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CouchingCouching
(extra capsular)(extra capsular)
(intracapsular)(intracapsular)
Microsurgery(extracap + IOL)
LLss
AqAqMicsMics
PMMAPMMA
SoftSoft
BiMBiMff
AccAcc
Ph-EPh-E
Preoperatory complication
bullGAbullLA bull TOPICAL
secondary to posterior diffusion of an ophthalmic viscosurgical device-lidocaine solution during complicated phacoemulsification
Falzon K - J Cataract Refract Surg - 01-AUG-2009 35(8) 1472-3
The main drawback of local anesthesia is to enable the patient to perform movements during operation
Intra operatory complications
All cases where conjunctival hydration
occurred were clear corneal incisions
There was no need to convert the capsulorhexis
into an can-opener in any situation
In intumescences cataracts we performed a smaller rexis to avoid its failure After closing the rexis and cortex aspiration
broadening the rexis bringing it to the normal diameter
In white cataracts (mature hyper mature) used a colored substance to reveal the anterior capsule under air protection
The anterior chamber should be reinflated with an OVD
The vector forces of the tear should be changed to redirect the tear in a more central direction
If the tear is lost beneath the iris the capsulorrhexis should be restarted from its origin proceeding in the opposite direction (if possible this new capsulorrhexis should finish by incorporating the original tear in an outside-in direction however the original tear is often too peripheral to permit this and a single radial tear is created)
An alternative approach to a ldquolostrdquo capsulorrhexis is to convert to a can-opener capsulectomy
Preventing radial tears in the anterior capsule
Endocapsular phacoemulsification without hydrodissection
an effective technique for cataract surgery
following anterior capsular tear
Excessively small capsulorrhexis
Two major complications of hydro dissection are
- inadequate hydro dissection - over inflation of the capsular bag
the viscodissection technique was safer and more efficient than the non-dissection technique
Detachment of Descemetrsquos membrane can be a major
postoperative complication
it results in persistent corneal edema and decreased visual acuity
To prevent Descemetrsquos detachment the surgeon should carefully observe
the inner lip at each phase of the procedure
To avoid blunt stripping of Descemetrsquos membrane during
enlargement of the wound a sharp metal or diamond blade
is recommended
usually is caused when the anterior chamber is entered too posteriorly
such as near the iris root
If this is noted early in the case and interferes with the easy introduction of instruments into the eye
it is advisable to suture the incision amp move to another location
A second and more ominous cause of iris prolapse is an acute increase of intraocular pressure (IOP) accompanied by
choroidal effusion or hemorrhage
Bleeding in the anterior chamber can come from intra operatory damage of iris
This occurs most frequently in temporal incisions located more posterior and deeper than normal
In these cases there are reached the blood vessels with higher risk of bleeding
it appears that there is no significant statistical correlation with anticoagulant therapy or chronic anti agregant
Temporarily elevating the IOP with a balanced salt solution or an OVD
Injecting a dilute solution of preservative-free epinephrine 15000 (or a weaker solution)
Direct cautery (if the bleeding vessel can be identified) with a needle-tipped cautery probe
Iris bleeding is caused by iris trauma
Intraocular bleeding can be stopped by
Temporary loss of the chamber
After adjusting the parameters of aspiration and irrigation
and the introduction of viscoelastic substances
with high molecular weight
the situation was resolved favorably
(281)
All cases of hypertonic eye have been associated with temporary shallow anterior chamber earlier the correlation being statistically significant
hypertonic eye amp posterior capsule rupture has been reported ( was needed vitrectomy)
Correlation was not statistically significant
If for any reason the flow is blocked a corneal burn can occur within 1ndash3 s
additional suturing was required several days later Postoperatively the patient has 5 D of surgically induced astigmatism that has persisted for more than 5 years
Yanoff amp Duker Ophthalmology 3rd ed
the surgeon should attempt to identify the cause and lower the IOP Sometimes digital massage on the eye pressing directly on the incision can successfully lower the pressure It is useful to examine the fundus to ascertain whether a choroidal effusion or hemorrhage exists With choroidal effusion aspiration of vitreous can be helpful as can the administration of intravenous mannitol If a choroidal hemorrhage occurs or if the increased IOP from an effusion is resistant to treatment
it usually is best to terminate surgery The wound is sutured carefully intraocular miotics are administered and a peripheral iridectomy may be performed to help reposition the iris For effusions surgery can be deferred until later in the day or the next day when the fluid dynamics of the eye have returned to a more normal state
If a limited choroidal hemorrhage has occurred it is best to wait 2ndash3 weeks before attempting further surgery
presumably occurs from the rupture of a blood vessel that is placed under stretch
Risk factors include hypertension
glaucoma
nanophthalmos
high myopia
and chronic intraocular inflammation[26]
still occur at a rate between
045 for very experienced surgeons [1]
amp up to 147 for residents in training [2]
The frequency of retained
lens fragments is estimated at 03 to 11 [34]
The challenge of cataract surgery is to minimize
the risk of complications and to manage optimally
complications that do occur
B-scan ultrasonography 1 day after dislocation
of a lens nucleus into the vitreous cavity
in a patient who has high myopia
the early signs of posterior capsular rupture include
unusual deepening of the anterior chamber
decentration of the nucleus
or loss of efficiency of aspiration which suggests occlusion of the tip with vitreous
Usually Posterior capsular rupture is the most common
intraoperative complication in initial cases
The key factors are to minimize ocular trauma meticulously clean prolapsed vitreous
from the anterior segment if present and ensure secure fixation of the IOL
The review yielded 392 patients
Six (153) had intraocular pressure (gt or = 30 mm Hg) requiring treatment
1 (026) had painless iris prolapse
11 (281) had corneal abrasions
and 7 (178) were given a more intensive steroid regime (UVEITIS)
Corneal edema
No cases of fibrinous uveitis were recorded
J Cataract Refract Surg 1999 Jul25(7)985-8
Corneal edema is categorized according to severity in reversible and irreversible
bull reversible corneal edema- in 7 days 842-in 30 days 103
bull irreversible corneal edema ndash edemato bullous keratopathy (Corneal endothelial damage)
a significant statistical correlation of the corneal edema post phaco with the phaco-time and the type of cataract
Most common in pre-existing endothelial disorder
Edema is most often caused by Mechanical trauma Prolonged intraocular irrigation Inflammation And elevated IOP Toxic Solutions
Vitreocorneal Adherence and Persistent Corneal EdemaVitreocorneal Adherence and Persistent Corneal Edema
Points in ManagementPoints in Management
If epithelial edema is present in the face of a compact stroma immediately after surgery it is likely due to elevated lOP with intact endothelium
Corneal edema generally resolves completely within 4-6 weeks
As a rule if the corneal periphery is clear
the corneal edema will usually resolve with time
Corneal edema persisting after 3 months usually
does not clear and may require penetrating keratoplasty
Small wounds under 32 mm are much less prone to this complication
The sealing of the wound depends
the quality of the corneo-scleral tissue
the quality of incision
This in turn depends on certain intraoperatory complications
certain chronic diseases
thermal injury of the wound
If needed case can use a therapeutic contact lens
Intraoperatory injury with the phaco tip or instruments
(complicate cases)
amp some local or general associated conditions may cause pupil asymmetries
This will translate clinically by decreased visual acuity
lack of adaptation to strong light
Post operatory intraocular inflammation can be acute and chronic (endophthalmitis)
Chronic uveal inflammation may occur in weeks months or years after cataract
chronic inflammation
significant statistical correlations between post-intraocular inflammation on the
one hand and rupture of thecapsule
Cystoid macular edema
Retinal detachment
Persistent increase in intraocular pressure
Intraocular lens dislocation or subluxation
Choroidal detachment
Endophthalmitis
Corneal edema
There were more cases of posterior capsule tears and vitreous
loss in the first 80 cases performed by the residents
the posterior capsule tear rate peaked at more than 10 after
40 cases
Spontaneous
in-the-Bag Intraocular Lens Luxation
into the Vitreous Cavity
A Balestrazzi G M Tosi M Alegente C Mazzotta et al Ophthalmologica Basel Aug 2009 Vol 223 Iss 5 pg 339 4 pgs
National Cataract Register (NCR)
type of anesthesia
history of trauma
ocular comorbidity
axial length
miosis
cornea pathology and poor visibility
previous intraocular operation
iris synechias small pupil
white cataract brunescenthard cataract
phacodonesis
presence of pseudoexfoliation
surgeon experience 3 years or less (operating under senior supervision) or more than 3 years of independent
phacoemulsification practice
Major complications occurred in 15 of 320 cases (47) and involved 10 cases of vitreous loss
the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2)
wrong IOL power requiring reoperation (1)
corneal wound burn (1)
and postoperative iris prolapse requiring wound revision
The mean postoperative BCVA was 2026 (logMAR 011)
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
Preoperatory complication
bullGAbullLA bull TOPICAL
secondary to posterior diffusion of an ophthalmic viscosurgical device-lidocaine solution during complicated phacoemulsification
Falzon K - J Cataract Refract Surg - 01-AUG-2009 35(8) 1472-3
The main drawback of local anesthesia is to enable the patient to perform movements during operation
Intra operatory complications
All cases where conjunctival hydration
occurred were clear corneal incisions
There was no need to convert the capsulorhexis
into an can-opener in any situation
In intumescences cataracts we performed a smaller rexis to avoid its failure After closing the rexis and cortex aspiration
broadening the rexis bringing it to the normal diameter
In white cataracts (mature hyper mature) used a colored substance to reveal the anterior capsule under air protection
The anterior chamber should be reinflated with an OVD
The vector forces of the tear should be changed to redirect the tear in a more central direction
If the tear is lost beneath the iris the capsulorrhexis should be restarted from its origin proceeding in the opposite direction (if possible this new capsulorrhexis should finish by incorporating the original tear in an outside-in direction however the original tear is often too peripheral to permit this and a single radial tear is created)
An alternative approach to a ldquolostrdquo capsulorrhexis is to convert to a can-opener capsulectomy
Preventing radial tears in the anterior capsule
Endocapsular phacoemulsification without hydrodissection
an effective technique for cataract surgery
following anterior capsular tear
Excessively small capsulorrhexis
Two major complications of hydro dissection are
- inadequate hydro dissection - over inflation of the capsular bag
the viscodissection technique was safer and more efficient than the non-dissection technique
Detachment of Descemetrsquos membrane can be a major
postoperative complication
it results in persistent corneal edema and decreased visual acuity
To prevent Descemetrsquos detachment the surgeon should carefully observe
the inner lip at each phase of the procedure
To avoid blunt stripping of Descemetrsquos membrane during
enlargement of the wound a sharp metal or diamond blade
is recommended
usually is caused when the anterior chamber is entered too posteriorly
such as near the iris root
If this is noted early in the case and interferes with the easy introduction of instruments into the eye
it is advisable to suture the incision amp move to another location
A second and more ominous cause of iris prolapse is an acute increase of intraocular pressure (IOP) accompanied by
choroidal effusion or hemorrhage
Bleeding in the anterior chamber can come from intra operatory damage of iris
This occurs most frequently in temporal incisions located more posterior and deeper than normal
In these cases there are reached the blood vessels with higher risk of bleeding
it appears that there is no significant statistical correlation with anticoagulant therapy or chronic anti agregant
Temporarily elevating the IOP with a balanced salt solution or an OVD
Injecting a dilute solution of preservative-free epinephrine 15000 (or a weaker solution)
Direct cautery (if the bleeding vessel can be identified) with a needle-tipped cautery probe
Iris bleeding is caused by iris trauma
Intraocular bleeding can be stopped by
Temporary loss of the chamber
After adjusting the parameters of aspiration and irrigation
and the introduction of viscoelastic substances
with high molecular weight
the situation was resolved favorably
(281)
All cases of hypertonic eye have been associated with temporary shallow anterior chamber earlier the correlation being statistically significant
hypertonic eye amp posterior capsule rupture has been reported ( was needed vitrectomy)
Correlation was not statistically significant
If for any reason the flow is blocked a corneal burn can occur within 1ndash3 s
additional suturing was required several days later Postoperatively the patient has 5 D of surgically induced astigmatism that has persisted for more than 5 years
Yanoff amp Duker Ophthalmology 3rd ed
the surgeon should attempt to identify the cause and lower the IOP Sometimes digital massage on the eye pressing directly on the incision can successfully lower the pressure It is useful to examine the fundus to ascertain whether a choroidal effusion or hemorrhage exists With choroidal effusion aspiration of vitreous can be helpful as can the administration of intravenous mannitol If a choroidal hemorrhage occurs or if the increased IOP from an effusion is resistant to treatment
it usually is best to terminate surgery The wound is sutured carefully intraocular miotics are administered and a peripheral iridectomy may be performed to help reposition the iris For effusions surgery can be deferred until later in the day or the next day when the fluid dynamics of the eye have returned to a more normal state
If a limited choroidal hemorrhage has occurred it is best to wait 2ndash3 weeks before attempting further surgery
presumably occurs from the rupture of a blood vessel that is placed under stretch
Risk factors include hypertension
glaucoma
nanophthalmos
high myopia
and chronic intraocular inflammation[26]
still occur at a rate between
045 for very experienced surgeons [1]
amp up to 147 for residents in training [2]
The frequency of retained
lens fragments is estimated at 03 to 11 [34]
The challenge of cataract surgery is to minimize
the risk of complications and to manage optimally
complications that do occur
B-scan ultrasonography 1 day after dislocation
of a lens nucleus into the vitreous cavity
in a patient who has high myopia
the early signs of posterior capsular rupture include
unusual deepening of the anterior chamber
decentration of the nucleus
or loss of efficiency of aspiration which suggests occlusion of the tip with vitreous
Usually Posterior capsular rupture is the most common
intraoperative complication in initial cases
The key factors are to minimize ocular trauma meticulously clean prolapsed vitreous
from the anterior segment if present and ensure secure fixation of the IOL
The review yielded 392 patients
Six (153) had intraocular pressure (gt or = 30 mm Hg) requiring treatment
1 (026) had painless iris prolapse
11 (281) had corneal abrasions
and 7 (178) were given a more intensive steroid regime (UVEITIS)
Corneal edema
No cases of fibrinous uveitis were recorded
J Cataract Refract Surg 1999 Jul25(7)985-8
Corneal edema is categorized according to severity in reversible and irreversible
bull reversible corneal edema- in 7 days 842-in 30 days 103
bull irreversible corneal edema ndash edemato bullous keratopathy (Corneal endothelial damage)
a significant statistical correlation of the corneal edema post phaco with the phaco-time and the type of cataract
Most common in pre-existing endothelial disorder
Edema is most often caused by Mechanical trauma Prolonged intraocular irrigation Inflammation And elevated IOP Toxic Solutions
Vitreocorneal Adherence and Persistent Corneal EdemaVitreocorneal Adherence and Persistent Corneal Edema
Points in ManagementPoints in Management
If epithelial edema is present in the face of a compact stroma immediately after surgery it is likely due to elevated lOP with intact endothelium
Corneal edema generally resolves completely within 4-6 weeks
As a rule if the corneal periphery is clear
the corneal edema will usually resolve with time
Corneal edema persisting after 3 months usually
does not clear and may require penetrating keratoplasty
Small wounds under 32 mm are much less prone to this complication
The sealing of the wound depends
the quality of the corneo-scleral tissue
the quality of incision
This in turn depends on certain intraoperatory complications
certain chronic diseases
thermal injury of the wound
If needed case can use a therapeutic contact lens
Intraoperatory injury with the phaco tip or instruments
(complicate cases)
amp some local or general associated conditions may cause pupil asymmetries
This will translate clinically by decreased visual acuity
lack of adaptation to strong light
Post operatory intraocular inflammation can be acute and chronic (endophthalmitis)
Chronic uveal inflammation may occur in weeks months or years after cataract
chronic inflammation
significant statistical correlations between post-intraocular inflammation on the
one hand and rupture of thecapsule
Cystoid macular edema
Retinal detachment
Persistent increase in intraocular pressure
Intraocular lens dislocation or subluxation
Choroidal detachment
Endophthalmitis
Corneal edema
There were more cases of posterior capsule tears and vitreous
loss in the first 80 cases performed by the residents
the posterior capsule tear rate peaked at more than 10 after
40 cases
Spontaneous
in-the-Bag Intraocular Lens Luxation
into the Vitreous Cavity
A Balestrazzi G M Tosi M Alegente C Mazzotta et al Ophthalmologica Basel Aug 2009 Vol 223 Iss 5 pg 339 4 pgs
National Cataract Register (NCR)
type of anesthesia
history of trauma
ocular comorbidity
axial length
miosis
cornea pathology and poor visibility
previous intraocular operation
iris synechias small pupil
white cataract brunescenthard cataract
phacodonesis
presence of pseudoexfoliation
surgeon experience 3 years or less (operating under senior supervision) or more than 3 years of independent
phacoemulsification practice
Major complications occurred in 15 of 320 cases (47) and involved 10 cases of vitreous loss
the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2)
wrong IOL power requiring reoperation (1)
corneal wound burn (1)
and postoperative iris prolapse requiring wound revision
The mean postoperative BCVA was 2026 (logMAR 011)
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
bullGAbullLA bull TOPICAL
secondary to posterior diffusion of an ophthalmic viscosurgical device-lidocaine solution during complicated phacoemulsification
Falzon K - J Cataract Refract Surg - 01-AUG-2009 35(8) 1472-3
The main drawback of local anesthesia is to enable the patient to perform movements during operation
Intra operatory complications
All cases where conjunctival hydration
occurred were clear corneal incisions
There was no need to convert the capsulorhexis
into an can-opener in any situation
In intumescences cataracts we performed a smaller rexis to avoid its failure After closing the rexis and cortex aspiration
broadening the rexis bringing it to the normal diameter
In white cataracts (mature hyper mature) used a colored substance to reveal the anterior capsule under air protection
The anterior chamber should be reinflated with an OVD
The vector forces of the tear should be changed to redirect the tear in a more central direction
If the tear is lost beneath the iris the capsulorrhexis should be restarted from its origin proceeding in the opposite direction (if possible this new capsulorrhexis should finish by incorporating the original tear in an outside-in direction however the original tear is often too peripheral to permit this and a single radial tear is created)
An alternative approach to a ldquolostrdquo capsulorrhexis is to convert to a can-opener capsulectomy
Preventing radial tears in the anterior capsule
Endocapsular phacoemulsification without hydrodissection
an effective technique for cataract surgery
following anterior capsular tear
Excessively small capsulorrhexis
Two major complications of hydro dissection are
- inadequate hydro dissection - over inflation of the capsular bag
the viscodissection technique was safer and more efficient than the non-dissection technique
Detachment of Descemetrsquos membrane can be a major
postoperative complication
it results in persistent corneal edema and decreased visual acuity
To prevent Descemetrsquos detachment the surgeon should carefully observe
the inner lip at each phase of the procedure
To avoid blunt stripping of Descemetrsquos membrane during
enlargement of the wound a sharp metal or diamond blade
is recommended
usually is caused when the anterior chamber is entered too posteriorly
such as near the iris root
If this is noted early in the case and interferes with the easy introduction of instruments into the eye
it is advisable to suture the incision amp move to another location
A second and more ominous cause of iris prolapse is an acute increase of intraocular pressure (IOP) accompanied by
choroidal effusion or hemorrhage
Bleeding in the anterior chamber can come from intra operatory damage of iris
This occurs most frequently in temporal incisions located more posterior and deeper than normal
In these cases there are reached the blood vessels with higher risk of bleeding
it appears that there is no significant statistical correlation with anticoagulant therapy or chronic anti agregant
Temporarily elevating the IOP with a balanced salt solution or an OVD
Injecting a dilute solution of preservative-free epinephrine 15000 (or a weaker solution)
Direct cautery (if the bleeding vessel can be identified) with a needle-tipped cautery probe
Iris bleeding is caused by iris trauma
Intraocular bleeding can be stopped by
Temporary loss of the chamber
After adjusting the parameters of aspiration and irrigation
and the introduction of viscoelastic substances
with high molecular weight
the situation was resolved favorably
(281)
All cases of hypertonic eye have been associated with temporary shallow anterior chamber earlier the correlation being statistically significant
hypertonic eye amp posterior capsule rupture has been reported ( was needed vitrectomy)
Correlation was not statistically significant
If for any reason the flow is blocked a corneal burn can occur within 1ndash3 s
additional suturing was required several days later Postoperatively the patient has 5 D of surgically induced astigmatism that has persisted for more than 5 years
Yanoff amp Duker Ophthalmology 3rd ed
the surgeon should attempt to identify the cause and lower the IOP Sometimes digital massage on the eye pressing directly on the incision can successfully lower the pressure It is useful to examine the fundus to ascertain whether a choroidal effusion or hemorrhage exists With choroidal effusion aspiration of vitreous can be helpful as can the administration of intravenous mannitol If a choroidal hemorrhage occurs or if the increased IOP from an effusion is resistant to treatment
it usually is best to terminate surgery The wound is sutured carefully intraocular miotics are administered and a peripheral iridectomy may be performed to help reposition the iris For effusions surgery can be deferred until later in the day or the next day when the fluid dynamics of the eye have returned to a more normal state
If a limited choroidal hemorrhage has occurred it is best to wait 2ndash3 weeks before attempting further surgery
presumably occurs from the rupture of a blood vessel that is placed under stretch
Risk factors include hypertension
glaucoma
nanophthalmos
high myopia
and chronic intraocular inflammation[26]
still occur at a rate between
045 for very experienced surgeons [1]
amp up to 147 for residents in training [2]
The frequency of retained
lens fragments is estimated at 03 to 11 [34]
The challenge of cataract surgery is to minimize
the risk of complications and to manage optimally
complications that do occur
B-scan ultrasonography 1 day after dislocation
of a lens nucleus into the vitreous cavity
in a patient who has high myopia
the early signs of posterior capsular rupture include
unusual deepening of the anterior chamber
decentration of the nucleus
or loss of efficiency of aspiration which suggests occlusion of the tip with vitreous
Usually Posterior capsular rupture is the most common
intraoperative complication in initial cases
The key factors are to minimize ocular trauma meticulously clean prolapsed vitreous
from the anterior segment if present and ensure secure fixation of the IOL
The review yielded 392 patients
Six (153) had intraocular pressure (gt or = 30 mm Hg) requiring treatment
1 (026) had painless iris prolapse
11 (281) had corneal abrasions
and 7 (178) were given a more intensive steroid regime (UVEITIS)
Corneal edema
No cases of fibrinous uveitis were recorded
J Cataract Refract Surg 1999 Jul25(7)985-8
Corneal edema is categorized according to severity in reversible and irreversible
bull reversible corneal edema- in 7 days 842-in 30 days 103
bull irreversible corneal edema ndash edemato bullous keratopathy (Corneal endothelial damage)
a significant statistical correlation of the corneal edema post phaco with the phaco-time and the type of cataract
Most common in pre-existing endothelial disorder
Edema is most often caused by Mechanical trauma Prolonged intraocular irrigation Inflammation And elevated IOP Toxic Solutions
Vitreocorneal Adherence and Persistent Corneal EdemaVitreocorneal Adherence and Persistent Corneal Edema
Points in ManagementPoints in Management
If epithelial edema is present in the face of a compact stroma immediately after surgery it is likely due to elevated lOP with intact endothelium
Corneal edema generally resolves completely within 4-6 weeks
As a rule if the corneal periphery is clear
the corneal edema will usually resolve with time
Corneal edema persisting after 3 months usually
does not clear and may require penetrating keratoplasty
Small wounds under 32 mm are much less prone to this complication
The sealing of the wound depends
the quality of the corneo-scleral tissue
the quality of incision
This in turn depends on certain intraoperatory complications
certain chronic diseases
thermal injury of the wound
If needed case can use a therapeutic contact lens
Intraoperatory injury with the phaco tip or instruments
(complicate cases)
amp some local or general associated conditions may cause pupil asymmetries
This will translate clinically by decreased visual acuity
lack of adaptation to strong light
Post operatory intraocular inflammation can be acute and chronic (endophthalmitis)
Chronic uveal inflammation may occur in weeks months or years after cataract
chronic inflammation
significant statistical correlations between post-intraocular inflammation on the
one hand and rupture of thecapsule
Cystoid macular edema
Retinal detachment
Persistent increase in intraocular pressure
Intraocular lens dislocation or subluxation
Choroidal detachment
Endophthalmitis
Corneal edema
There were more cases of posterior capsule tears and vitreous
loss in the first 80 cases performed by the residents
the posterior capsule tear rate peaked at more than 10 after
40 cases
Spontaneous
in-the-Bag Intraocular Lens Luxation
into the Vitreous Cavity
A Balestrazzi G M Tosi M Alegente C Mazzotta et al Ophthalmologica Basel Aug 2009 Vol 223 Iss 5 pg 339 4 pgs
National Cataract Register (NCR)
type of anesthesia
history of trauma
ocular comorbidity
axial length
miosis
cornea pathology and poor visibility
previous intraocular operation
iris synechias small pupil
white cataract brunescenthard cataract
phacodonesis
presence of pseudoexfoliation
surgeon experience 3 years or less (operating under senior supervision) or more than 3 years of independent
