LATE POST-OPERATIVE COMPLICATIONS

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LATE POST-OPERATIVE COMPLICATIONS:

LATE POST-OPERATIVE COMPLICATIONS KAMALJEET SINGH RANDHAWA 33/09 DMC&H

What are they ???:

What are they ??? Complications occuring after weeks, months & years of cataract surgery 5/30/2012 2

EXAMPLES :-:

EXAMPLES :- These include following complications : C YSTOID M ACULAR E DEMA [CME] D ELAYED C HRONIC P OST-OP E NDOPHTHALMITIS P SEUDOPHAKIC B ULLOUS K ERATOPATHY [PBK] R ETINAL D ETACHMENT [RD] E PITHELIAL I NGROWTH F IBROUS D OWNGROWTH A FTER C ATARACT G LAUCOMA IN A PHAKIA / P SEUDOPHAKIA 5/30/2012 3

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5/30/2012 4 NORMAL MACULA

1. CME  Cystoid Macular Edema:

1. CME  Cystoid Macular Edema “ collection of fluid in the form of cystic loculi in the henle’s layer of macula ” IMPORTANCE : Most frequent complication Occurs usually after 1-3m  diminished vision Clinically insignificant in most cases  no visual disturbance  & spontaneous regression 5/30/2012 5

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5/30/2012 6 CME

PATHOLOGY ::

PATHOLOGY : Excessive prostaglandin production 5/30/2012 7

EYE EXAMINATION ::

EYE EXAMINATION : 1. Funduscopy :- honeycomb appearance 2. Fluorescein Angiography :- flower petal pattern (d/t leakage of dye from perifoveal capillaries) 3. a/w incarceration in wound & mild iritis 5/30/2012 8

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TREATMENT ::

TREATMENT : CME c vitreous incarceration  anterior vitrectomy + steroids + antiprostaglandins Immediate peri / post operative use of antiprostaglandins e.g : indomethacin ; flurbiprofen ; ketorolac Improves VA & discomfort 5/30/2012 11

2. DELAYED CHRONIC POST-OP ENDOPHTHALMITIS:

2. DELAYED CHRONIC POST-OP ENDOPHTHALMITIS PATHOLOGY : organisms of low virulence ( propiobacterium acne/ staph epidermidis ) trapped in capsular bag slow growth & infection 5/30/2012 12

PREDISPOSING FACTORS ::

PREDISPOSING FACTORS : Sources of contamination : 1. patient’s own bacterial flora (skin, lids, conjunctiva, lacrimal apparatus ) 2. contaminated instruments, solutions, drapes, dressings, gloves 3. (in corneal transplants) donor cornea Patient factors : -- diabetes , immunosuppression 5/30/2012 13

SYMPTOMS & SIGNS :

SYMPTOMS & SIGNS  Symptoms Acute presentation: 1. visual loss 2. pain 3. redness 4. photophobia Signs Acute presentation: 1. lid oedema 2. conjunctival chemosis and hyperaemia 3. corneal haze 4. cells and flare in AC; fibrinous exudate and/or hypopyon if severe 5. pupil light reflex may be sluggish or absent 6. IOP can be normal, low or raised 7. vitritis (inflammation of the vitreous) may eliminate red reflex and preclude view of fundus Chronic presentation: similar , usually milder, delayed 5/30/2012 14

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5/30/2012 15 CHRONIC POST OP ENDOPHTHALMITIS

TREATMENT ::

TREATMENT : Anterior chamber / vitreous tap or vitrectomy followed by Antibiotics : topical, subconjunctival , intravitreal , systemic as indicated 3. Steroids : topical, intravitreal , systemic as indicated 5/30/2012 16

3. PSEUDOPHAKIC BULLOUS KERATOPATY:

3. PSEUDOPHAKIC BULLOUS KERATOPATY “Cataract surgery could lead to endothelial dysfunction and leading to a condition called pseudophakic bullous keratopathy (PBK )” ETIOLOGY : The endothelial cells can be damaged through direct contact with surgical instruments by turbulence from irrigating solutions, and from a phacoemulsification probe, which can cause ultrasonographic damage. The presence of iris-fixated intraocular lens implants or closed-loop, anterior chamber lenses predisposes patients to PBK 5/30/2012 17

CLINICAL FEATURES ::

CLINICAL FEATURES :  Corneal edema might appear on the day after an operation or months to years later.  Patients typically present with 1. decreased vision 2. the sensation of a foreign body in the eye 3. photophobia 5/30/2012 18

SLIT LAMP EXAMINATION ::

SLIT LAMP EXAMINATION : E pithelial and stromal edema Folds in the Descemet’s membrane—the basement membrane of the endothelial layer. Epithelial bullae , which are fluid-filled cysts within the epithelium (When they rupture, they cause severe pain and a strong sensation of a foreign body in the eye .) 5/30/2012 19

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TREATMENT ::

