plana vitrectomy).
  • Retained Cortex: Post-op inflammation (uveitis).
• IOL Related:
  • IOL Decentration/Tilt: Poor sizing, asymmetric fixation.
  • IOL Damage (optic scratch, haptic bend): During insertion.
  • Incorrect IOL power.
• Hemorrhage:
  • Suprachoroidal Hemorrhage (Expulsive): Acute massive bleed; rock-hard eye, loss of red reflex, pain.

    ⭐ Expulsive suprachoroidal hemorrhage: most dreaded intraoperative complication, high risk of severe, permanent vision loss.

  • Hyphema: Iris/ciliary body vessel bleed.
• Miscellaneous:
  • Corneal Endothelial Damage: Excessive phaco energy/time, instrument touch.
  • Vitreous Loss: From PCR/zonular dialysis; meticulous anterior vitrectomy vital.

Early Postoperative Complications - Quick Comebacks

• Corneal Edema:
  • Causes: Surgical trauma, ↑IOP, pre-existing endothelial dystrophy.
  • Rx: Hypertonic saline, topical steroids, IOP control. Often self-limiting.
• Wound Leak:
  • Signs: Shallow Anterior Chamber (AC), ↓IOP, positive Seidel's test.
  • Rx: Bandage contact lens (BCL), aqueous suppressants, resuturing if severe.
• Shallow/Flat AC:
  • Causes: Wound leak, pupillary block, ciliochoroidal detachment, suprachoroidal hemorrhage.
  • Rx: Address cause; cycloplegics, steroids, surgical intervention.
• Elevated Intraocular Pressure (IOP):
  • Causes: Retained viscoelastic, inflammation (trabeculitis), steroid response, pupillary block.
  • Rx: Anti-glaucoma medications (topical/systemic), AC paracentesis.
• Hyphema:
  • Rx: Rest, head elevation (30-45°), cycloplegics, topical steroids, IOP control. Avoid NSAIDs.
• Toxic Anterior Segment Syndrome (TASS):
  • Sterile, non-infectious inflammation, typically 12-48 hours post-op. Diffuse limbus-to-limbus corneal edema, significant AC reaction.
  • Rx: Intensive topical corticosteroids.

  ⭐ TASS is a sterile inflammatory reaction to intraocular substances, presenting 12-48 hours post-surgery with diffuse corneal edema and anterior chamber inflammation. Crucially differentiated from infectious endophthalmitis.

• Early Endophthalmitis:
  • Signs: Severe pain, ↓vision, hypopyon, marked AC reaction, vitritis. Usually 2-7 days post-op.
  • Rx: URGENT. Intravitreal antibiotics ± diagnostic/therapeutic vitrectomy.
• Retained Lens Matter (RLM):
  • Signs: Persistent uveitis, ↑IOP, corneal edema, cystoid macular edema.
  • Rx: Medical (topical steroids, NSAIDs, IOP control); surgical removal if significant/refractory inflammation.

Late Postoperative Complications - Long-Term Loops

• Posterior Capsular Opacification (PCO)
  • Most common; proliferation of lens epithelial cells (LECs) → Elschnig pearls, Soemmering ring.
  • Symptoms: ↓ Vision, glare.
  • Tx: Nd:YAG laser capsulotomy.
• Cystoid Macular Edema (CME) - Late/Chronic Irvine-Gass Syndrome
  • Persistent or recurrent months post-op.
  • Risks: Diabetes, uveitis, complicated surgery.
  • Tx: Topical NSAIDs/steroids; intravitreal anti-VEGF/steroids if refractory.
• Intraocular Lens (IOL) Issues
  • Decentration/Dislocation: Zonular weakness, capsular phimosis, trauma.
  • IOL Opacification: Glistenings (common, usually benign), calcification (rare, visually significant).
  • Uveitis-Glaucoma-Hyphema (UGH) Syndrome: IOL chafing iris/ciliary body.
• Secondary Glaucoma
  • Steroid-induced, pupillary block (adhesions, IOL malposition), UGH Syndrome.
• Chronic Postoperative Endophthalmitis
  • Low-grade infection (e.g., P. acnes, fungi).
  • Symptoms: Mild, persistent uveitis, white plaque on IOL/capsule.
  • Tx: Intravitreal antibiotics, possible IOL explantation.
• Retinal Detachment (Pseudophakic RD)
  • Incidence: 0.5-2%. Higher risk in myopia, intraoperative posterior capsular rent.
  • Symptoms: Floaters, flashes, field defect.
• Pseudophakic Bullous Keratopathy (PBK)
  • Corneal endothelial decompensation → chronic corneal edema.
  • Risks: Pre-existing endothelial dystrophy (e.g., Fuchs'), surgical trauma.
  • Tx: Corneal transplant (DSEK/DMEK/PKP).

⭐ PCO is the most frequent late complication following cataract surgery, often managed effectively with Nd:YAG laser capsulotomy.

High‑Yield Points - ⚡ Biggest Takeaways

• Posterior Capsular Opacification (PCO): Most common late complication; treat with Nd:YAG laser.
• Acute Endophthalmitis: Most feared early complication (2-7 days); Staph. epidermidis common.
• Cystoid Macular Edema (CME) / Irvine-Gass: Painless vision loss, peaks 4-12 weeks post-op.
• Retinal Detachment: Risk ↑, especially with high myopia or posterior capsule rupture.
• Toxic Anterior Segment Syndrome (TASS): Sterile inflammation (12-48 hours); differentiate from endophthalmitis.
• IOL malposition/dislocation: Can cause significant visual symptoms, may need repositioning.