phacoemulsification practice
Major complications occurred in 15 of 320 cases (47) and involved 10 cases of vitreous loss
the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2)
wrong IOL power requiring reoperation (1)
corneal wound burn (1)
and postoperative iris prolapse requiring wound revision
The mean postoperative BCVA was 2026 (logMAR 011)
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
secondary to posterior diffusion of an ophthalmic viscosurgical device-lidocaine solution during complicated phacoemulsification
Falzon K - J Cataract Refract Surg - 01-AUG-2009 35(8) 1472-3
The main drawback of local anesthesia is to enable the patient to perform movements during operation
Intra operatory complications
All cases where conjunctival hydration
occurred were clear corneal incisions
There was no need to convert the capsulorhexis
into an can-opener in any situation
In intumescences cataracts we performed a smaller rexis to avoid its failure After closing the rexis and cortex aspiration
broadening the rexis bringing it to the normal diameter
In white cataracts (mature hyper mature) used a colored substance to reveal the anterior capsule under air protection
The anterior chamber should be reinflated with an OVD
The vector forces of the tear should be changed to redirect the tear in a more central direction
If the tear is lost beneath the iris the capsulorrhexis should be restarted from its origin proceeding in the opposite direction (if possible this new capsulorrhexis should finish by incorporating the original tear in an outside-in direction however the original tear is often too peripheral to permit this and a single radial tear is created)
An alternative approach to a ldquolostrdquo capsulorrhexis is to convert to a can-opener capsulectomy
Preventing radial tears in the anterior capsule
Endocapsular phacoemulsification without hydrodissection
an effective technique for cataract surgery
following anterior capsular tear
Excessively small capsulorrhexis
Two major complications of hydro dissection are
- inadequate hydro dissection - over inflation of the capsular bag
the viscodissection technique was safer and more efficient than the non-dissection technique
Detachment of Descemetrsquos membrane can be a major
postoperative complication
it results in persistent corneal edema and decreased visual acuity
To prevent Descemetrsquos detachment the surgeon should carefully observe
the inner lip at each phase of the procedure
To avoid blunt stripping of Descemetrsquos membrane during
enlargement of the wound a sharp metal or diamond blade
is recommended
usually is caused when the anterior chamber is entered too posteriorly
such as near the iris root
If this is noted early in the case and interferes with the easy introduction of instruments into the eye
it is advisable to suture the incision amp move to another location
A second and more ominous cause of iris prolapse is an acute increase of intraocular pressure (IOP) accompanied by
choroidal effusion or hemorrhage
Bleeding in the anterior chamber can come from intra operatory damage of iris
This occurs most frequently in temporal incisions located more posterior and deeper than normal
In these cases there are reached the blood vessels with higher risk of bleeding
it appears that there is no significant statistical correlation with anticoagulant therapy or chronic anti agregant
Temporarily elevating the IOP with a balanced salt solution or an OVD
Injecting a dilute solution of preservative-free epinephrine 15000 (or a weaker solution)
Direct cautery (if the bleeding vessel can be identified) with a needle-tipped cautery probe
Iris bleeding is caused by iris trauma
Intraocular bleeding can be stopped by
Temporary loss of the chamber
After adjusting the parameters of aspiration and irrigation
and the introduction of viscoelastic substances
with high molecular weight
the situation was resolved favorably
(281)
All cases of hypertonic eye have been associated with temporary shallow anterior chamber earlier the correlation being statistically significant
hypertonic eye amp posterior capsule rupture has been reported ( was needed vitrectomy)
Correlation was not statistically significant
If for any reason the flow is blocked a corneal burn can occur within 1ndash3 s
additional suturing was required several days later Postoperatively the patient has 5 D of surgically induced astigmatism that has persisted for more than 5 years
Yanoff amp Duker Ophthalmology 3rd ed
the surgeon should attempt to identify the cause and lower the IOP Sometimes digital massage on the eye pressing directly on the incision can successfully lower the pressure It is useful to examine the fundus to ascertain whether a choroidal effusion or hemorrhage exists With choroidal effusion aspiration of vitreous can be helpful as can the administration of intravenous mannitol If a choroidal hemorrhage occurs or if the increased IOP from an effusion is resistant to treatment
it usually is best to terminate surgery The wound is sutured carefully intraocular miotics are administered and a peripheral iridectomy may be performed to help reposition the iris For effusions surgery can be deferred until later in the day or the next day when the fluid dynamics of the eye have returned to a more normal state
If a limited choroidal hemorrhage has occurred it is best to wait 2ndash3 weeks before attempting further surgery
presumably occurs from the rupture of a blood vessel that is placed under stretch
Risk factors include hypertension
glaucoma
nanophthalmos
high myopia
and chronic intraocular inflammation[26]
still occur at a rate between
045 for very experienced surgeons [1]
amp up to 147 for residents in training [2]
The frequency of retained
lens fragments is estimated at 03 to 11 [34]
The challenge of cataract surgery is to minimize
the risk of complications and to manage optimally
complications that do occur
B-scan ultrasonography 1 day after dislocation
of a lens nucleus into the vitreous cavity
in a patient who has high myopia
the early signs of posterior capsular rupture include
unusual deepening of the anterior chamber
decentration of the nucleus
or loss of efficiency of aspiration which suggests occlusion of the tip with vitreous
Usually Posterior capsular rupture is the most common
intraoperative complication in initial cases
The key factors are to minimize ocular trauma meticulously clean prolapsed vitreous
from the anterior segment if present and ensure secure fixation of the IOL
The review yielded 392 patients
Six (153) had intraocular pressure (gt or = 30 mm Hg) requiring treatment
1 (026) had painless iris prolapse
11 (281) had corneal abrasions
and 7 (178) were given a more intensive steroid regime (UVEITIS)
Corneal edema
No cases of fibrinous uveitis were recorded
J Cataract Refract Surg 1999 Jul25(7)985-8
Corneal edema is categorized according to severity in reversible and irreversible
bull reversible corneal edema- in 7 days 842-in 30 days 103
bull irreversible corneal edema ndash edemato bullous keratopathy (Corneal endothelial damage)
a significant statistical correlation of the corneal edema post phaco with the phaco-time and the type of cataract
Most common in pre-existing endothelial disorder
Edema is most often caused by Mechanical trauma Prolonged intraocular irrigation Inflammation And elevated IOP Toxic Solutions
Vitreocorneal Adherence and Persistent Corneal EdemaVitreocorneal Adherence and Persistent Corneal Edema
Points in ManagementPoints in Management
If epithelial edema is present in the face of a compact stroma immediately after surgery it is likely due to elevated lOP with intact endothelium
Corneal edema generally resolves completely within 4-6 weeks
As a rule if the corneal periphery is clear
the corneal edema will usually resolve with time
Corneal edema persisting after 3 months usually
does not clear and may require penetrating keratoplasty
Small wounds under 32 mm are much less prone to this complication
The sealing of the wound depends
the quality of the corneo-scleral tissue
the quality of incision
This in turn depends on certain intraoperatory complications
certain chronic diseases
thermal injury of the wound
If needed case can use a therapeutic contact lens
Intraoperatory injury with the phaco tip or instruments
(complicate cases)
amp some local or general associated conditions may cause pupil asymmetries
This will translate clinically by decreased visual acuity
lack of adaptation to strong light
Post operatory intraocular inflammation can be acute and chronic (endophthalmitis)
Chronic uveal inflammation may occur in weeks months or years after cataract
chronic inflammation
significant statistical correlations between post-intraocular inflammation on the
one hand and rupture of thecapsule
Cystoid macular edema
Retinal detachment
Persistent increase in intraocular pressure
Intraocular lens dislocation or subluxation
Choroidal detachment
Endophthalmitis
Corneal edema
There were more cases of posterior capsule tears and vitreous
loss in the first 80 cases performed by the residents
the posterior capsule tear rate peaked at more than 10 after
40 cases
Spontaneous
in-the-Bag Intraocular Lens Luxation
into the Vitreous Cavity
A Balestrazzi G M Tosi M Alegente C Mazzotta et al Ophthalmologica Basel Aug 2009 Vol 223 Iss 5 pg 339 4 pgs
National Cataract Register (NCR)
type of anesthesia
history of trauma
ocular comorbidity
axial length
miosis
cornea pathology and poor visibility
previous intraocular operation
iris synechias small pupil
white cataract brunescenthard cataract
phacodonesis
presence of pseudoexfoliation
surgeon experience 3 years or less (operating under senior supervision) or more than 3 years of independent
phacoemulsification practice
Major complications occurred in 15 of 320 cases (47) and involved 10 cases of vitreous loss
the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2)
wrong IOL power requiring reoperation (1)
corneal wound burn (1)
and postoperative iris prolapse requiring wound revision
The mean postoperative BCVA was 2026 (logMAR 011)
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
The main drawback of local anesthesia is to enable the patient to perform movements during operation
Intra operatory complications
All cases where conjunctival hydration
occurred were clear corneal incisions
There was no need to convert the capsulorhexis
into an can-opener in any situation
In intumescences cataracts we performed a smaller rexis to avoid its failure After closing the rexis and cortex aspiration
broadening the rexis bringing it to the normal diameter
In white cataracts (mature hyper mature) used a colored substance to reveal the anterior capsule under air protection
The anterior chamber should be reinflated with an OVD
The vector forces of the tear should be changed to redirect the tear in a more central direction
If the tear is lost beneath the iris the capsulorrhexis should be restarted from its origin proceeding in the opposite direction (if possible this new capsulorrhexis should finish by incorporating the original tear in an outside-in direction however the original tear is often too peripheral to permit this and a single radial tear is created)
An alternative approach to a ldquolostrdquo capsulorrhexis is to convert to a can-opener capsulectomy
Preventing radial tears in the anterior capsule
Endocapsular phacoemulsification without hydrodissection
an effective technique for cataract surgery
following anterior capsular tear
Excessively small capsulorrhexis
Two major complications of hydro dissection are
- inadequate hydro dissection - over inflation of the capsular bag
the viscodissection technique was safer and more efficient than the non-dissection technique
Detachment of Descemetrsquos membrane can be a major
postoperative complication
it results in persistent corneal edema and decreased visual acuity
To prevent Descemetrsquos detachment the surgeon should carefully observe
the inner lip at each phase of the procedure
To avoid blunt stripping of Descemetrsquos membrane during
enlargement of the wound a sharp metal or diamond blade
is recommended
usually is caused when the anterior chamber is entered too posteriorly
such as near the iris root
If this is noted early in the case and interferes with the easy introduction of instruments into the eye
it is advisable to suture the incision amp move to another location
A second and more ominous cause of iris prolapse is an acute increase of intraocular pressure (IOP) accompanied by
choroidal effusion or hemorrhage
Bleeding in the anterior chamber can come from intra operatory damage of iris
This occurs most frequently in temporal incisions located more posterior and deeper than normal
In these cases there are reached the blood vessels with higher risk of bleeding
it appears that there is no significant statistical correlation with anticoagulant therapy or chronic anti agregant
Temporarily elevating the IOP with a balanced salt solution or an OVD
Injecting a dilute solution of preservative-free epinephrine 15000 (or a weaker solution)
Direct cautery (if the bleeding vessel can be identified) with a needle-tipped cautery probe
Iris bleeding is caused by iris trauma
Intraocular bleeding can be stopped by
Temporary loss of the chamber
After adjusting the parameters of aspiration and irrigation
and the introduction of viscoelastic substances
with high molecular weight
the situation was resolved favorably
(281)
All cases of hypertonic eye have been associated with temporary shallow anterior chamber earlier the correlation being statistically significant
hypertonic eye amp posterior capsule rupture has been reported ( was needed vitrectomy)
Correlation was not statistically significant
If for any reason the flow is blocked a corneal burn can occur within 1ndash3 s
additional suturing was required several days later Postoperatively the patient has 5 D of surgically induced astigmatism that has persisted for more than 5 years
Yanoff amp Duker Ophthalmology 3rd ed
the surgeon should attempt to identify the cause and lower the IOP Sometimes digital massage on the eye pressing directly on the incision can successfully lower the pressure It is useful to examine the fundus to ascertain whether a choroidal effusion or hemorrhage exists With choroidal effusion aspiration of vitreous can be helpful as can the administration of intravenous mannitol If a choroidal hemorrhage occurs or if the increased IOP from an effusion is resistant to treatment
it usually is best to terminate surgery The wound is sutured carefully intraocular miotics are administered and a peripheral iridectomy may be performed to help reposition the iris For effusions surgery can be deferred until later in the day or the next day when the fluid dynamics of the eye have returned to a more normal state
If a limited choroidal hemorrhage has occurred it is best to wait 2ndash3 weeks before attempting further surgery
presumably occurs from the rupture of a blood vessel that is placed under stretch
Risk factors include hypertension
glaucoma
nanophthalmos
high myopia
and chronic intraocular inflammation[26]
still occur at a rate between
045 for very experienced surgeons [1]
amp up to 147 for residents in training [2]
The frequency of retained
lens fragments is estimated at 03 to 11 [34]
The challenge of cataract surgery is to minimize
the risk of complications and to manage optimally
complications that do occur
B-scan ultrasonography 1 day after dislocation
of a lens nucleus into the vitreous cavity
in a patient who has high myopia
the early signs of posterior capsular rupture include
unusual deepening of the anterior chamber
decentration of the nucleus
or loss of efficiency of aspiration which suggests occlusion of the tip with vitreous
Usually Posterior capsular rupture is the most common
intraoperative complication in initial cases
The key factors are to minimize ocular trauma meticulously clean prolapsed vitreous
from the anterior segment if present and ensure secure fixation of the IOL
The review yielded 392 patients
Six (153) had intraocular pressure (gt or = 30 mm Hg) requiring treatment
1 (026) had painless iris prolapse
11 (281) had corneal abrasions
and 7 (178) were given a more intensive steroid regime (UVEITIS)
Corneal edema
No cases of fibrinous uveitis were recorded
J Cataract Refract Surg 1999 Jul25(7)985-8
Corneal edema is categorized according to severity in reversible and irreversible
bull reversible corneal edema- in 7 days 842-in 30 days 103
bull irreversible corneal edema ndash edemato bullous keratopathy (Corneal endothelial damage)
a significant statistical correlation of the corneal edema post phaco with the phaco-time and the type of cataract
Most common in pre-existing endothelial disorder
Edema is most often caused by Mechanical trauma Prolonged intraocular irrigation Inflammation And elevated IOP Toxic Solutions
Vitreocorneal Adherence and Persistent Corneal EdemaVitreocorneal Adherence and Persistent Corneal Edema
Points in ManagementPoints in Management
If epithelial edema is present in the face of a compact stroma immediately after surgery it is likely due to elevated lOP with intact endothelium
Corneal edema generally resolves completely within 4-6 weeks
As a rule if the corneal periphery is clear
the corneal edema will usually resolve with time
Corneal edema persisting after 3 months usually
does not clear and may require penetrating keratoplasty
Small wounds under 32 mm are much less prone to this complication
The sealing of the wound depends
the quality of the corneo-scleral tissue
the quality of incision
This in turn depends on certain intraoperatory complications
certain chronic diseases
thermal injury of the wound
If needed case can use a therapeutic contact lens
Intraoperatory injury with the phaco tip or instruments
(complicate cases)
amp some local or general associated conditions may cause pupil asymmetries
This will translate clinically by decreased visual acuity
lack of adaptation to strong light
Post operatory intraocular inflammation can be acute and chronic (endophthalmitis)
Chronic uveal inflammation may occur in weeks months or years after cataract
chronic inflammation
significant statistical correlations between post-intraocular inflammation on the
one hand and rupture of thecapsule
Cystoid macular edema
Retinal detachment
Persistent increase in intraocular pressure
Intraocular lens dislocation or subluxation
Choroidal detachment
Endophthalmitis
Corneal edema
There were more cases of posterior capsule tears and vitreous
loss in the first 80 cases performed by the residents
the posterior capsule tear rate peaked at more than 10 after
40 cases
Spontaneous
in-the-Bag Intraocular Lens Luxation
into the Vitreous Cavity
A Balestrazzi G M Tosi M Alegente C Mazzotta et al Ophthalmologica Basel Aug 2009 Vol 223 Iss 5 pg 339 4 pgs
National Cataract Register (NCR)
type of anesthesia
history of trauma
ocular comorbidity
axial length
miosis
cornea pathology and poor visibility
previous intraocular operation
iris synechias small pupil
white cataract brunescenthard cataract
phacodonesis
presence of pseudoexfoliation
surgeon experience 3 years or less (operating under senior supervision) or more than 3 years of independent
phacoemulsification practice
Major complications occurred in 15 of 320 cases (47) and involved 10 cases of vitreous loss
the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2)
wrong IOL power requiring reoperation (1)
corneal wound burn (1)
and postoperative iris prolapse requiring wound revision
The mean postoperative BCVA was 2026 (logMAR 011)
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
Intra operatory complications
All cases where conjunctival hydration
occurred were clear corneal incisions
There was no need to convert the capsulorhexis
into an can-opener in any situation
In intumescences cataracts we performed a smaller rexis to avoid its failure After closing the rexis and cortex aspiration
broadening the rexis bringing it to the normal diameter
In white cataracts (mature hyper mature) used a colored substance to reveal the anterior capsule under air protection
The anterior chamber should be reinflated with an OVD
The vector forces of the tear should be changed to redirect the tear in a more central direction
If the tear is lost beneath the iris the capsulorrhexis should be restarted from its origin proceeding in the opposite direction (if possible this new capsulorrhexis should finish by incorporating the original tear in an outside-in direction however the original tear is often too peripheral to permit this and a single radial tear is created)
An alternative approach to a ldquolostrdquo capsulorrhexis is to convert to a can-opener capsulectomy
Preventing radial tears in the anterior capsule
Endocapsular phacoemulsification without hydrodissection
an effective technique for cataract surgery
following anterior capsular tear
Excessively small capsulorrhexis
Two major complications of hydro dissection are
- inadequate hydro dissection - over inflation of the capsular bag
the viscodissection technique was safer and more efficient than the non-dissection technique
Detachment of Descemetrsquos membrane can be a major
postoperative complication
it results in persistent corneal edema and decreased visual acuity
To prevent Descemetrsquos detachment the surgeon should carefully observe
the inner lip at each phase of the procedure
To avoid blunt stripping of Descemetrsquos membrane during
enlargement of the wound a sharp metal or diamond blade
is recommended
usually is caused when the anterior chamber is entered too posteriorly
such as near the iris root
If this is noted early in the case and interferes with the easy introduction of instruments into the eye
it is advisable to suture the incision amp move to another location
A second and more ominous cause of iris prolapse is an acute increase of intraocular pressure (IOP) accompanied by
choroidal effusion or hemorrhage
Bleeding in the anterior chamber can come from intra operatory damage of iris
This occurs most frequently in temporal incisions located more posterior and deeper than normal
In these cases there are reached the blood vessels with higher risk of bleeding
it appears that there is no significant statistical correlation with anticoagulant therapy or chronic anti agregant
Temporarily elevating the IOP with a balanced salt solution or an OVD
Injecting a dilute solution of preservative-free epinephrine 15000 (or a weaker solution)
Direct cautery (if the bleeding vessel can be identified) with a needle-tipped cautery probe
Iris bleeding is caused by iris trauma
Intraocular bleeding can be stopped by
Temporary loss of the chamber
After adjusting the parameters of aspiration and irrigation
and the introduction of viscoelastic substances
with high molecular weight
the situation was resolved favorably
(281)
All cases of hypertonic eye have been associated with temporary shallow anterior chamber earlier the correlation being statistically significant
hypertonic eye amp posterior capsule rupture has been reported ( was needed vitrectomy)
Correlation was not statistically significant
If for any reason the flow is blocked a corneal burn can occur within 1ndash3 s
additional suturing was required several days later Postoperatively the patient has 5 D of surgically induced astigmatism that has persisted for more than 5 years
Yanoff amp Duker Ophthalmology 3rd ed
the surgeon should attempt to identify the cause and lower the IOP Sometimes digital massage on the eye pressing directly on the incision can successfully lower the pressure It is useful to examine the fundus to ascertain whether a choroidal effusion or hemorrhage exists With choroidal effusion aspiration of vitreous can be helpful as can the administration of intravenous mannitol If a choroidal hemorrhage occurs or if the increased IOP from an effusion is resistant to treatment
it usually is best to terminate surgery The wound is sutured carefully intraocular miotics are administered and a peripheral iridectomy may be performed to help reposition the iris For effusions surgery can be deferred until later in the day or the next day when the fluid dynamics of the eye have returned to a more normal state
If a limited choroidal hemorrhage has occurred it is best to wait 2ndash3 weeks before attempting further surgery
presumably occurs from the rupture of a blood vessel that is placed under stretch
Risk factors include hypertension
glaucoma
nanophthalmos
high myopia
and chronic intraocular inflammation[26]
still occur at a rate between
045 for very experienced surgeons [1]
amp up to 147 for residents in training [2]
The frequency of retained
lens fragments is estimated at 03 to 11 [34]
The challenge of cataract surgery is to minimize
the risk of complications and to manage optimally
complications that do occur
B-scan ultrasonography 1 day after dislocation
of a lens nucleus into the vitreous cavity
in a patient who has high myopia
the early signs of posterior capsular rupture include
unusual deepening of the anterior chamber
decentration of the nucleus
or loss of efficiency of aspiration which suggests occlusion of the tip with vitreous
Usually Posterior capsular rupture is the most common
intraoperative complication in initial cases
The key factors are to minimize ocular trauma meticulously clean prolapsed vitreous
from the anterior segment if present and ensure secure fixation of the IOL
The review yielded 392 patients
Six (153) had intraocular pressure (gt or = 30 mm Hg) requiring treatment
1 (026) had painless iris prolapse
11 (281) had corneal abrasions
and 7 (178) were given a more intensive steroid regime (UVEITIS)
Corneal edema
No cases of fibrinous uveitis were recorded
J Cataract Refract Surg 1999 Jul25(7)985-8
Corneal edema is categorized according to severity in reversible and irreversible
bull reversible corneal edema- in 7 days 842-in 30 days 103
bull irreversible corneal edema ndash edemato bullous keratopathy (Corneal endothelial damage)
a significant statistical correlation of the corneal edema post phaco with the phaco-time and the type of cataract
Most common in pre-existing endothelial disorder
Edema is most often caused by Mechanical trauma Prolonged intraocular irrigation Inflammation And elevated IOP Toxic Solutions
Vitreocorneal Adherence and Persistent Corneal EdemaVitreocorneal Adherence and Persistent Corneal Edema
Points in ManagementPoints in Management
If epithelial edema is present in the face of a compact stroma immediately after surgery it is likely due to elevated lOP with intact endothelium
Corneal edema generally resolves completely within 4-6 weeks
As a rule if the corneal periphery is clear
the corneal edema will usually resolve with time
Corneal edema persisting after 3 months usually
does not clear and may require penetrating keratoplasty
Small wounds under 32 mm are much less prone to this complication
The sealing of the wound depends
the quality of the corneo-scleral tissue
the quality of incision
This in turn depends on certain intraoperatory complications
certain chronic diseases
thermal injury of the wound
If needed case can use a therapeutic contact lens
Intraoperatory injury with the phaco tip or instruments
(complicate cases)
amp some local or general associated conditions may cause pupil asymmetries
This will translate clinically by decreased visual acuity
lack of adaptation to strong light
Post operatory intraocular inflammation can be acute and chronic (endophthalmitis)
Chronic uveal inflammation may occur in weeks months or years after cataract
chronic inflammation
significant statistical correlations between post-intraocular inflammation on the
one hand and rupture of thecapsule
Cystoid macular edema
Retinal detachment
Persistent increase in intraocular pressure
Intraocular lens dislocation or subluxation
Choroidal detachment
Endophthalmitis
Corneal edema
There were more cases of posterior capsule tears and vitreous
loss in the first 80 cases performed by the residents
the posterior capsule tear rate peaked at more than 10 after
40 cases
Spontaneous
in-the-Bag Intraocular Lens Luxation
into the Vitreous Cavity
A Balestrazzi G M Tosi M Alegente C Mazzotta et al Ophthalmologica Basel Aug 2009 Vol 223 Iss 5 pg 339 4 pgs
National Cataract Register (NCR)
type of anesthesia
history of trauma
ocular comorbidity
axial length
miosis
cornea pathology and poor visibility
previous intraocular operation
iris synechias small pupil
white cataract brunescenthard cataract
phacodonesis
presence of pseudoexfoliation
surgeon experience 3 years or less (operating under senior supervision) or more than 3 years of independent
phacoemulsification practice
Major complications occurred in 15 of 320 cases (47) and involved 10 cases of vitreous loss
the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2)
wrong IOL power requiring reoperation (1)
corneal wound burn (1)
and postoperative iris prolapse requiring wound revision
