postoperative cataract complications Lecture 13 Liana Al-Labadi, O.D.

Early P.O Complications Management Transient Corneal Edema- secondary to minor surgical trauma to the corneal endothelium Control with topical steroids &/or hyperosmotics (Muro-128) Transient Anterior Iritis- i.e. Mild AC reaction Control with topical steroids Transient Ocular Hypertension- due to residual lens material & viscoelastic solution Control with beta blockers or CAI or alpha adrenergic receptors Consider paracentesis Wound Leakage- Due to inadequate wound sealing, trauma or eye rubbing. look for seidel’s sign; IOP usually low BCL + Antibiotic FB sensation- exposed suture vs SPK Treat as dry eye Lens remnant Uveitis- Causes severe uveitis & may result in secondary glaucoma Cylcoplegia BID & steroids Q2H; surgical intervention may be required Infectious Endophthalmitis- very poor prognosis (50% blindness) AB + Cycloplege + Steroids + (?IV AB) (

Corneal Edema

Mild Uveitis

Seidel’s Sign

Endophthalmitis Rarely occurs after modern cataract surgery Visually threatening condition Carries very poor prognosis- 50% blindness if treatment is delayed Can present as an acute form or chronic form Symptoms: Mild to severe pain Redness Loss of vision Floaters Photophobia Signs: The hallmark of endophthalmitis is vitreous inflammation Eyelid & periorbital edema Chemosis Corneal edema AC reaction Hypopyon Etiology: Toxic material introduced to the eye Poor sterlization- materials, injection needle, surgeon, nurses Management: Culture- must identify organism type IV AB & hospitalization

ENDophthalmitis

Complications Late P.O Complications Management Persistent Corneal Edema & Bullous Keratopathy Control with topical steroids &/or hyperosmotics (Muro-128); PK may be required Posterior Capsule Opacification (PCO) YAG Laser Cystoid Macular Edema NSAIDs Retinal Detachments RD repair

Pseudophakic Bullous Keratopathy (PBK) PBK is a post-op condition that can occur as a complication following PE PCIOL May present early or it may not present for many years Symptoms: Decreased vision Pain FBS & tearing Photophobia red eye Signs: Mild to marked persistent stromal edema in an eye in which the native lens has been removed Increased K thickness Bullous formation in severe cases--> these rupture & cause pain Descemet folds K vascularization CME may be present

Pseudophakic Bullous Keratopathy (PBK) Etiology: Due to compromised endothelial cell function Both intraoperative insult to the endothelium and long-term cell damage as a result of the lens implant can lead to PBK Proposed mechanism to endothelial cell loss include: Direct trauma during surgery Prolonged irrigation Toxic medications Persistent inflammation Increased IOP AC IOL- associated with more endothelial cell loss than PC IOL “Intermittent touch” between IOL & K Chronic low-grade inflammation caused by IOL haptics or footplates May disrupt the normal flow of aqueous in the AC which affects the nutrient flow to endothelial cells Management: Mild PBK Hypertonic saline drops (Muro 128-5% sodium chloride) Steroids BCL PK or DSAEK Prevention: Use of preoperative endothelial cell counts in high risk cases Use of viscoelastic solution during the surgery

PBK http://emedicine.medscape.com/article/1193218-overview http://www.doctorshangout.com/photo/bullous-keratopathy http://flylib.com/books/en/3.283.1.8/1

descemet folds

Posterior Capsular opacification (PCO) Aproliferation of lens epithelial cPosterior capsule becomes opacified as a result of continued proliferation of lens cells from the residual anterior lens epithelium or from residual fibrosis that could not be removed at the time of surgery ells can lead to posterior capsule opacificationfter ECCE & PE, Occurs in 50% of patients within 5 years after ECCE surgery Occurs in 1/5 people who undergo PE PCIOL Symptoms: decreased vision & FBS & pain if bullae present Signs: Blurry vision Glare “secondary cataracts” Asymptomatic Management: YAG laser capsulotomy Done when the patient is symptomatic Follow up in 1 week then 1 month s/p YAG Complications: Increased IOP Damage to IOL IOL dislocation Inflammatory reaction CME RD- especially in myopic patients (1-3% of patients)

PCO http://flylib.com/books/en/3.283.1.8/1/

PCO http://dro.hs.columbia.edu/pco2.htm

YAG

Cystoid macular edema (CME) A condition in which fluid accumulates within the sensory retina in the macular area May occur after intraocular surgery Cataract Filtration procedures RD surgery Associated with other systemic & ocular conditions including: Diabetes Peripheral uveitis RP May occur in as high as 20% of cataract surgeries, but only persists in 1-2% Onset: 6-10 wks s/p CE Symptoms: decreased hazy vision Signs: Hyperopic shift in RE Macular haze Petaloid appearance on FA is the hallmark of CME (or flower petal) Evidence suggests inflammation plays a role Management: May improve without treatment if no other surgical complications 70% of post-CE CME resolves spontaneously within 6 months NSAIDs CME may be recurrent CME secondary to CE is AKA Irvin-Grass Syndrome

CME http://dro.hs.columbia.edu/pco2.htm http://www.retinatexas.com/images/CSME.jpg

CME http://flylib.com/books/en/3.283.1.8/1/

Complications Late P.O Complications Management Persistent Corneal Edema & Bullous Keratopathy Control with topical steroids &/or hyperosmotics (Muro-128); PK may be required Posterior Capsule Opacification (PCO) YAG Laser Cystoid Macular Edema NSAIDs Retinal Detachments RD repair

Bye Bye Cataract- conclusion Approach cases in a conservative manner Correlate VA with anterior segment appearance Maintain communication with surgeon and family physicians Make referrals to experienced modern surgeons