What are the potential complications of cataract surgery?

Complications of Cataract Surgery

Cataract surgery is safe in over 95% of cases, but clinicians must recognize and manage both intraoperative and postoperative complications that can threaten vision, with posterior capsular rupture being the most common intraoperative complication and posterior capsular opacification the most common postoperative issue. 1

Intraoperative Complications

Posterior Capsular Rupture

• Posterior capsular rupture is the most common serious intraoperative complication, occurring when the posterior lens capsule tears during surgery 1
• This complication increases risk of vitreous loss, dropped nucleus into the vitreous cavity, and subsequent postoperative complications including cystoid macular edema and retinal detachment 1
• Risk factors include complex cataract surgery, prior eye surgery, and specific patient characteristics such as black race, diabetes mellitus, young age (<60 years), and hyperopia 2

Other Intraoperative Complications

• Globe perforation can occur, particularly in high-risk patients 3
• Dislocated lens fragments may fall into the vitreous cavity, requiring vitreoretinal intervention 3
• Hemorrhagic choroidal detachment represents an acute, vision-threatening intraoperative event 3

Early Postoperative Complications (Within Days to Weeks)

Endophthalmitis

• Endophthalmitis is the most devastating complication of cataract surgery, though its incidence has significantly decreased with routine use of intracameral antibiotics 1
• This represents a true ophthalmic emergency requiring immediate recognition and treatment 3
• The rate of endophthalmitis has declined in recent decades due to improved prophylactic measures 4

Toxic Anterior Segment Syndrome (TASS)

• TASS represents a sterile inflammatory response in the anterior segment following surgery 5
• Recognition requires distinguishing it from infectious endophthalmitis, as management differs fundamentally

Other Early Complications

• Elevated intraocular pressure can occur, particularly with corticosteroid use postoperatively 6
• Wound leak or dehiscence may develop if incisions are not properly sealed 5
• Corneal edema can result from endothelial damage during surgery 1

Late Postoperative Complications (Weeks to Years)

Posterior Capsular Opacification (PCO)

• PCO is the most common late complication of cataract surgery and occurs when residual lens epithelial cells proliferate on the posterior capsule 1
• This complication is readily treatable with Nd:YAG laser capsulotomy 1
• Nd:YAG capsulotomy itself carries a fourfold increased risk of retinal detachment, especially in myopic patients 5

Retinal Detachment

• The overall risk of retinal detachment after cataract surgery is approximately 1%, but this increases substantially in high-risk patients 5
• Risk factors include axial myopia, pre-existing vitreoretinal disease (particularly lattice degeneration), male gender, younger age, vitreous prolapse, vitreous loss, and spontaneous capsulotomy extension 5
• The major risk factor is postoperative development of posterior vitreous detachment (PVD), which occurs at a median of 7 months after surgery in eyes without pre-existing PVD 5
• Phakic fellow eyes in patients with pseudophakic retinal detachment have a 7% risk of retinal detachment 5
• Risk typically manifests 1-2 years postoperatively in uncomplicated cases 5

Cystoid Macular Edema (CME)

• CME represents a common cause of suboptimal visual outcomes after cataract surgery 1, 3
• Risk increases with posterior capsular rupture and vitreous loss 1
• Prophylaxis with topical NSAIDs (such as preservative-free ketorolac 0.45%) is recommended by the American Academy of Ophthalmology 6
• Diagnosis requires OCT or fluorescein angiography when suspected 5

Exacerbation of Pre-existing Retinal Conditions

• Diabetic retinopathy can worsen following cataract surgery 3
• Other retinal conditions may be exacerbated by the surgical intervention 3

Rare but Serious Complications

Suprachoroidal Hemorrhage

• This represents a rare but devastating complication with potential for severe vision loss 4
• Recent studies demonstrate declining incidence with modern surgical techniques 4

Toxic Posterior Segment Syndrome (TPSS)

• TPSS is a rare inflammatory condition affecting the posterior segment 5

Hemorrhagic Occlusive Retinal Vasculitis (HORV)

• HORV represents an extremely rare but severe postoperative complication 5

Risk Stratification and High-Risk Patients

Patient-Related Risk Factors

• Male sex increases risk of serious adverse events 4
• Concomitant diabetic retinopathy elevates complication risk 4
• Same-day combined intraocular procedures increase risk 4
• Tamsulosin use (for benign prostatic hyperplasia) increases risk of intraoperative floppy iris syndrome 4
• Young age (<60 years) paradoxically increases risk 2
• Hyperopia and high myopia both increase risk 2, 5

Surgeon-Related Risk Factors

• Low surgical volume correlates with higher complication rates 4
• Limited surgical experience increases risk 4
• Operating on high-risk patients requires specific expertise 4

Prevention and Management Strategies

Preoperative Assessment

• The most critical step is comprehensive preoperative assessment to identify high-risk patients and counsel them appropriately 1
• Identify ocular comorbidities including glaucoma, uveitis, diabetic retinopathy, macular degeneration, corneal pathology, and pre-existing vitreoretinal disease 5
• Assess for systemic comorbidities including diabetes, hypertension, and anticoagulant use 5
• Evaluate for lattice degeneration and myopia, which substantially increase retinal detachment risk 5

Postoperative Medication Regimen

• Standard regimen consists of topical antibiotic (moxifloxacin 0.5% three times daily for 7 days) combined with topical corticosteroid (prednisolone acetate 1% four times daily, tapered over 3-5 weeks) 6
• Preservative-free formulations are strongly preferred to minimize ocular surface toxicity 6
• High-risk patients (history of dry eye, multiple topical medications, diabetes, contact lens use) should prioritize preservative-free formulations 6
• The American Academy of Ophthalmology recommends preservative-free NSAIDs like ketorolac for CME prophylaxis within the first postoperative month 6

Postoperative Follow-up Schedule

• Low-risk patients should be seen within 48 hours of surgery; functionally monocular patients and high-risk patients within 24 hours 5
• Critical monitoring points include Day 1, Weeks 1-2,1 month, 2 months, and 3-6 months 6
• Each visit should assess visual acuity, intraocular pressure, anterior segment with slit-lamp, and symptoms 5
• Dilated fundus examination is indicated with symptoms, surgical complications, or reasonable suspicion of posterior segment problems 5

Specific Management Considerations

• Close IOP monitoring is essential with corticosteroid use, as prolonged use causes significant IOP elevation in a substantial proportion of patients 6
• Avoid systemic steroids in patients with uncontrolled glaucoma or history of steroid response 6
• Inadequate management of dry eye disease, which can be caused or exacerbated by surgery, requires more aggressive therapy than preoperative management 6

Common Pitfalls to Avoid

• Using preserved eye drops in high-risk patients significantly increases ocular surface toxicity and dry eye exacerbation 6
• Failing to recognize that absence of PVD at time of surgery in myopic eyes with lattice degeneration represents the major risk factor for subsequent retinal detachment 5
• Inadequate counseling of high-risk patients about their specific complication risks 1
• Delayed recognition of endophthalmitis, which requires immediate intervention 3
• Omitting dilated fundus examination when posterior segment complications are suspected 5