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Preoperative evaluation
Preoperative complications
Corneal Abrasion
Visualization of intraocular structures is a key element in successful
intraocular surgery. Preservation of corneal clarity is, therefore, a desirable
goal for surgery. Disruption of the corneal epithelium limits clear visibility.
Care should be taken to ensure corneal clarity during preparations, including
povidone-iodine ( Betadine ) preparations, drape placement, and lid
speculum insertion.
Retrobulbar Hemorrhage
Recent trends in topical anesthesia for cataract surgery notwithstanding,
orbital hemorrhage can be associated with retrobulbar injection and less
commonly with peribulbar injection.
The earliest signs of retrobulbar hemorrhage include a tense, immobile globe
that gives firm resistance to retropulsion, taut eyelids, diffuse
subconjunctival hemorrhage, and, at times, ecchymosis of the lids. Direct or
indirect opthalmoscopy should be performed to assess the status of the
central retinal artery. The goal of treatment of this condition is to maintain
patency of the central retina artery by reducing head against it.
Globe Trauma
Perforation of the globe, although rare, may occur during retrobulbar
anesthesia. Sudden softening of the eye and collapse of the posterior
chamber are he hallmarks of this occurrence. Myopic eyes with a longer
axial length are more susceptible to this injury during peribulbar or
retrobulbar anesthesia. In this instance, the surgery should e stopped, and the
patient should be referred to a vitreoretinal specialist for further evaluation
ad management.
Intraoperative complications
Orbital Adnexa
Inadvertent trauma to the eyelids, superior rectus, and levator occur
infrequently perioperatively or intraoperatively. Injury may include
hemoorhage, neurapraxia, or direct tissue damage. Bridal suture placement
has been implicated as a potential cause of damage to the superior rectus or
to the closely apposed levator complex,which may result in postoperative
ptosis.
Cornea
Descemet membrane detachment
Detachment of Descemet membrane may occur during the insertion of any
instrument into the anterior chamber, especially large instruments, such as
the phacoemulsification or irrigating – aspirating ( I - A ) tips. The
occurrence of descemet membrane detachment is greater with a relatively
shallow anterior chamber, because there is less space between the cornea
and iris.
Endothelial Trauma
Trauma to the corneal endothelium usually occurs from either direct contact
by instrument or from nuclear fragments that are liberated during
phacoemulsification. In both instances, some degree of proection to injury of
the endothelium is afforded by the use of viscoelastic materials th coat or
bind to the endothelium, and create space in the anterior segment. Trauma
secondary to nuclear fragments creaed during phacoemulsification is also
less likely with the capsulorhexis and in situ phacoemulsification techniques.
Iris
During the preoperative evaluation, the surgeon determines the suitability of
the patient for phacoemulsification or extracapsular cataract extraction
( ECCE ), considering the nature of nuclear hardness, related ocular
conditions, and the relative ease and completeness of pupil dilatation.
Various techniques to widen the pupil are available to facilitate
phacoemulsification. These include radial sphincterotomy, multiple
sphincterotomies, sector iridectomy, or the use of devices to widen the
papillary aperture, such as iris retractors.
Lens
Extension of anterior capsulotomy radial tear
The conventional can-opener anterior capsulotomy consists of multiple
small radial tears. During other portions of the extracapsular procedure,
nucleus removal, and irrigation and aspiration, these small tears can extend
to the lens equator and, at times, even extend to the posterior capsule.
Similar events can also occur with the so-called envelope technique. Other
factors contributing to the development of radial tears include insufficient
corneoscleral wound length and an anterior capsulotomy opening that is too
small, each of which may cause greater resistance to nucleus expression
during ECCE; significant posterior pressure; and high pressure of the I-A
bottle.
CAPSULORHEXIS. Capsulorhexis is a method of creating a smooth-
edged, continuous tear capsulotomy that obviates many of the problems
arising with the can-opener type of anterior capsulotomy.
