Complications
Fluctuations in eye pressure or trauma to the intra-ocular structures during surgery can cause bleeding.
In some cases, surgery needs to be aborted.
An expulsive choroidal haemorrhage is the most dire intraoperative complication in cataract surgery. This condition results from rupture or fracture of a choroidal artery and leads to massive bleeding into the supra-choroidal space. The increased pressure in the supra-choroidal space lifts the retina, and, as the blood continues to be pumped into the supra-choroidal space, can result in the vitreous and retina being expelled from the eye through the cataract incision, leading to blindness.
The most common adverse effect of cataract surgery.[116] Corneal oedema can occur due to endothelial damage during surgery.
Patients and surgical factors may contribute. For example, depending on the density of the cataract, significant ultrasonic power may be necessary to fracture the nucleus, causing collateral damage to the corneal endothelial cells and resulting in postoperative oedema.
Unless there are pre-existing problems with the corneal endothelium, such as Fuchs dystrophy, most oedema resolves with time.
Retained viscoelastic gel (used to maintain spaces during cataract surgery) following cataract surgery can obstruct the trabecular meshwork with concomitant elevation of intra-ocular pressure.[117]
These materials are cleared from the anterior chamber in about 24 hours, and pressure elevations resulting from these materials will generally resolve without sequelae.
The use of topical glaucoma medications or the release of a small amount of aqueous fluid from one of the surgical incisions (done in the clinic) can help control the pressure in the short term.
If cataracts are not removed and are allowed to progress, they can cause functional blindness. Removal commonly restores vision to the pre-cataract level, barring other posterior disease processes.
Cataract surgery can both cause and exacerbate pre-existing dry eye disease, affecting patients’ quality of life.
Causes include incisional nerve damage and trauma to the ocular surface from repeated drying and irrigation, phototoxicity, eye drops, and surgical trauma. Patients should be assessed and treated for dry eye disease preoperatively and steps taken during surgery to limit ocular surface trauma.
Postoperative treatment includes lubricating eye drops, lid hygiene, and anti-inflammatory drugs (such as topical corticosteroids and/or ciclosporin).[133][134] One meta-analysis of 2177 eyes showed that sodium hyaluronate eye drops with conventional treatment significantly improved dry eye symptom scores, tear film break-up time, Schirmer's wetting length, and fluorescein score compared with conventional treatment alone.[135]
The rate of infection (endophthalmitis) after cataract surgery is estimated to be 0.04% in the US.[110] Endophthalmitis occurs most commonly in younger patients, with anterior vitrectomy, and when cataract surgery is combined with other ophthalmic procedures.[110]
The most common organism responsible has been found to be coagulase-negative Staphylococcus. The source for infective organisms is thought to be the normal lid flora, although outbreaks of endophthalmitis due to contaminated solutions and instruments used in surgery have been reported.[111]
Postoperative checks at 1 day and 1-2 weeks help identify signs of infection.
Topical and/or intravitreal antibiotics or surgery, depending on the severity of the infection, is the necessary treatment.
There is extensive evidence that intracameral antibiotic injections are associated with reduced rates of endophthalmitis.[112][113][114][115]
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A form of macular retina thickening characterised by the appearance of cystic fluid-filled intra-retinal spaces. Considered to be related to ocular inflammation, and is a common complication of cataract surgery.
More commonly seen in people with diabetes mellitus.[118]
Treatment with topical corticosteroids and non-steroidal anti-inflammatory drugs, or an injection or implant of corticosteroids around or into the eye, generally results in resolution or prevention of this postoperative problem.[119][120][121][122][123][124]
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Cataract surgery can be complicated by a tear in the posterior surface of the bag that holds the lens in place in about <1% to 4% of cases.[125][126]
This lens capsule is about 5 micrometres in thickness and can become torn during surgery. If a tear occurs, the vitreous humour usually sequestered in the posterior chamber of the eye can come forwards and/or increase the chance of endophthalmitis postoperatively.[127]
Traction on the vitreous can increase the risk of macular oedema and/or retinal tears or detachment after cataract surgery.
Insertion of an IOL can occasionally lead to visual artifacts such as a small arc of light (positive dysphotopsia) or darkness (negative dysphotopsia), which can be bothersome.
Most resolve with time, but occasionally the effect is enough to lead to surgical modification of the lens (e.g., reverse optic capture).[128]
Traction on the vitreous can increase the risk of retinal tears or detachment after cataract surgery. This may require further surgery to repair the detachment.
Retinal tears are estimated to occur in 0.36% to 2.90% of cases within 10 years of phacoemulsification.[129] Data from the American Academy of Ophthalmology IRIS Registry indicate that retinal detachment occurs in approximately 1 in 500 cataract surgeries in patients aged >40 years within 1 year of surgery.[130]
Increased risk for retinal tear and retinal detachment is associated with younger age, male sex, complex cataract surgery, lattice degeneration, intraoperative vitreous loss, increasing axial length, and trainee surgeons.[129][130]
Toxic anterior segment syndrome (TASS) is characterised by sterile postoperative inflammation of the anterior segment after intra-ocular surgery (most often cataract surgery).[131] The inflammation can be mild or severe enough to cause marked cornea oedema and hypopyon. The onset can be acute (within days) or delayed (after several months).
In cases of severe TASS, control of inflammation with strong topical or systemic steroids is essential to prevent permanent damage.
The presentation of TASS frequently resembles that of early postoperative bacterial endophthalmitis. Considering the potential detrimental and irreversible ophthalmic sequelae of bacterial endophthalmitis, most cases of unusual postoperative inflammation after cataract surgery are regarded as infectious endophthalmitis until proven otherwise.[131]
Non-arteritic ischaemic optic neuropathy is a very rare complication of cataract surgery, estimated at 2.8 cases per 100,000 procedures, with most cases occurring within 3 weeks of the procedure.[132]
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