TREATMENT : 1. Topical hypertonic drops or ointment containing sodium chloride compound ( ie , Muro 128™ ,Bausch and Lomb) -  remove fluid from the cornea by osmosis. 2. Therapeutic soft-bandage contact lenses can be used for ruptured epithelial bullae. 3. Secondary infectious corneal ulceration from ruptured bullae or from soft contact lenses should be treated aggressively with topical antibiotics 4. Occasionally , medical treatment for PBK fails, and patients require corneal transplantation to restore vision 5/30/2012 21

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5/30/2012 22 LAYERS OF RETINA

3. RETINAL DETACHMENT : :

3. RETINAL DETACHMENT : “ It is the separation of neurosensory retina proper from the pigment epithelium.” RISK FACTORS : 1. It is higher in aphakic patients as compared to phakics . 2. RD is more common after ICCE than after ECCE. 3. Others like vitreous loss during operation, associated myopia and lattice degeneration of the retina. 5/30/2012 23

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SYMPTOMS  Localised Sudden painless loss of vision occurs when the detachment is large and central relative loss in the field of vision Q SIGNS  External examination, eye is usually normal. Intraocular pressure is usually slightly lower or may be normal. Marcus Gunn pupil (relative afferent pupillary defect ) is present in eyes with extensive RD. Plane mirror examination reveals an altered red reflex in pupillary area (i.e., greyish reflex in the quadrant of detached retina ). Ophthalmoscopy should be carried out both by direct and indirect techniques. Retinal detachment is best examined by indirect ophthalmoscopy using scleral indentation (to enhance visualization of the peripheral retina anterior to equator) 5/30/2012 25

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5/30/2012 26 INFERO MEDIAL RD

TREATMENT : :

TREATMENT : Seal retinal breaks SRF drainage Scleral buckling Pneumatic retinopexy Pars plana vitrectomy 5/30/2012 27

5. EPITHELIAL INGROWTH ::

5. EPITHELIAL INGROWTH : Rarely conjunctival epithelial cells may invade the anterior chamber through a defect in the incision . This abnormal epithelial membrane slowly grows and lines the back of cornea and trabecular meshwork leading to intractable glaucoma . In late stages, the epithelial membrane extends on the iris and anterior part of the vitreous. 5/30/2012 28

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5/30/2012 29 EPITHELIAL INGROWTH

6. FIBROUS DOWNGROWTH ::

6. FIBROUS DOWNGROWTH : Fibrous Downgrowth into the anterior chamber m ay occur very rarely when the cataract wound apposition is not perfect . It may cause secondary glaucoma, disorganisation of anterior segment and ultimately phthisis bulbi . 5/30/2012 30

7. AFTER CATARACT ::

7. AFTER CATARACT : “It is the opacity which persists or develops after extracapsular lens extraction” aka ‘2 cataract’ CAUSES : Residual opaque lens matter may persist as after cataract when it is imprisoned between the remains of the anterior and posterior capsule, surrounded by fibrin (following iritis ) or blood(following hyphaema ) Proliferative type of after cataract may develop from the left-out anterior epithelial cells. The proliferative hyaline bands may sweep across the whole posterior capsule 5/30/2012 31

Af Ct …………:

Af Ct ………… After cataract may present as thickened posterior capsule, or dense membranous after cataract Soemmering’s ring which refers to a thick ring of after cataract formed behind the iris, enclosed between the two layers of capsule Elschnig’s pearls in which the vacuolated subcapsular epithelial cells are clustered like soap bubbles along the posterior capsule 5/30/2012 32

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5/30/2012 33 SOEMMERING’S RING ELSCHNIG’S PEARLS

TREATMENT ::

TREATMENT : i. Thin membranous after cataract and thickened posterior capsule are best treated by YAG-laser capsulotomy or discission with cystitome orZeigler’s knife ii . Dense membranous after cataract needs surgical membranectomy . iii. Soemmering’s ring after cataract with clean central posterior capsule needs no treatment. iv. Elschnig’s pearls involving the central part of the posterior capsule can be treated by YAG laser capsulotomy or discission with cysti tome 5/30/2012 34

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5/30/2012 35 YAG LASER MACHINE

8. GLAUCOMA IN APHAKIA / PSEUDOPHAKIA:

8. GLAUCOMA IN APHAKIA / PSEUDOPHAKIA IT INCLUDES  Raised IOP with deep anterior chamber in early postoperative period : It may be due to hyphaema,inflammation , retained cortical matter or vitreous filling the anterior chamber. Secondary angle-closure glaucoma due to flat anterior chamber . It may occur following longstanding wound leak. Secondary angle-closure glaucoma due to pupil block . It may occur following formation of annular synechiae or vitreous herniation. Undiagnosed pre-existing primary open-angle glaucoma may be associated with aphakia / pseudophakia . 5/30/2012 36

Cont………:

Cont ……… 5. Steroid-induced glaucoma . It may develop in patients operated for cataract due to postoperative treatment with steroids 6 . Epithelial ingrowth may cause an intractable glaucoma in late postoperative period by invading the trabeculum and the anterior segment structures. 7 . Aphakic / pseudophakic malignant glaucoma 5/30/2012 37

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THANK YOU  5/30/2012 38