The mean postoperative BCVA was 2026 (logMAR 011)
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
All cases where conjunctival hydration
occurred were clear corneal incisions
There was no need to convert the capsulorhexis
into an can-opener in any situation
In intumescences cataracts we performed a smaller rexis to avoid its failure After closing the rexis and cortex aspiration
broadening the rexis bringing it to the normal diameter
In white cataracts (mature hyper mature) used a colored substance to reveal the anterior capsule under air protection
The anterior chamber should be reinflated with an OVD
The vector forces of the tear should be changed to redirect the tear in a more central direction
If the tear is lost beneath the iris the capsulorrhexis should be restarted from its origin proceeding in the opposite direction (if possible this new capsulorrhexis should finish by incorporating the original tear in an outside-in direction however the original tear is often too peripheral to permit this and a single radial tear is created)
An alternative approach to a ldquolostrdquo capsulorrhexis is to convert to a can-opener capsulectomy
Preventing radial tears in the anterior capsule
Endocapsular phacoemulsification without hydrodissection
an effective technique for cataract surgery
following anterior capsular tear
Excessively small capsulorrhexis
Two major complications of hydro dissection are
- inadequate hydro dissection - over inflation of the capsular bag
the viscodissection technique was safer and more efficient than the non-dissection technique
Detachment of Descemetrsquos membrane can be a major
postoperative complication
it results in persistent corneal edema and decreased visual acuity
To prevent Descemetrsquos detachment the surgeon should carefully observe
the inner lip at each phase of the procedure
To avoid blunt stripping of Descemetrsquos membrane during
enlargement of the wound a sharp metal or diamond blade
is recommended
usually is caused when the anterior chamber is entered too posteriorly
such as near the iris root
If this is noted early in the case and interferes with the easy introduction of instruments into the eye
it is advisable to suture the incision amp move to another location
A second and more ominous cause of iris prolapse is an acute increase of intraocular pressure (IOP) accompanied by
choroidal effusion or hemorrhage
Bleeding in the anterior chamber can come from intra operatory damage of iris
This occurs most frequently in temporal incisions located more posterior and deeper than normal
In these cases there are reached the blood vessels with higher risk of bleeding
it appears that there is no significant statistical correlation with anticoagulant therapy or chronic anti agregant
Temporarily elevating the IOP with a balanced salt solution or an OVD
Injecting a dilute solution of preservative-free epinephrine 15000 (or a weaker solution)
Direct cautery (if the bleeding vessel can be identified) with a needle-tipped cautery probe
Iris bleeding is caused by iris trauma
Intraocular bleeding can be stopped by
Temporary loss of the chamber
After adjusting the parameters of aspiration and irrigation
and the introduction of viscoelastic substances
with high molecular weight
the situation was resolved favorably
(281)
All cases of hypertonic eye have been associated with temporary shallow anterior chamber earlier the correlation being statistically significant
hypertonic eye amp posterior capsule rupture has been reported ( was needed vitrectomy)
Correlation was not statistically significant
If for any reason the flow is blocked a corneal burn can occur within 1ndash3 s
additional suturing was required several days later Postoperatively the patient has 5 D of surgically induced astigmatism that has persisted for more than 5 years
Yanoff amp Duker Ophthalmology 3rd ed
the surgeon should attempt to identify the cause and lower the IOP Sometimes digital massage on the eye pressing directly on the incision can successfully lower the pressure It is useful to examine the fundus to ascertain whether a choroidal effusion or hemorrhage exists With choroidal effusion aspiration of vitreous can be helpful as can the administration of intravenous mannitol If a choroidal hemorrhage occurs or if the increased IOP from an effusion is resistant to treatment
it usually is best to terminate surgery The wound is sutured carefully intraocular miotics are administered and a peripheral iridectomy may be performed to help reposition the iris For effusions surgery can be deferred until later in the day or the next day when the fluid dynamics of the eye have returned to a more normal state
If a limited choroidal hemorrhage has occurred it is best to wait 2ndash3 weeks before attempting further surgery
presumably occurs from the rupture of a blood vessel that is placed under stretch
Risk factors include hypertension
glaucoma
nanophthalmos
high myopia
and chronic intraocular inflammation[26]
still occur at a rate between
045 for very experienced surgeons [1]
amp up to 147 for residents in training [2]
The frequency of retained
lens fragments is estimated at 03 to 11 [34]
The challenge of cataract surgery is to minimize
the risk of complications and to manage optimally
complications that do occur
B-scan ultrasonography 1 day after dislocation
of a lens nucleus into the vitreous cavity
in a patient who has high myopia
the early signs of posterior capsular rupture include
unusual deepening of the anterior chamber
decentration of the nucleus
or loss of efficiency of aspiration which suggests occlusion of the tip with vitreous
Usually Posterior capsular rupture is the most common
intraoperative complication in initial cases
The key factors are to minimize ocular trauma meticulously clean prolapsed vitreous
from the anterior segment if present and ensure secure fixation of the IOL
The review yielded 392 patients
Six (153) had intraocular pressure (gt or = 30 mm Hg) requiring treatment
1 (026) had painless iris prolapse
11 (281) had corneal abrasions
and 7 (178) were given a more intensive steroid regime (UVEITIS)
Corneal edema
No cases of fibrinous uveitis were recorded
J Cataract Refract Surg 1999 Jul25(7)985-8
Corneal edema is categorized according to severity in reversible and irreversible
bull reversible corneal edema- in 7 days 842-in 30 days 103
bull irreversible corneal edema ndash edemato bullous keratopathy (Corneal endothelial damage)
a significant statistical correlation of the corneal edema post phaco with the phaco-time and the type of cataract
Most common in pre-existing endothelial disorder
Edema is most often caused by Mechanical trauma Prolonged intraocular irrigation Inflammation And elevated IOP Toxic Solutions
Vitreocorneal Adherence and Persistent Corneal EdemaVitreocorneal Adherence and Persistent Corneal Edema
Points in ManagementPoints in Management
If epithelial edema is present in the face of a compact stroma immediately after surgery it is likely due to elevated lOP with intact endothelium
Corneal edema generally resolves completely within 4-6 weeks
As a rule if the corneal periphery is clear
the corneal edema will usually resolve with time
Corneal edema persisting after 3 months usually
does not clear and may require penetrating keratoplasty
Small wounds under 32 mm are much less prone to this complication
The sealing of the wound depends
the quality of the corneo-scleral tissue
the quality of incision
This in turn depends on certain intraoperatory complications
certain chronic diseases
thermal injury of the wound
If needed case can use a therapeutic contact lens
Intraoperatory injury with the phaco tip or instruments
(complicate cases)
amp some local or general associated conditions may cause pupil asymmetries
This will translate clinically by decreased visual acuity
lack of adaptation to strong light
Post operatory intraocular inflammation can be acute and chronic (endophthalmitis)
Chronic uveal inflammation may occur in weeks months or years after cataract
chronic inflammation
significant statistical correlations between post-intraocular inflammation on the
one hand and rupture of thecapsule
Cystoid macular edema
Retinal detachment
Persistent increase in intraocular pressure
Intraocular lens dislocation or subluxation
Choroidal detachment
Endophthalmitis
Corneal edema
There were more cases of posterior capsule tears and vitreous
loss in the first 80 cases performed by the residents
the posterior capsule tear rate peaked at more than 10 after
40 cases
Spontaneous
in-the-Bag Intraocular Lens Luxation
into the Vitreous Cavity
A Balestrazzi G M Tosi M Alegente C Mazzotta et al Ophthalmologica Basel Aug 2009 Vol 223 Iss 5 pg 339 4 pgs
National Cataract Register (NCR)
type of anesthesia
history of trauma
ocular comorbidity
axial length
miosis
cornea pathology and poor visibility
previous intraocular operation
iris synechias small pupil
white cataract brunescenthard cataract
phacodonesis
presence of pseudoexfoliation
surgeon experience 3 years or less (operating under senior supervision) or more than 3 years of independent
phacoemulsification practice
Major complications occurred in 15 of 320 cases (47) and involved 10 cases of vitreous loss
the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2)
wrong IOL power requiring reoperation (1)
corneal wound burn (1)
and postoperative iris prolapse requiring wound revision
The mean postoperative BCVA was 2026 (logMAR 011)
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
There was no need to convert the capsulorhexis
into an can-opener in any situation
In intumescences cataracts we performed a smaller rexis to avoid its failure After closing the rexis and cortex aspiration
broadening the rexis bringing it to the normal diameter
In white cataracts (mature hyper mature) used a colored substance to reveal the anterior capsule under air protection
The anterior chamber should be reinflated with an OVD
The vector forces of the tear should be changed to redirect the tear in a more central direction
If the tear is lost beneath the iris the capsulorrhexis should be restarted from its origin proceeding in the opposite direction (if possible this new capsulorrhexis should finish by incorporating the original tear in an outside-in direction however the original tear is often too peripheral to permit this and a single radial tear is created)
An alternative approach to a ldquolostrdquo capsulorrhexis is to convert to a can-opener capsulectomy
Preventing radial tears in the anterior capsule
Endocapsular phacoemulsification without hydrodissection
an effective technique for cataract surgery
following anterior capsular tear
Excessively small capsulorrhexis
Two major complications of hydro dissection are
- inadequate hydro dissection - over inflation of the capsular bag
the viscodissection technique was safer and more efficient than the non-dissection technique
Detachment of Descemetrsquos membrane can be a major
postoperative complication
it results in persistent corneal edema and decreased visual acuity
To prevent Descemetrsquos detachment the surgeon should carefully observe
the inner lip at each phase of the procedure
To avoid blunt stripping of Descemetrsquos membrane during
enlargement of the wound a sharp metal or diamond blade
is recommended
usually is caused when the anterior chamber is entered too posteriorly
such as near the iris root
If this is noted early in the case and interferes with the easy introduction of instruments into the eye
it is advisable to suture the incision amp move to another location
A second and more ominous cause of iris prolapse is an acute increase of intraocular pressure (IOP) accompanied by
choroidal effusion or hemorrhage
Bleeding in the anterior chamber can come from intra operatory damage of iris
This occurs most frequently in temporal incisions located more posterior and deeper than normal
In these cases there are reached the blood vessels with higher risk of bleeding
it appears that there is no significant statistical correlation with anticoagulant therapy or chronic anti agregant
Temporarily elevating the IOP with a balanced salt solution or an OVD
Injecting a dilute solution of preservative-free epinephrine 15000 (or a weaker solution)
Direct cautery (if the bleeding vessel can be identified) with a needle-tipped cautery probe
Iris bleeding is caused by iris trauma
Intraocular bleeding can be stopped by
Temporary loss of the chamber
After adjusting the parameters of aspiration and irrigation
and the introduction of viscoelastic substances
with high molecular weight
the situation was resolved favorably
(281)
All cases of hypertonic eye have been associated with temporary shallow anterior chamber earlier the correlation being statistically significant
hypertonic eye amp posterior capsule rupture has been reported ( was needed vitrectomy)
Correlation was not statistically significant
If for any reason the flow is blocked a corneal burn can occur within 1ndash3 s
additional suturing was required several days later Postoperatively the patient has 5 D of surgically induced astigmatism that has persisted for more than 5 years
Yanoff amp Duker Ophthalmology 3rd ed
the surgeon should attempt to identify the cause and lower the IOP Sometimes digital massage on the eye pressing directly on the incision can successfully lower the pressure It is useful to examine the fundus to ascertain whether a choroidal effusion or hemorrhage exists With choroidal effusion aspiration of vitreous can be helpful as can the administration of intravenous mannitol If a choroidal hemorrhage occurs or if the increased IOP from an effusion is resistant to treatment
it usually is best to terminate surgery The wound is sutured carefully intraocular miotics are administered and a peripheral iridectomy may be performed to help reposition the iris For effusions surgery can be deferred until later in the day or the next day when the fluid dynamics of the eye have returned to a more normal state
If a limited choroidal hemorrhage has occurred it is best to wait 2ndash3 weeks before attempting further surgery
presumably occurs from the rupture of a blood vessel that is placed under stretch
Risk factors include hypertension
glaucoma
nanophthalmos
high myopia
and chronic intraocular inflammation[26]
still occur at a rate between
045 for very experienced surgeons [1]
amp up to 147 for residents in training [2]
The frequency of retained
lens fragments is estimated at 03 to 11 [34]
The challenge of cataract surgery is to minimize
the risk of complications and to manage optimally
complications that do occur
B-scan ultrasonography 1 day after dislocation
of a lens nucleus into the vitreous cavity
in a patient who has high myopia
the early signs of posterior capsular rupture include
unusual deepening of the anterior chamber
decentration of the nucleus
or loss of efficiency of aspiration which suggests occlusion of the tip with vitreous
Usually Posterior capsular rupture is the most common
intraoperative complication in initial cases
The key factors are to minimize ocular trauma meticulously clean prolapsed vitreous
from the anterior segment if present and ensure secure fixation of the IOL
The review yielded 392 patients
Six (153) had intraocular pressure (gt or = 30 mm Hg) requiring treatment
1 (026) had painless iris prolapse
11 (281) had corneal abrasions
and 7 (178) were given a more intensive steroid regime (UVEITIS)
Corneal edema
No cases of fibrinous uveitis were recorded
J Cataract Refract Surg 1999 Jul25(7)985-8
Corneal edema is categorized according to severity in reversible and irreversible
bull reversible corneal edema- in 7 days 842-in 30 days 103
bull irreversible corneal edema ndash edemato bullous keratopathy (Corneal endothelial damage)
a significant statistical correlation of the corneal edema post phaco with the phaco-time and the type of cataract
Most common in pre-existing endothelial disorder
Edema is most often caused by Mechanical trauma Prolonged intraocular irrigation Inflammation And elevated IOP Toxic Solutions
Vitreocorneal Adherence and Persistent Corneal EdemaVitreocorneal Adherence and Persistent Corneal Edema
Points in ManagementPoints in Management
If epithelial edema is present in the face of a compact stroma immediately after surgery it is likely due to elevated lOP with intact endothelium
Corneal edema generally resolves completely within 4-6 weeks
As a rule if the corneal periphery is clear
the corneal edema will usually resolve with time
Corneal edema persisting after 3 months usually
does not clear and may require penetrating keratoplasty
Small wounds under 32 mm are much less prone to this complication
The sealing of the wound depends
the quality of the corneo-scleral tissue
the quality of incision
This in turn depends on certain intraoperatory complications
certain chronic diseases
thermal injury of the wound
If needed case can use a therapeutic contact lens
Intraoperatory injury with the phaco tip or instruments
(complicate cases)
amp some local or general associated conditions may cause pupil asymmetries
This will translate clinically by decreased visual acuity
lack of adaptation to strong light
Post operatory intraocular inflammation can be acute and chronic (endophthalmitis)
Chronic uveal inflammation may occur in weeks months or years after cataract
chronic inflammation
significant statistical correlations between post-intraocular inflammation on the
one hand and rupture of thecapsule
Cystoid macular edema
Retinal detachment
Persistent increase in intraocular pressure
Intraocular lens dislocation or subluxation
Choroidal detachment
Endophthalmitis
Corneal edema
There were more cases of posterior capsule tears and vitreous
loss in the first 80 cases performed by the residents
the posterior capsule tear rate peaked at more than 10 after
40 cases
Spontaneous
in-the-Bag Intraocular Lens Luxation
into the Vitreous Cavity
A Balestrazzi G M Tosi M Alegente C Mazzotta et al Ophthalmologica Basel Aug 2009 Vol 223 Iss 5 pg 339 4 pgs
National Cataract Register (NCR)
type of anesthesia
history of trauma
ocular comorbidity
axial length
miosis
cornea pathology and poor visibility
previous intraocular operation
iris synechias small pupil
white cataract brunescenthard cataract
phacodonesis
presence of pseudoexfoliation
surgeon experience 3 years or less (operating under senior supervision) or more than 3 years of independent
phacoemulsification practice
Major complications occurred in 15 of 320 cases (47) and involved 10 cases of vitreous loss
the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2)
wrong IOL power requiring reoperation (1)
corneal wound burn (1)
and postoperative iris prolapse requiring wound revision
The mean postoperative BCVA was 2026 (logMAR 011)
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
The anterior chamber should be reinflated with an OVD
The vector forces of the tear should be changed to redirect the tear in a more central direction
If the tear is lost beneath the iris the capsulorrhexis should be restarted from its origin proceeding in the opposite direction (if possible this new capsulorrhexis should finish by incorporating the original tear in an outside-in direction however the original tear is often too peripheral to permit this and a single radial tear is created)
An alternative approach to a ldquolostrdquo capsulorrhexis is to convert to a can-opener capsulectomy
Preventing radial tears in the anterior capsule
Endocapsular phacoemulsification without hydrodissection
an effective technique for cataract surgery
following anterior capsular tear
Excessively small capsulorrhexis
Two major complications of hydro dissection are
- inadequate hydro dissection - over inflation of the capsular bag
the viscodissection technique was safer and more efficient than the non-dissection technique
Detachment of Descemetrsquos membrane can be a major
postoperative complication
it results in persistent corneal edema and decreased visual acuity
To prevent Descemetrsquos detachment the surgeon should carefully observe
the inner lip at each phase of the procedure
To avoid blunt stripping of Descemetrsquos membrane during
enlargement of the wound a sharp metal or diamond blade
is recommended
usually is caused when the anterior chamber is entered too posteriorly
such as near the iris root
If this is noted early in the case and interferes with the easy introduction of instruments into the eye
it is advisable to suture the incision amp move to another location
A second and more ominous cause of iris prolapse is an acute increase of intraocular pressure (IOP) accompanied by
choroidal effusion or hemorrhage
Bleeding in the anterior chamber can come from intra operatory damage of iris
This occurs most frequently in temporal incisions located more posterior and deeper than normal
In these cases there are reached the blood vessels with higher risk of bleeding
it appears that there is no significant statistical correlation with anticoagulant therapy or chronic anti agregant
Temporarily elevating the IOP with a balanced salt solution or an OVD
Injecting a dilute solution of preservative-free epinephrine 15000 (or a weaker solution)
Direct cautery (if the bleeding vessel can be identified) with a needle-tipped cautery probe
Iris bleeding is caused by iris trauma
Intraocular bleeding can be stopped by
Temporary loss of the chamber
After adjusting the parameters of aspiration and irrigation
and the introduction of viscoelastic substances
with high molecular weight
the situation was resolved favorably
(281)
All cases of hypertonic eye have been associated with temporary shallow anterior chamber earlier the correlation being statistically significant
hypertonic eye amp posterior capsule rupture has been reported ( was needed vitrectomy)
Correlation was not statistically significant
If for any reason the flow is blocked a corneal burn can occur within 1ndash3 s
additional suturing was required several days later Postoperatively the patient has 5 D of surgically induced astigmatism that has persisted for more than 5 years
Yanoff amp Duker Ophthalmology 3rd ed
the surgeon should attempt to identify the cause and lower the IOP Sometimes digital massage on the eye pressing directly on the incision can successfully lower the pressure It is useful to examine the fundus to ascertain whether a choroidal effusion or hemorrhage exists With choroidal effusion aspiration of vitreous can be helpful as can the administration of intravenous mannitol If a choroidal hemorrhage occurs or if the increased IOP from an effusion is resistant to treatment
it usually is best to terminate surgery The wound is sutured carefully intraocular miotics are administered and a peripheral iridectomy may be performed to help reposition the iris For effusions surgery can be deferred until later in the day or the next day when the fluid dynamics of the eye have returned to a more normal state
If a limited choroidal hemorrhage has occurred it is best to wait 2ndash3 weeks before attempting further surgery
presumably occurs from the rupture of a blood vessel that is placed under stretch
Risk factors include hypertension
glaucoma
nanophthalmos
high myopia
and chronic intraocular inflammation[26]
still occur at a rate between
045 for very experienced surgeons [1]
amp up to 147 for residents in training [2]
The frequency of retained
lens fragments is estimated at 03 to 11 [34]
The challenge of cataract surgery is to minimize
the risk of complications and to manage optimally
complications that do occur
B-scan ultrasonography 1 day after dislocation
of a lens nucleus into the vitreous cavity
in a patient who has high myopia
the early signs of posterior capsular rupture include
unusual deepening of the anterior chamber
decentration of the nucleus
or loss of efficiency of aspiration which suggests occlusion of the tip with vitreous
Usually Posterior capsular rupture is the most common
intraoperative complication in initial cases
The key factors are to minimize ocular trauma meticulously clean prolapsed vitreous
from the anterior segment if present and ensure secure fixation of the IOL
The review yielded 392 patients
Six (153) had intraocular pressure (gt or = 30 mm Hg) requiring treatment
1 (026) had painless iris prolapse
11 (281) had corneal abrasions
and 7 (178) were given a more intensive steroid regime (UVEITIS)
Corneal edema
No cases of fibrinous uveitis were recorded
J Cataract Refract Surg 1999 Jul25(7)985-8
Corneal edema is categorized according to severity in reversible and irreversible
bull reversible corneal edema- in 7 days 842-in 30 days 103
bull irreversible corneal edema ndash edemato bullous keratopathy (Corneal endothelial damage)
a significant statistical correlation of the corneal edema post phaco with the phaco-time and the type of cataract
Most common in pre-existing endothelial disorder
Edema is most often caused by Mechanical trauma Prolonged intraocular irrigation Inflammation And elevated IOP Toxic Solutions
Vitreocorneal Adherence and Persistent Corneal EdemaVitreocorneal Adherence and Persistent Corneal Edema
Points in ManagementPoints in Management
If epithelial edema is present in the face of a compact stroma immediately after surgery it is likely due to elevated lOP with intact endothelium
Corneal edema generally resolves completely within 4-6 weeks
As a rule if the corneal periphery is clear
the corneal edema will usually resolve with time
Corneal edema persisting after 3 months usually
does not clear and may require penetrating keratoplasty
Small wounds under 32 mm are much less prone to this complication
The sealing of the wound depends
the quality of the corneo-scleral tissue
the quality of incision
This in turn depends on certain intraoperatory complications
certain chronic diseases
thermal injury of the wound
If needed case can use a therapeutic contact lens
Intraoperatory injury with the phaco tip or instruments
(complicate cases)
amp some local or general associated conditions may cause pupil asymmetries
This will translate clinically by decreased visual acuity
lack of adaptation to strong light
Post operatory intraocular inflammation can be acute and chronic (endophthalmitis)
Chronic uveal inflammation may occur in weeks months or years after cataract
chronic inflammation
significant statistical correlations between post-intraocular inflammation on the
one hand and rupture of thecapsule
Cystoid macular edema
Retinal detachment
Persistent increase in intraocular pressure
Intraocular lens dislocation or subluxation
Choroidal detachment
Endophthalmitis
Corneal edema
There were more cases of posterior capsule tears and vitreous
loss in the first 80 cases performed by the residents
the posterior capsule tear rate peaked at more than 10 after
40 cases
Spontaneous
in-the-Bag Intraocular Lens Luxation
into the Vitreous Cavity
A Balestrazzi G M Tosi M Alegente C Mazzotta et al Ophthalmologica Basel Aug 2009 Vol 223 Iss 5 pg 339 4 pgs
National Cataract Register (NCR)
type of anesthesia
history of trauma
ocular comorbidity
axial length
miosis
cornea pathology and poor visibility
previous intraocular operation
iris synechias small pupil
white cataract brunescenthard cataract
phacodonesis
presence of pseudoexfoliation
surgeon experience 3 years or less (operating under senior supervision) or more than 3 years of independent
phacoemulsification practice
Major complications occurred in 15 of 320 cases (47) and involved 10 cases of vitreous loss
the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2)
wrong IOL power requiring reoperation (1)
corneal wound burn (1)
and postoperative iris prolapse requiring wound revision
The mean postoperative BCVA was 2026 (logMAR 011)
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
Endocapsular phacoemulsification without hydrodissection
an effective technique for cataract surgery
following anterior capsular tear
Excessively small capsulorrhexis
Two major complications of hydro dissection are
- inadequate hydro dissection - over inflation of the capsular bag
the viscodissection technique was safer and more efficient than the non-dissection technique
Detachment of Descemetrsquos membrane can be a major
postoperative complication
it results in persistent corneal edema and decreased visual acuity
To prevent Descemetrsquos detachment the surgeon should carefully observe
the inner lip at each phase of the procedure
To avoid blunt stripping of Descemetrsquos membrane during
enlargement of the wound a sharp metal or diamond blade
is recommended
usually is caused when the anterior chamber is entered too posteriorly
such as near the iris root
If this is noted early in the case and interferes with the easy introduction of instruments into the eye
it is advisable to suture the incision amp move to another location
A second and more ominous cause of iris prolapse is an acute increase of intraocular pressure (IOP) accompanied by
choroidal effusion or hemorrhage
Bleeding in the anterior chamber can come from intra operatory damage of iris
This occurs most frequently in temporal incisions located more posterior and deeper than normal
