Management of the complications of intraocular surgery

MANAGEMENT OF THE COMPLICATIONS INTRAOCULAR SURGERY EVERETT Ophthalmologist

Hermann,

Southern

L.

GOAR,

M.D.,

Pacific and Houston HOUSTON,

A

NY discussion of the compIications of intraocuIar surgery must naturaIIy faII into two groups-prevention of such comphcations and treatment after they occur. Many comphcations may be avoided by the systematic empIoyment of methods that diminish the hazards of intraocuIar surgery. The scope of this paper wiI1 not permit discussion of a11 compIications that may happen in every intraocuIar operation, and as the purpose of the articIe is to present the subject from the most practica1 standpoint possibIe, it wiI1 be confined Iargely to the two conditions that every ophthaImic surgeon must attempt to aIIeviate, viz., cataract and gIaucoma. The b&e noire of a11 ophthaImic surgeons, as with genera1 surgeons, is hemorrhage and infection, and this may occur at the time of operation or Iater during convaIescence. If these two hazards couId be eIiminated, the Iife of the ophthaImic surgeon wouId be much more carefree than it is now. Many of the detaiIs in the technique of intraocuIar surgery which couId diminish the hazards of compIications are not used even by the best ophthaImic surgeons. Some operators are so skiIfu1 with their hands and have such compIete contro1 of their patients that they do not fee1 the need of safety devices. Others do not agree that such methods diminish the hazards, and as one watches surgeons in various cIinics and studies their technique, it becomes apparent that to a Iarge extent, the resuIts of eye surgery depend upon the surgeon, and each surgeon must deveIop the technique that is safest in his hands. No procedure has been devised to prevent compIications in the hands of an untrained 62

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or heavy-handed surgeon. This paper is therefore written by an average ophthaImic surgeon for others of the same type, and onIy methods that have been put to the test of actua1 experience wiI1 be advocated. CATARACTS

When a patient consuIts the surgeon as a prospective candidate for cataract operation, there are certain essentia1 facts that must be ascertained. A rubber stamp containing the foIIowing data is used on the record : Pre 0~. Cataract V. R.Lt. Proj. CoIor Lacrimal system Tension R. Stage Smear CuIture B. P. Urine FocaI infection Bleeding time Clotting time

Record L.

L2.

Each of the subheads bears a direct relation to the prevention of a complication during or foIIowing operation. Each of these wiI1 be brieffy discussed. The vision of each eye is an important bit of evidence to have upon the history, and vision with the best correcting Iens shouId be recorded. There is not much justification for subjecting an eIderIy patient to cataract operation when the vision is norma or practicaIIy so in the opposite eye. The patient wiI1 not use the eye afterward and wiI1 suffer more annoyance than before operation. The attempt to

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fit an aphakic eye with an ordinary cataract Iens when the other eye sees we11 is foIIy. The new type of minimizing Ienses offer some hope when their manufacture and fitting become practica1. Light projection and coIor perception in an eye with mature cataract are important points to ascertain. They give some evidence of the integrity of the retina and optic nerve. It is much better if the surgeon has been abIe to examine the fundus during earIier stages when the condition of the vitreous, retina, optic disc and vesseIs may be noted. In mature cataract the point of fusion and division of two smaI1 Iights is a IittIe heIp in determining the soundness of the retina and optic nerve. Every ophthaImic surgeon makes a preoperative examination of the IacrimaI sac, aIthough some Iimit their efforts to mere pressure over the sac. It is better practice to diIate the punctum sIightIy and find out if fluid wiI1 pass into the nose without pressure. In case the sac is found infected, the safest procedure is to remove it before attempting intraocuIar surgery. In case of dacryostenosis without apparent infection, probing may be tried. If this faiIs, Iigation of the upper and Iower canaIicuIi by temporary sutures shouId be done. The intraocuIar tension shouId aIways be taken with whatever tonometer the surgeon is familiar. In the presence of abnormaIIy high tension one shouId proceed with infinite caution. One must then decide whether he is deaIing with cataract in a gIaucomatous eye or with a rise in tension due to an intumescent Iens. In either event preIiminary iridectomy is indicated if the tension remains high in spite of medica treatment. The stage of deveIopment of a cataract often determines the type of operation that is to be attempted. CertainIy in immature cataract intracapsuIar extraction is the operation of choice. In mature cataract the type of operation depends upon the experience and ski11 of the surgeon. Many exceIIent surgeons believe that the capsuIotomy operation is safer and yieIds better

