Anterior segment surgeons should be prepared for posterior complications

January 15, 2022

2 minute read



Mieler WF. Posterior segment complications of anterior segment surgery. Featured at: Hawaiian Eye; January 15-21, 2022; Waikoloa, Hawaii.

Disclosures: Mieler does not report any relevant financial information.

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WAIKOLOA, Hawaii — Even though the majority of anterior segment surgeries go smoothly, it is possible for posterior segment complications to ensue, either acutely or days or weeks after surgery, said a presenter here.

“Keep in mind that acute problems can occur,” including subluxed or dislocated lens fragments and suprachoroidal hemorrhage, “as well as a range of delayed problems,” William F. Mieler, MD, said during a presentation at Hawaiian Eye 2022.

A delayed complication, endophthalmitis, occurs in 0.02% to 0.5% of cases after cataract surgery, with most cases following routine cataract extraction. The incidence increases slightly with a disrupted posterior capsule, vitreous loss, vitreous lens particle loss, and in some systemic diseases, Mieler said.

General approaches that cataract surgeons can use to prevent endophthalmitis include adding antibiotics to infusion solutions, injecting antibiotics intracamerally, implanting antibiotic-coated contact lenses therapy, implantation of subconjunctival sustained release devices, control of nasal contamination, and incorporation of sustained drug delivery techniques.

“Infection is one of the biggest concerns with anterior segment surgery,” Mieler said. “The risks are quite limited, but they increase slightly if there is loss of lens particles or rupture of the posterior capsule.”

While the development and use of intravitreal antibiotics and vitrectomy have contributed to “extraordinary” advances in the treatment and prophylaxis of infections over the past 30 years, more recent significant advances have taken place in the area of antimicrobial therapy, including antibacterial and antifungal agents. , Mieler said in the presentation.

“Ongoing work on prolonged drug administration will likely further change our treatment and prophylaxis against infections,” Mieler said.

In the acute period, a subluxed lens or a piece of lens that has fallen into the vitreous can be managed with a pars plana vitrectomy (PPV), ideally at the time of the initial cataract surgery but usually within 3 weeks, according to Mieler. .

Associated posterior segment complications include endophthalmitis, suprachoroidal hemorrhage, and cystoid macular edema, as well as giant retinal tear and retinal detachment.

The risk of retinal tear is 5% and retinal detachment is about 9% to 13%, he said, regardless of PPV risks.

“With a posterior capsule rupture, it is imperative to clean out any prolapsed vitreous,” Mieler said. “In the context of lens loss in the vitreous cavity, use the expertise of a vitreoretinal surgeon.”

Another rare but serious complication of eye surgery is suprachoroidal hemorrhage, occurring in about 0.03% of routine phacoemulsification surgeries, with surgical drainages sometimes indicated, Mieler said.

Suprachoroidal hemorrhage is a “frightening and potentially devastating complication of eye surgery,” Mieler said in the presentation. “The visual prognosis is reserved despite the drainage of the hemorrhage and the surgical management of the complications.”

Mieler also said most anterior segment surgeries “go well,” but noted that problems can arise that can be “not entirely prevented but treated.”

“We look forward to helping whenever there is an issue involving the posterior segment team,” concluded Mieler.

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