Surgical Risks and Complications

As previously mentioned, cataract surgery is one of the safest medical procedures performed in the world. However, complications can happen in a small number of cases. On rare occasions, complications are serious enough to cause permanent visual problems and even blindness.
Here are the most common or most feared risks associated with cataract surgery.

Anesthesia

Cataract surgery is most frequently performed under “local” anesthesia. The most common form is topical (with eye drops) or “intracameral” (anesthesia placed inside the eye through one of the small incisions necessary to remove the cataract). Often an IV or oral sedative is also used to relieve anxiety. Some surgeons use retrobulbar injections, a type of regional anesthesia, during cataract surgery. Retrobulbar anesthesia is administered beside the eye using a sharp needle. While uncommon, needles can pierce the eye causing bleeding, retinal detachment, and even blindness. Even more concerning, if the needle pierces the sleeve around the optic nerve, the anesthesia can go into the brain and result in respiratory depression and, rarely, even death.

Fortunately, retrobulbar anesthesia is rarely used today. Licensed anesthesiologists or nurse anesthetists are also generally present during surgery to ensure the patient’s safety.

Capsular Bag Tear

The most frequently encountered intraoperative (during surgery) complication is a capsular tear. Capsular bag tears are uncommon, noted in only 1% to 2% of surgeries. Also known as posterior capsule rupture, this complication occurs when the natural bag that holds the cataract is weak or torn during a surgical maneuver. The capsular bag is used to support the new synthetic intraocular lens (IOL) that will replace the cataract. If the bag is torn, it may not be possible to place the IOL in the bag. Even when torn, however, the capsular bag may still support the new lens. This depends both on the location and size of the tear as well as surgeon skill. However, on rare occasions, the tear is so severe that a new IOL cannot be placed into the eye at the time of cataract surgery. When this happens, a separate surgery may be necessary to attach the IOL to the wall of the eye (sclera).

Certain conditions, such as pseudoexfoliation syndrome, increase the likelihood of the capsular bag rupturing during surgery. Medications like Flomax (tamsulosin and others in this class) can also increase a patient’s risk for capsular bag tear.

Postoperative Infection

While rare, infection can occur and when it happens can be very devastating. Infections can progress rapidly and lead to blindness. Some symptoms to watch out for after surgery include redness, pain, loss of vision, and discharge.

If any symptoms of infection occur after the surgery, you should contact your surgeon immediately.

Retinal Detachment

Retinal detachment happens when the retina at the back of the eye pulls away from the wall of the eye. Symptoms of retinal detachment include floaters, flashes in your vision, or loss of an area of vision.

Retinal detachment happens in one in every 100 patients. However, younger patients as well as those with myopia (nearsightedness) are at a higher risk for retinal detachment.

Intraocular Pressure Elevation

During surgery, a gel is placed inside the eye to protect the structures inside. Residue from this gel can temporarily clog up the eye’s drainage system, leading to intraocular pressure (IOP) elevation. Those with glaucoma are more likely to experience elevation of the IOP after surgery. Some symptoms of intraocular pressure elevation include severe eye pain or headache after surgery. High eye pressure can be detected in the exam room and is generally treated with prescription eye drops, oral medication, or a quick in-office procedure.

Corneal Swelling

The cornea can become swollen after the surgery, especially at the incision site. Swelling almost always goes away within days or weeks. However, certain conditions (such as Fuchs’ dystrophy and denser cataracts) can increase the risk of the swelling not going away. In the unlikely case of chronic post-operative swelling of the cornea, a second surgery (partial or “full thickness” corneal transplantation) may be necessary in order to improve the vision.

Macular Edema

Macular edema happens when blood vessels leak into the central part of the retina called the macula. Macular edema is a random occurrence after cataract surgery and may not appear until one to three months after surgery, so it is important to keep your post-operative appointments with your eye doctor. When detected, it can usually be treated with prescription anti-inflammatory eye drops or injections into the eye. This condition is more common in those with diabetes or pre-existing macular conditions such as an epi-retinal membrane.

Refractive Surprise

Refractive surprise happens when the lens placed at the time of cataract surgery fails to achieve the intended postoperative vision. Although not to be expected, this can happen to anyone as the methods of choosing an IOL are dependent upon measurements of the eye taken prior to or during surgery and cannot fully predict how the eye will heal. People who have previously undergone other refractive surgeries, such as LASIK, PRK, or RK, are more at risk for refractive surprise. Those with dry eye, blepharitis, or other “ocular surface” condition are also at greater risk of this complication.

Refractive surprise can be treated with the use of contact lenses or eyeglasses. At times it may be necessary to undergo refractive surgery or even return to the operating room to exchange the IOL for a different power.

Posterior Capsular Opacification

Technically, this is not a complication, as this is actually part of the body’s natural healing response to having a synthetic lens in the eye. However, as it can limit vision after surgery it is worth including in this discussion. Sometimes, the part of the lens capsule that remains in the eye after surgery becomes cloudy, which can affect your vision. When this happens it can usually be treated with a laser procedure often done in the office or surgery center. Vision generally improves to what it was early after the cataract surgery, and there are very few risks to having the laser done.