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results, and this is certainIy true in the hands of the occasiona operator. No surgeon has the temerity to open an eyebaI1 in a patient with a dirty, inflamed conjunctiva if it can be avoided. Some stir1 reIy upon inspection aIone, beIieving that any apparentIy cIean eye is safe enough to risk operation. Others insist upon bIood agar cuItures. ConjunctivaI and epitheIia1 smears which show an absence of Ieucocytes and pathogenic bacteria have served me we11 for many years, with the added precaution of the use of I :g,ooo oxycyanide of mercury severa days previous to operation. KnowIedge of the state of the bIood pressure and urine is essentia1. Persistent high flood pressure indicates a poor operative risk, and patients of this type shouId be put to bed for a whiIe under the care of an internist, every effort being made to reduce the pressure before operation. If this is unsuccessful, venesection may be done an hour before operation. It is in this type of patient that the most dreaded of a11 compIications is prone to occur-choroida1 or so caIIed expuIsive hemorrhage. The use of hypertonic sucrose soIution intravenousIy’ has been advocated in ocuIar hypertension, and the reports upon its use are encouraging. I have used it a number of times very successfuIIy. Diabetics of course must be we11 under contro1 before operation is advisabIe. Concerning the eIimination of foci of infection before operation, there is a marked difference of opinion. Surgeons of continenta Europe pay Iittle or no attention to it, but certainIy whenever possibIe, a fou1 mouth shouId be cIeaned up. It is not necessary to put an eIderIy person to the discomfort of having tonsiIs removed unIess they are frankIy infected. UndoubtedIy an occasiona uveitis wiI1 foIIow operation due to their presence, but, on the whoIe, this seIdom happens. If the bIeeding time or cIotting time is Iong delayed, the administration of caIcium some days beforehand wiII often save annoying bIeeding at the time of operation

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or Iater. Indeed, the preIiminary administration of caIcium a few days before operation is a wise precaution in any case. Within the past fifteen or twenty years severa detaiIs of technique in cataract operation which have made the operation easier and safer for the average surgeon, have come into genera1 use. Of first vaIue perhaps is the use of hypnotics. By this means the patient may have a good night’s rest and come to surgery free from nervousness. It is best to avoid opium in any form unIess it has been tried thoroughIy on the patient previousIy, because of the danger of nausea and vomiting. ScopoIamine shouId never be used in eIderIy persons. Bromides and chIora1 or one of the numerous barbituric acid preparations are sufficient to aIIay nervousness and yet maintain the patient’s coaperation. Akinesia, either by the Van Lint method of injection of procaine into the orbicuIaris or the O’Brien method of bIocking the facia1 nerve, is essentia1, as this eliminates to a great extent the hazard of squeezing. Insertion of a superior rectus suture is a practica1 measure in patients who have diffIcuIty in controIIing the eye movements. Retrobulbar injection of procaine with suprarenin softens the eyebaI1 and Iessens the danger of vitreous proIapse. It shouId be reserved for cases in which intracapsular extraction is to be attempted, as it sometimes softens the gIobe enough to cause embarrassment in delivering the nucIeus in capsuIotomy operation. Some form of cornea1 or conjunctiva1 suture is used by most American ophthaImic surgeons to prevent vitreous and iris proIapse. One or two conjunctiva1 sutures wiI1 prevent the foIding back of the cornea which occasionaIIy occurs foIIowing operation. Cornea1 sutures may be reserved for unruIy patients or those whom it is desirabIe to aIIow up very soon after operation. COMPLICATIONS CATARACT

OCCURRING

DURING

OPERATION

Involuntary Iridectomy. This occurs during the section for a number of reasons.

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First is probabIy failure to compIete the incision immediateIy the counter-puncture is made, hence aIIowing the aqueous to Pressure with the fixation spil1 earIy. forceps may force the iris up ahead of the knife. Whatever the reason for the accident, the incision may be compIeted if an iridectomy was contemplated. Otherwise the knife shouId be withdrawn and the incision compIeted with scissors. No harm is done in any event. Hemorrhage into the Anterior Chamber. This frequentIy happens and unless it is severe, it need cause no concern. It shouId be irrigated out before the bIood clots, eIse it obscures the fieId and makes the manipuIation more diffIcuIt. The free use of adrenaIin before operation wiI1 IargeIy prevent hemorrhage from the conjunctiva1 vesseIs. Vitreous Prolapse. This is one of the commonest and yet one of the most dreaded of aI accidents during cataract extraction. It is especiaIIy Iikely to occur in high myopes and in persons with a previous choroiditis, because in these persons the vitreous is more ffuid. It undoubtedIy occurs more frequentIy in intracapsuIar operations in the hands of the average operator. The posterior capsuIe, whiIe very thin, exerts quite a restraining inffuence upon the vitreous body. Heavy handed surgery, especiaIIy too much pressure with the fixation forceps is a potent cause of proIapse. If vitreous presents immediateIy after the incision and before the Iens has been deIivered, the surgeon has one of two methods open. He must see that there is no pressure whatever on the gIobe. An intracapsuIar capsuIe forceps may be introduced into the wound, the capsuIe grasped, and an attempt made to deIiver the Iens by gentIe traction. If this faiIs, the other recourse is to introduce a wire Ioop, hugging the posterior capsuIe of the Lens, then Iifting the lens forward against the cornea and deIivering it. The sutures are then tied and the eye cIosed. Attempts to remove cortica1 materia1 shouId not be made after vitreous has been Iost.

