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Complications of cataract Surgery

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Author : Dr Deepak Garg

Introduction

Cataract Surgery is the commonest 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 technique known as 'Phacoemulsification'.  We have come a long way from the older technique of doing cataract surgery called 'Extracapsular cataract extraction'.  The oldest technique of performing cataract surgery which is almost not performed these days is 'Intracapsular cataract extraction'.  These required much larger incisions than the modern day surgery.

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

Before you continue reading it is important to note that risk of complications can exist with any activity you do.  It could be driving on the highway and 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 to just let you know that certain complications can occur.  Now, the complication rates of the below mentioned complications are very very low but not zero.  Infact Modern cataract surgery has overtime become a very frequently performed procedure.  At Eye solutions cataract surgeries are performed at all our locations almost everyday.  Most of these surgeries are for adult cataracts.  These days cataract surgeries are done without any injections or sutures.  Infact even the eye patch that place right after surgery is removed just 10 minutes after.  In other words you leave the hosptial without an eye patch.  You shuold know that cataracts can also occur in children and children who have cataracts have to be operated for as soon as possible.  For an uncomplicated cataract surgery the time taken is between 10-15 minutes.  The surgery is done without any injections or any use of sutures.  The visual outcomes for all our patients is excellent.

What are Cataract Surgery Complications ?

Cataract surgical procedures have very low rate of surgical complications.  Which means most of the time they go off well.  These complicatons can be divided into those that happen during the surgery and after the surgery.

Cataract surgery complications which occur during surgery

Posterior capsule rupture

The most dreaded complication during cataract surgery is what is known as "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 the cataract operations your eye doctor removes part of the front facing portion of the bag to be able 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 anteior capsule and the back part of the bag.  This back part is also called as the posterior capsule.  This posterior capsule separates the front and the back part of our eyes.  Also known as the anteior chamber and posterior chamber.  It is on this layer that your eye doctor places the artifical lens inside the eye.  This artifical 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 Lenes 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 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 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 sucess 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 too a retina specialist has to perform a surgery to remove the lens and place another lens in the correct position inside the eye.

Most of the times however, if a tear occurs, it is recognized by experienced surgeons.  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 in 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 is done so that the intraocular lens is well supported in the eye.

DM Detachment

DM stands for descemets membrane.  This is one of the layers of the cornea.  Cornea is the 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 descmets detachment.  This layer detaches from the cornea.  Small detachments dont cause any problem at all and most of the times reattatch to the cornea.  Large attachments however can cause corneal edema after surgery.

Usually these detachments are tackled by your eye surgeon during the procedure itself.  And as mentioned earlier they reattach.

Surgery requires a suture

This is not a complication but sometimes patients consider using a suture during the surgery as a complicaton 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 main wound of the eye.  This does not mean that the surgery did not go well or that there was a problem.  If your surgeon feels that the main 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 is known as Endophthalmitis.  This cataract procedure complication has the potential to 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 bacetria or fungi more commonly and viruses more rarely.  Out of the first two, bacetrial infections are more common.  Fungal infections are more severe.  Most common bacteria are staphylococcus Aureus also known as staphylococci.  Infact endophthalmitis can occur after any intraocular surgery, a 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 important that you go to an eye hosptial that you think maintains strict aspetic precaustions during surgery.  It is very important that the hospital uses very good equipment for sterlization of all its instruments.

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

What increases the risk of endophthalmitis ?

If a patient has any preoperative infection the risk of endophthalmitis increases.  It is for this reason we order some blood tests before the surgery.  We also ask the patient if he or she has a boil somewhere which is hurting or fever or cough or cold.  If we suspect any infection in the body we postpone the surgery and treat that infecton before we operate.

Uncontrolled diabetes also increases the risk of endophthalmitis.  A normal blood sugar level is a must before surgery and if high the surgery is postponed till such time that the blood sugar returns to normal.

It is to avoid this infection that eye doctors impose certain restrictions after cataract surgeries.  You can read more about precautions after cataract surgery.

Post operative inflammation and corneal edema

Ater every surgery there is some inflammation and corneal edema.  The amount may vary.  when its very less its considered normal and patient is usally confortable.  However, the inflammation may be severe and so could the swelling in the cornea or corneal edema.  This may lead to pain and watering and blurry vision.  However, these usually subside with steroid eye drops which are anyways prescribed after cataract surgery.  This 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 know as PCO.  This too is not really a complication.  But it can occur in patients who undergo cataract surgery.  Infact upto 50% of patients who undergo a cataract surgery can have a posterior capsule opacity.  This is also known as secondary cataract.  Posterior capsule opacity usually occurs after a few months to a few years after the procedure. 

The reason we dont consider this a complication is because this can be considered as part of the healing process of the eye.  After we remove the cataract we place an 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 posteior capsule.  Thus there is a possibility of the posterior capsule becomming opaque and white.  This in turn reduces vision or causes blurry vision.

The treatment for PCO is something called as Yag Laser posterior Capsulotomy.  Its a very quick 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.  In the video you will be able to actually see the laser beam removing the cloudy capsule.

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 types of lenses like the multifocal lenses and trifocal lenses patients become glass free for almost all their activities.  Infact 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 eye ball.  We use certain formulas to calculate the power of the lens that we are going to use in your eye.

Overall these formulas work really well but the glass power or eye number that patients get 2-3 weeks after surgery is also dependant on how the eye behaved 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 dont need corrective lenses or glasses.  For those that need they end up wearing these glasses only sometime when there is a need to see crystal clear.

As I mentioned this is not at all a complication but since expectations of our patients have changed over time, this was mentioned 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 because of the steroid eye drops that are prescribed the eye pressure increases.  This 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 personally perform all the congenital cataract surgeries at Eye Solutions.  Because the eye is very young, sometimes as young as 6 weeks, it behaves differently than adult eyes.  There are also a few additional steps in pediatric cataract surgery.  For eg, sutures are taken for all pediatric cataract surgeries.  Most of the risks of surgery are the same but there are few more.  It will not be possible to explain without getting very technical but there is a risk of not being able to do an intraocular lens implantation in children sometimes.  Another difference in children is we are not aiming for a zero glass power after surgery.  The refractive outcome ( power of glasses ) is not the most important thing in these eyes.  Also the eye is going to be growing as the child grows and that 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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