QFaced with a rock-hard lens, how would you handle this small pupil? The most notable risk is a small chance that the retina separates from the inner back of the eye. It is unclear what happened to the missing haptic and why the original implanting surgeon did not recognize the complication and remove the IOL at the time of the original surgery. Given the advanced state of the cataract, perhaps the positive pressure inside the lens was the reason the defect extended far enough to the periphery that it could not be included in the circular tear capsulotomy (a mini-Argentinean flag sign). Typically, a prophylactic antibiotic and perhaps pressure-lowering drops or ointment will be put on your eye to help the healing start immediately, Goel says; and a patch or a shield will be placed over the eye. If this happens to you, call your doctor right away. Frequently, this discontinuity is so small that the surgeon is not aware that it exists. Small-incision cataract surgery (SICS) is actually a dying art in most developed countries, and residents rarely can see it performed, let alone practice it. The polar cataract is a discoid opaque area of the posterior lens composed of malformed lens fibers. The crystalline lens is a biconvex structure that focuses light on the retina. You should be able to go home on the same day as your cataract surgery. You may have a pad and plastic shield over your treated eye when you leave hospital, which can usually be removed the day after surgery. Feeling should start to return to your eye within a few hours of surgery, but it may take a few days for your vision to fully return. Your vision continues to be foggy or blurred. Patients should be aware of the common after-surgery side effects, as well as the rare complications that can occur. (If both the CTR and CTS could be retained and sutured, then this would be a viable option.) During preoperative counseling, surgeons and their staff should warn patients and their family members that there are no guarantees of spectacle independence, even with multifocal IOLs. It is the full set of physical findings that directs the surgeon to the etiology and thus to the treatment. This is more likely to occur in younger patients, and is the result of the retina pulling away from the back of the eye. The defect might have been caused by the pupil instrumentation. Another rare complication, wound leaks occur when fluid leaks around the incision sites. In the latter instance, sulcus placement of a three-piece IOL is indicated. The first question refers to the single most important change that a surgeon can make when operating on a posterior polar cataract. Get instant access to discounts, programs, services, and the information you need to benefit every area of your life. This caused bleeding from the angle. But it could also be a sign of another issue, like too much inflammation in your eye, and you may need eye drops. I placed a pars plana 23-gauge trocar system vitrector in a sutureless manner prior to opening the eye. After a pupil expansion ring was implanted, a defect was noted in the anterior capsule. QAt this point, with an anterior capsular tear/defect and a moderately firm nucleus, what would be your strategy? These patients may have foggy vision or feel like they are in a steam room at first. Cataract Surgery Complications - Optometrists.org Photopsia. Be sure to have a preoperative evaluation done, says Ravi Goel, M.D., clinical spokesperson for the AAO and ophthalmologist at Regional Eye Associates in Cherry Hill, New Jersey. I agree, as it is quite easy and safe to perform. The haptics of this lens will serve as a CTR and can be sutured to the sclera or peripheral iris using 10-0 Prolene sutures with a CIF 4 or CTC 6 needle (Ethicon). To prevent late subluxation of the IOL, one must suture the CTR to the sclera. Kenalog staining will determine whether an anterior vitrectomy is needed. This case emphasizes the importance of recognizing the relationships between the lens and the pars plana in eyes that have experienced significant trauma. The patient is satisfied, as is the referring ophthalmologist, who continues to refer. If a posterior capsular tear occurs following a radial anterior capsular extension and a posterior CCC is achieved, either a single-piece IOL in the bag or a three-piece IOL in the sulcus is appropriate for long-term stability, unless the posterior CCC is too large to ensure in-the-bag stability. In cases of weakened zonules with a tenuous capsular bag/IOL complex, this can, at times, be an acceptable option. Severe damage to intraocular structures has been reported. Dick MackoolThe audience has it right, although I didnt do what they advised. It was not in this case, and the patient has done well with three years of follow-up. WebWith the advancement of surgical technology and techniques, cataract surgery has evolved to small-incisional surgery with rapid visual recovery, good visual outcomes, and minimal complications in most patients. After surgery, you have a slightly higher chance that it pulls away from the back of the eye -- a problem called retinal detachment. Your doctor may suggest lubricating eye drops to help with this problem. You may experience some floaters afterward, but these should resolve within a few weeks. Find an eyecare professional and book online in minutes! WebCataract surgery is the most commonly performed surgical procedure, compared with any other surgery in medicine. 