In these cases there are reached the blood vessels with higher risk of bleeding
it appears that there is no significant statistical correlation with anticoagulant therapy or chronic anti agregant
Temporarily elevating the IOP with a balanced salt solution or an OVD
Injecting a dilute solution of preservative-free epinephrine 15000 (or a weaker solution)
Direct cautery (if the bleeding vessel can be identified) with a needle-tipped cautery probe
Iris bleeding is caused by iris trauma
Intraocular bleeding can be stopped by
Temporary loss of the chamber
After adjusting the parameters of aspiration and irrigation
and the introduction of viscoelastic substances
with high molecular weight
the situation was resolved favorably
(281)
All cases of hypertonic eye have been associated with temporary shallow anterior chamber earlier the correlation being statistically significant
hypertonic eye amp posterior capsule rupture has been reported ( was needed vitrectomy)
Correlation was not statistically significant
If for any reason the flow is blocked a corneal burn can occur within 1ndash3 s
additional suturing was required several days later Postoperatively the patient has 5 D of surgically induced astigmatism that has persisted for more than 5 years
Yanoff amp Duker Ophthalmology 3rd ed
the surgeon should attempt to identify the cause and lower the IOP Sometimes digital massage on the eye pressing directly on the incision can successfully lower the pressure It is useful to examine the fundus to ascertain whether a choroidal effusion or hemorrhage exists With choroidal effusion aspiration of vitreous can be helpful as can the administration of intravenous mannitol If a choroidal hemorrhage occurs or if the increased IOP from an effusion is resistant to treatment
it usually is best to terminate surgery The wound is sutured carefully intraocular miotics are administered and a peripheral iridectomy may be performed to help reposition the iris For effusions surgery can be deferred until later in the day or the next day when the fluid dynamics of the eye have returned to a more normal state
If a limited choroidal hemorrhage has occurred it is best to wait 2ndash3 weeks before attempting further surgery
presumably occurs from the rupture of a blood vessel that is placed under stretch
Risk factors include hypertension
glaucoma
nanophthalmos
high myopia
and chronic intraocular inflammation[26]
still occur at a rate between
045 for very experienced surgeons [1]
amp up to 147 for residents in training [2]
The frequency of retained
lens fragments is estimated at 03 to 11 [34]
The challenge of cataract surgery is to minimize
the risk of complications and to manage optimally
complications that do occur
B-scan ultrasonography 1 day after dislocation
of a lens nucleus into the vitreous cavity
in a patient who has high myopia
the early signs of posterior capsular rupture include
unusual deepening of the anterior chamber
decentration of the nucleus
or loss of efficiency of aspiration which suggests occlusion of the tip with vitreous
Usually Posterior capsular rupture is the most common
intraoperative complication in initial cases
The key factors are to minimize ocular trauma meticulously clean prolapsed vitreous
from the anterior segment if present and ensure secure fixation of the IOL
The review yielded 392 patients
Six (153) had intraocular pressure (gt or = 30 mm Hg) requiring treatment
1 (026) had painless iris prolapse
11 (281) had corneal abrasions
and 7 (178) were given a more intensive steroid regime (UVEITIS)
Corneal edema
No cases of fibrinous uveitis were recorded
J Cataract Refract Surg 1999 Jul25(7)985-8
Corneal edema is categorized according to severity in reversible and irreversible
bull reversible corneal edema- in 7 days 842-in 30 days 103
bull irreversible corneal edema ndash edemato bullous keratopathy (Corneal endothelial damage)
a significant statistical correlation of the corneal edema post phaco with the phaco-time and the type of cataract
Most common in pre-existing endothelial disorder
Edema is most often caused by Mechanical trauma Prolonged intraocular irrigation Inflammation And elevated IOP Toxic Solutions
Vitreocorneal Adherence and Persistent Corneal EdemaVitreocorneal Adherence and Persistent Corneal Edema
Points in ManagementPoints in Management
If epithelial edema is present in the face of a compact stroma immediately after surgery it is likely due to elevated lOP with intact endothelium
Corneal edema generally resolves completely within 4-6 weeks
As a rule if the corneal periphery is clear
the corneal edema will usually resolve with time
Corneal edema persisting after 3 months usually
does not clear and may require penetrating keratoplasty
Small wounds under 32 mm are much less prone to this complication
The sealing of the wound depends
the quality of the corneo-scleral tissue
the quality of incision
This in turn depends on certain intraoperatory complications
certain chronic diseases
thermal injury of the wound
If needed case can use a therapeutic contact lens
Intraoperatory injury with the phaco tip or instruments
(complicate cases)
amp some local or general associated conditions may cause pupil asymmetries
This will translate clinically by decreased visual acuity
lack of adaptation to strong light
Post operatory intraocular inflammation can be acute and chronic (endophthalmitis)
Chronic uveal inflammation may occur in weeks months or years after cataract
chronic inflammation
significant statistical correlations between post-intraocular inflammation on the
one hand and rupture of thecapsule
Cystoid macular edema
Retinal detachment
Persistent increase in intraocular pressure
Intraocular lens dislocation or subluxation
Choroidal detachment
Endophthalmitis
Corneal edema
There were more cases of posterior capsule tears and vitreous
loss in the first 80 cases performed by the residents
the posterior capsule tear rate peaked at more than 10 after
40 cases
Spontaneous
in-the-Bag Intraocular Lens Luxation
into the Vitreous Cavity
A Balestrazzi G M Tosi M Alegente C Mazzotta et al Ophthalmologica Basel Aug 2009 Vol 223 Iss 5 pg 339 4 pgs
National Cataract Register (NCR)
type of anesthesia
history of trauma
ocular comorbidity
axial length
miosis
cornea pathology and poor visibility
previous intraocular operation
iris synechias small pupil
white cataract brunescenthard cataract
phacodonesis
presence of pseudoexfoliation
surgeon experience 3 years or less (operating under senior supervision) or more than 3 years of independent
phacoemulsification practice
Major complications occurred in 15 of 320 cases (47) and involved 10 cases of vitreous loss
the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2)
wrong IOL power requiring reoperation (1)
corneal wound burn (1)
and postoperative iris prolapse requiring wound revision
The mean postoperative BCVA was 2026 (logMAR 011)
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
Excessively small capsulorrhexis
Two major complications of hydro dissection are
- inadequate hydro dissection - over inflation of the capsular bag
the viscodissection technique was safer and more efficient than the non-dissection technique
Detachment of Descemetrsquos membrane can be a major
postoperative complication
it results in persistent corneal edema and decreased visual acuity
To prevent Descemetrsquos detachment the surgeon should carefully observe
the inner lip at each phase of the procedure
To avoid blunt stripping of Descemetrsquos membrane during
enlargement of the wound a sharp metal or diamond blade
is recommended
usually is caused when the anterior chamber is entered too posteriorly
such as near the iris root
If this is noted early in the case and interferes with the easy introduction of instruments into the eye
it is advisable to suture the incision amp move to another location
A second and more ominous cause of iris prolapse is an acute increase of intraocular pressure (IOP) accompanied by
choroidal effusion or hemorrhage
Bleeding in the anterior chamber can come from intra operatory damage of iris
This occurs most frequently in temporal incisions located more posterior and deeper than normal
In these cases there are reached the blood vessels with higher risk of bleeding
it appears that there is no significant statistical correlation with anticoagulant therapy or chronic anti agregant
Temporarily elevating the IOP with a balanced salt solution or an OVD
Injecting a dilute solution of preservative-free epinephrine 15000 (or a weaker solution)
Direct cautery (if the bleeding vessel can be identified) with a needle-tipped cautery probe
Iris bleeding is caused by iris trauma
Intraocular bleeding can be stopped by
Temporary loss of the chamber
After adjusting the parameters of aspiration and irrigation
and the introduction of viscoelastic substances
with high molecular weight
the situation was resolved favorably
(281)
All cases of hypertonic eye have been associated with temporary shallow anterior chamber earlier the correlation being statistically significant
hypertonic eye amp posterior capsule rupture has been reported ( was needed vitrectomy)
Correlation was not statistically significant
If for any reason the flow is blocked a corneal burn can occur within 1ndash3 s
additional suturing was required several days later Postoperatively the patient has 5 D of surgically induced astigmatism that has persisted for more than 5 years
Yanoff amp Duker Ophthalmology 3rd ed
the surgeon should attempt to identify the cause and lower the IOP Sometimes digital massage on the eye pressing directly on the incision can successfully lower the pressure It is useful to examine the fundus to ascertain whether a choroidal effusion or hemorrhage exists With choroidal effusion aspiration of vitreous can be helpful as can the administration of intravenous mannitol If a choroidal hemorrhage occurs or if the increased IOP from an effusion is resistant to treatment
it usually is best to terminate surgery The wound is sutured carefully intraocular miotics are administered and a peripheral iridectomy may be performed to help reposition the iris For effusions surgery can be deferred until later in the day or the next day when the fluid dynamics of the eye have returned to a more normal state
If a limited choroidal hemorrhage has occurred it is best to wait 2ndash3 weeks before attempting further surgery
presumably occurs from the rupture of a blood vessel that is placed under stretch
Risk factors include hypertension
glaucoma
nanophthalmos
high myopia
and chronic intraocular inflammation[26]
still occur at a rate between
045 for very experienced surgeons [1]
amp up to 147 for residents in training [2]
The frequency of retained
lens fragments is estimated at 03 to 11 [34]
The challenge of cataract surgery is to minimize
the risk of complications and to manage optimally
complications that do occur
B-scan ultrasonography 1 day after dislocation
of a lens nucleus into the vitreous cavity
in a patient who has high myopia
the early signs of posterior capsular rupture include
unusual deepening of the anterior chamber
decentration of the nucleus
or loss of efficiency of aspiration which suggests occlusion of the tip with vitreous
Usually Posterior capsular rupture is the most common
intraoperative complication in initial cases
The key factors are to minimize ocular trauma meticulously clean prolapsed vitreous
from the anterior segment if present and ensure secure fixation of the IOL
The review yielded 392 patients
Six (153) had intraocular pressure (gt or = 30 mm Hg) requiring treatment
1 (026) had painless iris prolapse
11 (281) had corneal abrasions
and 7 (178) were given a more intensive steroid regime (UVEITIS)
Corneal edema
No cases of fibrinous uveitis were recorded
J Cataract Refract Surg 1999 Jul25(7)985-8
Corneal edema is categorized according to severity in reversible and irreversible
bull reversible corneal edema- in 7 days 842-in 30 days 103
bull irreversible corneal edema ndash edemato bullous keratopathy (Corneal endothelial damage)
a significant statistical correlation of the corneal edema post phaco with the phaco-time and the type of cataract
Most common in pre-existing endothelial disorder
Edema is most often caused by Mechanical trauma Prolonged intraocular irrigation Inflammation And elevated IOP Toxic Solutions
Vitreocorneal Adherence and Persistent Corneal EdemaVitreocorneal Adherence and Persistent Corneal Edema
Points in ManagementPoints in Management
If epithelial edema is present in the face of a compact stroma immediately after surgery it is likely due to elevated lOP with intact endothelium
Corneal edema generally resolves completely within 4-6 weeks
As a rule if the corneal periphery is clear
the corneal edema will usually resolve with time
Corneal edema persisting after 3 months usually
does not clear and may require penetrating keratoplasty
Small wounds under 32 mm are much less prone to this complication
The sealing of the wound depends
the quality of the corneo-scleral tissue
the quality of incision
This in turn depends on certain intraoperatory complications
certain chronic diseases
thermal injury of the wound
If needed case can use a therapeutic contact lens
Intraoperatory injury with the phaco tip or instruments
(complicate cases)
amp some local or general associated conditions may cause pupil asymmetries
This will translate clinically by decreased visual acuity
lack of adaptation to strong light
Post operatory intraocular inflammation can be acute and chronic (endophthalmitis)
Chronic uveal inflammation may occur in weeks months or years after cataract
chronic inflammation
significant statistical correlations between post-intraocular inflammation on the
one hand and rupture of thecapsule
Cystoid macular edema
Retinal detachment
Persistent increase in intraocular pressure
Intraocular lens dislocation or subluxation
Choroidal detachment
Endophthalmitis
Corneal edema
There were more cases of posterior capsule tears and vitreous
loss in the first 80 cases performed by the residents
the posterior capsule tear rate peaked at more than 10 after
40 cases
Spontaneous
in-the-Bag Intraocular Lens Luxation
into the Vitreous Cavity
A Balestrazzi G M Tosi M Alegente C Mazzotta et al Ophthalmologica Basel Aug 2009 Vol 223 Iss 5 pg 339 4 pgs
National Cataract Register (NCR)
type of anesthesia
history of trauma
ocular comorbidity
axial length
miosis
cornea pathology and poor visibility
previous intraocular operation
iris synechias small pupil
white cataract brunescenthard cataract
phacodonesis
presence of pseudoexfoliation
surgeon experience 3 years or less (operating under senior supervision) or more than 3 years of independent
phacoemulsification practice
Major complications occurred in 15 of 320 cases (47) and involved 10 cases of vitreous loss
the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2)
wrong IOL power requiring reoperation (1)
corneal wound burn (1)
and postoperative iris prolapse requiring wound revision
The mean postoperative BCVA was 2026 (logMAR 011)
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
Two major complications of hydro dissection are
- inadequate hydro dissection - over inflation of the capsular bag
the viscodissection technique was safer and more efficient than the non-dissection technique
Detachment of Descemetrsquos membrane can be a major
postoperative complication
it results in persistent corneal edema and decreased visual acuity
To prevent Descemetrsquos detachment the surgeon should carefully observe
the inner lip at each phase of the procedure
To avoid blunt stripping of Descemetrsquos membrane during
enlargement of the wound a sharp metal or diamond blade
is recommended
usually is caused when the anterior chamber is entered too posteriorly
such as near the iris root
If this is noted early in the case and interferes with the easy introduction of instruments into the eye
it is advisable to suture the incision amp move to another location
A second and more ominous cause of iris prolapse is an acute increase of intraocular pressure (IOP) accompanied by
choroidal effusion or hemorrhage
Bleeding in the anterior chamber can come from intra operatory damage of iris
This occurs most frequently in temporal incisions located more posterior and deeper than normal
In these cases there are reached the blood vessels with higher risk of bleeding
it appears that there is no significant statistical correlation with anticoagulant therapy or chronic anti agregant
Temporarily elevating the IOP with a balanced salt solution or an OVD
Injecting a dilute solution of preservative-free epinephrine 15000 (or a weaker solution)
Direct cautery (if the bleeding vessel can be identified) with a needle-tipped cautery probe
Iris bleeding is caused by iris trauma
Intraocular bleeding can be stopped by
Temporary loss of the chamber
After adjusting the parameters of aspiration and irrigation
and the introduction of viscoelastic substances
with high molecular weight
the situation was resolved favorably
(281)
All cases of hypertonic eye have been associated with temporary shallow anterior chamber earlier the correlation being statistically significant
hypertonic eye amp posterior capsule rupture has been reported ( was needed vitrectomy)
Correlation was not statistically significant
If for any reason the flow is blocked a corneal burn can occur within 1ndash3 s
additional suturing was required several days later Postoperatively the patient has 5 D of surgically induced astigmatism that has persisted for more than 5 years
Yanoff amp Duker Ophthalmology 3rd ed
the surgeon should attempt to identify the cause and lower the IOP Sometimes digital massage on the eye pressing directly on the incision can successfully lower the pressure It is useful to examine the fundus to ascertain whether a choroidal effusion or hemorrhage exists With choroidal effusion aspiration of vitreous can be helpful as can the administration of intravenous mannitol If a choroidal hemorrhage occurs or if the increased IOP from an effusion is resistant to treatment
it usually is best to terminate surgery The wound is sutured carefully intraocular miotics are administered and a peripheral iridectomy may be performed to help reposition the iris For effusions surgery can be deferred until later in the day or the next day when the fluid dynamics of the eye have returned to a more normal state
If a limited choroidal hemorrhage has occurred it is best to wait 2ndash3 weeks before attempting further surgery
presumably occurs from the rupture of a blood vessel that is placed under stretch
Risk factors include hypertension
glaucoma
nanophthalmos
high myopia
and chronic intraocular inflammation[26]
still occur at a rate between
045 for very experienced surgeons [1]
amp up to 147 for residents in training [2]
The frequency of retained
lens fragments is estimated at 03 to 11 [34]
The challenge of cataract surgery is to minimize
the risk of complications and to manage optimally
complications that do occur
B-scan ultrasonography 1 day after dislocation
of a lens nucleus into the vitreous cavity
in a patient who has high myopia
the early signs of posterior capsular rupture include
unusual deepening of the anterior chamber
decentration of the nucleus
or loss of efficiency of aspiration which suggests occlusion of the tip with vitreous
Usually Posterior capsular rupture is the most common
intraoperative complication in initial cases
The key factors are to minimize ocular trauma meticulously clean prolapsed vitreous
from the anterior segment if present and ensure secure fixation of the IOL
The review yielded 392 patients
Six (153) had intraocular pressure (gt or = 30 mm Hg) requiring treatment
1 (026) had painless iris prolapse
11 (281) had corneal abrasions
and 7 (178) were given a more intensive steroid regime (UVEITIS)
Corneal edema
No cases of fibrinous uveitis were recorded
J Cataract Refract Surg 1999 Jul25(7)985-8
Corneal edema is categorized according to severity in reversible and irreversible
bull reversible corneal edema- in 7 days 842-in 30 days 103
bull irreversible corneal edema ndash edemato bullous keratopathy (Corneal endothelial damage)
a significant statistical correlation of the corneal edema post phaco with the phaco-time and the type of cataract
Most common in pre-existing endothelial disorder
Edema is most often caused by Mechanical trauma Prolonged intraocular irrigation Inflammation And elevated IOP Toxic Solutions
Vitreocorneal Adherence and Persistent Corneal EdemaVitreocorneal Adherence and Persistent Corneal Edema
Points in ManagementPoints in Management
If epithelial edema is present in the face of a compact stroma immediately after surgery it is likely due to elevated lOP with intact endothelium
Corneal edema generally resolves completely within 4-6 weeks
As a rule if the corneal periphery is clear
the corneal edema will usually resolve with time
Corneal edema persisting after 3 months usually
does not clear and may require penetrating keratoplasty
Small wounds under 32 mm are much less prone to this complication
The sealing of the wound depends
the quality of the corneo-scleral tissue
the quality of incision
This in turn depends on certain intraoperatory complications
certain chronic diseases
thermal injury of the wound
If needed case can use a therapeutic contact lens
Intraoperatory injury with the phaco tip or instruments
(complicate cases)
amp some local or general associated conditions may cause pupil asymmetries
This will translate clinically by decreased visual acuity
lack of adaptation to strong light
Post operatory intraocular inflammation can be acute and chronic (endophthalmitis)
Chronic uveal inflammation may occur in weeks months or years after cataract
chronic inflammation
significant statistical correlations between post-intraocular inflammation on the
one hand and rupture of thecapsule
Cystoid macular edema
Retinal detachment
Persistent increase in intraocular pressure
Intraocular lens dislocation or subluxation
Choroidal detachment
Endophthalmitis
Corneal edema
There were more cases of posterior capsule tears and vitreous
loss in the first 80 cases performed by the residents
the posterior capsule tear rate peaked at more than 10 after
40 cases
Spontaneous
in-the-Bag Intraocular Lens Luxation
into the Vitreous Cavity
A Balestrazzi G M Tosi M Alegente C Mazzotta et al Ophthalmologica Basel Aug 2009 Vol 223 Iss 5 pg 339 4 pgs
National Cataract Register (NCR)
type of anesthesia
history of trauma
ocular comorbidity
axial length
miosis
cornea pathology and poor visibility
previous intraocular operation
iris synechias small pupil
white cataract brunescenthard cataract
phacodonesis
presence of pseudoexfoliation
surgeon experience 3 years or less (operating under senior supervision) or more than 3 years of independent
phacoemulsification practice
Major complications occurred in 15 of 320 cases (47) and involved 10 cases of vitreous loss
the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2)
wrong IOL power requiring reoperation (1)
corneal wound burn (1)
and postoperative iris prolapse requiring wound revision
The mean postoperative BCVA was 2026 (logMAR 011)
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
the viscodissection technique was safer and more efficient than the non-dissection technique
Detachment of Descemetrsquos membrane can be a major
postoperative complication
it results in persistent corneal edema and decreased visual acuity
To prevent Descemetrsquos detachment the surgeon should carefully observe
the inner lip at each phase of the procedure
To avoid blunt stripping of Descemetrsquos membrane during
enlargement of the wound a sharp metal or diamond blade
is recommended
usually is caused when the anterior chamber is entered too posteriorly
such as near the iris root
If this is noted early in the case and interferes with the easy introduction of instruments into the eye
it is advisable to suture the incision amp move to another location
A second and more ominous cause of iris prolapse is an acute increase of intraocular pressure (IOP) accompanied by
choroidal effusion or hemorrhage
Bleeding in the anterior chamber can come from intra operatory damage of iris
This occurs most frequently in temporal incisions located more posterior and deeper than normal
In these cases there are reached the blood vessels with higher risk of bleeding
it appears that there is no significant statistical correlation with anticoagulant therapy or chronic anti agregant
Temporarily elevating the IOP with a balanced salt solution or an OVD
Injecting a dilute solution of preservative-free epinephrine 15000 (or a weaker solution)
Direct cautery (if the bleeding vessel can be identified) with a needle-tipped cautery probe
Iris bleeding is caused by iris trauma
Intraocular bleeding can be stopped by
Temporary loss of the chamber
After adjusting the parameters of aspiration and irrigation
and the introduction of viscoelastic substances
with high molecular weight
the situation was resolved favorably
(281)
All cases of hypertonic eye have been associated with temporary shallow anterior chamber earlier the correlation being statistically significant
hypertonic eye amp posterior capsule rupture has been reported ( was needed vitrectomy)
Correlation was not statistically significant
If for any reason the flow is blocked a corneal burn can occur within 1ndash3 s
additional suturing was required several days later Postoperatively the patient has 5 D of surgically induced astigmatism that has persisted for more than 5 years
Yanoff amp Duker Ophthalmology 3rd ed
the surgeon should attempt to identify the cause and lower the IOP Sometimes digital massage on the eye pressing directly on the incision can successfully lower the pressure It is useful to examine the fundus to ascertain whether a choroidal effusion or hemorrhage exists With choroidal effusion aspiration of vitreous can be helpful as can the administration of intravenous mannitol If a choroidal hemorrhage occurs or if the increased IOP from an effusion is resistant to treatment
it usually is best to terminate surgery The wound is sutured carefully intraocular miotics are administered and a peripheral iridectomy may be performed to help reposition the iris For effusions surgery can be deferred until later in the day or the next day when the fluid dynamics of the eye have returned to a more normal state
If a limited choroidal hemorrhage has occurred it is best to wait 2ndash3 weeks before attempting further surgery
presumably occurs from the rupture of a blood vessel that is placed under stretch
Risk factors include hypertension
glaucoma
nanophthalmos
high myopia
and chronic intraocular inflammation[26]
still occur at a rate between
045 for very experienced surgeons [1]
amp up to 147 for residents in training [2]
The frequency of retained
lens fragments is estimated at 03 to 11 [34]
The challenge of cataract surgery is to minimize
the risk of complications and to manage optimally
complications that do occur
B-scan ultrasonography 1 day after dislocation
of a lens nucleus into the vitreous cavity
in a patient who has high myopia
the early signs of posterior capsular rupture include
unusual deepening of the anterior chamber
decentration of the nucleus
or loss of efficiency of aspiration which suggests occlusion of the tip with vitreous
Usually Posterior capsular rupture is the most common
intraoperative complication in initial cases
The key factors are to minimize ocular trauma meticulously clean prolapsed vitreous
from the anterior segment if present and ensure secure fixation of the IOL
The review yielded 392 patients
Six (153) had intraocular pressure (gt or = 30 mm Hg) requiring treatment
1 (026) had painless iris prolapse
11 (281) had corneal abrasions
and 7 (178) were given a more intensive steroid regime (UVEITIS)
Corneal edema
No cases of fibrinous uveitis were recorded
J Cataract Refract Surg 1999 Jul25(7)985-8
Corneal edema is categorized according to severity in reversible and irreversible
bull reversible corneal edema- in 7 days 842-in 30 days 103
bull irreversible corneal edema ndash edemato bullous keratopathy (Corneal endothelial damage)
a significant statistical correlation of the corneal edema post phaco with the phaco-time and the type of cataract
Most common in pre-existing endothelial disorder
Edema is most often caused by Mechanical trauma Prolonged intraocular irrigation Inflammation And elevated IOP Toxic Solutions
Vitreocorneal Adherence and Persistent Corneal EdemaVitreocorneal Adherence and Persistent Corneal Edema
Points in ManagementPoints in Management
If epithelial edema is present in the face of a compact stroma immediately after surgery it is likely due to elevated lOP with intact endothelium
Corneal edema generally resolves completely within 4-6 weeks
As a rule if the corneal periphery is clear
the corneal edema will usually resolve with time
Corneal edema persisting after 3 months usually
