Complications of cataract surgery refer to adverse events that occur during or after surgery to remove the cloudy lens and insert an intraocular lens (IOL). The history of cataract surgery dates back to the 1700s. Complications have decreased due to advances in techniques, infection control, and equipment.
Major vision-threatening complications include infectious endophthalmitis, toxic anterior segment syndrome (TASS), toxic posterior segment syndrome (TPSS), suprachoroidal hemorrhage, cystoid macular edema, retinal detachment, persistent corneal edema, intraocular lens dislocation, and secondary glaucoma1). Complications leading to permanent vision loss are rare 1).
In large studies, the incidence of serious complications (endophthalmitis, suprachoroidal hemorrhage, RD) within one year after surgery was 0.5% overall 1). This rate has decreased over time, from 0.6% in the 1994–1995 cohort to 0.4% in the 2005–2006 cohort 1). In a UK study, the overall complication rate after phacoemulsification was 9%, with serious complications accounting for 2% 1).
QHow often do complications of cataract surgery occur?
A
The incidence of serious complications (endophthalmitis, suprachoroidal hemorrhage, retinal detachment) is approximately 0.5% 1). It has been decreasing over the years with advances in technology. Including milder complications such as posterior capsule opacification, the overall complication rate is higher.
Complications are broadly classified by timing into intraoperative and postoperative complications.
Intraoperative Complications
Posterior capsule rupture: The most important complication to watch for during surgery. Signs include deepening of the anterior chamber, loss of followability of lens material, and vitreous prolapse1).
Vitreous prolapse: Secondary to posterior capsule rupture. It can cause secondary complications such as retinal detachment and endophthalmitis1).
Anterior capsule tear: Occurs during capsulotomy or nucleus processing. It may extend to the posterior capsule, posing a risk of nucleus drop2).
Iris injury: May cause mydriasis due to iris sphincter damage, iridodialysis, and hyphema1).
Suprachoroidal hemorrhage: Signs include sudden severe pain, loss of red reflex, and shallow anterior chamber. Prompt wound closure is important1).
Postoperative Complications
Posterior capsule opacification: The most frequent postoperative complication. Prevalence ranges from 0.3% to 28.4%, with modern techniques achieving approximately 5% or less2).
Cystoid macular edema: Peaks at 6–10 weeks postoperatively. Incidence is approximately 1–2%1).
Infectious endophthalmitis: Incidence 0.04–0.2%. Has a significant impact on visual prognosis 1).
The incidence of posterior capsule rupture and zonular dehiscence averages about 2% in low-risk cases and reaches up to 9% in eyes with a history of vitrectomy1).
Risk Factor
Category
Advanced age, male sex
Patient factor
Pseudoexfoliation syndrome
Patient factor
Miosis, shallow anterior chamber
Ocular factor
In addition to the above, the following factors have also been reported1)2).
Type of cataract: Brown cataract, white cataract, and posterior polar cataract increase the risk1).
Axial length >26 mm: High myopia is often associated with zonular weakness1).
Diabetic retinopathy: It also increases the risk of persistent postoperative inflammation and cystoid macular edema1). In diabetic patients or those using pupil dilation devices, the incidence of cystoid macular edema has been reported to reach up to 29.5%1).
History of glaucoma or vitrectomy: These are associated with increased risk of zonular laxity and posterior capsule rupture1).
COPD and obesity: These have been identified as systemic risk factors2).
Surgery by residents: Surgeon experience is also a risk factor1).
Risk factors for delayed posterior capsule rupture
Posterior capsule rupture can also occur in the late postoperative period.
Chen et al. (2022) reported a case of bilateral posterior capsule rupture and anterior vitreous prolapse occurring 11 years after uneventful bilateral cataract surgery due to vigorous eye rubbing4). Pseudoexfoliation syndrome, IFIS associated with tamsulosin use, and vigorous eye rubbing due to allergic conjunctivitis were considered risk factors.
QCan cataract surgery be performed while taking tamsulosin?
A
Surgery is possible, but there is a risk of intraoperative floppy iris syndrome1). By reporting your medication history before surgery and having the surgeon take appropriate measures such as using viscoelastic agents and low perfusion settings, the surgery can be performed safely.
Endophthalmitis: Hypopyon, vitreous opacities, and acute worsening of eye pain and redness are diagnostic clues. Culture of vitreous fluid is important for definitive diagnosis.
