Complications of Cataract Surgery — MCQs
In which of the following conditions does IOL implantation after cataract surgery require the greatest caution and specialized management?
Floppy iris syndrome is associated with usage of
A 65-year-old male presents with blurred vision and a history of cataract surgery. Upon examination, fluffy white deposits are noted on the anterior lens capsule. What is the most likely diagnosis?
Which of the following is a complication of prolonged use of corticosteroid eye drops?
A crucial step in the phacoemulsification procedure for a 70-year-old man scheduled for cataract surgery is which of the following?
Which triad is seen after an acute attack of angle-closure glaucoma?
A 25 -year-old lady with past history of seeing colored haloes was watching a movie in a theater when she started having right eye pain. She started feeling nauseous and had to leave the movie midway due to vomiting. On examination she is found to have ciliary and conjunctival congestion and the pupil is vertically oval. The picture of the eye is given below. All are true about the condition shown except:
Which of the following is a contraindication to topical steroids?
In a patient with acute anterior uveitis presenting with raised intraocular pressure, the PRIMARY treatment should be:
A 56 year old patient presents after 3 days of cataract surgery with a history of increasing pain and diminution of vision after an initial improvement. The most likely cause would be:
Complications of Cataract Surgery Indian Medical PG Practice Questions and MCQs
Question 1: In which of the following conditions does IOL implantation after cataract surgery require the greatest caution and specialized management?
- A. Fuchs' heterochromic iridocyclitis
- B. Psoriatic arthritis
- C. Reiter's syndrome
- D. Juvenile rheumatoid arthritis (Correct Answer)
Explanation: ***Juvenile rheumatoid arthritis*** - Patients with **juvenile rheumatoid arthritis (JRA)**, particularly those with **pauciarticular JRA** and **ANA positivity**, are at high risk for developing chronic uveitis, which can lead to significant cataract formation and severe postoperative complications. - Due to the high risk of severe postoperative inflammation, glaucoma, and vision loss, IOL implantation in JRA patients requires extensive preoperative optimization of inflammation and careful intraoperative/postoperative management. *Fuchs' heterochromic iridocyclitis* - This condition presents with chronic, low-grade, **non-granulomatous anterior uveitis** and often leads to cataract formation. - While IOL implantation in these patients is generally well-tolerated, it does not pose the same high risk of severe postoperative inflammation and complications as seen in JRA-associated uveitis. *Psoriatic arthritis* - Psoriatic arthritis can be associated with acute anterior uveitis, but it typically presents as an acute, intermittent inflammation. - The risk of chronic, severe uveitis leading to complex cataract surgery and significant postoperative complications is not as consistently high or as severe as in JRA. *Reiter's syndrome* - Reiter's syndrome (now part of **reactive arthritis**) is another seronegative spondyloarthropathy that can cause acute anterior uveitis. - Similar to psoriatic arthritis, the uveitis is usually acute and self-limiting, and while ocular inflammation needs to be controlled, the risk profile for IOL implantation is not as challenging as in JRA.
Question 2: Floppy iris syndrome is associated with usage of
- A. 5 alpha reductase inhibitor
- B. PDE-5 inhibitor
- C. Anticholinergics
- D. Selective alpha-adrenergic antagonist (Correct Answer)
Explanation: ***Selective alpha-adrenergic antagonist*** - **Intraoperative Floppy Iris Syndrome (IFIS)** is classically associated with the use of **alpha-1 adrenergic antagonists**, particularly **tamsulosin**. - These drugs cause **flaccidity of the iris** and **prolapse through the incision** during **cataract surgery** by blocking **alpha-1 receptors** in the iris dilator muscle. *5 alpha reductase inhibitor* - These drugs, such as **finasteride** and **dutasteride**, inhibit the conversion of **testosterone to dihydrotestosterone (DHT)**. - They are used to treat **benign prostatic hyperplasia (BPH)** and **androgenetic alopecia** and have no known association with IFIS. *PDE-5 inhibitor* - **Phosphodiesterase-5 (PDE5) inhibitors** like **sildenafil** and **tadalafil** are used to treat **erectile dysfunction**. - While they can cause visual disturbances due to effects on retinal PDE6, they are **not associated with IFIS**. *Anticholinergics* - **Anticholinergic drugs** block the action of **acetylcholine** and are used for various conditions, including **overactive bladder** and **irritable bowel syndrome**. - They tend to cause **mydriasis (pupil dilation)**, but they do **not cause iris floppiness** or IFIS.