does not clear and may require penetrating keratoplasty
Small wounds under 32 mm are much less prone to this complication
The sealing of the wound depends
the quality of the corneo-scleral tissue
the quality of incision
This in turn depends on certain intraoperatory complications
certain chronic diseases
thermal injury of the wound
If needed case can use a therapeutic contact lens
Intraoperatory injury with the phaco tip or instruments
(complicate cases)
amp some local or general associated conditions may cause pupil asymmetries
This will translate clinically by decreased visual acuity
lack of adaptation to strong light
Post operatory intraocular inflammation can be acute and chronic (endophthalmitis)
Chronic uveal inflammation may occur in weeks months or years after cataract
chronic inflammation
significant statistical correlations between post-intraocular inflammation on the
one hand and rupture of thecapsule
Cystoid macular edema
Retinal detachment
Persistent increase in intraocular pressure
Intraocular lens dislocation or subluxation
Choroidal detachment
Endophthalmitis
Corneal edema
There were more cases of posterior capsule tears and vitreous
loss in the first 80 cases performed by the residents
the posterior capsule tear rate peaked at more than 10 after
40 cases
Spontaneous
in-the-Bag Intraocular Lens Luxation
into the Vitreous Cavity
A Balestrazzi G M Tosi M Alegente C Mazzotta et al Ophthalmologica Basel Aug 2009 Vol 223 Iss 5 pg 339 4 pgs
National Cataract Register (NCR)
type of anesthesia
history of trauma
ocular comorbidity
axial length
miosis
cornea pathology and poor visibility
previous intraocular operation
iris synechias small pupil
white cataract brunescenthard cataract
phacodonesis
presence of pseudoexfoliation
surgeon experience 3 years or less (operating under senior supervision) or more than 3 years of independent
phacoemulsification practice
Major complications occurred in 15 of 320 cases (47) and involved 10 cases of vitreous loss
the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2)
wrong IOL power requiring reoperation (1)
corneal wound burn (1)
and postoperative iris prolapse requiring wound revision
The mean postoperative BCVA was 2026 (logMAR 011)
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
Detachment of Descemetrsquos membrane can be a major
postoperative complication
it results in persistent corneal edema and decreased visual acuity
To prevent Descemetrsquos detachment the surgeon should carefully observe
the inner lip at each phase of the procedure
To avoid blunt stripping of Descemetrsquos membrane during
enlargement of the wound a sharp metal or diamond blade
is recommended
usually is caused when the anterior chamber is entered too posteriorly
such as near the iris root
If this is noted early in the case and interferes with the easy introduction of instruments into the eye
it is advisable to suture the incision amp move to another location
A second and more ominous cause of iris prolapse is an acute increase of intraocular pressure (IOP) accompanied by
choroidal effusion or hemorrhage
Bleeding in the anterior chamber can come from intra operatory damage of iris
This occurs most frequently in temporal incisions located more posterior and deeper than normal
In these cases there are reached the blood vessels with higher risk of bleeding
it appears that there is no significant statistical correlation with anticoagulant therapy or chronic anti agregant
Temporarily elevating the IOP with a balanced salt solution or an OVD
Injecting a dilute solution of preservative-free epinephrine 15000 (or a weaker solution)
Direct cautery (if the bleeding vessel can be identified) with a needle-tipped cautery probe
Iris bleeding is caused by iris trauma
Intraocular bleeding can be stopped by
Temporary loss of the chamber
After adjusting the parameters of aspiration and irrigation
and the introduction of viscoelastic substances
with high molecular weight
the situation was resolved favorably
(281)
All cases of hypertonic eye have been associated with temporary shallow anterior chamber earlier the correlation being statistically significant
hypertonic eye amp posterior capsule rupture has been reported ( was needed vitrectomy)
Correlation was not statistically significant
If for any reason the flow is blocked a corneal burn can occur within 1ndash3 s
additional suturing was required several days later Postoperatively the patient has 5 D of surgically induced astigmatism that has persisted for more than 5 years
Yanoff amp Duker Ophthalmology 3rd ed
the surgeon should attempt to identify the cause and lower the IOP Sometimes digital massage on the eye pressing directly on the incision can successfully lower the pressure It is useful to examine the fundus to ascertain whether a choroidal effusion or hemorrhage exists With choroidal effusion aspiration of vitreous can be helpful as can the administration of intravenous mannitol If a choroidal hemorrhage occurs or if the increased IOP from an effusion is resistant to treatment
it usually is best to terminate surgery The wound is sutured carefully intraocular miotics are administered and a peripheral iridectomy may be performed to help reposition the iris For effusions surgery can be deferred until later in the day or the next day when the fluid dynamics of the eye have returned to a more normal state
If a limited choroidal hemorrhage has occurred it is best to wait 2ndash3 weeks before attempting further surgery
presumably occurs from the rupture of a blood vessel that is placed under stretch
Risk factors include hypertension
glaucoma
nanophthalmos
high myopia
and chronic intraocular inflammation[26]
still occur at a rate between
045 for very experienced surgeons [1]
amp up to 147 for residents in training [2]
The frequency of retained
lens fragments is estimated at 03 to 11 [34]
The challenge of cataract surgery is to minimize
the risk of complications and to manage optimally
complications that do occur
B-scan ultrasonography 1 day after dislocation
of a lens nucleus into the vitreous cavity
in a patient who has high myopia
the early signs of posterior capsular rupture include
unusual deepening of the anterior chamber
decentration of the nucleus
or loss of efficiency of aspiration which suggests occlusion of the tip with vitreous
Usually Posterior capsular rupture is the most common
intraoperative complication in initial cases
The key factors are to minimize ocular trauma meticulously clean prolapsed vitreous
from the anterior segment if present and ensure secure fixation of the IOL
The review yielded 392 patients
Six (153) had intraocular pressure (gt or = 30 mm Hg) requiring treatment
1 (026) had painless iris prolapse
11 (281) had corneal abrasions
and 7 (178) were given a more intensive steroid regime (UVEITIS)
Corneal edema
No cases of fibrinous uveitis were recorded
J Cataract Refract Surg 1999 Jul25(7)985-8
Corneal edema is categorized according to severity in reversible and irreversible
bull reversible corneal edema- in 7 days 842-in 30 days 103
bull irreversible corneal edema ndash edemato bullous keratopathy (Corneal endothelial damage)
a significant statistical correlation of the corneal edema post phaco with the phaco-time and the type of cataract
Most common in pre-existing endothelial disorder
Edema is most often caused by Mechanical trauma Prolonged intraocular irrigation Inflammation And elevated IOP Toxic Solutions
Vitreocorneal Adherence and Persistent Corneal EdemaVitreocorneal Adherence and Persistent Corneal Edema
Points in ManagementPoints in Management
If epithelial edema is present in the face of a compact stroma immediately after surgery it is likely due to elevated lOP with intact endothelium
Corneal edema generally resolves completely within 4-6 weeks
As a rule if the corneal periphery is clear
the corneal edema will usually resolve with time
Corneal edema persisting after 3 months usually
does not clear and may require penetrating keratoplasty
Small wounds under 32 mm are much less prone to this complication
The sealing of the wound depends
the quality of the corneo-scleral tissue
the quality of incision
This in turn depends on certain intraoperatory complications
certain chronic diseases
thermal injury of the wound
If needed case can use a therapeutic contact lens
Intraoperatory injury with the phaco tip or instruments
(complicate cases)
amp some local or general associated conditions may cause pupil asymmetries
This will translate clinically by decreased visual acuity
lack of adaptation to strong light
Post operatory intraocular inflammation can be acute and chronic (endophthalmitis)
Chronic uveal inflammation may occur in weeks months or years after cataract
chronic inflammation
significant statistical correlations between post-intraocular inflammation on the
one hand and rupture of thecapsule
Cystoid macular edema
Retinal detachment
Persistent increase in intraocular pressure
Intraocular lens dislocation or subluxation
Choroidal detachment
Endophthalmitis
Corneal edema
There were more cases of posterior capsule tears and vitreous
loss in the first 80 cases performed by the residents
the posterior capsule tear rate peaked at more than 10 after
40 cases
Spontaneous
in-the-Bag Intraocular Lens Luxation
into the Vitreous Cavity
A Balestrazzi G M Tosi M Alegente C Mazzotta et al Ophthalmologica Basel Aug 2009 Vol 223 Iss 5 pg 339 4 pgs
National Cataract Register (NCR)
type of anesthesia
history of trauma
ocular comorbidity
axial length
miosis
cornea pathology and poor visibility
previous intraocular operation
iris synechias small pupil
white cataract brunescenthard cataract
phacodonesis
presence of pseudoexfoliation
surgeon experience 3 years or less (operating under senior supervision) or more than 3 years of independent
phacoemulsification practice
Major complications occurred in 15 of 320 cases (47) and involved 10 cases of vitreous loss
the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2)
wrong IOL power requiring reoperation (1)
corneal wound burn (1)
and postoperative iris prolapse requiring wound revision
The mean postoperative BCVA was 2026 (logMAR 011)
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
usually is caused when the anterior chamber is entered too posteriorly
such as near the iris root
If this is noted early in the case and interferes with the easy introduction of instruments into the eye
it is advisable to suture the incision amp move to another location
A second and more ominous cause of iris prolapse is an acute increase of intraocular pressure (IOP) accompanied by
choroidal effusion or hemorrhage
Bleeding in the anterior chamber can come from intra operatory damage of iris
This occurs most frequently in temporal incisions located more posterior and deeper than normal
In these cases there are reached the blood vessels with higher risk of bleeding
it appears that there is no significant statistical correlation with anticoagulant therapy or chronic anti agregant
Temporarily elevating the IOP with a balanced salt solution or an OVD
Injecting a dilute solution of preservative-free epinephrine 15000 (or a weaker solution)
Direct cautery (if the bleeding vessel can be identified) with a needle-tipped cautery probe
Iris bleeding is caused by iris trauma
Intraocular bleeding can be stopped by
Temporary loss of the chamber
After adjusting the parameters of aspiration and irrigation
and the introduction of viscoelastic substances
with high molecular weight
the situation was resolved favorably
(281)
All cases of hypertonic eye have been associated with temporary shallow anterior chamber earlier the correlation being statistically significant
hypertonic eye amp posterior capsule rupture has been reported ( was needed vitrectomy)
Correlation was not statistically significant
If for any reason the flow is blocked a corneal burn can occur within 1ndash3 s
additional suturing was required several days later Postoperatively the patient has 5 D of surgically induced astigmatism that has persisted for more than 5 years
Yanoff amp Duker Ophthalmology 3rd ed
the surgeon should attempt to identify the cause and lower the IOP Sometimes digital massage on the eye pressing directly on the incision can successfully lower the pressure It is useful to examine the fundus to ascertain whether a choroidal effusion or hemorrhage exists With choroidal effusion aspiration of vitreous can be helpful as can the administration of intravenous mannitol If a choroidal hemorrhage occurs or if the increased IOP from an effusion is resistant to treatment
it usually is best to terminate surgery The wound is sutured carefully intraocular miotics are administered and a peripheral iridectomy may be performed to help reposition the iris For effusions surgery can be deferred until later in the day or the next day when the fluid dynamics of the eye have returned to a more normal state
If a limited choroidal hemorrhage has occurred it is best to wait 2ndash3 weeks before attempting further surgery
presumably occurs from the rupture of a blood vessel that is placed under stretch
Risk factors include hypertension
glaucoma
nanophthalmos
high myopia
and chronic intraocular inflammation[26]
still occur at a rate between
045 for very experienced surgeons [1]
amp up to 147 for residents in training [2]
The frequency of retained
lens fragments is estimated at 03 to 11 [34]
The challenge of cataract surgery is to minimize
the risk of complications and to manage optimally
complications that do occur
B-scan ultrasonography 1 day after dislocation
of a lens nucleus into the vitreous cavity
in a patient who has high myopia
the early signs of posterior capsular rupture include
unusual deepening of the anterior chamber
decentration of the nucleus
or loss of efficiency of aspiration which suggests occlusion of the tip with vitreous
Usually Posterior capsular rupture is the most common
intraoperative complication in initial cases
The key factors are to minimize ocular trauma meticulously clean prolapsed vitreous
from the anterior segment if present and ensure secure fixation of the IOL
The review yielded 392 patients
Six (153) had intraocular pressure (gt or = 30 mm Hg) requiring treatment
1 (026) had painless iris prolapse
11 (281) had corneal abrasions
and 7 (178) were given a more intensive steroid regime (UVEITIS)
Corneal edema
No cases of fibrinous uveitis were recorded
J Cataract Refract Surg 1999 Jul25(7)985-8
Corneal edema is categorized according to severity in reversible and irreversible
bull reversible corneal edema- in 7 days 842-in 30 days 103
bull irreversible corneal edema ndash edemato bullous keratopathy (Corneal endothelial damage)
a significant statistical correlation of the corneal edema post phaco with the phaco-time and the type of cataract
Most common in pre-existing endothelial disorder
Edema is most often caused by Mechanical trauma Prolonged intraocular irrigation Inflammation And elevated IOP Toxic Solutions
Vitreocorneal Adherence and Persistent Corneal EdemaVitreocorneal Adherence and Persistent Corneal Edema
Points in ManagementPoints in Management
If epithelial edema is present in the face of a compact stroma immediately after surgery it is likely due to elevated lOP with intact endothelium
Corneal edema generally resolves completely within 4-6 weeks
As a rule if the corneal periphery is clear
the corneal edema will usually resolve with time
Corneal edema persisting after 3 months usually
does not clear and may require penetrating keratoplasty
Small wounds under 32 mm are much less prone to this complication
The sealing of the wound depends
the quality of the corneo-scleral tissue
the quality of incision
This in turn depends on certain intraoperatory complications
certain chronic diseases
thermal injury of the wound
If needed case can use a therapeutic contact lens
Intraoperatory injury with the phaco tip or instruments
(complicate cases)
amp some local or general associated conditions may cause pupil asymmetries
This will translate clinically by decreased visual acuity
lack of adaptation to strong light
Post operatory intraocular inflammation can be acute and chronic (endophthalmitis)
Chronic uveal inflammation may occur in weeks months or years after cataract
chronic inflammation
significant statistical correlations between post-intraocular inflammation on the
one hand and rupture of thecapsule
Cystoid macular edema
Retinal detachment
Persistent increase in intraocular pressure
Intraocular lens dislocation or subluxation
Choroidal detachment
Endophthalmitis
Corneal edema
There were more cases of posterior capsule tears and vitreous
loss in the first 80 cases performed by the residents
the posterior capsule tear rate peaked at more than 10 after
40 cases
Spontaneous
in-the-Bag Intraocular Lens Luxation
into the Vitreous Cavity
A Balestrazzi G M Tosi M Alegente C Mazzotta et al Ophthalmologica Basel Aug 2009 Vol 223 Iss 5 pg 339 4 pgs
National Cataract Register (NCR)
type of anesthesia
history of trauma
ocular comorbidity
axial length
miosis
cornea pathology and poor visibility
previous intraocular operation
iris synechias small pupil
white cataract brunescenthard cataract
phacodonesis
presence of pseudoexfoliation
surgeon experience 3 years or less (operating under senior supervision) or more than 3 years of independent
phacoemulsification practice
Major complications occurred in 15 of 320 cases (47) and involved 10 cases of vitreous loss
the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2)
wrong IOL power requiring reoperation (1)
corneal wound burn (1)
and postoperative iris prolapse requiring wound revision
The mean postoperative BCVA was 2026 (logMAR 011)
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
Bleeding in the anterior chamber can come from intra operatory damage of iris
This occurs most frequently in temporal incisions located more posterior and deeper than normal
In these cases there are reached the blood vessels with higher risk of bleeding
it appears that there is no significant statistical correlation with anticoagulant therapy or chronic anti agregant
Temporarily elevating the IOP with a balanced salt solution or an OVD
Injecting a dilute solution of preservative-free epinephrine 15000 (or a weaker solution)
Direct cautery (if the bleeding vessel can be identified) with a needle-tipped cautery probe
Iris bleeding is caused by iris trauma
Intraocular bleeding can be stopped by
Temporary loss of the chamber
After adjusting the parameters of aspiration and irrigation
and the introduction of viscoelastic substances
with high molecular weight
the situation was resolved favorably
(281)
All cases of hypertonic eye have been associated with temporary shallow anterior chamber earlier the correlation being statistically significant
hypertonic eye amp posterior capsule rupture has been reported ( was needed vitrectomy)
Correlation was not statistically significant
If for any reason the flow is blocked a corneal burn can occur within 1ndash3 s
additional suturing was required several days later Postoperatively the patient has 5 D of surgically induced astigmatism that has persisted for more than 5 years
Yanoff amp Duker Ophthalmology 3rd ed
the surgeon should attempt to identify the cause and lower the IOP Sometimes digital massage on the eye pressing directly on the incision can successfully lower the pressure It is useful to examine the fundus to ascertain whether a choroidal effusion or hemorrhage exists With choroidal effusion aspiration of vitreous can be helpful as can the administration of intravenous mannitol If a choroidal hemorrhage occurs or if the increased IOP from an effusion is resistant to treatment
it usually is best to terminate surgery The wound is sutured carefully intraocular miotics are administered and a peripheral iridectomy may be performed to help reposition the iris For effusions surgery can be deferred until later in the day or the next day when the fluid dynamics of the eye have returned to a more normal state
If a limited choroidal hemorrhage has occurred it is best to wait 2ndash3 weeks before attempting further surgery
presumably occurs from the rupture of a blood vessel that is placed under stretch
Risk factors include hypertension
glaucoma
nanophthalmos
high myopia
and chronic intraocular inflammation[26]
still occur at a rate between
045 for very experienced surgeons [1]
amp up to 147 for residents in training [2]
The frequency of retained
lens fragments is estimated at 03 to 11 [34]
The challenge of cataract surgery is to minimize
the risk of complications and to manage optimally
complications that do occur
B-scan ultrasonography 1 day after dislocation
of a lens nucleus into the vitreous cavity
in a patient who has high myopia
the early signs of posterior capsular rupture include
unusual deepening of the anterior chamber
decentration of the nucleus
or loss of efficiency of aspiration which suggests occlusion of the tip with vitreous
Usually Posterior capsular rupture is the most common
intraoperative complication in initial cases
The key factors are to minimize ocular trauma meticulously clean prolapsed vitreous
from the anterior segment if present and ensure secure fixation of the IOL
The review yielded 392 patients
Six (153) had intraocular pressure (gt or = 30 mm Hg) requiring treatment
1 (026) had painless iris prolapse
11 (281) had corneal abrasions
and 7 (178) were given a more intensive steroid regime (UVEITIS)
Corneal edema
No cases of fibrinous uveitis were recorded
J Cataract Refract Surg 1999 Jul25(7)985-8
Corneal edema is categorized according to severity in reversible and irreversible
bull reversible corneal edema- in 7 days 842-in 30 days 103
bull irreversible corneal edema ndash edemato bullous keratopathy (Corneal endothelial damage)
a significant statistical correlation of the corneal edema post phaco with the phaco-time and the type of cataract
Most common in pre-existing endothelial disorder
Edema is most often caused by Mechanical trauma Prolonged intraocular irrigation Inflammation And elevated IOP Toxic Solutions
Vitreocorneal Adherence and Persistent Corneal EdemaVitreocorneal Adherence and Persistent Corneal Edema
Points in ManagementPoints in Management
If epithelial edema is present in the face of a compact stroma immediately after surgery it is likely due to elevated lOP with intact endothelium
Corneal edema generally resolves completely within 4-6 weeks
As a rule if the corneal periphery is clear
the corneal edema will usually resolve with time
Corneal edema persisting after 3 months usually
does not clear and may require penetrating keratoplasty
Small wounds under 32 mm are much less prone to this complication
The sealing of the wound depends
the quality of the corneo-scleral tissue
the quality of incision
This in turn depends on certain intraoperatory complications
certain chronic diseases
thermal injury of the wound
If needed case can use a therapeutic contact lens
Intraoperatory injury with the phaco tip or instruments
(complicate cases)
amp some local or general associated conditions may cause pupil asymmetries
This will translate clinically by decreased visual acuity
lack of adaptation to strong light
Post operatory intraocular inflammation can be acute and chronic (endophthalmitis)
Chronic uveal inflammation may occur in weeks months or years after cataract
chronic inflammation
significant statistical correlations between post-intraocular inflammation on the
one hand and rupture of thecapsule
Cystoid macular edema
Retinal detachment
Persistent increase in intraocular pressure
Intraocular lens dislocation or subluxation
Choroidal detachment
Endophthalmitis
Corneal edema
There were more cases of posterior capsule tears and vitreous
loss in the first 80 cases performed by the residents
the posterior capsule tear rate peaked at more than 10 after
40 cases
Spontaneous
in-the-Bag Intraocular Lens Luxation
into the Vitreous Cavity
A Balestrazzi G M Tosi M Alegente C Mazzotta et al Ophthalmologica Basel Aug 2009 Vol 223 Iss 5 pg 339 4 pgs
National Cataract Register (NCR)
type of anesthesia
history of trauma
ocular comorbidity
axial length
miosis
cornea pathology and poor visibility
previous intraocular operation
iris synechias small pupil
white cataract brunescenthard cataract
phacodonesis
presence of pseudoexfoliation
surgeon experience 3 years or less (operating under senior supervision) or more than 3 years of independent
phacoemulsification practice
Major complications occurred in 15 of 320 cases (47) and involved 10 cases of vitreous loss
the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2)
wrong IOL power requiring reoperation (1)
corneal wound burn (1)
and postoperative iris prolapse requiring wound revision
The mean postoperative BCVA was 2026 (logMAR 011)
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
Temporarily elevating the IOP with a balanced salt solution or an OVD
Injecting a dilute solution of preservative-free epinephrine 15000 (or a weaker solution)
Direct cautery (if the bleeding vessel can be identified) with a needle-tipped cautery probe
Iris bleeding is caused by iris trauma
Intraocular bleeding can be stopped by
Temporary loss of the chamber
After adjusting the parameters of aspiration and irrigation
and the introduction of viscoelastic substances
with high molecular weight
the situation was resolved favorably
(281)
All cases of hypertonic eye have been associated with temporary shallow anterior chamber earlier the correlation being statistically significant
hypertonic eye amp posterior capsule rupture has been reported ( was needed vitrectomy)
Correlation was not statistically significant
If for any reason the flow is blocked a corneal burn can occur within 1ndash3 s
additional suturing was required several days later Postoperatively the patient has 5 D of surgically induced astigmatism that has persisted for more than 5 years
Yanoff amp Duker Ophthalmology 3rd ed
the surgeon should attempt to identify the cause and lower the IOP Sometimes digital massage on the eye pressing directly on the incision can successfully lower the pressure It is useful to examine the fundus to ascertain whether a choroidal effusion or hemorrhage exists With choroidal effusion aspiration of vitreous can be helpful as can the administration of intravenous mannitol If a choroidal hemorrhage occurs or if the increased IOP from an effusion is resistant to treatment
it usually is best to terminate surgery The wound is sutured carefully intraocular miotics are administered and a peripheral iridectomy may be performed to help reposition the iris For effusions surgery can be deferred until later in the day or the next day when the fluid dynamics of the eye have returned to a more normal state
If a limited choroidal hemorrhage has occurred it is best to wait 2ndash3 weeks before attempting further surgery
presumably occurs from the rupture of a blood vessel that is placed under stretch
Risk factors include hypertension
glaucoma
nanophthalmos
high myopia
and chronic intraocular inflammation[26]
still occur at a rate between
045 for very experienced surgeons [1]
amp up to 147 for residents in training [2]
The frequency of retained
lens fragments is estimated at 03 to 11 [34]
The challenge of cataract surgery is to minimize
the risk of complications and to manage optimally
complications that do occur
B-scan ultrasonography 1 day after dislocation
of a lens nucleus into the vitreous cavity
in a patient who has high myopia
the early signs of posterior capsular rupture include
unusual deepening of the anterior chamber
decentration of the nucleus
or loss of efficiency of aspiration which suggests occlusion of the tip with vitreous
Usually Posterior capsular rupture is the most common
intraoperative complication in initial cases
The key factors are to minimize ocular trauma meticulously clean prolapsed vitreous
from the anterior segment if present and ensure secure fixation of the IOL
The review yielded 392 patients
Six (153) had intraocular pressure (gt or = 30 mm Hg) requiring treatment
1 (026) had painless iris prolapse
11 (281) had corneal abrasions
and 7 (178) were given a more intensive steroid regime (UVEITIS)
Corneal edema
No cases of fibrinous uveitis were recorded
J Cataract Refract Surg 1999 Jul25(7)985-8
Corneal edema is categorized according to severity in reversible and irreversible
bull reversible corneal edema- in 7 days 842-in 30 days 103
bull irreversible corneal edema ndash edemato bullous keratopathy (Corneal endothelial damage)
a significant statistical correlation of the corneal edema post phaco with the phaco-time and the type of cataract
Most common in pre-existing endothelial disorder
Edema is most often caused by Mechanical trauma Prolonged intraocular irrigation Inflammation And elevated IOP Toxic Solutions
Vitreocorneal Adherence and Persistent Corneal EdemaVitreocorneal Adherence and Persistent Corneal Edema
Points in ManagementPoints in Management
If epithelial edema is present in the face of a compact stroma immediately after surgery it is likely due to elevated lOP with intact endothelium