PCO can be effectively treated with Nd:YAG laser posterior capsulotomy, with almost immediate visual improvement 2). However, there is a slight increase in the risk of retinal detachment after YAG laser capsulotomy 1).
When posterior capsule rupture occurs, prompt action is required to minimize further damage 1).
Anterior Vitrectomy
Indication: Performed when vitreous prolapse occurs.
Purpose: Removal of vitreous traction and preservation of the remaining lens capsule to maintain intraocular lens fixation.
Points to note: It is important to minimize traction on the retina.
Alternative Methods for Intraocular Lens Fixation
Ciliary sulcus-fixated intraocular lens: An option when capsular support is insufficient. Ciliary sulcus insertion of a one-piece acrylic intraocular lens carries a high risk of complications7).
Intrascleral fixation (Yamane technique): A method of fixing the haptic in an intrascleral tunnel1).
A network meta-analysis has shown that among intraocular lens fixation methods, iris fixation, transscleral fixation, and intrascleral fixation are all effective when capsular support is poor1).
The incidence of lens fragment drop into the vitreous cavity is 0.1–0.28%1).
Bardoloi et al. (2021) reported a modified posterior-assisted levitation (PAL) method in which a 23G vitrector is inserted through the pars plana after posterior capsule rupture, anterior vitrectomy is performed, and the dropped nucleus is elevated into the anterior chamber using the same vitrector3). This method has the advantage of reducing vitreous traction by vitrectomy through the pars plana.
If the nucleus drops into the mid to posterior vitreous cavity, vitreoretinal surgery (PPV) by a specialist is required3).
If visual acuity is light perception or better, intravitreal antibiotic injection is performed; in severe cases with worse than light perception, vitrectomy combined with antibiotic administration is performed1).
Intracameral cefuroxime or moxifloxacin injection during surgery has been reported to reduce the risk of endophthalmitis1).
Topical steroids and nonsteroidal anti-inflammatory drugs (NSAIDs) are first-line treatments. Abrupt discontinuation of topical steroids may lead to rebound inflammation or recurrence of cystoid macular edema1).
Management of Intraoperative Shallow Anterior Chamber
During surgery, the anterior chamber may gradually become shallow, making it difficult to continue. Common causes include inappropriate infusion settings, excessive fluid leakage from the wound, and eyeball compression due to the lid speculum or retrobulbar hemorrhage. If the shallow anterior chamber is sudden and not due to the above causes, infusion misdirection syndrome (IMS) should be suspected, and surgery should be temporarily stopped for fundus examination. If there is no suprachoroidal hemorrhage or effusion, IMS is diagnosed, and surgery is resumed after waiting about 1 hour for intraocular pressure to decrease.
QHow is posterior capsule opacification treated?
A
Nd:YAG laser posterior capsulotomy can be performed as an outpatient procedure in a short time 2). Visual improvement is almost immediate. However, because the risk of retinal detachment increases slightly after the procedure, regular fundus examinations are recommended 1).
QWhat happens if the posterior capsule ruptures during surgery?
A
Posterior capsule rupture can lead to secondary complications such as vitreous prolapse, cystoid macular edema, retinal detachment, and endophthalmitis1). After performing anterior vitrectomy to remove vitreous traction, the intraocular lens is fixed using alternative methods such as ciliary sulcus-fixated IOL, anterior chamberIOL, or scleral-fixated IOL.
PCO is a condition in which residual lens epithelial cells (LECs) proliferate and migrate postoperatively, forming opacities on the posterior capsule 2)5). Surgical invasion of the anterior capsule disrupts the LEC barrier, initiating cell proliferation as a wound healing response 5). LECs migrate to the posterior capsule via cell adhesion molecules and differentiate into myofibroblasts. This process involves TGF-β signaling, which promotes differentiation while suppressing LEC proliferation 5).
Intraocular lens material affects PCO incidence. Reported rates are PMMA 28.3%, silicone 21.6%, and acrylic 8.9%. Acrylic IOLs promote adhesion to the capsule through binding with extracellular matrix proteins, inhibiting LEC migration 5). Additionally, rare cases of calcification deposits on the IOL surface coexisting with PCO have been reported, suggesting involvement of interactions between IOL material and the host environment 8).