Question 3: A 65-year-old male presents with blurred vision and a history of cataract surgery. Upon examination, fluffy white deposits are noted on the anterior lens capsule. What is the most likely diagnosis?
- A. Intraocular foreign body
- B. Pseudoexfoliation syndrome (Correct Answer)
- C. Ocular trauma
- D. Vossius ring
Explanation: ***Pseudoexfoliation syndrome*** - The description of **fluffy white deposits on the anterior lens capsule** in an older patient with blurred vision and a history of cataract surgery is highly characteristic of **pseudoexfoliation syndrome**. - This condition is caused by the abnormal production and accumulation of an **extracellular fibrillar material**, which can also affect the iris, ciliary body, and trabecular meshwork, potentially leading to **glaucoma** and lens subluxation. *Intraocular foreign body* - An intraocular foreign body would typically present with a history of **trauma** and might be visible as a distinct object, rather than diffuse fluffy deposits. - While it can cause inflammation and vision changes, its appearance is not consistent with the described findings. *Ocular trauma* - Ocular trauma would typically have an associated history of injury and could present with various signs like hyphema, iritis, or retinal detachment, but not specifically this type of **fluffy white deposit** on the lens. - While it can lead to vision issues, the specific clinical findings do not point towards acute or chronic sequelae of trauma as the primary diagnosis. *Vossius ring* - A **Vossius ring** is a deposition of iris pigment on the anterior lens capsule, forming a circular ring corresponding to the pupil margin at the time of blunt trauma. - It would appear as a **pigmented ring**, not fluffy white deposits, and is directly linked to a history of blunt trauma.
Question 4: Which of the following is a complication of prolonged use of corticosteroid eye drops?
- A. Posterior Subcapsular cataract (Correct Answer)
- B. Nuclear cataract
- C. Capsular cataract
- D. Cortical cataract
Explanation: ***Posterior Subcapsular cataract*** - Prolonged use of **corticosteroids**, both topical and systemic, is a well-established risk factor for developing **posterior subcapsular cataracts**. - This type of cataract forms at the **back surface of the lens** and often causes significant glare and reduced vision, especially in bright light. *Nuclear cataract* - **Nuclear cataracts** are primarily associated with the natural **aging process** and develop in the central nucleus of the lens. - While they cause a gradual yellowing and hardening of the lens, they are **not typically linked** to corticosteroid use. *Capsular cataract* - This is a broad term that could refer to changes in the lens capsule itself, but it is **not a specific, recognized type of cataract** directly caused by corticosteroids in the same way posterior subcapsular cataracts are. - Corticosteroids affect the **lens fibers themselves**, leading to opacities rather than just the capsule. *Cortical cataract* - **Cortical cataracts** appear as wedge-shaped opacities that begin in the periphery of the lens and extend inwards. - They are commonly associated with **aging, diabetes, and ultraviolet light exposure**, but not primarily with corticosteroid use.
Question 5: A crucial step in the phacoemulsification procedure for a 70-year-old man scheduled for cataract surgery is which of the following?
- A. Scleral buckling
- B. Corneal transplantation
- C. Continuous curvilinear capsulorrhexis (Correct Answer)
- D. Trabeculectomy
Explanation: ***Continuous curvilinear capsulorrhexis*** - This step creates a smooth, continuous, and appropriately sized opening in the **anterior lens capsule**, which is crucial for the safe and effective removal of the cataractous lens material. - A well-executed capsulorrhexis ensures the **intraocular lens (IOL)** can be stably implanted within the capsular bag, minimizing complications like IOL decentering. *Scleral buckling* - **Scleral buckling** is a surgical procedure primarily used to repair **retinal detachments**, not for cataract removal. - It involves placing a silicone band on the outer surface of the sclera to indent the eye wall, supporting the retina. *Corneal transplantation* - **Corneal transplantation** (keratoplasty) is performed to replace a diseased or damaged cornea, typically for conditions like **keratoconus** or corneal scarring. - It is not a component of routine cataract surgery. *Trabeculectomy* - **Trabeculectomy** is a surgical procedure to treat **glaucoma** by creating a new drainage pathway for aqueous humor, thereby reducing intraocular pressure. - It is unrelated to the process of cataract extraction.