Corneal edema generally resolves completely within 4-6 weeks
As a rule if the corneal periphery is clear
the corneal edema will usually resolve with time
Corneal edema persisting after 3 months usually
does not clear and may require penetrating keratoplasty
Small wounds under 32 mm are much less prone to this complication
The sealing of the wound depends
the quality of the corneo-scleral tissue
the quality of incision
This in turn depends on certain intraoperatory complications
certain chronic diseases
thermal injury of the wound
If needed case can use a therapeutic contact lens
Intraoperatory injury with the phaco tip or instruments
(complicate cases)
amp some local or general associated conditions may cause pupil asymmetries
This will translate clinically by decreased visual acuity
lack of adaptation to strong light
Post operatory intraocular inflammation can be acute and chronic (endophthalmitis)
Chronic uveal inflammation may occur in weeks months or years after cataract
chronic inflammation
significant statistical correlations between post-intraocular inflammation on the
one hand and rupture of thecapsule
Cystoid macular edema
Retinal detachment
Persistent increase in intraocular pressure
Intraocular lens dislocation or subluxation
Choroidal detachment
Endophthalmitis
Corneal edema
There were more cases of posterior capsule tears and vitreous
loss in the first 80 cases performed by the residents
the posterior capsule tear rate peaked at more than 10 after
40 cases
Spontaneous
in-the-Bag Intraocular Lens Luxation
into the Vitreous Cavity
A Balestrazzi G M Tosi M Alegente C Mazzotta et al Ophthalmologica Basel Aug 2009 Vol 223 Iss 5 pg 339 4 pgs
National Cataract Register (NCR)
type of anesthesia
history of trauma
ocular comorbidity
axial length
miosis
cornea pathology and poor visibility
previous intraocular operation
iris synechias small pupil
white cataract brunescenthard cataract
phacodonesis
presence of pseudoexfoliation
surgeon experience 3 years or less (operating under senior supervision) or more than 3 years of independent
phacoemulsification practice
Major complications occurred in 15 of 320 cases (47) and involved 10 cases of vitreous loss
the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2)
wrong IOL power requiring reoperation (1)
corneal wound burn (1)
and postoperative iris prolapse requiring wound revision
The mean postoperative BCVA was 2026 (logMAR 011)
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
Temporary loss of the chamber
After adjusting the parameters of aspiration and irrigation
and the introduction of viscoelastic substances
with high molecular weight
the situation was resolved favorably
(281)
All cases of hypertonic eye have been associated with temporary shallow anterior chamber earlier the correlation being statistically significant
hypertonic eye amp posterior capsule rupture has been reported ( was needed vitrectomy)
Correlation was not statistically significant
If for any reason the flow is blocked a corneal burn can occur within 1ndash3 s
additional suturing was required several days later Postoperatively the patient has 5 D of surgically induced astigmatism that has persisted for more than 5 years
Yanoff amp Duker Ophthalmology 3rd ed
the surgeon should attempt to identify the cause and lower the IOP Sometimes digital massage on the eye pressing directly on the incision can successfully lower the pressure It is useful to examine the fundus to ascertain whether a choroidal effusion or hemorrhage exists With choroidal effusion aspiration of vitreous can be helpful as can the administration of intravenous mannitol If a choroidal hemorrhage occurs or if the increased IOP from an effusion is resistant to treatment
it usually is best to terminate surgery The wound is sutured carefully intraocular miotics are administered and a peripheral iridectomy may be performed to help reposition the iris For effusions surgery can be deferred until later in the day or the next day when the fluid dynamics of the eye have returned to a more normal state
If a limited choroidal hemorrhage has occurred it is best to wait 2ndash3 weeks before attempting further surgery
presumably occurs from the rupture of a blood vessel that is placed under stretch
Risk factors include hypertension
glaucoma
nanophthalmos
high myopia
and chronic intraocular inflammation[26]
still occur at a rate between
045 for very experienced surgeons [1]
amp up to 147 for residents in training [2]
The frequency of retained
lens fragments is estimated at 03 to 11 [34]
The challenge of cataract surgery is to minimize
the risk of complications and to manage optimally
complications that do occur
B-scan ultrasonography 1 day after dislocation
of a lens nucleus into the vitreous cavity
in a patient who has high myopia
the early signs of posterior capsular rupture include
unusual deepening of the anterior chamber
decentration of the nucleus
or loss of efficiency of aspiration which suggests occlusion of the tip with vitreous
Usually Posterior capsular rupture is the most common
intraoperative complication in initial cases
The key factors are to minimize ocular trauma meticulously clean prolapsed vitreous
from the anterior segment if present and ensure secure fixation of the IOL
The review yielded 392 patients
Six (153) had intraocular pressure (gt or = 30 mm Hg) requiring treatment
1 (026) had painless iris prolapse
11 (281) had corneal abrasions
and 7 (178) were given a more intensive steroid regime (UVEITIS)
Corneal edema
No cases of fibrinous uveitis were recorded
J Cataract Refract Surg 1999 Jul25(7)985-8
Corneal edema is categorized according to severity in reversible and irreversible
bull reversible corneal edema- in 7 days 842-in 30 days 103
bull irreversible corneal edema ndash edemato bullous keratopathy (Corneal endothelial damage)
a significant statistical correlation of the corneal edema post phaco with the phaco-time and the type of cataract
Most common in pre-existing endothelial disorder
Edema is most often caused by Mechanical trauma Prolonged intraocular irrigation Inflammation And elevated IOP Toxic Solutions
Vitreocorneal Adherence and Persistent Corneal EdemaVitreocorneal Adherence and Persistent Corneal Edema
Points in ManagementPoints in Management
If epithelial edema is present in the face of a compact stroma immediately after surgery it is likely due to elevated lOP with intact endothelium
Corneal edema generally resolves completely within 4-6 weeks
As a rule if the corneal periphery is clear
the corneal edema will usually resolve with time
Corneal edema persisting after 3 months usually
does not clear and may require penetrating keratoplasty
Small wounds under 32 mm are much less prone to this complication
The sealing of the wound depends
the quality of the corneo-scleral tissue
the quality of incision
This in turn depends on certain intraoperatory complications
certain chronic diseases
thermal injury of the wound
If needed case can use a therapeutic contact lens
Intraoperatory injury with the phaco tip or instruments
(complicate cases)
amp some local or general associated conditions may cause pupil asymmetries
This will translate clinically by decreased visual acuity
lack of adaptation to strong light
Post operatory intraocular inflammation can be acute and chronic (endophthalmitis)
Chronic uveal inflammation may occur in weeks months or years after cataract
chronic inflammation
significant statistical correlations between post-intraocular inflammation on the
one hand and rupture of thecapsule
Cystoid macular edema
Retinal detachment
Persistent increase in intraocular pressure
Intraocular lens dislocation or subluxation
Choroidal detachment
Endophthalmitis
Corneal edema
There were more cases of posterior capsule tears and vitreous
loss in the first 80 cases performed by the residents
the posterior capsule tear rate peaked at more than 10 after
40 cases
Spontaneous
in-the-Bag Intraocular Lens Luxation
into the Vitreous Cavity
A Balestrazzi G M Tosi M Alegente C Mazzotta et al Ophthalmologica Basel Aug 2009 Vol 223 Iss 5 pg 339 4 pgs
National Cataract Register (NCR)
type of anesthesia
history of trauma
ocular comorbidity
axial length
miosis
cornea pathology and poor visibility
previous intraocular operation
iris synechias small pupil
white cataract brunescenthard cataract
phacodonesis
presence of pseudoexfoliation
surgeon experience 3 years or less (operating under senior supervision) or more than 3 years of independent
phacoemulsification practice
Major complications occurred in 15 of 320 cases (47) and involved 10 cases of vitreous loss
the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2)
wrong IOL power requiring reoperation (1)
corneal wound burn (1)
and postoperative iris prolapse requiring wound revision
The mean postoperative BCVA was 2026 (logMAR 011)
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
(281)
All cases of hypertonic eye have been associated with temporary shallow anterior chamber earlier the correlation being statistically significant
hypertonic eye amp posterior capsule rupture has been reported ( was needed vitrectomy)
Correlation was not statistically significant
If for any reason the flow is blocked a corneal burn can occur within 1ndash3 s
additional suturing was required several days later Postoperatively the patient has 5 D of surgically induced astigmatism that has persisted for more than 5 years
Yanoff amp Duker Ophthalmology 3rd ed
the surgeon should attempt to identify the cause and lower the IOP Sometimes digital massage on the eye pressing directly on the incision can successfully lower the pressure It is useful to examine the fundus to ascertain whether a choroidal effusion or hemorrhage exists With choroidal effusion aspiration of vitreous can be helpful as can the administration of intravenous mannitol If a choroidal hemorrhage occurs or if the increased IOP from an effusion is resistant to treatment
it usually is best to terminate surgery The wound is sutured carefully intraocular miotics are administered and a peripheral iridectomy may be performed to help reposition the iris For effusions surgery can be deferred until later in the day or the next day when the fluid dynamics of the eye have returned to a more normal state
If a limited choroidal hemorrhage has occurred it is best to wait 2ndash3 weeks before attempting further surgery
presumably occurs from the rupture of a blood vessel that is placed under stretch
Risk factors include hypertension
glaucoma
nanophthalmos
high myopia
and chronic intraocular inflammation[26]
still occur at a rate between
045 for very experienced surgeons [1]
amp up to 147 for residents in training [2]
The frequency of retained
lens fragments is estimated at 03 to 11 [34]
The challenge of cataract surgery is to minimize
the risk of complications and to manage optimally
complications that do occur
B-scan ultrasonography 1 day after dislocation
of a lens nucleus into the vitreous cavity
in a patient who has high myopia
the early signs of posterior capsular rupture include
unusual deepening of the anterior chamber
decentration of the nucleus
or loss of efficiency of aspiration which suggests occlusion of the tip with vitreous
Usually Posterior capsular rupture is the most common
intraoperative complication in initial cases
The key factors are to minimize ocular trauma meticulously clean prolapsed vitreous
from the anterior segment if present and ensure secure fixation of the IOL
The review yielded 392 patients
Six (153) had intraocular pressure (gt or = 30 mm Hg) requiring treatment
1 (026) had painless iris prolapse
11 (281) had corneal abrasions
and 7 (178) were given a more intensive steroid regime (UVEITIS)
Corneal edema
No cases of fibrinous uveitis were recorded
J Cataract Refract Surg 1999 Jul25(7)985-8
Corneal edema is categorized according to severity in reversible and irreversible
bull reversible corneal edema- in 7 days 842-in 30 days 103
bull irreversible corneal edema ndash edemato bullous keratopathy (Corneal endothelial damage)
a significant statistical correlation of the corneal edema post phaco with the phaco-time and the type of cataract
Most common in pre-existing endothelial disorder
Edema is most often caused by Mechanical trauma Prolonged intraocular irrigation Inflammation And elevated IOP Toxic Solutions
Vitreocorneal Adherence and Persistent Corneal EdemaVitreocorneal Adherence and Persistent Corneal Edema
Points in ManagementPoints in Management
If epithelial edema is present in the face of a compact stroma immediately after surgery it is likely due to elevated lOP with intact endothelium
Corneal edema generally resolves completely within 4-6 weeks
As a rule if the corneal periphery is clear
the corneal edema will usually resolve with time
Corneal edema persisting after 3 months usually
does not clear and may require penetrating keratoplasty
Small wounds under 32 mm are much less prone to this complication
The sealing of the wound depends
the quality of the corneo-scleral tissue
the quality of incision
This in turn depends on certain intraoperatory complications
certain chronic diseases
thermal injury of the wound
If needed case can use a therapeutic contact lens
Intraoperatory injury with the phaco tip or instruments
(complicate cases)
amp some local or general associated conditions may cause pupil asymmetries
This will translate clinically by decreased visual acuity
lack of adaptation to strong light
Post operatory intraocular inflammation can be acute and chronic (endophthalmitis)
Chronic uveal inflammation may occur in weeks months or years after cataract
chronic inflammation
significant statistical correlations between post-intraocular inflammation on the
one hand and rupture of thecapsule
Cystoid macular edema
Retinal detachment
Persistent increase in intraocular pressure
Intraocular lens dislocation or subluxation
Choroidal detachment
Endophthalmitis
Corneal edema
There were more cases of posterior capsule tears and vitreous
loss in the first 80 cases performed by the residents
the posterior capsule tear rate peaked at more than 10 after
40 cases
Spontaneous
in-the-Bag Intraocular Lens Luxation
into the Vitreous Cavity
A Balestrazzi G M Tosi M Alegente C Mazzotta et al Ophthalmologica Basel Aug 2009 Vol 223 Iss 5 pg 339 4 pgs
National Cataract Register (NCR)
type of anesthesia
history of trauma
ocular comorbidity
axial length
miosis
cornea pathology and poor visibility
previous intraocular operation
iris synechias small pupil
white cataract brunescenthard cataract
phacodonesis
presence of pseudoexfoliation
surgeon experience 3 years or less (operating under senior supervision) or more than 3 years of independent
phacoemulsification practice
Major complications occurred in 15 of 320 cases (47) and involved 10 cases of vitreous loss
the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2)
wrong IOL power requiring reoperation (1)
corneal wound burn (1)
and postoperative iris prolapse requiring wound revision
The mean postoperative BCVA was 2026 (logMAR 011)
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
If for any reason the flow is blocked a corneal burn can occur within 1ndash3 s
additional suturing was required several days later Postoperatively the patient has 5 D of surgically induced astigmatism that has persisted for more than 5 years
Yanoff amp Duker Ophthalmology 3rd ed
the surgeon should attempt to identify the cause and lower the IOP Sometimes digital massage on the eye pressing directly on the incision can successfully lower the pressure It is useful to examine the fundus to ascertain whether a choroidal effusion or hemorrhage exists With choroidal effusion aspiration of vitreous can be helpful as can the administration of intravenous mannitol If a choroidal hemorrhage occurs or if the increased IOP from an effusion is resistant to treatment
it usually is best to terminate surgery The wound is sutured carefully intraocular miotics are administered and a peripheral iridectomy may be performed to help reposition the iris For effusions surgery can be deferred until later in the day or the next day when the fluid dynamics of the eye have returned to a more normal state
If a limited choroidal hemorrhage has occurred it is best to wait 2ndash3 weeks before attempting further surgery
presumably occurs from the rupture of a blood vessel that is placed under stretch
Risk factors include hypertension
glaucoma
nanophthalmos
high myopia
and chronic intraocular inflammation[26]
still occur at a rate between
045 for very experienced surgeons [1]
amp up to 147 for residents in training [2]
The frequency of retained
lens fragments is estimated at 03 to 11 [34]
The challenge of cataract surgery is to minimize
the risk of complications and to manage optimally
complications that do occur
B-scan ultrasonography 1 day after dislocation
of a lens nucleus into the vitreous cavity
in a patient who has high myopia
the early signs of posterior capsular rupture include
unusual deepening of the anterior chamber
decentration of the nucleus
or loss of efficiency of aspiration which suggests occlusion of the tip with vitreous
Usually Posterior capsular rupture is the most common
intraoperative complication in initial cases
The key factors are to minimize ocular trauma meticulously clean prolapsed vitreous
from the anterior segment if present and ensure secure fixation of the IOL
The review yielded 392 patients
Six (153) had intraocular pressure (gt or = 30 mm Hg) requiring treatment
1 (026) had painless iris prolapse
11 (281) had corneal abrasions
and 7 (178) were given a more intensive steroid regime (UVEITIS)
Corneal edema
No cases of fibrinous uveitis were recorded
J Cataract Refract Surg 1999 Jul25(7)985-8
Corneal edema is categorized according to severity in reversible and irreversible
bull reversible corneal edema- in 7 days 842-in 30 days 103
bull irreversible corneal edema ndash edemato bullous keratopathy (Corneal endothelial damage)
a significant statistical correlation of the corneal edema post phaco with the phaco-time and the type of cataract
Most common in pre-existing endothelial disorder
Edema is most often caused by Mechanical trauma Prolonged intraocular irrigation Inflammation And elevated IOP Toxic Solutions
Vitreocorneal Adherence and Persistent Corneal EdemaVitreocorneal Adherence and Persistent Corneal Edema
Points in ManagementPoints in Management
If epithelial edema is present in the face of a compact stroma immediately after surgery it is likely due to elevated lOP with intact endothelium
Corneal edema generally resolves completely within 4-6 weeks
As a rule if the corneal periphery is clear
the corneal edema will usually resolve with time
Corneal edema persisting after 3 months usually
does not clear and may require penetrating keratoplasty
Small wounds under 32 mm are much less prone to this complication
The sealing of the wound depends
the quality of the corneo-scleral tissue
the quality of incision
This in turn depends on certain intraoperatory complications
certain chronic diseases
thermal injury of the wound
If needed case can use a therapeutic contact lens
Intraoperatory injury with the phaco tip or instruments
(complicate cases)
amp some local or general associated conditions may cause pupil asymmetries
This will translate clinically by decreased visual acuity
lack of adaptation to strong light
Post operatory intraocular inflammation can be acute and chronic (endophthalmitis)
Chronic uveal inflammation may occur in weeks months or years after cataract
chronic inflammation
significant statistical correlations between post-intraocular inflammation on the
one hand and rupture of thecapsule
Cystoid macular edema
Retinal detachment
Persistent increase in intraocular pressure
Intraocular lens dislocation or subluxation
Choroidal detachment
Endophthalmitis
Corneal edema
There were more cases of posterior capsule tears and vitreous
loss in the first 80 cases performed by the residents
the posterior capsule tear rate peaked at more than 10 after
40 cases
Spontaneous
in-the-Bag Intraocular Lens Luxation
into the Vitreous Cavity
A Balestrazzi G M Tosi M Alegente C Mazzotta et al Ophthalmologica Basel Aug 2009 Vol 223 Iss 5 pg 339 4 pgs
National Cataract Register (NCR)
type of anesthesia
history of trauma
ocular comorbidity
axial length
miosis
cornea pathology and poor visibility
previous intraocular operation
iris synechias small pupil
white cataract brunescenthard cataract
phacodonesis
presence of pseudoexfoliation
surgeon experience 3 years or less (operating under senior supervision) or more than 3 years of independent
phacoemulsification practice
Major complications occurred in 15 of 320 cases (47) and involved 10 cases of vitreous loss
the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2)
wrong IOL power requiring reoperation (1)
corneal wound burn (1)
and postoperative iris prolapse requiring wound revision
The mean postoperative BCVA was 2026 (logMAR 011)
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
additional suturing was required several days later Postoperatively the patient has 5 D of surgically induced astigmatism that has persisted for more than 5 years
Yanoff amp Duker Ophthalmology 3rd ed
the surgeon should attempt to identify the cause and lower the IOP Sometimes digital massage on the eye pressing directly on the incision can successfully lower the pressure It is useful to examine the fundus to ascertain whether a choroidal effusion or hemorrhage exists With choroidal effusion aspiration of vitreous can be helpful as can the administration of intravenous mannitol If a choroidal hemorrhage occurs or if the increased IOP from an effusion is resistant to treatment
it usually is best to terminate surgery The wound is sutured carefully intraocular miotics are administered and a peripheral iridectomy may be performed to help reposition the iris For effusions surgery can be deferred until later in the day or the next day when the fluid dynamics of the eye have returned to a more normal state
If a limited choroidal hemorrhage has occurred it is best to wait 2ndash3 weeks before attempting further surgery
presumably occurs from the rupture of a blood vessel that is placed under stretch
Risk factors include hypertension
glaucoma
nanophthalmos
high myopia
and chronic intraocular inflammation[26]
still occur at a rate between
045 for very experienced surgeons [1]
amp up to 147 for residents in training [2]
The frequency of retained
lens fragments is estimated at 03 to 11 [34]
The challenge of cataract surgery is to minimize
the risk of complications and to manage optimally
complications that do occur
B-scan ultrasonography 1 day after dislocation
of a lens nucleus into the vitreous cavity
in a patient who has high myopia
the early signs of posterior capsular rupture include
unusual deepening of the anterior chamber
decentration of the nucleus
or loss of efficiency of aspiration which suggests occlusion of the tip with vitreous
Usually Posterior capsular rupture is the most common
intraoperative complication in initial cases
The key factors are to minimize ocular trauma meticulously clean prolapsed vitreous
from the anterior segment if present and ensure secure fixation of the IOL
The review yielded 392 patients
Six (153) had intraocular pressure (gt or = 30 mm Hg) requiring treatment
1 (026) had painless iris prolapse
11 (281) had corneal abrasions
and 7 (178) were given a more intensive steroid regime (UVEITIS)
Corneal edema
No cases of fibrinous uveitis were recorded
J Cataract Refract Surg 1999 Jul25(7)985-8
Corneal edema is categorized according to severity in reversible and irreversible
bull reversible corneal edema- in 7 days 842-in 30 days 103
bull irreversible corneal edema ndash edemato bullous keratopathy (Corneal endothelial damage)
a significant statistical correlation of the corneal edema post phaco with the phaco-time and the type of cataract
Most common in pre-existing endothelial disorder
Edema is most often caused by Mechanical trauma Prolonged intraocular irrigation Inflammation And elevated IOP Toxic Solutions
Vitreocorneal Adherence and Persistent Corneal EdemaVitreocorneal Adherence and Persistent Corneal Edema
Points in ManagementPoints in Management
If epithelial edema is present in the face of a compact stroma immediately after surgery it is likely due to elevated lOP with intact endothelium
Corneal edema generally resolves completely within 4-6 weeks
As a rule if the corneal periphery is clear
the corneal edema will usually resolve with time
Corneal edema persisting after 3 months usually
does not clear and may require penetrating keratoplasty
Small wounds under 32 mm are much less prone to this complication
The sealing of the wound depends
the quality of the corneo-scleral tissue
the quality of incision
This in turn depends on certain intraoperatory complications
certain chronic diseases
thermal injury of the wound
If needed case can use a therapeutic contact lens
Intraoperatory injury with the phaco tip or instruments
(complicate cases)
amp some local or general associated conditions may cause pupil asymmetries
This will translate clinically by decreased visual acuity
lack of adaptation to strong light
Post operatory intraocular inflammation can be acute and chronic (endophthalmitis)
Chronic uveal inflammation may occur in weeks months or years after cataract
chronic inflammation
significant statistical correlations between post-intraocular inflammation on the
one hand and rupture of thecapsule
Cystoid macular edema
Retinal detachment
Persistent increase in intraocular pressure
Intraocular lens dislocation or subluxation
Choroidal detachment
Endophthalmitis
Corneal edema
There were more cases of posterior capsule tears and vitreous
loss in the first 80 cases performed by the residents
the posterior capsule tear rate peaked at more than 10 after
40 cases
Spontaneous
in-the-Bag Intraocular Lens Luxation
into the Vitreous Cavity
A Balestrazzi G M Tosi M Alegente C Mazzotta et al Ophthalmologica Basel Aug 2009 Vol 223 Iss 5 pg 339 4 pgs
National Cataract Register (NCR)
type of anesthesia
history of trauma
ocular comorbidity
axial length
miosis
cornea pathology and poor visibility
previous intraocular operation
iris synechias small pupil
white cataract brunescenthard cataract
phacodonesis
presence of pseudoexfoliation
surgeon experience 3 years or less (operating under senior supervision) or more than 3 years of independent
phacoemulsification practice
Major complications occurred in 15 of 320 cases (47) and involved 10 cases of vitreous loss
the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2)
wrong IOL power requiring reoperation (1)
corneal wound burn (1)
and postoperative iris prolapse requiring wound revision
The mean postoperative BCVA was 2026 (logMAR 011)
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
the surgeon should attempt to identify the cause and lower the IOP Sometimes digital massage on the eye pressing directly on the incision can successfully lower the pressure It is useful to examine the fundus to ascertain whether a choroidal effusion or hemorrhage exists With choroidal effusion aspiration of vitreous can be helpful as can the administration of intravenous mannitol If a choroidal hemorrhage occurs or if the increased IOP from an effusion is resistant to treatment
it usually is best to terminate surgery The wound is sutured carefully intraocular miotics are administered and a peripheral iridectomy may be performed to help reposition the iris For effusions surgery can be deferred until later in the day or the next day when the fluid dynamics of the eye have returned to a more normal state
If a limited choroidal hemorrhage has occurred it is best to wait 2ndash3 weeks before attempting further surgery
presumably occurs from the rupture of a blood vessel that is placed under stretch
Risk factors include hypertension
glaucoma
nanophthalmos
high myopia
and chronic intraocular inflammation[26]
still occur at a rate between
045 for very experienced surgeons [1]
amp up to 147 for residents in training [2]
The frequency of retained
lens fragments is estimated at 03 to 11 [34]
The challenge of cataract surgery is to minimize
the risk of complications and to manage optimally
complications that do occur
B-scan ultrasonography 1 day after dislocation
of a lens nucleus into the vitreous cavity
in a patient who has high myopia
the early signs of posterior capsular rupture include
unusual deepening of the anterior chamber
decentration of the nucleus
or loss of efficiency of aspiration which suggests occlusion of the tip with vitreous
Usually Posterior capsular rupture is the most common
intraoperative complication in initial cases
The key factors are to minimize ocular trauma meticulously clean prolapsed vitreous
from the anterior segment if present and ensure secure fixation of the IOL
The review yielded 392 patients
Six (153) had intraocular pressure (gt or = 30 mm Hg) requiring treatment
1 (026) had painless iris prolapse
