What Are the Real Risks of Cataract Surgery?

Cataract surgery complications are continuing to decrease. General anesthesia, which includes a rare risk of stroke and death, is rarely needed for cataract surgery. Peribulbar anesthesia, where a needle is used to inject anesthesia behind the eye and even Subtenons anesthesia, where we use a cannula placed under the conjunctiva (clear covering of the white part of the eye) to inject surgery is also rarely needed. Peribulbar and Subtenons anesthesia carry a rare risk of optic nerve injury, retro-orbital hemorrhage (bleeding) and subsequent loss of vision.

Thus most surgeries are done with local anesthesia: just anesthetic eye drops.

Most patients do still get intravenous sedation but in some patients this is also not needed.

Currently the below are the most common risks in order of most common with approximate % risk if widely known. This not meant to include every possible risk published but are the key risks.

1. The most common “risk” after surgery is the need for glasses for reading, computer, and distance even if a patient has purchased Advance Technology Premium Intraocular Lenses which try to help patients be as close to glasses-free as possible.

2. Complaint of Poor Quality of Vision due to Uncorrected Astigmatism (the front surface of the eye, the Cornea, still has the shape of a football instead of a basketball) either due to natural astigmatism or from a Poor Quality Tear or Dry Eye Syndrome: This risk decreases with the warm compress routine and using steps on the “Step Ladder for Dry Eye” prior to cataract surgery eye measurements and after cataract surgery:
https://drcremers.com/2015/07/new-innovations-in-dry-eye-treatments.html

This risk, believe it or not, has been observed to be partly associated with a patient’s personality: physicians have noted that patients with “easy going” personalities tend to not notice these slight imperfections in vision compared to “perfectionists.” The risks thus partly varies according to personality and profession: physicians have frequently noted that patients who are “perfectionists” and in particular professions (ie, engineers, mathematicians, physicists, lawyers) may notice these types of imperfections more than others, though this has not been published as a proven fact.

4. Posterior Capsular Opacification (PCO): the back part of the capsule of the Lens can get hazy in between 20-30% of patients

5. Dry eye symptoms can worsen in some patients after surgery due to the incisions we make in the cornea. Usually most patients return to their status prior to cataract surgery.

6. Risk of vitreous loss: the lens is covered by a capsule. The Posterior Capsule is 3.5 micrometers and can break open during cataract surgery. This can occur even in the best cataract surgeons in the world. Vitreous Loss can increase the risk of needing another surgery, risk of retinal detachment, risk of needing a corneal transplant, risk of infection which remains low in most cases.

7. Rare risks:
a. Risk of needing another surgery: (ie, part of cataract [nucleus or cortex (part around nucleus of cataract] was not able to be removed; iris damage; Implant moves or dislocates; risk of wrong implant placed}
b. Risk of retinal hole or detachment
c. Risk of infection
d. Risk of loss of vision
e. Risk of having a blind painful eye
f. Risk of loss of the eye

8. Very rare risks: increases minimally with general anesthesia
a. having a heart attack during or immediately after surgery
b. having a stroke during or immediately after surgery
c. death from any cause during or immediately after surgery

Below is a recent review of risks in the United Kingdom as a comparison.

http://www.medscape.com/viewarticle/852645?src=wnl_edit_tp10&uac=170908AK&impID=876999&faf=1

Complications of Anesthesia for Cataract Surgery: Rare But Possible

By Shannon Aymes

October 15, 2015

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NEW YORK (Reuters Health) – Although rates are trending down, serious complications remain possible with local anesthesia for cataract surgery, according to a new study.

“We’ve documented a big change in the way we do cataract surgery. This means that it is no longer always mandatory to have a completely numb and immobile eye. Previously, we’d use a sharp needle to inject local anesthetic (LA) into the orbit,” Dr. Tom Eke, with the Department of Ophthalmology of Norfolk and Norwich University Hospital in Norwich, UK, told Reuters Health by email.

“This does give a nice numb/still eye, but sometimes the LA needle might inadvertently damage the eyeball or the optic nerve. This was rare but potentially devastating. Therefore, the advent of small-incision surgery allowed the development of less invasive LA techniques,” he said.

For a 13-month period in 2012-2013, Dr. Eke and colleagues in the British Ophthalmological Surveillance Unit sent monthly mailings to all senior British ophthalmologists, asking for reports of potentially sight-threatening or life-threatening complications of LA for cataract surgery.

Of the 1163 ophthalmologists they attempted to reach, 49% (n=570) returned the questionnaires. The investigators estimated a total of 357,000 cataract procedures were conducted during the study period under the National Health Service (NHS).

As reported September 24 in the British Journal of Ophthalmology, the responses suggested that 92.5% of cataract surgeries under the NHS were done with local anesthesia without sedation, 4.1% with local anesthesia and sedation, and 3.4% with general anesthesia. The reported techniques for local anesthesia included sub-Tenon’s (50.5%), topical-intracameral (24.2%), topical (13.8%), peribulbar (8.8%), sub-conjunctival (1.4%), and retrobulbar (1.3%).

Respondents reported 13 local anesthetic cataract surgery complications. Nine were considered potentially sight-threatening and included globe penetration or perforation after peribulbar local anesthesia (n=7), cilioretinal artery occlusion after sub-Tenon’s local anesthesia without hyaluronidase (n=1), and severe epithelial and stromal edema with topical tetracaine (n=1).

Potentially life-threatening complications included a silent myocardial infarction after sub-Tenon’s anesthesia, supraventricular tachycardia after retrobulbar anesthesia, a vasovagal event after peribulbar anesthesia, and anaphylaxis after sub-Tenon’s anesthesia with authors noting a possible relationship to hyaluronidase.

Comparing their current findings to an analysis they did in 2003, the authors found that complication rates had dropped, from 11.1 per 10,000 to 4.8 per 10,000.

“Our three surveys have documented a gradual decline in sharp-needle LA techniques in the UK over the years, and now most cataract surgery is done with either sub-Tenon’s or topical/intracameral. We’ve shown that the number of reported serious adverse events has gone down significantly. We think this is partly because of the move away from sharp-needle techniques, but also due to improved techniques for those using sharp-needle LA,” Dr. Eke told Reuters Health.

Dr. Eke continued, “We also confirmed that the sub-Tenon’s and even topical LA are not entirely free of risk. An adverse event might occur in any patient who has LA cataract surgery. Therefore, systems must be in place for resuscitation if necessary,”

The study was partially funded by the British Ophthalmic Anaesthesia Society.

SOURCE: http://bit.ly/1GlosyM

Br J Ophthalmol 2015.