Cataract Surgery Complications
Maria E. Lim, MD
Complications from pediatric cataract surgery are varied and may occur at any point in the intraoperative and postoperative period. Continued long-term followup for aphakic and pseudophakic children is therefore recommended to monitor for these visually significant sequelae.
CAPSULE TEARS
Anterior capsular tears.
Determine the extent of the tear.
If the tear extends to the zonules, use microinsional scissors or the vitrector hand piece to truncate the residual capsular flap.
Proceed with care aspirating lens material once the residual flap is removed.
If attempting a continuous curvilinear capsulorrhexis (CCC), stop, place viscoelastic in the anterior chamber, and use the Little maneuver to pull the capsule centrally to save the CCC (Fig. 8.1). If unsuccessful, try to create a second flap and tear in the opposite direction. Use microincisional scissors to truncate the aborted residual flap.
If while creating a vitrectorhexis a “tear-shaped” anterior capsular tear (a tear with a “V” shape pointing peripherally) occurs, proceed with caution to avoid pressure on this area as it may extend peripherally.
Posterior capsular tears.
When there is significant lens material in the capsular bag, attempt to prolapse the lens into the anterior chamber and aspirate from there.
Aspirate only when the vitrectomy tip is occluded to avoid aspirating vitreous. Turn the cutter on whenever there is suspicion of vitreous, but be careful not to cut the capsule.
Once lens material is cleared, inspect the capsular bag and determine the extent of the posterior capsular tear.
If implanting an IOL, an attempt to place the lens in the capsular bag with a small, round posterior capsular tear may be made. Use the vitrector with a high cut rate to even out the edges if they are not smooth.
If the tear is large, place a 3-piece sulcus lens or leave the patient aphakic with plans to place a secondary IOL in the future if there is enough support.
 FIGURE 8.1. Schematic showing the Little maneuver, which is used to redirect a continuous curvilinear capsulorrhexis. A. First, pull the flap opposite the direction of the rhexis. B. Then, pull the flap centrally to redirect the rhexis. |
DROPPED LENS
Very large lens fragments that fall posteriorly should be removed by a vitreoretinal surgeon.
If lens material falls to the anterior vitreous face, attempt to carefully cut with the vitrector.
If small fragments fall posteriorly, they can be left and the patient monitored closely as the lens material resorbs.
It may take weeks to months for the retained lens material to resorb, depending on the size of the fragment.
The patient should be monitored for lens-induced uveitis and secondary glaucoma.
The patient can be placed on steroids, both topical and oral (prednisolone 1 mg/kg/day), to treat postoperative inflammation (see Chapter 3).
ELEVATED INTRAOCULAR PRESSURE
Determine the etiology of elevated intraocular pressure. Possible etiologies include inflammation, steroid response, trabeculodysgenesis (especially in congenital cataracts), secondary angle closure from posterior synechiae, and/or vitreous prolapse into anterior chamber.
Start with topical antihypertensives.
Avoid brimonidine in children <2 years old.
Use 0.25% timolol in children <6 months age.
Can also use acetazolamide (5 mg/kg q6h) if refractory to topical medications.
Consider changing topical steroid (ie, from prednisolone or difluprednate/Durezol) to one that does not result in as much of an elevation in intraocular pressure (ie, fluorometholone). Taper off steroids as soon as possible.
If patient has secondary angle closure, may need to return to OR for synechiolysis, anterior vitrectomy and/or peripheral iridotomy (PI). PI options include:
Awake laser peripheral iridotomy (LPI) if patient can cooperate:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
