Transcript Intra-operative management of cataract surgery complications

INTRA-OPERATIVE
MANAGEMENT OF CATARACT
SURGERY COMPLICATIONS
Dr. H. Razmjoo
Isfahan University of Medical
Sciences
High Risk Cases for VL
 1- Loose zonules & Phacodonesis
 2- Lens subluxation
 3- Miotic pupil
 4- Glucomatus cases with shallow
AC
 5- Brunescent lenses
 6- High refractory errors
High Risk Cases for VL








7 -Pseudoexfoliation Syndrome
8 -Traumatic Cataract
9- Fellow eye of Complicated Cataract
Surgery
10 - Eyes with Transillumination defects in Iris
11- Previously Vitrectomized eyes
12- Hypermature cataracts
13- Very Aged patient
14- Intra operative floppy iris syndrome
• Management of Phacodonesis
 Chopping technique is preferred for
phacoemulsification
 Use CTR
 Lens removal in the presence of severe
phacodonesis can be facilitated by
temporary suspension of the capsule
using iris hooks.
 A capsular tension ring alone is not sufficient if the
zonular defect is larger than 5 h(150 Degree)
Capsule Tension Rings
 Dialysis of 2–3 h (<90°)—CTR is an
option, not a necessity.
 Dialysis of 3–5 h (90–150°)—CTR is
required to assure capsular stability
and IOL centration.
 Dialysis of 5–7 h (150–210°)—CTR
can be used, but may not be
sufficient. The lens or the ring
should also sutured to adjacent
structures.
 Dialysis of more than 7 h usually
requires complete lens removal and
implantation of an AC-IOL (angle or
iris supported) or PC-IOL sutured to
the sclera and/or iris.
Insertion of CTR
 An intact capsular bag and a
continuous capsulorhexis are
prerequisites for using a CTR.
 Usage of Iris hooks for bag fixation:
If the CTR was not successful use
Scleral fixation of PC IOL or using
Artisan lens
MANAGEMENT OF
SMALL PUPIL
 Adequate pupil size is
imperative for safe
 Adequate pupil size is imperative for safe
cataract
removal.
cataract removal.
 Flomax has led to intraoperative
floppy iris syndrome. It will also
prolapse into the phaco and
side port incisions.
 Small pupil is generally defined as a
pupil less than 4 mm in diameter.
 It has been shown that about 1.6% of
cases will fall into this category.
 The presence of a small pupil is a
significant risk factor for the development
of complications during cataract surgery.
Starting the surgery
 Intracameral 0.5 cc of unpreserved
lidocaine 1% with 1:100,000 unpreserved
epinephrine.
 Injection of viscoelastic.
 Inspection of the iris with an instrument to
identify synechia.
 The most common cause of a small
surgical pupil is the pseudoexfoliation
syndrome.
Methods of pupil dilation
(1)
 Two-Instrument Iris Stretch
Methods of pupil dilation
(2)
 use of instruments that have been
designed to produce a three- or fourpoint stretch with one hand.
Methods of pupil
dilation (3)
Iris retractors
 There are both nylon and titanium iris
retractors available to dilate the pupil.
Methods of pupil dilation
(4)
 Pupil Expanders: silicone or PMMA
Methods of pupil
dilation (5)
 Multiple Sphincterotomies
VITREOUS
LOSS
Vitreous loss is inevitable
 Broken capsules occur at a rate
between 0.45% for very
experienced surgeons
 And up to 14.7% for residents in
training.
Complications of VL