3) Is the red reflex lost or asymmetrically lost, with an irregularly shallowed chamber (choroidal hemorrhage)? You may see the edge of the lens implant, or you may even develop double vision. This case was more extreme, with free vitreous in the anterior chamber. The irrigation is discontinued as the viscoelastic fills the eye, and the needle can be removed. In Geoff Tabins case of a white mature cataract, the dye-stained anterior capsule split in both directions (Argentinean flag sign). Sometimes, you may need to wearsunglassesfor a few months until iritis goes away. Pain is an expected complication of most surgical procedures. July 1998. After surgery, have the person who will drive you home listen to any additional instructions you're given, just in case you're a bit groggy, and don't catch everything. Although sometimes referred to as a second cataract, it is not. It can be successfully treated with medication and diet, but may take a few months to resolve. The lens capsule surrounds the eye's lens. If you notice any of the following symptoms, contact an eye doctor immediately: When the cataract is removed, your surgeon makes every attempt to maintain the integrity of the lens capsule, and normally your vision after cataract surgery should be very clear. Q With this defect in the anterior and posterior capsules, Id implant: Rich HoffmanThis was a case of a 24-year-old female with Marfan syndrome who requested lens extraction of her moderately subluxed crystalline lenses. I began my capsulotomy with a bent 27-gauge needle connected to a syringe. More fluid was drained, allowing completion of the surgery with insertion of a 40-D IOL in the capsular bag and a 14-D IOL in the ciliary sulcus. The remaining natural lens cells create a fibrous material that contracts, reducing the size of the thin membrane that surrounds the lens. Matteo Piovella presented a case in which a large posterior capsular rent was noted following multifocal IOL implantation. American Journal of Ophthalmology. Sadly, hardness combined with a small pupil is not too unusual. Following the anterior vitrectomy, a three-piece acrylic optic IOL was placed into the sulcus to act as a scaffold for the residual nuclear material.1The residual nuclear material was removed with a slow-motion technique involving low vacuum and low bottle height.2. A suprachoroidal process is high on the differential diagnosis in Dr. Kochs case. If there is no obvious focal process, the differential includes diffuse choroidal expansion or misdirection of the irrigating fluid. versus late traumatic cataract surgery and intraocular You are leaving AARP.org and going to the website of our trusted provider. But in this instance, ring removal before nucleus extraction with the loop definitely will be the best option. A little swelling and redness after surgery is normal. It is also one of the safest surgical procedures. Samuel Masket, MD, concluded the symposium by delivering the ninth annual AAO Charles Kelman Lecture. As one can see, the presence of the large zonular dialysis and CTS/CTR in the bag creates additional issues in the presence of a posterior chamber rent. Dr. Mackool chose a unique method of solving this problem by making a small cut in the area of the haptic/optic junction where the haptic had been torn loose from the IOL during the original insertion. Neither of these options would worsen the condition if the etiology was in fact increased vitreous pressure. The nerves generally will heal in about three months, but until then, your eye may not feel when it is dry and decrease tear production. Vote for your favorite AARP Benefits Badass now ataarpbenefitsbadass.org. These complications can occur after patients have gone home. Of note, both eyes also exhibited mild superior lens subluxation and inferior zonular deficiency (approximately 4 clock-hours) on dilated examination with no phacodonesis. Instead, once the nucleus is emulsified, use iris hooks to assess the capsule and then decide whether to put the IOL in the sulcus or do a glued IOL. Even in skilled hands, 40 percent of anterior capsular tears will wrap around to involve the posterior capsule, and 20 percent will develop vitreous prolapse, requiring a vitrectomy.1Therefore, all anterior capsular extensions should be managed as carefully as posterior capsular tears. In this case, prevention was not successful, and the capsule integrity was compromised with nuclear material remaining in the anterior chamber. The retina sits way back in your eye, sensing light and sending messages to the brain. I agree with the use of capsule retractors to help stabilize the capsule. It usually requires antibiotics or a referral to a specialist. It is only when surgeons stray out of their comfort zone, especially when they are unsure of the exact diagnosis, that indefensible harm may occur. Patients who have cornea disease, such as Fuchs dystrophy, may take longer up to a month or more to get rid of the swelling. Some cases go well, whereas some land up with serious problems. When your surgeon makes contact with your eye, a small amount of white blood cells or protein may build up in the front chamber of the eye, creating blurred vision or light sensitivity. Typically, you wait and see if it gets better. Iris fixation, an ACIOL, sulcus fixation, or a glued IOL require pupilloplasty, rendering the subsequent