11 (281) had corneal abrasions
and 7 (178) were given a more intensive steroid regime (UVEITIS)
Corneal edema
No cases of fibrinous uveitis were recorded
J Cataract Refract Surg 1999 Jul25(7)985-8
Corneal edema is categorized according to severity in reversible and irreversible
bull reversible corneal edema- in 7 days 842-in 30 days 103
bull irreversible corneal edema ndash edemato bullous keratopathy (Corneal endothelial damage)
a significant statistical correlation of the corneal edema post phaco with the phaco-time and the type of cataract
Most common in pre-existing endothelial disorder
Edema is most often caused by Mechanical trauma Prolonged intraocular irrigation Inflammation And elevated IOP Toxic Solutions
Vitreocorneal Adherence and Persistent Corneal EdemaVitreocorneal Adherence and Persistent Corneal Edema
Points in ManagementPoints in Management
If epithelial edema is present in the face of a compact stroma immediately after surgery it is likely due to elevated lOP with intact endothelium
Corneal edema generally resolves completely within 4-6 weeks
As a rule if the corneal periphery is clear
the corneal edema will usually resolve with time
Corneal edema persisting after 3 months usually
does not clear and may require penetrating keratoplasty
Small wounds under 32 mm are much less prone to this complication
The sealing of the wound depends
the quality of the corneo-scleral tissue
the quality of incision
This in turn depends on certain intraoperatory complications
certain chronic diseases
thermal injury of the wound
If needed case can use a therapeutic contact lens
Intraoperatory injury with the phaco tip or instruments
(complicate cases)
amp some local or general associated conditions may cause pupil asymmetries
This will translate clinically by decreased visual acuity
lack of adaptation to strong light
Post operatory intraocular inflammation can be acute and chronic (endophthalmitis)
Chronic uveal inflammation may occur in weeks months or years after cataract
chronic inflammation
significant statistical correlations between post-intraocular inflammation on the
one hand and rupture of thecapsule
Cystoid macular edema
Retinal detachment
Persistent increase in intraocular pressure
Intraocular lens dislocation or subluxation
Choroidal detachment
Endophthalmitis
Corneal edema
There were more cases of posterior capsule tears and vitreous
loss in the first 80 cases performed by the residents
the posterior capsule tear rate peaked at more than 10 after
40 cases
Spontaneous
in-the-Bag Intraocular Lens Luxation
into the Vitreous Cavity
A Balestrazzi G M Tosi M Alegente C Mazzotta et al Ophthalmologica Basel Aug 2009 Vol 223 Iss 5 pg 339 4 pgs
National Cataract Register (NCR)
type of anesthesia
history of trauma
ocular comorbidity
axial length
miosis
cornea pathology and poor visibility
previous intraocular operation
iris synechias small pupil
white cataract brunescenthard cataract
phacodonesis
presence of pseudoexfoliation
surgeon experience 3 years or less (operating under senior supervision) or more than 3 years of independent
phacoemulsification practice
Major complications occurred in 15 of 320 cases (47) and involved 10 cases of vitreous loss
the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2)
wrong IOL power requiring reoperation (1)
corneal wound burn (1)
and postoperative iris prolapse requiring wound revision
The mean postoperative BCVA was 2026 (logMAR 011)
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
presumably occurs from the rupture of a blood vessel that is placed under stretch
Risk factors include hypertension
glaucoma
nanophthalmos
high myopia
and chronic intraocular inflammation[26]
still occur at a rate between
045 for very experienced surgeons [1]
amp up to 147 for residents in training [2]
The frequency of retained
lens fragments is estimated at 03 to 11 [34]
The challenge of cataract surgery is to minimize
the risk of complications and to manage optimally
complications that do occur
B-scan ultrasonography 1 day after dislocation
of a lens nucleus into the vitreous cavity
in a patient who has high myopia
the early signs of posterior capsular rupture include
unusual deepening of the anterior chamber
decentration of the nucleus
or loss of efficiency of aspiration which suggests occlusion of the tip with vitreous
Usually Posterior capsular rupture is the most common
intraoperative complication in initial cases
The key factors are to minimize ocular trauma meticulously clean prolapsed vitreous
from the anterior segment if present and ensure secure fixation of the IOL
The review yielded 392 patients
Six (153) had intraocular pressure (gt or = 30 mm Hg) requiring treatment
1 (026) had painless iris prolapse
11 (281) had corneal abrasions
and 7 (178) were given a more intensive steroid regime (UVEITIS)
Corneal edema
No cases of fibrinous uveitis were recorded
J Cataract Refract Surg 1999 Jul25(7)985-8
Corneal edema is categorized according to severity in reversible and irreversible
bull reversible corneal edema- in 7 days 842-in 30 days 103
bull irreversible corneal edema ndash edemato bullous keratopathy (Corneal endothelial damage)
a significant statistical correlation of the corneal edema post phaco with the phaco-time and the type of cataract
Most common in pre-existing endothelial disorder
Edema is most often caused by Mechanical trauma Prolonged intraocular irrigation Inflammation And elevated IOP Toxic Solutions
Vitreocorneal Adherence and Persistent Corneal EdemaVitreocorneal Adherence and Persistent Corneal Edema
Points in ManagementPoints in Management
If epithelial edema is present in the face of a compact stroma immediately after surgery it is likely due to elevated lOP with intact endothelium
Corneal edema generally resolves completely within 4-6 weeks
As a rule if the corneal periphery is clear
the corneal edema will usually resolve with time
Corneal edema persisting after 3 months usually
does not clear and may require penetrating keratoplasty
Small wounds under 32 mm are much less prone to this complication
The sealing of the wound depends
the quality of the corneo-scleral tissue
the quality of incision
This in turn depends on certain intraoperatory complications
certain chronic diseases
thermal injury of the wound
If needed case can use a therapeutic contact lens
Intraoperatory injury with the phaco tip or instruments
(complicate cases)
amp some local or general associated conditions may cause pupil asymmetries
This will translate clinically by decreased visual acuity
lack of adaptation to strong light
Post operatory intraocular inflammation can be acute and chronic (endophthalmitis)
Chronic uveal inflammation may occur in weeks months or years after cataract
chronic inflammation
significant statistical correlations between post-intraocular inflammation on the
one hand and rupture of thecapsule
Cystoid macular edema
Retinal detachment
Persistent increase in intraocular pressure
Intraocular lens dislocation or subluxation
Choroidal detachment
Endophthalmitis
Corneal edema
There were more cases of posterior capsule tears and vitreous
loss in the first 80 cases performed by the residents
the posterior capsule tear rate peaked at more than 10 after
40 cases
Spontaneous
in-the-Bag Intraocular Lens Luxation
into the Vitreous Cavity
A Balestrazzi G M Tosi M Alegente C Mazzotta et al Ophthalmologica Basel Aug 2009 Vol 223 Iss 5 pg 339 4 pgs
National Cataract Register (NCR)
type of anesthesia
history of trauma
ocular comorbidity
axial length
miosis
cornea pathology and poor visibility
previous intraocular operation
iris synechias small pupil
white cataract brunescenthard cataract
phacodonesis
presence of pseudoexfoliation
surgeon experience 3 years or less (operating under senior supervision) or more than 3 years of independent
phacoemulsification practice
Major complications occurred in 15 of 320 cases (47) and involved 10 cases of vitreous loss
the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2)
wrong IOL power requiring reoperation (1)
corneal wound burn (1)
and postoperative iris prolapse requiring wound revision
The mean postoperative BCVA was 2026 (logMAR 011)
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
still occur at a rate between
045 for very experienced surgeons [1]
amp up to 147 for residents in training [2]
The frequency of retained
lens fragments is estimated at 03 to 11 [34]
The challenge of cataract surgery is to minimize
the risk of complications and to manage optimally
complications that do occur
B-scan ultrasonography 1 day after dislocation
of a lens nucleus into the vitreous cavity
in a patient who has high myopia
the early signs of posterior capsular rupture include
unusual deepening of the anterior chamber
decentration of the nucleus
or loss of efficiency of aspiration which suggests occlusion of the tip with vitreous
Usually Posterior capsular rupture is the most common
intraoperative complication in initial cases
The key factors are to minimize ocular trauma meticulously clean prolapsed vitreous
from the anterior segment if present and ensure secure fixation of the IOL
The review yielded 392 patients
Six (153) had intraocular pressure (gt or = 30 mm Hg) requiring treatment
1 (026) had painless iris prolapse
11 (281) had corneal abrasions
and 7 (178) were given a more intensive steroid regime (UVEITIS)
Corneal edema
No cases of fibrinous uveitis were recorded
J Cataract Refract Surg 1999 Jul25(7)985-8
Corneal edema is categorized according to severity in reversible and irreversible
bull reversible corneal edema- in 7 days 842-in 30 days 103
bull irreversible corneal edema ndash edemato bullous keratopathy (Corneal endothelial damage)
a significant statistical correlation of the corneal edema post phaco with the phaco-time and the type of cataract
Most common in pre-existing endothelial disorder
Edema is most often caused by Mechanical trauma Prolonged intraocular irrigation Inflammation And elevated IOP Toxic Solutions
Vitreocorneal Adherence and Persistent Corneal EdemaVitreocorneal Adherence and Persistent Corneal Edema
Points in ManagementPoints in Management
If epithelial edema is present in the face of a compact stroma immediately after surgery it is likely due to elevated lOP with intact endothelium
Corneal edema generally resolves completely within 4-6 weeks
As a rule if the corneal periphery is clear
the corneal edema will usually resolve with time
Corneal edema persisting after 3 months usually
does not clear and may require penetrating keratoplasty
Small wounds under 32 mm are much less prone to this complication
The sealing of the wound depends
the quality of the corneo-scleral tissue
the quality of incision
This in turn depends on certain intraoperatory complications
certain chronic diseases
thermal injury of the wound
If needed case can use a therapeutic contact lens
Intraoperatory injury with the phaco tip or instruments
(complicate cases)
amp some local or general associated conditions may cause pupil asymmetries
This will translate clinically by decreased visual acuity
lack of adaptation to strong light
Post operatory intraocular inflammation can be acute and chronic (endophthalmitis)
Chronic uveal inflammation may occur in weeks months or years after cataract
chronic inflammation
significant statistical correlations between post-intraocular inflammation on the
one hand and rupture of thecapsule
Cystoid macular edema
Retinal detachment
Persistent increase in intraocular pressure
Intraocular lens dislocation or subluxation
Choroidal detachment
Endophthalmitis
Corneal edema
There were more cases of posterior capsule tears and vitreous
loss in the first 80 cases performed by the residents
the posterior capsule tear rate peaked at more than 10 after
40 cases
Spontaneous
in-the-Bag Intraocular Lens Luxation
into the Vitreous Cavity
A Balestrazzi G M Tosi M Alegente C Mazzotta et al Ophthalmologica Basel Aug 2009 Vol 223 Iss 5 pg 339 4 pgs
National Cataract Register (NCR)
type of anesthesia
history of trauma
ocular comorbidity
axial length
miosis
cornea pathology and poor visibility
previous intraocular operation
iris synechias small pupil
white cataract brunescenthard cataract
phacodonesis
presence of pseudoexfoliation
surgeon experience 3 years or less (operating under senior supervision) or more than 3 years of independent
phacoemulsification practice
Major complications occurred in 15 of 320 cases (47) and involved 10 cases of vitreous loss
the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2)
wrong IOL power requiring reoperation (1)
corneal wound burn (1)
and postoperative iris prolapse requiring wound revision
The mean postoperative BCVA was 2026 (logMAR 011)
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
B-scan ultrasonography 1 day after dislocation
of a lens nucleus into the vitreous cavity
in a patient who has high myopia
the early signs of posterior capsular rupture include
unusual deepening of the anterior chamber
decentration of the nucleus
or loss of efficiency of aspiration which suggests occlusion of the tip with vitreous
Usually Posterior capsular rupture is the most common
intraoperative complication in initial cases
The key factors are to minimize ocular trauma meticulously clean prolapsed vitreous
from the anterior segment if present and ensure secure fixation of the IOL
The review yielded 392 patients
Six (153) had intraocular pressure (gt or = 30 mm Hg) requiring treatment
1 (026) had painless iris prolapse
11 (281) had corneal abrasions
and 7 (178) were given a more intensive steroid regime (UVEITIS)
Corneal edema
No cases of fibrinous uveitis were recorded
J Cataract Refract Surg 1999 Jul25(7)985-8
Corneal edema is categorized according to severity in reversible and irreversible
bull reversible corneal edema- in 7 days 842-in 30 days 103
bull irreversible corneal edema ndash edemato bullous keratopathy (Corneal endothelial damage)
a significant statistical correlation of the corneal edema post phaco with the phaco-time and the type of cataract
Most common in pre-existing endothelial disorder
Edema is most often caused by Mechanical trauma Prolonged intraocular irrigation Inflammation And elevated IOP Toxic Solutions
Vitreocorneal Adherence and Persistent Corneal EdemaVitreocorneal Adherence and Persistent Corneal Edema
Points in ManagementPoints in Management
If epithelial edema is present in the face of a compact stroma immediately after surgery it is likely due to elevated lOP with intact endothelium
Corneal edema generally resolves completely within 4-6 weeks
As a rule if the corneal periphery is clear
the corneal edema will usually resolve with time
Corneal edema persisting after 3 months usually
does not clear and may require penetrating keratoplasty
Small wounds under 32 mm are much less prone to this complication
The sealing of the wound depends
the quality of the corneo-scleral tissue
the quality of incision
This in turn depends on certain intraoperatory complications
certain chronic diseases
thermal injury of the wound
If needed case can use a therapeutic contact lens
Intraoperatory injury with the phaco tip or instruments
(complicate cases)
amp some local or general associated conditions may cause pupil asymmetries
This will translate clinically by decreased visual acuity
lack of adaptation to strong light
Post operatory intraocular inflammation can be acute and chronic (endophthalmitis)
Chronic uveal inflammation may occur in weeks months or years after cataract
chronic inflammation
significant statistical correlations between post-intraocular inflammation on the
one hand and rupture of thecapsule
Cystoid macular edema
Retinal detachment
Persistent increase in intraocular pressure
Intraocular lens dislocation or subluxation
Choroidal detachment
Endophthalmitis
Corneal edema
There were more cases of posterior capsule tears and vitreous
loss in the first 80 cases performed by the residents
the posterior capsule tear rate peaked at more than 10 after
40 cases
Spontaneous
in-the-Bag Intraocular Lens Luxation
into the Vitreous Cavity
A Balestrazzi G M Tosi M Alegente C Mazzotta et al Ophthalmologica Basel Aug 2009 Vol 223 Iss 5 pg 339 4 pgs
National Cataract Register (NCR)
type of anesthesia
history of trauma
ocular comorbidity
axial length
miosis
cornea pathology and poor visibility
previous intraocular operation
iris synechias small pupil
white cataract brunescenthard cataract
phacodonesis
presence of pseudoexfoliation
surgeon experience 3 years or less (operating under senior supervision) or more than 3 years of independent
phacoemulsification practice
Major complications occurred in 15 of 320 cases (47) and involved 10 cases of vitreous loss
the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2)
wrong IOL power requiring reoperation (1)
corneal wound burn (1)
and postoperative iris prolapse requiring wound revision
The mean postoperative BCVA was 2026 (logMAR 011)
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
the early signs of posterior capsular rupture include
unusual deepening of the anterior chamber
decentration of the nucleus
or loss of efficiency of aspiration which suggests occlusion of the tip with vitreous
Usually Posterior capsular rupture is the most common
intraoperative complication in initial cases
The key factors are to minimize ocular trauma meticulously clean prolapsed vitreous
from the anterior segment if present and ensure secure fixation of the IOL
The review yielded 392 patients
Six (153) had intraocular pressure (gt or = 30 mm Hg) requiring treatment
1 (026) had painless iris prolapse
11 (281) had corneal abrasions
and 7 (178) were given a more intensive steroid regime (UVEITIS)
Corneal edema
No cases of fibrinous uveitis were recorded
J Cataract Refract Surg 1999 Jul25(7)985-8
Corneal edema is categorized according to severity in reversible and irreversible
bull reversible corneal edema- in 7 days 842-in 30 days 103
bull irreversible corneal edema ndash edemato bullous keratopathy (Corneal endothelial damage)
a significant statistical correlation of the corneal edema post phaco with the phaco-time and the type of cataract
Most common in pre-existing endothelial disorder
Edema is most often caused by Mechanical trauma Prolonged intraocular irrigation Inflammation And elevated IOP Toxic Solutions
Vitreocorneal Adherence and Persistent Corneal EdemaVitreocorneal Adherence and Persistent Corneal Edema
Points in ManagementPoints in Management
If epithelial edema is present in the face of a compact stroma immediately after surgery it is likely due to elevated lOP with intact endothelium
Corneal edema generally resolves completely within 4-6 weeks
As a rule if the corneal periphery is clear
the corneal edema will usually resolve with time
Corneal edema persisting after 3 months usually
does not clear and may require penetrating keratoplasty
Small wounds under 32 mm are much less prone to this complication
The sealing of the wound depends
the quality of the corneo-scleral tissue
the quality of incision
This in turn depends on certain intraoperatory complications
certain chronic diseases
thermal injury of the wound
If needed case can use a therapeutic contact lens
Intraoperatory injury with the phaco tip or instruments
(complicate cases)
amp some local or general associated conditions may cause pupil asymmetries
This will translate clinically by decreased visual acuity
lack of adaptation to strong light
Post operatory intraocular inflammation can be acute and chronic (endophthalmitis)
Chronic uveal inflammation may occur in weeks months or years after cataract
chronic inflammation
significant statistical correlations between post-intraocular inflammation on the
one hand and rupture of thecapsule
Cystoid macular edema
Retinal detachment
Persistent increase in intraocular pressure
Intraocular lens dislocation or subluxation
Choroidal detachment
Endophthalmitis
Corneal edema
There were more cases of posterior capsule tears and vitreous
loss in the first 80 cases performed by the residents
the posterior capsule tear rate peaked at more than 10 after
40 cases
Spontaneous
in-the-Bag Intraocular Lens Luxation
into the Vitreous Cavity
A Balestrazzi G M Tosi M Alegente C Mazzotta et al Ophthalmologica Basel Aug 2009 Vol 223 Iss 5 pg 339 4 pgs
National Cataract Register (NCR)
type of anesthesia
history of trauma
ocular comorbidity
axial length
miosis
cornea pathology and poor visibility
previous intraocular operation
iris synechias small pupil
white cataract brunescenthard cataract
phacodonesis
presence of pseudoexfoliation
surgeon experience 3 years or less (operating under senior supervision) or more than 3 years of independent
phacoemulsification practice
Major complications occurred in 15 of 320 cases (47) and involved 10 cases of vitreous loss
the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2)
wrong IOL power requiring reoperation (1)
corneal wound burn (1)
and postoperative iris prolapse requiring wound revision
The mean postoperative BCVA was 2026 (logMAR 011)
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
Usually Posterior capsular rupture is the most common
intraoperative complication in initial cases
The key factors are to minimize ocular trauma meticulously clean prolapsed vitreous
from the anterior segment if present and ensure secure fixation of the IOL
The review yielded 392 patients
Six (153) had intraocular pressure (gt or = 30 mm Hg) requiring treatment
1 (026) had painless iris prolapse
11 (281) had corneal abrasions
and 7 (178) were given a more intensive steroid regime (UVEITIS)
Corneal edema
No cases of fibrinous uveitis were recorded
J Cataract Refract Surg 1999 Jul25(7)985-8
Corneal edema is categorized according to severity in reversible and irreversible
bull reversible corneal edema- in 7 days 842-in 30 days 103
bull irreversible corneal edema ndash edemato bullous keratopathy (Corneal endothelial damage)
a significant statistical correlation of the corneal edema post phaco with the phaco-time and the type of cataract
Most common in pre-existing endothelial disorder
Edema is most often caused by Mechanical trauma Prolonged intraocular irrigation Inflammation And elevated IOP Toxic Solutions
Vitreocorneal Adherence and Persistent Corneal EdemaVitreocorneal Adherence and Persistent Corneal Edema
Points in ManagementPoints in Management
If epithelial edema is present in the face of a compact stroma immediately after surgery it is likely due to elevated lOP with intact endothelium
Corneal edema generally resolves completely within 4-6 weeks
As a rule if the corneal periphery is clear
the corneal edema will usually resolve with time
Corneal edema persisting after 3 months usually
does not clear and may require penetrating keratoplasty
Small wounds under 32 mm are much less prone to this complication
The sealing of the wound depends
the quality of the corneo-scleral tissue
the quality of incision
This in turn depends on certain intraoperatory complications
certain chronic diseases
thermal injury of the wound
If needed case can use a therapeutic contact lens
Intraoperatory injury with the phaco tip or instruments
(complicate cases)
amp some local or general associated conditions may cause pupil asymmetries
This will translate clinically by decreased visual acuity
lack of adaptation to strong light
Post operatory intraocular inflammation can be acute and chronic (endophthalmitis)
Chronic uveal inflammation may occur in weeks months or years after cataract
chronic inflammation
significant statistical correlations between post-intraocular inflammation on the
one hand and rupture of thecapsule
Cystoid macular edema
Retinal detachment
Persistent increase in intraocular pressure
Intraocular lens dislocation or subluxation
Choroidal detachment
Endophthalmitis
Corneal edema
There were more cases of posterior capsule tears and vitreous
loss in the first 80 cases performed by the residents
the posterior capsule tear rate peaked at more than 10 after
40 cases
Spontaneous
in-the-Bag Intraocular Lens Luxation
into the Vitreous Cavity
A Balestrazzi G M Tosi M Alegente C Mazzotta et al Ophthalmologica Basel Aug 2009 Vol 223 Iss 5 pg 339 4 pgs
National Cataract Register (NCR)
type of anesthesia
history of trauma
ocular comorbidity
axial length
miosis
cornea pathology and poor visibility
previous intraocular operation
iris synechias small pupil
white cataract brunescenthard cataract
phacodonesis
presence of pseudoexfoliation
surgeon experience 3 years or less (operating under senior supervision) or more than 3 years of independent
phacoemulsification practice
Major complications occurred in 15 of 320 cases (47) and involved 10 cases of vitreous loss
the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2)
wrong IOL power requiring reoperation (1)
corneal wound burn (1)
and postoperative iris prolapse requiring wound revision
The mean postoperative BCVA was 2026 (logMAR 011)
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
The key factors are to minimize ocular trauma meticulously clean prolapsed vitreous
from the anterior segment if present and ensure secure fixation of the IOL
The review yielded 392 patients
Six (153) had intraocular pressure (gt or = 30 mm Hg) requiring treatment
1 (026) had painless iris prolapse
11 (281) had corneal abrasions
and 7 (178) were given a more intensive steroid regime (UVEITIS)
Corneal edema
No cases of fibrinous uveitis were recorded
J Cataract Refract Surg 1999 Jul25(7)985-8
Corneal edema is categorized according to severity in reversible and irreversible
bull reversible corneal edema- in 7 days 842-in 30 days 103
bull irreversible corneal edema ndash edemato bullous keratopathy (Corneal endothelial damage)
a significant statistical correlation of the corneal edema post phaco with the phaco-time and the type of cataract
Most common in pre-existing endothelial disorder
Edema is most often caused by Mechanical trauma Prolonged intraocular irrigation Inflammation And elevated IOP Toxic Solutions
Vitreocorneal Adherence and Persistent Corneal EdemaVitreocorneal Adherence and Persistent Corneal Edema
Points in ManagementPoints in Management
If epithelial edema is present in the face of a compact stroma immediately after surgery it is likely due to elevated lOP with intact endothelium
Corneal edema generally resolves completely within 4-6 weeks
As a rule if the corneal periphery is clear
the corneal edema will usually resolve with time
Corneal edema persisting after 3 months usually
does not clear and may require penetrating keratoplasty
Small wounds under 32 mm are much less prone to this complication
The sealing of the wound depends
the quality of the corneo-scleral tissue
the quality of incision
This in turn depends on certain intraoperatory complications
certain chronic diseases
thermal injury of the wound
If needed case can use a therapeutic contact lens
Intraoperatory injury with the phaco tip or instruments
(complicate cases)
amp some local or general associated conditions may cause pupil asymmetries
This will translate clinically by decreased visual acuity
lack of adaptation to strong light
Post operatory intraocular inflammation can be acute and chronic (endophthalmitis)
Chronic uveal inflammation may occur in weeks months or years after cataract
chronic inflammation
significant statistical correlations between post-intraocular inflammation on the
one hand and rupture of thecapsule
Cystoid macular edema
Retinal detachment
Persistent increase in intraocular pressure
Intraocular lens dislocation or subluxation
Choroidal detachment
Endophthalmitis
Corneal edema
There were more cases of posterior capsule tears and vitreous
loss in the first 80 cases performed by the residents
the posterior capsule tear rate peaked at more than 10 after
40 cases
Spontaneous
in-the-Bag Intraocular Lens Luxation
into the Vitreous Cavity
A Balestrazzi G M Tosi M Alegente C Mazzotta et al Ophthalmologica Basel Aug 2009 Vol 223 Iss 5 pg 339 4 pgs
National Cataract Register (NCR)
type of anesthesia
history of trauma
ocular comorbidity
axial length
miosis
cornea pathology and poor visibility
previous intraocular operation
iris synechias small pupil
white cataract brunescenthard cataract
phacodonesis
presence of pseudoexfoliation
surgeon experience 3 years or less (operating under senior supervision) or more than 3 years of independent
phacoemulsification practice
Major complications occurred in 15 of 320 cases (47) and involved 10 cases of vitreous loss
the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2)
wrong IOL power requiring reoperation (1)
corneal wound burn (1)
and postoperative iris prolapse requiring wound revision
The mean postoperative BCVA was 2026 (logMAR 011)
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
The review yielded 392 patients
Six (153) had intraocular pressure (gt or = 30 mm Hg) requiring treatment
1 (026) had painless iris prolapse
11 (281) had corneal abrasions
and 7 (178) were given a more intensive steroid regime (UVEITIS)
Corneal edema
No cases of fibrinous uveitis were recorded
J Cataract Refract Surg 1999 Jul25(7)985-8
