What are the intraoperative complications of cataract surgery due to a deep incision (intraocular surgical wound)?

From the Guidelines

Deep incisions during cataract surgery are a serious intraoperative complication that requires immediate management to prevent further complications and ensure the best possible outcome in terms of morbidity, mortality, and quality of life. When a surgeon creates an incision that is too deep, potentially extending into the posterior chamber or damaging surrounding structures, prompt action is necessary. The first step is to stabilize the anterior chamber by injecting a cohesive viscoelastic material like sodium hyaluronate to maintain chamber depth and prevent further complications, as suggested by the principles of managing intraoperative complications 1. If vitreous loss occurs, a vitrectomy should be performed using a vitrector at a cut rate of 5000-8000 cuts per minute with low vacuum settings (100-250 mmHg). The wound should be secured with 10-0 nylon sutures in a watertight fashion, typically using a simple interrupted or horizontal mattress technique.

Some key considerations in managing deep incisions include:

• Preventing endophthalmitis through the use of intracameral antibiotic administration, which has been shown to reduce the risk of postoperative bacterial endophthalmitis 1
• Controlling inflammation with topical nonsteroidal anti-inflammatory drugs (NSAIDs) or prednisolone acetate 1%, although the long-term benefit of NSAIDs has not been demonstrated 1
• Monitoring for complications such as astigmatism, delayed healing, and increased infection risk due to compromised wound architecture and potential vitreous wicking
• Ensuring meticulous wound construction and careful instrumentation to prevent such complications, as the risk of globe perforation, oculocardiac reflex, and other serious complications can be significant 1

Postoperatively, patients should receive intensive topical antibiotics such as moxifloxacin 0.5% or fortified antibiotics every 1-2 hours for the first 24-48 hours, along with prednisolone acetate 1% to control inflammation. Close monitoring for endophthalmitis, hypotony, or choroidal detachment is essential with follow-up within 24 hours. By prioritizing these measures, clinicians can minimize the risks associated with deep incisions during cataract surgery and optimize patient outcomes.

From the Research

Intraoperative Complications - Deep Incision in Cataract Surgery

• Deep incision in cataract surgery can lead to various intraoperative complications, including wound leakage, hypotony, corneal edema, and lens dislocation 2
• The management of vitreous loss and dropped nucleus during cataract surgery is crucial to prevent further complications, and a well-rehearsed plan is necessary for both staff and surgeons 3
• The use of wound sealants, such as polyethylene glycol (PEG)-based hydrogels, can provide a watertight wound seal with less foreign-body sensation and surgically induced astigmatism compared to sutures 2
• The incidence of intraocular pressure (IOP) lower than 10 mmHg did not differ significantly between long and short clear corneal incision groups, suggesting that wound stability is equivalent when the incision is securely closed with wound hydration 4
• Positive vitreous pressure can occur during anterior segment intraocular surgery, leading to complications such as repeated iris prolapse, zonular rupture, and vitreous or lens prolapse, and can be prevented and managed by understanding its pathophysiology 5

Prevention and Management of Complications

• Preventative measures, early recognition, and damage control are essential in managing intraoperative complications during cataract surgery 3
• The use of appropriate wound closure techniques, such as stromal hydration or suturing, can help prevent wound leakage and related complications 2, 4
• Understanding the pathophysiology of positive vitreous pressure can help in its prevention and management, reducing the risk of intraoperative complications 5