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Complications of cataract Surgery

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Author : Dr Deepak Garg

Introduction

Cataract Surgery is the most routine eye surgery performed at Eye Solutions.  "What are the complications of cataract surgery ?" is thus probably one of the most frequently asked questions.  There are a few possible techniques for cataract surgeries.  These days cataract surgery is done by a method known as 'Phacoemulsification'.  We have come a long way from the older method of doing cataract surgery called 'Extracapsular cataract extraction'.  The oldest technique of performing cataract surgery which is almost not performed nowadays is 'Intracapsular cataract extraction'.  These required much larger incisions than modern-day surgery.

Cataract in adults is an age-related change that occurs in the eyes.  It's not a disease.  You can read more about cataract surgery and cataract consultation.

Before you continue reading, it is essential to note that the risk of complications can exist with any activity you do.  It could be driving on the highway. There is no way that someone can guarantee that there would not be an accident, similarly, with any surgery or medical procedure and so with cataract surgery.  

Even though we have tried and listed all the complications here, the idea is not to scare you.  It is just to let you know that certain complications can occur.  The complication rates of the below-mentioned complications are very, very low but not zero.  Modern cataract surgery has, over time, become a very frequently performed procedure.  At Eye solutions, cataract surgeries are performed at all our locations almost every day.  Most of these surgeries are for adult cataracts.  These days cataract surgeries are done without any injections or sutures.  We remove the eye patch just 10 min after surgery.  In other words, you leave the hospital without an eye patch.  You should know that cataracts can also occur in children, and children who have cataracts are operated upon as soon as possible.  For uncomplicated cataract surgery, the time taken is between 10-15 minutes.  The surgery is without any injections or any use of sutures.  The visual outcomes for all our patients are excellent.

What are Cataract Surgery Complications ?

Cataract surgical procedures have a low rate of surgical complications which means most of the time, they go off well.  These complications are those that happen during and after surgery.

Cataract surgery complications which occur during surgery

Posterior capsule rupture

The most dreaded complication during cataract surgery is "Nucleus drop ".   The natural lens of the eye has become cataractous.  This natural lens is present in a bag inside the eye.  This bag is known as the lens capsule.  During cataract operations, your eye doctor removes part of the front-facing portion of the bag to reach the lens material.  This front portion is also called the anterior capsule.  The lens material is then removed and what we are left with is part of the anterior capsule and the back part of the bag.  This back part is also called the posterior capsule, which separates the front and back of our eyes. They are also known as the anterior chamber and posterior chamber.  On this layer, your eye doctor places the artificial lens inside the eye.  This artificial lens is also known as the Intraocular lens implant or IOL.  These lenses are different from contact lenses which are worn on the eye.  IOLs are implanted inside the eye.

There are various types of intraocular lenses, and you can read about the best cataract lens.  Depending on the shape of your eye and your lifestyle requirements, your ophthalmologist would be able to suggest the best lens for you.  These could range from Monofocal, Toric lenses, Multifocal lenses or Trifocal Lenses and Extended depth of focus lenses.

It is of utmost importance that there is no tear in the posterior capsule.  This tear can happen at the time of cataract removal.  It is also known as posterior capsular rupture.  If it does happen, then part of the whole of the cataract can drop through that tear into the back part of the eye.  Basically, it falls on the retina.  The retina is the back-most layer of the eye and is the light-sensitive layer of the eye.  It transmits the light from the eye to the brain.

If a whole or part of cataractous material falls at the back, then another surgery has to be performed to remove that part.  This second surgery would be performed by a retina specialist.  Even though the success of the second surgery is good, it still comes with its own set of complications.  This second surgery is called vitrectomy.  This surgery can lead to a retinal tear sometimes, which in turn leads to retinal detachment.

If this tear in the posterior capsule happens after the cataract is removed and it goes unnoticed, there is a chance that the intraocular lens too may drop in the back part of the eye during intraocular lens implantation.  Again for this to a retina specialist has to perform surgery to remove the lens and place another lens in the correct position inside the eye.

However, if a tear occurs, it is recognised by experienced surgeons most of the time.  Steps are taken to prevent further complications.  The intraocular lens is still placed in the eye.  The difference is, it is not placed in the bag but the sulcus.  The Sulcus is the space between the anterior capsule and the iris.  In other words, it is the space just behind the iris, the coloured portion of your eyes.  Sulcus implantation of the intraocular lens is well supported in the eye.

DM Detachment

DM stands for Descemet's membrane and is one of the layers of the cornea, which is a transparent layer and is the front-most layer of the eye.  While we are performing the cataract surgery, there is a chance of a small or large Descemet's detachment.  This layer detaches from the cornea.  Small detachments don't cause any problem and, most of the time, reattach to the cornea.  Large attachments, however, can cause corneal oedema after surgery.

Usually, your eye surgeon treats these detachments during the cataract surgery itself.  And as mentioned earlier, they reattach.

Surgery requires a suture

Using a suture is not a complication, but sometimes patients consider using a suture during the surgery as a complication and thus the mention.  Modern cataract surgery is sutureless.  Post-surgery the eye is sealed without sutures.  Sometimes, however, a suture may be needed to close the primary wound of the eye.  Requiring a suture does not mean that the surgery did not go well or is a problem.  If your surgeon feels that the primary surgery wound is not closing as well as it should, then to be safe, your surgeon may take a suture to close the wound.

Cataract surgery complicatons which occur after surgery 

The most dreaded complication of cataract surgery is an eye infection.  This infection is known as Endophthalmitis.  This cataract procedure complication can cause blindness or significant loss of vision and is one of the most devastating complications if not treated in time.  

How does endophthalmitis occur ?