Endophthalmitis
Cystoid Macular Edema
Retinal Detachment
Persistent increase in Intraocular
Pressure
Intraocular Lens
Dislocation/Subluxation
Choroidal Detachment
Suprachoroidal hemorrhage
Corneal edema
Categories:
 Broken capsule with an intact
anterior hyaloid.
 Vitreous prolapse into AC
 Vitreous loss through the
incision
SEQUELAE ;RD
 RD may occur at the rate of 1% after
uncomplicated surgery
 Increases up to 8.6% following VL
 RD increases to 14.5% when lens
fragments are retained.
 The most common sequela of
complicated surgery is an increased
risk of cystoid macular edema (CME)
EARLY
RECOGNITION
Early signs of break in the
posterior capsule:
 A bounce of the iris diaphragm
 Change in anterior chamber depth
 Change in pupil size
A posterior capsule tear
Loss of followability of lens
material
Loss of phaco efficiency during
surgery
are reliable signs that vitreous is
present.
 A peaked pupil or movements of the
pupil edge with remote touch are classic
signs not to be ignored.
EARLY
RESPONSE
FIRST
 Do not pull out of the eye when
recognizing a complication.
 The phaco tip between the lips of the
wound controls the intraocular
environment.
 Upon recognition of a problem go to foot
position zero but do not move the phaco
tip.
 Remove the non-dominant hand
instrument from the paracentesis
 Prepare to inject OVD (Ophthalmic Viscosurgical Device )
through the paracentesis incision.
 Only after OVD injection can the phaco
tip be withdrawn from the eye.
 If not, the chamber will collapse and the
stage of complication may progress from
capsular rupture to vitreous prolapse or
to vitreous loss.
 Avoid reintroduction of intracameral
unpreserved 1% xylocaine with broken
zonules or a capsule rupture.
 There will be a transient amaurosis, This
can be disconcerting or even frightening
to both patient and surgeon.
DAMAGE
CONTROL
 compartmentalization with a dispersive
OVD.
 If the rent in the posterior capsule is
central, this must be converted to a
circular posterior capsulorhexis
Tear is redirected
to a posterior
capsulorrhexis
 Posterior chamber nuclear
fragments must be raised above
the iris plane into the anterior
chamber with OVD.
 If the lens fragment is below the
posterior capsule and has
descended into the posterior
segment, the fragments should
be left in place for later removal
with a full three-port pars plana
vitrectomy.
DROPPED NUCLEUS
DURING CATARACT
SURGERY
 Lens material cannot damage
the retina, unless manipulated by
a surgeon.
 Posterior assisted levitation to
raise a dropped nucleus into the
anterior chamber for removal
creating unsafe vitreoretinal
traction.
 If a capsular defect is observed and the
nucleus has not dropped, viscoelastic
injection should be used to create a
barrier over the capsular defect.
If the nucleus drops….
 Focus upon safe management of the
vitreous.
 Consider lens implantation
 Manage the wound
 Refer to posterior segment surgeon
 The timing of the deep vitrectomy is
determined on an individual case basis.
 Early vitrectomy (fewer than 3 weeks)
was associated with better visual results.
 Some cases may require delay to permit
clearing of corneal edema for surgical
visualization.
 Urgent surgical intervention may
be indicated in: Cases with
markedly elevated intraocular
pressure refractory to medical
management.
TO PHACO OR
CONVERT TO
Continue Phaco…
 It is essential there be no admixture of
vitreous and lens material.
 vitreous will be attracted to the phaco
port displacing nucleus and preventing
aspiration of lens material with a high
likelihood of retinal tear and detachment.
 Unless vitreous can be isolated
and compartmentalized away
from lens fragments, the phaco
hand piece should not be used.
In the presence of a
controlled capsule
tear
 Tear must be adequately covered by
OVD, or a lens glide to minimize the risk
of forcing nuclear fragments posteriorly
or displacing vitreous.
Small rent in post capsule
Lowering the infusion bottle
Full occlusion of the aspiration port
Minimal phaco power .
Will reduce the risk of further damage
to the capsule and aspiration of
vitreous .
Capsular rupture
If the majority of the nucleus remains
and the capsular tear is large further
attempts at phaco should be
abandoned .
 A slow motion technique should be
employed
 with low
flow,
 moderate vacuum and
 appropriate pulses of energy
 adequate flow to avoid wound burn
to promote follow ability and to minimize
chatter.
How convert to ECCE?
 Choose the incision based on the size of
the remaining fragments.
 If the fragment is judged to fit 4mm, the clear
corneal incision can be utilized.
If you need > 4mm incision
 Move superiorly and perform an
adequate limbal or scleral tunnel
incision appropriate to the
fragment size.
Removal of remained lens material
.
Surgeon should enlarge the incision
and remove the nucleus with a lens
loop or spoon .
 Do not express with external pressure
 Remove the fragment with a cystotome,
forceps or a vectus glide
VITRECTOMY
TECHNIQUE
Vitreous is virtually
invisible
 Preservative free triamcinolone acetate
(Kenalog) particulate marking of the
vitreous should be used to identify its
presence and to delineate the extent of
prolapse.
Insertion of a second instrument
On lens glide behind the nuclear
remnant may help prevent its
dislocation in to the vitreous .
 Remove as much triamcinolone as
possible.
 Some patients may show a steroid
response of ocular hypertension.
 Cellulose sponges are used by many
surgeons for anterior vitrectomy as well
as for testing for vitreous in the anterior
chamber, in the wound, or on the iris.
 It inherently causes marked
instantaneous vitreoretinal traction.
 Traction on the anterior vitreous is
particularly dangerous because of
 proximity to the vitreoretinal adherence at
the vitreous base
 peripheral retina is more fragile
 The vitreous cutter should be used to
amputate any posterior connection to
wound-entrapped vitreous.
 In some instances OVD can be used to
reposit vitreous.
Vitrectomy
Perform anterior vitrectomy to avoid
vitreous prolapse .
Cut rate:
 Fast cutting rate reduces vitreoretinal
traction.
 Fast cut increase fluidic stability
Suction:
 Low suction levels and low flow rates are
safer.
 The suction or flow rate should be slowly
increased until vitreous starts being
removed.
INSPECTION AND IOL
CHOICE
Viscoelastic
Can be introduced posteriorly to the
fragment in an effort to float it
anteriorly and removing .




Be sure the pupil is round.
Be certain incisions are sealable.
Evaluate the intactness of the CCC
Evaluate the extent of the posterior
capsule tear and residual sulcus support.
Place foldable IOL
in the bag:
 if the posterior tear has been converted
to a CCC
 There are less than 3 hours of
zonulolysis
 The haptic should be placed to support
the area of zonulolysis.
Iol implantation
Bag if safe , ciliary sulcus or Artisan
lens .
 If the anterior CCC is intact the
foldable lens should have sulcus
haptic placement
 In the absence of an intact CCC, a sulcus
IOL may be placed entirely in the sulcus
 if there is adequate posterior capsule
support 180 degrees apart.
 Avoid plate haptic and one-piece
acrylic lenses.
 The sulcus lens haptic diameter should be at
least 13mm.
In the absence of capsular
support:
 Posterior chamber lens with scleral
fixation
 Artisan lens
 An anterior chamber open loop lens?
POSTOPERATIVE
CARE
Post op care .
Frequent postop topical steroid
,NSAIDS and IOP lowering agents
can be used .
Intraocular pressure
elevation:
 High IOP within the first 24 hours is often
due to retained OVD
 High pressure secondary to retained lens
fragments takes several days
 the surgeon should anticipate
increased post-op inflammation
 Require intensive topical steroids
 Intracameral antibiotic injection
 Non-steroidal anti-inflammatory
medications.
 Peribulbar steroids
There is a significantly
increased risk of
endophthalmitis
 Consider intracameral injection of
antibiotics
 Oral dosing of fourth generation
fluroquinolone
Conclusion:
 Effectively dealing with crisis is a
matter of having prepared for it.
Thank You