vitrectomy more difficult. One option at this point would have been to convert to an intracapsular extraction and then place a secondary IOL. The presence of this then permitted the optic to be captured in the capsulorrhexis. During cataract surgery, a surgeon replaces the affected lens with an artificial lens. A backup IOL is another possibility, in case sulcus or iris fixation is necessary. The operation While some cataracts, may be congenital, secondary to trauma, or drug-induced, most cataracts are age-related. QHow would you address this subluxating IOL? Anesthesia for cataract surgery: Recent trends. ThisEyeNetarticle reports the results of the audience response questions, along with written commentary from presenters and panelists. For most people, surgery restores vision and has no complications. The audience response seems to indicate that most surgeons are not comfortable with a posterior rhexis in this setting. Some issues to consider are as follows: 1) Did the block go smoothly, and could this be a retrobulbar hemorrhage compressing the eye posteriorly (proptotic eye, chemosis, ecchymosis)? At this point, I elected to attempt a posterior CCC to prevent the tear from extending further into the periphery during cortical removal and IOL insertionwhich is a major risk with the CTR in placeas well as to retain the advantages of in-the-bag placement of the capsular tension devices and the PCIOL. This condition can be treated with a quick and safe laser procedure called a YAG laser capsulotomy. I typically go for about 3 mm, as this will still be sutureless but will improve access considerably. With Clearing the Fog of Cataracts, youll This case is ideally managed from a combined posterior and anterior approach. This case had a posterior capsular rupture. Up to half of those having cataract surgery will experience some increase in pressure in their eye after the procedure, but pressure levels usually return to normal within 24 hours. A safer phaco needle with rounded edges will reduce the likelihood of damage should the capsule become engaged. In the United States, about 4 million cataract surgery procedures are performed every year. Randolph K, et al. Cataract Surgery Complications All rights reserved. This problem is almost always temporary and gets better in days or weeks. Dr. Piovella reminds us that, as seen in his case, these procedures may not go as planned. Cataract surgery is very safe. The haptic/optic on this side was sharp and irregular and located in front of the capsular bag. The patient had an uneventful vitrectomy-lensectomy, and the patient and retina surgeon chose to leave her aphakic, although I would have chosen a glued sulcus-fixated IOL and pupilloplasty at the time of the second surgery, had I been given a vote. Skip NichaminThe audiences leading response was to stop and do nothing. I injected a small air bubble through a side port incision and then painted the anterior capsule with trypan blue. Once your cataract is removed, it does not regrow. The initial pars plana vitrectomy should be focused on removing the anteriorly displaced vitreous and can be enhanced with triamcinolone staining of the vitreous gel. This complication, which occurs far more often than is discussed, can usually be avoided by these precautions. Sometimes blurry vision is caused by PCO, a fairly common complication that can occur weeks, months or (more frequently) years after cataract surgery. It happens when the lens capsule, the membrane that holds your new, intraocular lens in place, becomes hazy or wrinkled and starts to cloud vision. Sinha R, et al. Subsequent wound suturing creates a significant amount of surgically induced astigmatism, delaying visual recovery. Once that was done, I thought my problem was solved, as I only had to put the IOL into the sulcus. Infections after cataract surgery are rare, but if you have one, you'll get a shot of antibiotics into your eye. QAbsent capsular support, Id choose (for myself): Amar AgarwalThe audience was asked which IOL they would like in their own eye, and 38 percent said ACIOL and 18 percent glued IOL. Even though vitreous did not present immediately, a dispersive OVD can sometimes prevent vitreous prolapse during I&A of the residual paranuclear material and cortex. Once the posterior CCC was created, cortical removal was performed, and 7-0 Gore-Tex suture was used to suture the CTS to the sclera in the area of dialysis. Passing a needle through the pars plana in the setting of evolving choroidal hemorrhage or effusion could create a retinal tear or worse. David F. Chang, MDCataract Spotlight Program Cochairman. Nick MamalisThis is an interesting case of a single-piece with haptic, hydrophobic acrylic PCIOL. Meet Me in Vegas Award for the surgeon who had the luckiest outcome: Lisa Arbisser presented a case that involved a traumatic subluxated dense cataract (the patient had previously been kicked by a horse) with a large zonular dialysis. In some cases, a PCO may occur because a few of the old cataract cells are not removed during the surgery. After fixing an infusion cannula (I like fluid in the eye when operating on such complications), I used the posterior assisted levitation (PAL) technique to bring the nucleus anteriorly above the iris. Botton line: There's low risk and high rewards with cataract surgery, but avoiding even the slightest chance of a problem by carefully selecting