Loss of nucleus into the vitreous cavity. Loss of the lens nucleus into the
vitreous is relatively rare but requires prompt attention. Management
depends on the surgeon’s experience with vitreoretinal techniques. For
surgeons who do not usually perform vitreoretinal surgery, we recommend
thoroughly clearing the anterior segment of residual nuclear and cortical
material, as well as vitreous while maintaining as much of the anterior and
posterior capsules as possible. A posterior chamber IOL can be implanted at
this time. The wound is closed appropriately and the patient referred to a
vitreoretinal surgeon for pars plana nucleus removal. In those instances in
which the surgeon is adept with vitreoretinal surgery, the nucleus can be
removed by means of a pars plana or combined approach at the time of the
primary surgery.
Posterior capsule tears during cortical cleanup. When a posterior capsule tear
occurs during cortical cleanup, the surgeon should weigh the potential risks
in pursuing residual cortex and causing additional trauma to the posterior
capsule and zonules. In most cases, leaving cortex behind is well tolerated,
and it often resorbs over time.
Zonular Dialysis
Preoperative evaluation may reveal several clues that zonular integrity is
compremised, most important of which are phacodonesis and iridodonesis.
Weakened or absent zonules cause lens and iris tremulousness with eye
movements. Visible vitreous strands in the anterior chamber also indicate
imperefect zonular in tegrity in anterior chamber. Less subtle signs are the
edge of the lens visible within the pupi, indicative of a greater degree of
zonular dialysis sufficient to cause lens subluxation. Unequal chamber
depths are also indicative of lens luxation.
Vitreous Loss
Retina
Endophthalmitis
Because endophthalmitis is covered in a separate chapter in this book, we
discuss only those points regarding endophthalmitis that are pertinent to
cataract surgery.
The onset of symptoms of endophthalmitis after cataract surgery is usually
sudden, with pain and decreased visual acuity within 1 to 4 days
postoperatively. The initial symptoms may be difficult to differentiate from
routine postoperative iritis and intraocular inflammation, as both produce
conjunctival and episcleral injection, in addition to cells and flare in the
anterior chamber.
Cornea
Wound leak
Postoperative wound leaks occur less commonly today as a result of
improved surgical techniques, instrumentation, and suture materials.
However, problems in either the creation or the closure of the wound may
increase the possibility of a wound leak.
Corneal edema
Corneal stromal edema is most commonly a transient postoperative
phenomenon secondary to compromised endothelial function after
intraocular surgery. If, however, corneal edema persists postoperatively, this
may reflect irreversible endothelial damage.
Epithelial downgrowth
Epithelial downgrowth is a serious but rare complication after cataract
surgery, with a reported incidence of less than 0,1% by Weiner and
associates in a 30year clinicopathologic review. Given the vastly improved
surgical technique and suture materials that have been incorporated within
the last decade or so, the incidence of this grave complication is probably
even lower than this reported value.
Fibrous ingrowth
Fibrous ingrowth is another rare complication related to poor wound closure.
The source of the fibroblasts that cause fibrous ingrowth is controversial,
with likely sources including subepithelial connective tissue, corneal or
limbal stroma, and metaplastic endothelium. The clinical appearance of
fibrous in growth may be similar to epithelial downgrowth , with a
retrocorneal membrane that has advanced over the angle structures, iris,
pupil, and ciliary body. One clinical distinction is the presence of an
advancing irregular border of fibrous tissue in fibrous ingrowth, as opposed
to the generally well-defined border of heaped-up epithelial cells that are
seen epithelial downgrowth.
Hypotony
The most common causes of postoperative hypotony are wound leak and
ciliochoroidal detachment, although these two entities are often found
together. Jaffe and coworkers summarized the clinical situations encountered
in hypotony as follows : (1) wound leak and a normal anterior chamber
depth – no ciliary body detachment; (2) wound leak and shallow anterior
chamber depth – probable ciliary body detachment; and (3) no wound leak
and shallow anterior chamber depth – probable ciliary body detachment.
Hyphema
IOL Dislocation
Posterior chamber IOL may become malpositioned in four basic ways: pupil
capture, decentration, windshield- wiper syndrome, and sunset syndrome.
Vitreous Hemorrhage
Retinal detachment
Approximemately 1% to 3% of patient undergoing cataract extraction
subsequently develop rhegmatogenous retinal detachment. This compares
with an overall incidence of 0,005% to 0,01% in the general population, so
that the relative risk among patients undergoing cataract extraction is 100 to
200 times the general risk.