What to do when vitreous is present in the anterior chamber after cataract surgery?

Management of Vitreous in the Anterior Chamber Post-Cataract Surgery

Immediate anterior vitrectomy is the essential intervention when vitreous is present in the anterior chamber after cataract surgery, and this should be performed meticulously to prevent serious complications including retinal detachment, chronic inflammation, and secondary glaucoma. 1, 2

Immediate Intraoperative Management

When vitreous loss is recognized during cataract surgery, the following steps are critical:

Stop All Phacoemulsification

• Never attempt phacoemulsification in the presence of vitreous - this is a critical error that dramatically increases the risk of retinal complications 1
• If nuclear fragments have dropped posteriorly, do not attempt retrieval without vitrectomy capability 1

Perform Anterior Vitrectomy

• Anterior vitrectomy should be performed immediately when vitreous prolapse is identified 1, 2
• The pars plana approach is superior to anterior chamber vitrectomy, as it provides better vitreous removal and reduces traction 1
• Use of 23-gauge sutureless instruments facilitates this approach 1
• The vitrectomy must be meticulous and complete - inadequate anterior vitrectomy at the time of cataract surgery is a significant predictor of poor visual outcomes (20/200 or worse) 2

IOL Placement Considerations

• A posterior chamber IOL should be placed in the sulcus if the capsular bag is compromised - this is associated with better visual outcomes 2
• Placement of a sulcus lens is a predictor of better final vision (20/40 or better in 72.3% of cases) 2
• If posterior chamber placement is not feasible, anterior chamber IOL is acceptable, though with slightly higher complication rates 3

Postoperative Detection and Management

Clinical Presentation

When vitreous prolapse occurs or is detected postoperatively:

• Most common symptoms include blurry vision (60%), floaters, and visual disturbances 4
• Elevated intraocular pressure is common (mean 26.4 mmHg in delayed cases) 4
• May present with pain, redness, and decreased vision 5

Timing of Intervention

• If retained lens material is present with vitreous, pars plana vitrectomy should be performed within 7 days - this timing significantly reduces the risk of secondary glaucoma 2
• Delayed vitreous prolapse (≥3 months post-surgery) requires surgical intervention with posterior vitrectomy 4

Triggers for Delayed Vitreous Prolapse

Be aware that vitreous prolapse can occur later due to:

• YAG laser capsulotomy (25% of delayed cases) 6, 4
• History of intraoperative posterior capsular tears with sulcus IOL placement (15%) 4
• IOL dislocation (15%) 4
• Aphakia from previous surgeries (15%) 4

Monitoring and Follow-Up

Early Postoperative Period

• Examine on postoperative day 1 and at 1-2 weeks 6
• Earlier or more frequent visits are mandatory if there is: 6
  • High or low intraocular pressure
  • Wound leak
  • Pain or worsening vision
  • Any concern for retinal complications

Essential Examination Components

• Interval history focusing on new symptoms 6
• Measurement of intraocular pressure - critical for detecting secondary glaucoma 6, 2
• Slit-lamp biomicroscopy of anterior segment and wound sites 6
• Indirect binocular ophthalmoscopy of the peripheral retina - essential for detecting retinal breaks or detachment 6

Complications to Monitor

Retinal Detachment

• Risk of retinal detachment is significantly elevated after vitreous loss 1, 3
• Dislocation of lens nuclear fragments into the vitreous carries particularly high risk of retinal detachment, secondary glaucoma, and cystoid macular edema 1
• Axial myopia, male gender, young age, and vitreous prolapse into the anterior chamber increase retinal detachment risk 6

Secondary Glaucoma

• Absence of anterior vitrectomy at cataract surgery predicts development of glaucoma 2
• Early PPV (within 7 days) reduces glaucoma risk 2

Visual Outcomes

• With meticulous anterior vitrectomy and appropriate IOL placement, 72-83% of patients can achieve 20/40 or better vision 3, 2
• Better presenting vision, posterior chamber lens insertion, and absence of preoperative eye disease predict 20/40 or better outcomes 2

Patient Counseling

Educate patients about warning signs requiring immediate contact: 6

• Increase in floaters
• Loss of visual field
• Flashes of light
• Decrease in visual acuity
• New onset of pain or redness

Specialist Referral

• Immediate retinal specialist consultation is recommended when lens fragments drop posteriorly or if vitreous loss is complicated 1
• Management requires specialized vitreoretinal surgical skills and equipment 6