As mentioned earlier, this is an infection that occurs after cataract surgery.  As with all infections, this too is caused by infection-causing organisms.  These organisms can be bacteria or fungi more commonly and viruses more rarely.  Out of the first two, bacterial infections are more common.  Fungal infections are more severe.  The most common bacteria are staphylococcus Aureus also known as staphylococci. Endophthalmitis can occur after any intraocular surgery, where surgical tools are inserted within the eyes.

These organisms can enter the eye during or after the surgery.  Most commonly, they enter the eye during the procedure.  It is thus most vital that you go to an eye hospital that you think maintains strict aseptic precautions during surgery.  The hospital must use excellent equipment to sterilise all its instruments.

This infection usually occurs in the first few days after cataract surgery.  The patient may complain of redness, pain, decreased vision, or watering.  The doctor would most likely see you immediately and treat the infection.  Treatment could be the use of antibiotic eye drops or eye injections.  In advanced cases, the patient may need surgery to help the eye heal.  This surgery is called vitrectomy.

What increases the risk of endophthalmitis ?

Suppose a patient has any preoperative infection, the risk of endophthalmitis increases.  For this reason, we order some blood tests before the surgery.  We also ask the patient if they have a boil somewhere that is hurting, fever, cough, or cold.  If we suspect any infection in the body, we postpone the surgery and treatment before we operate.

Uncontrolled diabetes also increases the risk of endophthalmitis. An average blood sugar level is a must before surgery, and if high, the surgery is postponed until the blood sugar returns to normal.

To avoid this infection, eye doctors impose certain restrictions after cataract surgeries.  You can read more about precautions after cataract surgery.

Post operative inflammation and corneal edema

After every surgery, there is some inflammation and corneal oedema.  The amount may vary when it's significantly less, it's considered normal, and the patient is usually comfortable.  However, the inflammation may be severe, and so could the swelling in the cornea or corneal oedema.  This inflammation may lead to pain, watering, and blurry vision.  However, these usually subside with steroid eye drops prescribed after cataract surgery.  This inflammation may happen in hard cataracts or advanced cataracts.  These are also known as dense cataracts.  Sometimes inflammation post-cataract surgery is also seen in diabetics.

Posterior capsular opacification

Posterior capsule opacification is a common complication and is also known as PCO.  PCO is not a complication.  But it can occur in patients who undergo cataract surgery.  Up to 50% of patients who undergo cataract surgery can have a posterior capsule opacity, also known as a secondary cataract.  Posterior capsule opacity usually occurs a few months to a few years after the procedure. 

We don't consider this a complication because this is part of the eye's healing process.  After we remove the cataract, we place intraocular lenses in the bag.  The intraocular lens implant is lying on the posterior capsule.  After the surgery, the eye thinks there is no lens and tries to form a new lens by making new cellular material.  This new material grows on the posterior capsule.  Thus, the posterior capsule may become opaque and white, which reduces vision or causes blurry vision.

The treatment for PCO is something called Yag Laser posterior Capsulotomy.  It's a speedy, painless laser procedure.   We do not impose any restrictions after this laser treatment, and all you have to do is use certain steroid eye drops for 4-5 days.  You can see the actual video of laser capsulotomy and read more about it.  You will notice the laser beam removing the cloudy capsule in the video.

Need for glasses post surgery

Gone are the days when cataract surgery was merely a surgery performed to get rid of the cataract.  Today this procedure also leads to glass-free vision.  With newer lenses like multifocal lenses and trifocal lenses, patients become glass-free for almost all their activities.  There is a wide range of these premium IOLs available.

Over time, patients want clear glass free vision after cataract surgery.  

However, the lens power that we insert in the eye is dependant on a few factors.  Most important is the shape of the eyeball.  We use specific formulas to calculate the power of the lens that we are going to use in your eye.

Overall, these formulas work well, but the glass power or eye number that patients get 2-3 weeks after surgery is also dependant on how the eye behaves after the surgery.  Patients may always get a small number post-surgery.  Medically this is not a problem at all.  However, the expectation before surgery may have been to become glass-free, and now post-surgery, you may have a small number.  Patients may thus believe that something went wrong, which is not the case.  Usually, patients don't need corrective lenses or glasses.  Those who need it end up wearing these glasses only sometimes when there is a need to see crystal clear.

As I mentioned, this is not a complication, but since expectations of our patients have changed over time, I have mentioned this here.

Secondary Glaucoma after cataract surgery

One of the cataract surgery risks is postoperative glaucoma.  Glaucoma means the eye pressure rises.  You can read more about glaucoma.  Sometimes, because of the actual surgery or the prescribed steroid eye drops, the eye pressure increases.  This raised pressure leads to eye redness, pain and glare from lights.  Usually, this is temporary and is treated with tablets or glaucoma eye drops.

Complications of surgery for congenital cataracts

I perform all the congenital cataract surgeries at Eye Solutions.  Because the eye is very young, sometimes as young as six weeks, it behaves differently than adult eyes.  There are also a few additional steps in pediatric cataract surgery.  E.g., sutures are taken for all pediatric cataract surgeries.  Most of the risks of surgery are the same, but there are a few more.  It will not be possible to explain without getting very technical, but there is a risk of not doing intraocular lens implantation in children sometimes.  Another difference in children is we are not aiming for zero glass power after surgery.  The refractive outcome ( power of glasses ) is not an essential thing in these eyes.  Also, the eye will be growing as the child grows, which will change the eye power, and thus we will have to change the glass power over the next few years.

Here are some related topics 

Cost of cataract surgery in Mumbai

Monofocal IOL - Here, you will also read about the Eyhance Lens, the newest Monofocal IOL.

Multifocal IOL - These lenses will give you glass-free vision for about 80% of all your activities after surgery.

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