Cataract Surgery Complications

Cataract surgery is one of the most common surgery carried out in the world. At present the gold standard cataract surgery technique in the UK and Asia is phacoemulsification. This literally means using ultrasound energy to liquefy the cataract so that the cataract can be removed from a small cut on the eye. Cataract surgery is often a quick operation lasting approximately 15 to 30 minutes. Despite being a quick operation, cataract surgery is by no means a simple operation. I believe it is one of the most difficult surgeries to master. A surgeon needs good binocular vision in order to judge the depth of the instruments within the eye. In addition the surgeon requires manual dexterity in both hands and total concentration in order to operate on the cataract. The success rate for cataract surgery is in the order of porcupine% and above, however, complications may occur during cataract surgery leading to undesirable surgical outcome.

Studies have shown that an inexperienced surgeon produces more complications. So what are the complications of cataract surgery?

Complications during the surgery:
1. Rupture of the lens capsule
2. Injury to the cornea
3. Injury to the iris (the coloured part of the eye)
4. Incomplete removal of cataract
5. Catastrophic bleeding of the eye (expulsive haemorrhage)

Posterior Capsular Rupture
The goal of cataract surgery is to remove the opacified lens from the eye but leaving the transparent covering of the lens intact. The thickness of the lens capsule is so thin that it is measured in microns. If the back surface of the lens capsule is torn, vitreous jelly will ooze into the front chamber of the eye. This is associated with an increased risk of infection and retinal detachment. Infection and retinal detachment may potentially lead to permanent loss of sight.

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Corneal Injury
The cornea is the outermost tissue of the eye. It is transparent and has no blood supply to maximise visual clarity. This tissue has a high metabolic activity to regulate the amount of moisture within the tissue. When the tissue is injured the cornea becomes swollen and it is no longer transparent. The cornea can be injured by direct contact of the surgical instruments due to poor instrument control. Inexperienced surgeons tend to have more hand tremor and unnecessary instrument movements in the eye. The ultrasound energy used to liquefy the lens can also injury the cornea. An experienced surgeon uses ultrasound energy efficiently to minimise damage to the cornea. Corneal injury following cataract surgery tend to resolve with time but in some cases it may worsen leading to loss of vision.

Injury to the iris
The coloured part of the eye may be injured during the surgery. It may cause bleeding within the eye and if the iris muscle is weakened, it may prolapse outside the eye.

Incomplete removal of cataract
The cataract may becomes unsteady and drop into the vitreous jelly. This is called a dropped nucleus. If this happens during the surgery, your doctor may request you to see a vitreo retinal surgeon to remove the cataract from the vitreous jelly.

Expulsive haemorrhage
This is the most feared complication. It happens in patients with high blood pressures. The eye pressure increases rapidly leading to expulsion of ocular contents from the wound. This is a potentially blinding complication.

How can you as a patient reduce your risk of developing a cataract surgery complication?

1. Don’t leave your cataract for too long.
It is a common misnomer that a cataract has to be ‘ripe’ before one can remove it. The softer the cataract the easier it is to remove. Very dense cataract is linked with increased complication during surgery. So please, arrange a consultation with an ophthalmologist and if your vision is affected, then consider having the surgery sooner rather than later.

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2. Find an experienced eye surgeon
Like any technical skills, practice makes perfect. The more surgery the surgeon does the better he becomes. An ophthalmologist becomes a safe cataract surgeon when he had done about 300 cataract surgeries. In the UK, this is the minimum number of cataract surgery needed in order to graduate from the training programme. In London, where there are more trainees in the hospitals, the opportunities to perform cataract surgery is somewhat diluted. A surgeon who is trained in a more rural town or city tend to do far more cataract surgery. This is because there are more elderly patients in the rural areas therefore more cataract workload for the trainees. I did almost 800 cataract surgeries when I completed my training in the southwest of England.

I watch my senior trainee surgeon operate on a cataract. The surgery is digitally recorded into my laptop for future reference and feedback. Complications can occur so quickly that some surgeon doesn’t even know how it happened. For the more junior suegeons, I will get scrubbed and sit next to the operating surgeon.

3. Prepare yourself


Diabetes control:
Make sure your sugar diabetes is well controlled. Blood sugar should be less than 10 before the surgery can proceed safely. High blood sugar is associated with an increased risk of infection.
Control your blood pressure:
An elevated blood pressure is a risk factor for bleeding. Patients should take their blood pressure pills in the morning prior to the operation.
This patient is a walking time bomb. He could develop a stroke at anytime. I had to cancel his operation until his blood pressure is under control.
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A word of caution on complementary herbal medicine:
” don’t waste your money and risk your health taking herbal medicine “
Herbal preparations are often unregulated and there are no stringent quality control to ensure patient safety. I had a patient who took porcupine bezoar before her tear duct surgery and she bled profusely. Although cataract surgery is a bloodless operation, I still strongly advise absolute abstinence from preparations not prescribed by a qualified and certified doctor.
Complications can still occur after a seemingly uneventful cataract surgery.
Here are a list of common or serious post cataract surgery complications:
1. Macular swelling
2. Retinal detachment
3. Transient raised Intraocular pressure
4. Endophthalmitis ( serious and potentially blinding infection of the eye)
5. Opacity of the back surface of lens implant

In summary, cataract surgery is one of the safest operation with high success rate. However, one may develop a complication and it is important to understand the risk involved prior to signing the consent form.

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Dunny Nasution
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