a qualified eye surgeon, following instructions, and reporting any symptoms of a potential problem will ensure that you have the best outcome possible. Complications can occur during any surgical procedure. This is accomplished by obtaining pupillary capture of the IOL and suturing the IOL loops to the iris with 10-0 Prolene sutures. Cataracts are the worlds leading cause of remediable blindness. Cataract Surgery What now? That may include obtaining any medications you may need post-surgery. For See your eye doctor right away if you: When your doctor removes your cloudy lens during cataract surgery, some pieces may fall into your eye and get left behind. Make sure to wait 5 minutes after applying prescription drops before using the tears so that the medicine does not get diluted. Generous use of a cohesive OVD to maintain space and a dispersive agent to tamponade the area of exposed hyaloid would also be key considerations. On further questioning and examination, I could elicit no history or evidence of ocular trauma, previous eye surgery, or known causes of lens subluxation, such as Marfan syndrome, homocystinuria, and pseudoexfoliation (PXF). When I tried to pull the nuclear fragment from the eye, the Malyugin ring trapped me inside! Be sure to report floaters, flashes of light and any curtain-like vision loss to your ophthalmologist immediately. Of course, the best approach is to do everything possible to maintain some level of capsular support in a complicated case. Doctors are not exactly sure what causes it. We describe 3 patients who presented with an accumulation of homogeneous milky fluid in the capsular bag several years after continuous curvilinear capsulorhexis, phacoemulsification, and posterior chamber intraocular lens (IOL) implantation. In most of these cases, my preference is definitely the Malyugin ring. Depending on the size of the fragment versus the tear, this incision enlargement may allow for simple viscoexpression. With symptoms of normal side effects and serious complications being so similar, you may wonder when its worth calling your doctor after cataract surgery. My personal choice was to add three more defects in the capsulorrhexis, at 3, 6, and 9 oclock relative to the incision. What do the numbers on your eyeglass frames mean? Join today and save 25% off the standard annual rate. The complications included anterior capsular tears (both with and without the femtosecond laser); instrument snafus (jammed forceps and projectile cannulas); entanglement with capsule retractors, capsular tension rings (CTRs), and Malyugin rings; suprachoroidal effusion; descending nuclei and intraocular lenses (IOLs); IOL exchange complications; and capsules or zonules ruptured at virtually every stage of surgery. QWhat is your time limit for performing a multifocal IOL exchange? Elevated pressure in the eye, or ocular hypertension, can also cause you to feel like you want to throw up. Given the size of the lens, with its diameter of approximately 11 mm, even with the biggest ring size (7 mm) it will not be technically possible to pass the cataract through the pupil. All About Vision does not provide medical advice, diagnosis or treatment. I like to always have a vitrectomy probe and triamcinolone at hand in case the integrity of the capsular bag is compromised. This posed the question of whether to attempt a posterior capsulorrhexisor to simply place an IOL in the ciliary sulcus. Germs that get in your eye during surgery can lead to an infection. AARP Membership-Join AARP for just $12 for your first year when you enroll in automatic renewal, New vision tests and technology can help save your sight. The plurality of the audience voted to place a three-piece PCIOL in the sulcus with optic capture. The patients BCVA improved after Nd:YAG laser capsulotomy was cataracts A little bit of blood isn't a problem, but larger amounts could lead to loss of vision. Early cataracts are cataracts that occur before 60 years of age. Other causes of ongoing blurry vision include residual refractive error (your eyes still need some additional correction with glasses), dry eye or posterior capsule opacity (PCO). After uneventful phacoemulsification of the lens and aspiration of all cortical material, a CTR was inserted into the capsular bag with a Geuder injector without incident. Other times, PCO can be the culprit, and YAG laser treatment can resolve the issue. This is caused by a buildup of fluid in the macula, the center part of the retina at the back of the eye. Shah R. (2010). The lesson I learned is, always remove the Malyugin ring before inserting an irrigating lens loop. Richard LindstromRelease of a cannula into the eye while fluid is being injected can result in severe complications. (2012). In some cases, there may be tiny pieces of your natural lens left behind after cataract surgery. www.aarp.org/volunteer. In the setting of preexisting vitreous prolapse, placement of transconjunctival trocars (either 25 or 23 gauge) should be performed through the pars plana 3.5 mm posterior to the limbus. On the other hand, the treatment for a choroidal effusion is either deferring surgery (to later in the day or even a few days later) or scleral cutdown. A laser removes the hazy posterior capsule from your line of sight without making an incision or "touching" the eye. as the Complication of Cataract Surgery Pediatric Cataract Surgery: Post-operative