Question 6: Which triad is seen after an acute attack of angle-closure glaucoma?
- A. Gaucher triad
- B. Virchow triad
- C. Vogt's triad (Correct Answer)
- D. Hutchinson's triad
Explanation: ***Vogt's triad*** - **Vogt's triad** refers to the classical findings seen after an acute attack of **angle-closure glaucoma**. - The triad consists of: **glaukomflecken** (anterior subcapsular lens opacities from ischemic necrosis of lens epithelium), **iris stromal atrophy** (sectoral iris atrophy in the area of ischemia), and **fixed mid-dilated pupil** (due to iris sphincter damage). - These signs indicate **ischemic damage** to the anterior segment following the acute episode of elevated intraocular pressure. *Gaucher triad* - **Gaucher triad** refers to the characteristic systemic symptoms of **Gaucher disease**, an inherited lipid storage disorder. - It involves **hepatosplenomegaly**, **bone pain**, and **thrombocytopenia**, which are unrelated to glaucoma. *Virchow triad* - The **Virchow triad** describes the three main factors contributing to **thrombus formation**: **stasis** of blood flow, **endothelial injury**, and **hypercoagulability**. - This triad is relevant to cardiovascular pathology, not the effects of angle-closure glaucoma. *Hutchinson's triad* - **Hutchinson's triad** is a set of symptoms associated with **congenital syphilis**. - It includes **interstitial keratitis**, **Hutchinson's teeth**, and **eighth nerve deafness**, which are entirely distinct from ocular hypertension.
Question 7: A 25 -year-old lady with past history of seeing colored haloes was watching a movie in a theater when she started having right eye pain. She started feeling nauseous and had to leave the movie midway due to vomiting. On examination she is found to have ciliary and conjunctival congestion and the pupil is vertically oval. The picture of the eye is given below. All are true about the condition shown except:
- A. Loss of iris pattern
- B. Steamy insensitive cornea
- C. Absent reaction to light and accommodation
- D. Present PL (Correct Answer)
Explanation: ***Present PL (Perception of Light)*** - In **acute angle-closure glaucoma (AACG)**, visual acuity is typically severely reduced due to corneal edema and elevated intraocular pressure, but **perception of light (PL) is usually preserved** in acute presentations. - While vision may be reduced to counting fingers or hand movements, **complete loss of light perception is uncommon** unless there is severe, prolonged attack with irreversible optic nerve damage. - All other features listed (loss of iris pattern, steamy cornea, absent pupillary reactions) are **consistently present** in AACG, whereas PL can be variable but is typically **present initially**. - This makes "Present PL" the **correct answer** as it is the statement that is **NOT always/universally true** - though PL is often present, the question implies it as a definitive feature when it's actually variable. *Loss of iris pattern* - This is a **consistent finding** in AACG during an acute attack. - The iris becomes **edematous** due to elevated intraocular pressure (often >40 mmHg), which obscures the normal radial folds and crypts. - The iris appears dull, muddy, and featureless - a key diagnostic sign. *Steamy insensitive cornea* - The markedly elevated intraocular pressure causes **corneal epithelial and stromal edema**. - This produces a **hazy or "steamy" appearance** that interferes with visualization of anterior chamber structures. - Corneal sensation may be reduced due to epithelial edema and ischemia. *Absent reaction to light and accommodation* - The pupil in AACG is characteristically **fixed and mid-dilated (4-6 mm)**, often vertically oval as described. - **Complete absence of pupillary light reflex** (both direct and consensual) occurs due to iris sphincter ischemia. - **No accommodation response** due to the fixed, dilated pupil and compromised iris function.
Question 8: Which of the following is a contraindication to topical steroids?