Corneal edema is categorized according to severity in reversible and irreversible
bull reversible corneal edema- in 7 days 842-in 30 days 103
bull irreversible corneal edema ndash edemato bullous keratopathy (Corneal endothelial damage)
a significant statistical correlation of the corneal edema post phaco with the phaco-time and the type of cataract
Most common in pre-existing endothelial disorder
Edema is most often caused by Mechanical trauma Prolonged intraocular irrigation Inflammation And elevated IOP Toxic Solutions
Vitreocorneal Adherence and Persistent Corneal EdemaVitreocorneal Adherence and Persistent Corneal Edema
Points in ManagementPoints in Management
If epithelial edema is present in the face of a compact stroma immediately after surgery it is likely due to elevated lOP with intact endothelium
Corneal edema generally resolves completely within 4-6 weeks
As a rule if the corneal periphery is clear
the corneal edema will usually resolve with time
Corneal edema persisting after 3 months usually
does not clear and may require penetrating keratoplasty
Small wounds under 32 mm are much less prone to this complication
The sealing of the wound depends
the quality of the corneo-scleral tissue
the quality of incision
This in turn depends on certain intraoperatory complications
certain chronic diseases
thermal injury of the wound
If needed case can use a therapeutic contact lens
Intraoperatory injury with the phaco tip or instruments
(complicate cases)
amp some local or general associated conditions may cause pupil asymmetries
This will translate clinically by decreased visual acuity
lack of adaptation to strong light
Post operatory intraocular inflammation can be acute and chronic (endophthalmitis)
Chronic uveal inflammation may occur in weeks months or years after cataract
chronic inflammation
significant statistical correlations between post-intraocular inflammation on the
one hand and rupture of thecapsule
Cystoid macular edema
Retinal detachment
Persistent increase in intraocular pressure
Intraocular lens dislocation or subluxation
Choroidal detachment
Endophthalmitis
Corneal edema
There were more cases of posterior capsule tears and vitreous
loss in the first 80 cases performed by the residents
the posterior capsule tear rate peaked at more than 10 after
40 cases
Spontaneous
in-the-Bag Intraocular Lens Luxation
into the Vitreous Cavity
A Balestrazzi G M Tosi M Alegente C Mazzotta et al Ophthalmologica Basel Aug 2009 Vol 223 Iss 5 pg 339 4 pgs
National Cataract Register (NCR)
type of anesthesia
history of trauma
ocular comorbidity
axial length
miosis
cornea pathology and poor visibility
previous intraocular operation
iris synechias small pupil
white cataract brunescenthard cataract
phacodonesis
presence of pseudoexfoliation
surgeon experience 3 years or less (operating under senior supervision) or more than 3 years of independent
phacoemulsification practice
Major complications occurred in 15 of 320 cases (47) and involved 10 cases of vitreous loss
the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2)
wrong IOL power requiring reoperation (1)
corneal wound burn (1)
and postoperative iris prolapse requiring wound revision
The mean postoperative BCVA was 2026 (logMAR 011)
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
Corneal edema is categorized according to severity in reversible and irreversible
bull reversible corneal edema- in 7 days 842-in 30 days 103
bull irreversible corneal edema ndash edemato bullous keratopathy (Corneal endothelial damage)
a significant statistical correlation of the corneal edema post phaco with the phaco-time and the type of cataract
Most common in pre-existing endothelial disorder
Edema is most often caused by Mechanical trauma Prolonged intraocular irrigation Inflammation And elevated IOP Toxic Solutions
Vitreocorneal Adherence and Persistent Corneal EdemaVitreocorneal Adherence and Persistent Corneal Edema
Points in ManagementPoints in Management
If epithelial edema is present in the face of a compact stroma immediately after surgery it is likely due to elevated lOP with intact endothelium
Corneal edema generally resolves completely within 4-6 weeks
As a rule if the corneal periphery is clear
the corneal edema will usually resolve with time
Corneal edema persisting after 3 months usually
does not clear and may require penetrating keratoplasty
Small wounds under 32 mm are much less prone to this complication
The sealing of the wound depends
the quality of the corneo-scleral tissue
the quality of incision
This in turn depends on certain intraoperatory complications
certain chronic diseases
thermal injury of the wound
If needed case can use a therapeutic contact lens
Intraoperatory injury with the phaco tip or instruments
(complicate cases)
amp some local or general associated conditions may cause pupil asymmetries
This will translate clinically by decreased visual acuity
lack of adaptation to strong light
Post operatory intraocular inflammation can be acute and chronic (endophthalmitis)
Chronic uveal inflammation may occur in weeks months or years after cataract
chronic inflammation
significant statistical correlations between post-intraocular inflammation on the
one hand and rupture of thecapsule
Cystoid macular edema
Retinal detachment
Persistent increase in intraocular pressure
Intraocular lens dislocation or subluxation
Choroidal detachment
Endophthalmitis
Corneal edema
There were more cases of posterior capsule tears and vitreous
loss in the first 80 cases performed by the residents
the posterior capsule tear rate peaked at more than 10 after
40 cases
Spontaneous
in-the-Bag Intraocular Lens Luxation
into the Vitreous Cavity
A Balestrazzi G M Tosi M Alegente C Mazzotta et al Ophthalmologica Basel Aug 2009 Vol 223 Iss 5 pg 339 4 pgs
National Cataract Register (NCR)
type of anesthesia
history of trauma
ocular comorbidity
axial length
miosis
cornea pathology and poor visibility
previous intraocular operation
iris synechias small pupil
white cataract brunescenthard cataract
phacodonesis
presence of pseudoexfoliation
surgeon experience 3 years or less (operating under senior supervision) or more than 3 years of independent
phacoemulsification practice
Major complications occurred in 15 of 320 cases (47) and involved 10 cases of vitreous loss
the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2)
wrong IOL power requiring reoperation (1)
corneal wound burn (1)
and postoperative iris prolapse requiring wound revision
The mean postoperative BCVA was 2026 (logMAR 011)
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
Most common in pre-existing endothelial disorder
Edema is most often caused by Mechanical trauma Prolonged intraocular irrigation Inflammation And elevated IOP Toxic Solutions
Vitreocorneal Adherence and Persistent Corneal EdemaVitreocorneal Adherence and Persistent Corneal Edema
Points in ManagementPoints in Management
If epithelial edema is present in the face of a compact stroma immediately after surgery it is likely due to elevated lOP with intact endothelium
Corneal edema generally resolves completely within 4-6 weeks
As a rule if the corneal periphery is clear
the corneal edema will usually resolve with time
Corneal edema persisting after 3 months usually
does not clear and may require penetrating keratoplasty
Small wounds under 32 mm are much less prone to this complication
The sealing of the wound depends
the quality of the corneo-scleral tissue
the quality of incision
This in turn depends on certain intraoperatory complications
certain chronic diseases
thermal injury of the wound
If needed case can use a therapeutic contact lens
Intraoperatory injury with the phaco tip or instruments
(complicate cases)
amp some local or general associated conditions may cause pupil asymmetries
This will translate clinically by decreased visual acuity
lack of adaptation to strong light
Post operatory intraocular inflammation can be acute and chronic (endophthalmitis)
Chronic uveal inflammation may occur in weeks months or years after cataract
chronic inflammation
significant statistical correlations between post-intraocular inflammation on the
one hand and rupture of thecapsule
Cystoid macular edema
Retinal detachment
Persistent increase in intraocular pressure
Intraocular lens dislocation or subluxation
Choroidal detachment
Endophthalmitis
Corneal edema
There were more cases of posterior capsule tears and vitreous
loss in the first 80 cases performed by the residents
the posterior capsule tear rate peaked at more than 10 after
40 cases
Spontaneous
in-the-Bag Intraocular Lens Luxation
into the Vitreous Cavity
A Balestrazzi G M Tosi M Alegente C Mazzotta et al Ophthalmologica Basel Aug 2009 Vol 223 Iss 5 pg 339 4 pgs
National Cataract Register (NCR)
type of anesthesia
history of trauma
ocular comorbidity
axial length
miosis
cornea pathology and poor visibility
previous intraocular operation
iris synechias small pupil
white cataract brunescenthard cataract
phacodonesis
presence of pseudoexfoliation
surgeon experience 3 years or less (operating under senior supervision) or more than 3 years of independent
phacoemulsification practice
Major complications occurred in 15 of 320 cases (47) and involved 10 cases of vitreous loss
the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2)
wrong IOL power requiring reoperation (1)
corneal wound burn (1)
and postoperative iris prolapse requiring wound revision
The mean postoperative BCVA was 2026 (logMAR 011)
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
Points in ManagementPoints in Management
If epithelial edema is present in the face of a compact stroma immediately after surgery it is likely due to elevated lOP with intact endothelium
Corneal edema generally resolves completely within 4-6 weeks
As a rule if the corneal periphery is clear
the corneal edema will usually resolve with time
Corneal edema persisting after 3 months usually
does not clear and may require penetrating keratoplasty
Small wounds under 32 mm are much less prone to this complication
The sealing of the wound depends
the quality of the corneo-scleral tissue
the quality of incision
This in turn depends on certain intraoperatory complications
certain chronic diseases
thermal injury of the wound
If needed case can use a therapeutic contact lens
Intraoperatory injury with the phaco tip or instruments
(complicate cases)
amp some local or general associated conditions may cause pupil asymmetries
This will translate clinically by decreased visual acuity
lack of adaptation to strong light
Post operatory intraocular inflammation can be acute and chronic (endophthalmitis)
Chronic uveal inflammation may occur in weeks months or years after cataract
chronic inflammation
significant statistical correlations between post-intraocular inflammation on the
one hand and rupture of thecapsule
Cystoid macular edema
Retinal detachment
Persistent increase in intraocular pressure
Intraocular lens dislocation or subluxation
Choroidal detachment
Endophthalmitis
Corneal edema
There were more cases of posterior capsule tears and vitreous
loss in the first 80 cases performed by the residents
the posterior capsule tear rate peaked at more than 10 after
40 cases
Spontaneous
in-the-Bag Intraocular Lens Luxation
into the Vitreous Cavity
A Balestrazzi G M Tosi M Alegente C Mazzotta et al Ophthalmologica Basel Aug 2009 Vol 223 Iss 5 pg 339 4 pgs
National Cataract Register (NCR)
type of anesthesia
history of trauma
ocular comorbidity
axial length
miosis
cornea pathology and poor visibility
previous intraocular operation
iris synechias small pupil
white cataract brunescenthard cataract
phacodonesis
presence of pseudoexfoliation
surgeon experience 3 years or less (operating under senior supervision) or more than 3 years of independent
phacoemulsification practice
Major complications occurred in 15 of 320 cases (47) and involved 10 cases of vitreous loss
the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2)
wrong IOL power requiring reoperation (1)
corneal wound burn (1)
and postoperative iris prolapse requiring wound revision
The mean postoperative BCVA was 2026 (logMAR 011)
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
Small wounds under 32 mm are much less prone to this complication
The sealing of the wound depends
the quality of the corneo-scleral tissue
the quality of incision
This in turn depends on certain intraoperatory complications
certain chronic diseases
thermal injury of the wound
If needed case can use a therapeutic contact lens
Intraoperatory injury with the phaco tip or instruments
(complicate cases)
amp some local or general associated conditions may cause pupil asymmetries
This will translate clinically by decreased visual acuity
lack of adaptation to strong light
Post operatory intraocular inflammation can be acute and chronic (endophthalmitis)
Chronic uveal inflammation may occur in weeks months or years after cataract
chronic inflammation
significant statistical correlations between post-intraocular inflammation on the
one hand and rupture of thecapsule
Cystoid macular edema
Retinal detachment
Persistent increase in intraocular pressure
Intraocular lens dislocation or subluxation
Choroidal detachment
Endophthalmitis
Corneal edema
There were more cases of posterior capsule tears and vitreous
loss in the first 80 cases performed by the residents
the posterior capsule tear rate peaked at more than 10 after
40 cases
Spontaneous
in-the-Bag Intraocular Lens Luxation
into the Vitreous Cavity
A Balestrazzi G M Tosi M Alegente C Mazzotta et al Ophthalmologica Basel Aug 2009 Vol 223 Iss 5 pg 339 4 pgs
National Cataract Register (NCR)
type of anesthesia
history of trauma
ocular comorbidity
axial length
miosis
cornea pathology and poor visibility
previous intraocular operation
iris synechias small pupil
white cataract brunescenthard cataract
phacodonesis
presence of pseudoexfoliation
surgeon experience 3 years or less (operating under senior supervision) or more than 3 years of independent
phacoemulsification practice
Major complications occurred in 15 of 320 cases (47) and involved 10 cases of vitreous loss
the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2)
wrong IOL power requiring reoperation (1)
corneal wound burn (1)
and postoperative iris prolapse requiring wound revision
The mean postoperative BCVA was 2026 (logMAR 011)
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
Intraoperatory injury with the phaco tip or instruments
(complicate cases)
amp some local or general associated conditions may cause pupil asymmetries
This will translate clinically by decreased visual acuity
lack of adaptation to strong light
Post operatory intraocular inflammation can be acute and chronic (endophthalmitis)
Chronic uveal inflammation may occur in weeks months or years after cataract
chronic inflammation
significant statistical correlations between post-intraocular inflammation on the
one hand and rupture of thecapsule
Cystoid macular edema
Retinal detachment
Persistent increase in intraocular pressure
Intraocular lens dislocation or subluxation
Choroidal detachment
Endophthalmitis
Corneal edema
There were more cases of posterior capsule tears and vitreous
loss in the first 80 cases performed by the residents
the posterior capsule tear rate peaked at more than 10 after
40 cases
Spontaneous
in-the-Bag Intraocular Lens Luxation
into the Vitreous Cavity
A Balestrazzi G M Tosi M Alegente C Mazzotta et al Ophthalmologica Basel Aug 2009 Vol 223 Iss 5 pg 339 4 pgs
National Cataract Register (NCR)
type of anesthesia
history of trauma
ocular comorbidity
axial length
miosis
cornea pathology and poor visibility
previous intraocular operation
iris synechias small pupil
white cataract brunescenthard cataract
phacodonesis
presence of pseudoexfoliation
surgeon experience 3 years or less (operating under senior supervision) or more than 3 years of independent
phacoemulsification practice
Major complications occurred in 15 of 320 cases (47) and involved 10 cases of vitreous loss
the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2)
wrong IOL power requiring reoperation (1)
corneal wound burn (1)
and postoperative iris prolapse requiring wound revision
The mean postoperative BCVA was 2026 (logMAR 011)
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
Post operatory intraocular inflammation can be acute and chronic (endophthalmitis)
Chronic uveal inflammation may occur in weeks months or years after cataract
chronic inflammation
significant statistical correlations between post-intraocular inflammation on the
one hand and rupture of thecapsule
Cystoid macular edema
Retinal detachment
Persistent increase in intraocular pressure
Intraocular lens dislocation or subluxation
Choroidal detachment
Endophthalmitis
Corneal edema
There were more cases of posterior capsule tears and vitreous
loss in the first 80 cases performed by the residents
the posterior capsule tear rate peaked at more than 10 after
40 cases
Spontaneous
in-the-Bag Intraocular Lens Luxation
into the Vitreous Cavity
A Balestrazzi G M Tosi M Alegente C Mazzotta et al Ophthalmologica Basel Aug 2009 Vol 223 Iss 5 pg 339 4 pgs
National Cataract Register (NCR)
type of anesthesia
history of trauma
ocular comorbidity
axial length
miosis
cornea pathology and poor visibility
previous intraocular operation
iris synechias small pupil
white cataract brunescenthard cataract
phacodonesis
presence of pseudoexfoliation
surgeon experience 3 years or less (operating under senior supervision) or more than 3 years of independent
phacoemulsification practice
Major complications occurred in 15 of 320 cases (47) and involved 10 cases of vitreous loss
the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2)
wrong IOL power requiring reoperation (1)
corneal wound burn (1)
and postoperative iris prolapse requiring wound revision
The mean postoperative BCVA was 2026 (logMAR 011)
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
Cystoid macular edema
Retinal detachment
Persistent increase in intraocular pressure
Intraocular lens dislocation or subluxation
Choroidal detachment
Endophthalmitis
Corneal edema
There were more cases of posterior capsule tears and vitreous
loss in the first 80 cases performed by the residents
the posterior capsule tear rate peaked at more than 10 after
40 cases
Spontaneous
in-the-Bag Intraocular Lens Luxation
into the Vitreous Cavity
A Balestrazzi G M Tosi M Alegente C Mazzotta et al Ophthalmologica Basel Aug 2009 Vol 223 Iss 5 pg 339 4 pgs
National Cataract Register (NCR)
type of anesthesia
history of trauma
ocular comorbidity
axial length
miosis
cornea pathology and poor visibility
previous intraocular operation
iris synechias small pupil
white cataract brunescenthard cataract
phacodonesis
presence of pseudoexfoliation
surgeon experience 3 years or less (operating under senior supervision) or more than 3 years of independent
phacoemulsification practice
Major complications occurred in 15 of 320 cases (47) and involved 10 cases of vitreous loss
the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2)
wrong IOL power requiring reoperation (1)
corneal wound burn (1)
and postoperative iris prolapse requiring wound revision
The mean postoperative BCVA was 2026 (logMAR 011)
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
There were more cases of posterior capsule tears and vitreous
loss in the first 80 cases performed by the residents
the posterior capsule tear rate peaked at more than 10 after
40 cases
Spontaneous
in-the-Bag Intraocular Lens Luxation
into the Vitreous Cavity
A Balestrazzi G M Tosi M Alegente C Mazzotta et al Ophthalmologica Basel Aug 2009 Vol 223 Iss 5 pg 339 4 pgs
National Cataract Register (NCR)
type of anesthesia
history of trauma
ocular comorbidity
axial length
miosis
cornea pathology and poor visibility
previous intraocular operation
iris synechias small pupil
white cataract brunescenthard cataract
phacodonesis
presence of pseudoexfoliation
surgeon experience 3 years or less (operating under senior supervision) or more than 3 years of independent
phacoemulsification practice
Major complications occurred in 15 of 320 cases (47) and involved 10 cases of vitreous loss
the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2)
wrong IOL power requiring reoperation (1)
corneal wound burn (1)
and postoperative iris prolapse requiring wound revision
The mean postoperative BCVA was 2026 (logMAR 011)
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
Spontaneous
in-the-Bag Intraocular Lens Luxation
into the Vitreous Cavity
A Balestrazzi G M Tosi M Alegente C Mazzotta et al Ophthalmologica Basel Aug 2009 Vol 223 Iss 5 pg 339 4 pgs
National Cataract Register (NCR)
type of anesthesia
history of trauma
ocular comorbidity
axial length
miosis
cornea pathology and poor visibility
previous intraocular operation
iris synechias small pupil
white cataract brunescenthard cataract
phacodonesis
presence of pseudoexfoliation
surgeon experience 3 years or less (operating under senior supervision) or more than 3 years of independent
phacoemulsification practice
Major complications occurred in 15 of 320 cases (47) and involved 10 cases of vitreous loss
the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2)
wrong IOL power requiring reoperation (1)
corneal wound burn (1)
and postoperative iris prolapse requiring wound revision
The mean postoperative BCVA was 2026 (logMAR 011)
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
National Cataract Register (NCR)
type of anesthesia
history of trauma
ocular comorbidity
axial length
miosis
cornea pathology and poor visibility
previous intraocular operation
iris synechias small pupil
white cataract brunescenthard cataract
phacodonesis
presence of pseudoexfoliation
surgeon experience 3 years or less (operating under senior supervision) or more than 3 years of independent
phacoemulsification practice
Major complications occurred in 15 of 320 cases (47) and involved 10 cases of vitreous loss
the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2)
wrong IOL power requiring reoperation (1)
corneal wound burn (1)
and postoperative iris prolapse requiring wound revision
The mean postoperative BCVA was 2026 (logMAR 011)
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
Major complications occurred in 15 of 320 cases (47) and involved 10 cases of vitreous loss
the other 5 cases involved malpositioned intraocular lens (IOL) requiring reoperation (2)
wrong IOL power requiring reoperation (1)
corneal wound burn (1)
and postoperative iris prolapse requiring wound revision
The mean postoperative BCVA was 2026 (logMAR 011)
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
Severity of retro bulbar bleeding is varied
Eyeball protrusion may occur
Massive subconjunctival hematoma appears
Consequent an increase of the intraocular
pressure may involve structural changes in the eyeball
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
Visual results and complications of temporal incision phacoemulsification performed
with the non-dominant left hand by junior ophthalmologists
Ophthalmology trainees could successfully learn the technique with both hands The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts
all parameters had no difference in both sides
Br J Ophthalmol 2002861222-1224 doi101136bjo86111222 Scientific correspondence
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
An iatrogenic Descemetorhexis is an extremely rare complication amp to our knowledge has been described only once previously in literature by Altmann and Tympner2
In this instance our case study presented
a hazy cornea immediately postoperatively along with corneal oedema both of which had resolved within one month of surgery
and continued to remain clear at the two-year postoperative follow-up
This positive outcome was a result of
the spread and enlargement of the remaining endothelial cells
which successfully reformed the endothelial cell layer
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
prolapse or emulsification with a phacoemulsification tip can produce an irregularly shaped pupil and iris atrophy
and can predispose to posterior synechiae formation If iris damage is produced inferiorly through contact with the phacoemulsification tip
loose strands of tissue should be cut to reduce the likelihood of these being aspirated into the phacoemulsification tip
Another option is to use a single iris hook to retract the inferior iris holding it away from the phacoemulsification tip for the duration of the procedure
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
the nucleus seems to be trapped within the capsular bag
This usually indicates a nucleus that requires
further hydrodissectionviscodissection can be performed
When re-entering the eye with the phacoemulsification tip irrigation should not be used until a second instrument has been inserted through the stab
incision and placed below the nucleus when irrigation and aspiration begin and the OVD is removed the second instrument prevents the nuclear piece from falling back into the posterior chamber
After the nucleus has been sufficiently thinned an instrument such as a Sinskey hook or spatula can be teased posteriorly through the remaining nuclear tissue
this enables elevation of a portion of the nucleus and thereby facilitates access to the remainder
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
Fig 5-7-2 Vacuum rise-time as a function of aspiration rate Graph showing the effect of increasing aspiration rate (pump speed) on the time to reach certain vacuum levels
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
POSTOCCLUSION SURGE Intraocular pressure (IOP) during post occlusion surge
Yanoff amp Duker Ophthalmology 3rd ed Copyright copy 2008 Mosby
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
A statistically significant decrease in posterior capsule tears with vitreous loss has occurred since FY 1995 following the change from venturi to peristaltic driven phacoemulsification
(Plt0001)
We suspect that the higher inherent vacuum levels present in the venturi driven system
may have led to an
increased incidence of posterior capsule tears and vitreous loss
in the beginning resident surgeon Other factors that were analyzed and may be important include attending surgeon experience phacoemulsification technique machine parameters used and the content of preparatory phacoemulsification courses
Ophthalmology amp Vis Sci University Chicago Chicago IL2 Ophthalmology and Visual Science The University of Chicago Chicago IL
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
Most surgeons recommend
completing the procedure with careful anterior vitrectomy and removal of remaining accessible lens material In general IOL implantation is permissible one exception might be loss of an extremely hard dense nucleus that would require removal through a limbal incision
If a significant amount of nuclear material has been retained vitreoretinal surgery needs to be performed 1ndash2 days postoperatively
Patients whose eyes have small residual nuclear fragments may be observed and referred if increased IOP or uveitis refractory to medical treatment develops
Some surgeons advocate
irrigating the vitreous with fluid in an attempt to float the nucleus back into position An obvious concern is that this additional turbulence could increase vitreous traction on the retina and cause retinal tears
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
during phacoemulsification complicated by a posterior capsule tear
10-0 nylon are tied to the trailing haptic of the IOL Then the IOL is inserted into the sulcus
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
Poor pupillary dilation
Zonular dehiscence
Capsular rupture
Vitreous loss amp dropped nucleous
IOP control in the early postoperative period seems to be more important in patients with PEX
Ophthalmologica 2008222112-116
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
1048708 Improve amp stabilize blood glucose
1048708 A1c lt 65 (ideally)
1048708 Strive for a low standard deviation
1048708Phacoemulsification when prudent or necessary
1048708 Much higher risk of post- operative CME and worsening retinopathy
1048708 Always address retinopathy prior to surgery
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
- Bandyopadhyay S - Indian J Ophthalmol - 01-MAY-2007 55(3) 238-9
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
may occur at the rate of 1
after uncomplicated cataract surgery
and increases
to between 68 and 86 following intraoperative vitreous loss [6]
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
Complications of PhacoemulsificationComplications of Phacoemulsification
Holding the phaco tip too close to the cornea
Performing phacoemulsification or allowing lens fragments to circulate
in the anterior chamber
Retained nuclear fragments in the anterior chamber angle may contribute to focal corneal edema
These cases may demonstrate corneal edema on the first postoperative day or months to years following surgery
Removing retained nuclear material may allow for the corneal edema to resolve