Complications Performing a limited pars plana vitrectomy in an eye with an evolving choroidal hemorrhage, for example, is a sure way to create significant retinal damage. A one-piece IOL in the bag was out of the question. Late complications can occur months or even years after surgery. This rarely happens, but immediate surgery to correct it is necessary for a good outcome. I usually advise patients to wait until their vision is frustrating on a daily basis. Next, I attempted to hydrodissect the nucleus out of the bag. A CTR will place centrifugal force symmetrically on the bagand because the tear did not extend, it would make sense to attempt a posterior rhexis. A larger capsulotomy also reduces the later chances of phimosis of the anterior capsule. WebPosterior capsular opacification (secondary cataract) is a clouding of your eyes lens capsule that can occur as a complication of cataract surgery. Once the chamber is stabilized, then one can decide how to approach the situation. These effects can be more noticeable in between surgery on the first and second eye. Every surgeon has and will have complications. Witness Protection Program Award for the surgeon who displayed the most courage by his willingness to present his complication in public: Financial interests are designated by C, E, L, O, P, or S: Your browser doesn't support the HTML5 video tag. Although switching to I&A may work well, hydrodissection should be done prior to lens aspiration. I thought I was done and home free. Because of a capsular defect, the posterior capsule tore when the anterior chamber suddenly shallowed after the I&A tip was withdrawn. But theres a simple solution. IOL power for emmetropia was 54 D, and piggyback IOL implantation was planned. For those experienced in sutureless small-incision ECCE, this is a perfect case, and it avoids any issue with nuclear hardness or pupillary concerns. People with glaucoma may experience elevated eye pressure. Once a cataract is removed, it doesn't come back. Iris retractors can be used on the edge of the capsule to support the capsular bag as the cataract is being removed. We all appreciate their humility, courage, and generosity in sharing these cases with us so that we might all improve our surgical judgment and skills. QWhat has been your personal experience with multifocal IOL explantation? Finally, as the fragment is typically accessible and mobile, reducing vacuum and flow while maintaining irrigation will decrease postocclusion surge for this last fragment. IOL rotations are best performed within the first few weeks after the initial cataract surgery. When the vitreous did present, triamcinolone could have been used to identify it, making bimanual vitrectomy through paracentesis incisions easier and potentially less traumatic. Dispersive OVD was injected posterior to the tear, and microscissors were used to cut and create a flap in the posterior chamber just beyond the central tear. Because of the anonymous nature of this polling method, the audience opinions are always interesting and were discussed in real time during the symposium by our panelists. Another example of a cataract surgery complication is a malpositioned or dislocated intraocular lens. In the hands of an expert, it takes minutes and has impressive results. An analysis of several studies found that posterior capsule opacification occurred in 11.8% of patients at one year after cataract surgery, in 20.7% at 3 years, and in 28.4% at 5 years. In addition, I always tighten all cannulas when they are handed to me. This causes you to see visual effects, and there are two types: Doctors don't know why it happens, and it often goes away on its own. The Grand Rounds Award voted for the surgeon who presented the best teaching case: Rich Hoffman presented a case of ectopia lentis with severe subluxation of the crystalline lens. Because the retractor holds the capsulorrhexis at a single point along its contour, and the tips of the retractors are not always rounded, applying tension to the hooks can cause the capsulorrhexis to split. Over the years, improvements made to surgical techniques and lens implants have reduced the risk of complications. I then created a scleral tunnel incision that extended 1.5 mm into clear cornea, widening as it entered the cornea. An anterior approach is less likely to clear vitreous and can result in further unzipping of the zonular network. You end up with better vision and recover without any long-term issues. This way, I could emulsify the nucleus comfortably without the fear of the nucleus falling into the vitreous cavity. While some cataracts, may be congenital, secondary to trauma, or drug-induced, most cataracts are (2013). Special gels used during surgery may temporarily raise the pressure in the eye. The complication could have been prevented if a more thorough hydrodissection had been performed from the outset. Having an IOL, cortex, and nucleus all deep-sixed in the vitreous is more variety than I like! Reshaping the phaco tunnel into the bigger valve incision usually results in the wound having an irregular internal aspect. Go to: Introduction While your doctor should give you specific advice on when to call for help after the procedure, some signs to watch for include: Cataract surgery is one of the most commonly performed surgical procedures. A single-piece toric PCIOL was then placed in the bag and positioned carefully.