Navia et al. (2024) reported two cases of PCO developing just two weeks after silicone IOL insertion using reverse optic capture (ROC) technique to prevent negative dysphotopsia5). In ROC, the optic is placed anterior to the anterior capsule, eliminating the barrier between LECs and the posterior capsule, leading to rapid PCO.
A Soemmering ring is a type of annular PCO formed in the periphery by adhesion of the anterior capsule edge and posterior capsule 6). It is usually asymptomatic, hidden behind the iris, but if dislocated, it can cause glaucoma and corneal endothelial damage.
AlQahtani et al. (2023) reported a case of a 20-year-old male who developed corneal edema and bullous keratopathy due to anterior chamber dislocation of a Soemmering ring 14 years after lens aspiration for congenital cataract6). Aphakia, high myopia, and surgery in early childhood were risk factors.
Cystoid macular edema results from increased permeability of perifoveal capillaries and breakdown of the blood-retinal barrier1). Fluid accumulates in the Henle fiber layer and outer plexiform layer, forming cysts. The accumulated fluid exerts mechanical stress on Müller cells, manifesting as decreased central vision and scotoma 1).
Suprachoroidal hemorrhage is a condition in which blood accumulates in the suprachoroidal space due to rupture of posterior ciliary arteries or vortex veins caused by intraocular pressure fluctuations during intraocular surgery 2). In phacoemulsification, the incidence is considered even lower because the surgery time is short and the duration of hypotony is brief 1). Continuous use of anticoagulants (warfarin) is not reported to significantly increase the frequency of suprachoroidal hemorrhage1).
Corneal endothelium is damaged by mechanical trauma from instrument manipulation and prolonged exposure to ultrasonic energy 1). Improper instrument insertion can cause tears or detachment of Descemet’s membrane 1). Small Descemet’s membrane detachments have also been reported in femtosecond laser-assisted cataract surgery 1).
7. Latest Research and Future Perspectives (Investigational Reports)
Comparisons between FLACS and conventional surgery have been examined in multiple randomized controlled trials.
In the FEMCAT and FACTS trials, no significant difference in posterior capsule rupture rate was found between FLACS and conventional phacoemulsification1). In the FEMCAT trial, the success rate was 41.1% for FLACS and 43.6% for conventional surgery, showing no superiority of FLACS (OR 0.85; 95% CI 0.64–1.12).
In a case study by Navia et al. (2024), posterior capsule polishing to remove lens epithelial cells (LECs) was suggested to reduce the incidence of PCO, but it is not widely adopted due to unknown risks 5). Posterior capsulotomy (posterior CCC) can permanently eliminate the possibility of PCO, but it carries the risk of vitreous prolapse 5).
Intracameral Antibiotic Prophylaxis for Endophthalmitis
Intracameral injection of cefuroxime or moxifloxacin at the end of surgery is being considered as an effective option for preventing endophthalmitis1).
American Academy of Ophthalmology Cataract/Anterior Segment Panel. Cataract in the Adult Eye Preferred Practice Pattern. Ophthalmology. 2022;129(1):S1-S126.
European Society of Cataract and Refractive Surgeons (ESCRS). ESCRS Clinical Guidelines: Cataract Surgery. 2024.
Bardoloi N, Sarkar S, Kalita P, et al. Posterior-assisted levitation in a modified way for nucleus retrieval after posterior capsule rupture. BMJ Case Rep. 2021;14:e247245.
Chen DA, Yassari N, Kiss S, et al. Bilateral posterior capsule rupture and anterior vitreous prolapse from vigorous eye rubbing. Am J Ophthalmol Case Rep. 2022;26:101426.
Navia JC, Huang JJ, Reategui JA, et al. Rapid posterior capsular opacification in two patients treated for negative dysphotopsias. BMC Ophthalmol. 2024;24:485.
AlQahtani GMS, Alotaibi FA, Almuwarraee SM, et al. Dislocated Sömmering ring with decompensated cornea presenting 14 years after lens aspiration and anterior vitrectomy. Am J Case Rep. 2023;24:e942519.
Elksnis E, Vanags J, Elksne E, et al. Isolated posterior capsule rupture after blunt eye injury. Clin Case Rep. 2021;9:2105-2108.
Kaur K, Mishra S, Gurnani B. First case of sunflower pattern calcific deposits and posterior capsular opacification on a pseudophakos. Clin Case Rep. 2022;10:e06345.
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