- A. Dendritic ulcer (Correct Answer)
- B. Herpetic stromal keratitis without epithelial defect
- C. Elevated intraocular pressure
- D. Non-infectious anterior uveitis
Explanation: ***Dendritic ulcer*** - A **dendritic ulcer** is characteristic of **herpes simplex keratitis**, which is an active viral infection of the cornea. - **Topical steroids** are contraindicated because they can suppress the immune response, leading to viral replication, corneal melt, and potentially severe vision loss or perforation. *Herpetic stromal keratitis without epithelial defect* - In cases of **stromal keratitis**, where the infection is deeper and an intact epithelium is present, topical steroids may be used cautiously in conjunction with antiviral agents to reduce inflammation and scarring. - The primary concern with steroids in herpes simplex keratitis is activating viral replication in the presence of an **epithelial defect**, which is not present here. *Elevated intraocular pressure* - **Elevated intraocular pressure** is a known side effect of topical steroid use, especially with prolonged administration, but it is not an absolute contraindication in itself. - It necessitates careful monitoring and may require concurrent glaucoma treatment, but the primary condition needing steroids may still warrant their use. *Non-infectious anterior uveitis* - **Topical corticosteroids** are the **mainstay of treatment** for non-infectious anterior uveitis to reduce inflammation and prevent complications such as synechiae and vision loss. - The benefits of controlling inflammation in uveitis generally outweigh the risks associated with judicious steroid use.
Question 9: In a patient with acute anterior uveitis presenting with raised intraocular pressure, the PRIMARY treatment should be:
- A. Topical steroids (Correct Answer)
- B. Topical beta-blockers
- C. Cycloplegics
- D. Miotics
Explanation: ***Topical steroids*** - **Topical corticosteroids** are the primary treatment for **anterior uveitis** to reduce inflammation, which is the underlying cause of both the uveitis and often the raised IOP. - While IOP is elevated, managing the inflammation with steroids is crucial, as the inflammation itself can lead to secondary **IOP elevation** due to trabecular meshwork dysfunction or synechiae formation. *Topical beta-blockers* - **Topical beta-blockers** are used to lower intraocular pressure, but they do not address the underlying **inflammation** in acute anterior uveitis. - Using them alone without treating the inflammation can lead to progression of the uveitis and further ocular damage. *Cycloplegics* - **Cycloplegics** (e.g., atropine, cyclopentolate) are important adjuncts in acute anterior uveitis to relieve pain from ciliary spasm and prevent posterior synechiae formation by dilating the pupil. - They do not, however, treat the **inflammation** directly or primarily address the elevated intraocular pressure. *Miotics* - **Miotics** (e.g., pilocarpine) **constrict the pupil**, which can worsen symptoms in acute anterior uveitis by increasing ciliary body spasm and potentially increasing the risk of posterior synechiae formation. - They are contraindicated in acute anterior uveitis as they exacerbate pain and inflammation, and do not treat the underlying cause.
Question 10: A 56 year old patient presents after 3 days of cataract surgery with a history of increasing pain and diminution of vision after an initial improvement. The most likely cause would be:
- A. Endophthalmitis (Correct Answer)
- B. Central retinal vein occlusion
- C. Posterior capsular opacification (PCO)
- D. Retinal detachment
Explanation: ***Endophthalmitis*** - **Endophthalmitis** is a severe inflammation of the intraocular fluids (vitreous and aqueous humor), most commonly caused by infection following cataract surgery. - The presentation of **increasing pain** and **diminution of vision** a few days after initial improvement is a classic sign of acute post-operative endophthalmitis. *Central retinal vein occlusion* - **Central retinal vein occlusion (CRVO)** typically causes sudden, painless vision loss. - It is not commonly associated with **increasing pain** or a temporal relationship to recent cataract surgery in this manner. *Posterior capsular opacification (PCO)* - **Posterior capsular opacification (PCO)** develops weeks or months after cataract surgery, not within a few days. - It presents as gradual, painless blurring of vision without significant pain. *Retinal detachment* - **Retinal detachment** typically presents with sudden vision loss, flashes of light (photopsia), and floaters. - While it can occur after cataract surgery, it is less likely to present with **increasing pain** as the primary symptom described.
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