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It is astonishing what good vision may be obtained after the Ioss of a comparativeIy Iarge amount of vitreous. NevertheIess it is a compIication that is to be avoided if at a11 possibIe. Unwise and persistent attempts to remove a Iens in its capsuIe rather than to do a capsuIotomy when dif5cuIties are encountered, accounts for a high percentage of vitreous Ioss in many series. The idea that it is better to Iose a smaI1 amount of vitreous to remove the Iens in the capsuIe than to Ieave some cortex behind is to be condemned. In case the vitreous proIapses after the Iens has been extracted, the sutures shouId be tied, the vitreous cut away with the scissors, and the piIIars repIaced. During these maneuvers the Iids must be held we11 forward by the assistant to prevent the sIightest pressure upon the eyebalI, and to produce negative pressure within the orbit. The eye is then gentIy cIosed and not examined for four or five days unIess the patient compIains of pain. Dislocation of the Lens into the Vitreous. This compIication rareIy happens at the hands of an experienced surgeon. Not infrequentIy the zonuIe ruptures due to too much pressure with the capsuIe forceps, and the nucIeus is disIocated upward behind the iris and ciIiary body. It may be easiIy stroked back into position by gentIe manipuIation through the cornea above and then deIivered in the usua1 manner. DisIocation deep into the vitreous is a serious compIication, and this is more IikeIy to occur in hypermature cataracts with a smaI1 nucIeus. RemovaI with a wire Ioop is the onIy soIution, and this is a diffrcuIt feat because the nucIeus cannot be seen easily by the operator. HiIdreth’s uItravioIet Iight, which produces fIuorescence of the Iens, is very vaIuabIe when this compIication occurs. Expulsive Hemorrhage. This is the most dreaded of a11 accidents that occur to the ophthaImic surgeon. It is estimated that it happens about once in a thousand operations. This unweIcome compIication is prone to occur in patients with both vascu-

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Iar and intraocuIar hypertension, and carefu1 preoperative preparation wiI1 Iessen the probabiIity. The hemorrhage comes from the friabIe choroida1 vesseIs foIIowing the sudden reIease of intraocuIar pressure. ImmediateIy foIIowing the incision the Iens may be expeIIed spontaneously, foIIowed by the contents of the eyebaI1 and a gush of bIood. EnucIeation is usuaIIy necessary foIIowing this disaster. OccasionaIIy it occurs a few hours after the operation. The patient then compIains of sudden severe pain, often of nausea and the dressing is found soaked with blood. The eye is usuaIIy Iost. Vail2 recommends immediate posterior scIerotomy when this accident occurs. COMPLICATIONS

FOLLOWING

THE

OPERATION

Wound’ Infection. This usuaIIy occurs in patients who have been operated upon in the face of a contaminated conjunctiva. It is manifestIy impossibIe to steriIize the conjunctiva, for saprophytic organisms are aIways present, and the Iid margins and meibomian gIands harbor pathogenic bacteria. NevertheIess careful preparation to excIude contamination is usuaIIy successful. Improper steriIization of instruments and sutures is a not infrequent cause of wound infection. It occasionaIIy happens that a patient forces infection through a patuIous IacrimaI duct into an eye by bIowing the nose vigorousIy soon after operation. In the presence of infection, the patient compIains of an undue amount of pain within twenty-four hours. When the dressing is removed, the Iids wiI1 be found swoIIen, there is marked chemosis and a sIough covered with mucopuruIent secretion is found aIong the upper Iip of the incision. Hypopyon occurs earIy. Prompt and drastic treatment aIone wiI1 save such an eye. The wound must be cauterized by trichIoracetic acid or the actua1 cautery, a Iarge dose of typhoid vaccine given intravenousIy and coId appIications used constantIy. SuIfaniIimide offers some hope in this unfortunate situa-

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tion. UsuaIIy if the in.fection is a viruIent one, in spite of a11treatment, the eye is Iost. This is seen in patients Late Infection. who do not do we11 after operation. The eye stays more congested than it shouId. There is pain in or about the eye, and the sIit Iamp shows a11 the signs of a more or Iess severe uveitis. Such patients wiI1 usuaIIy be found to harbor a focus of infection, and the most common sites in my experience have been in the sequence of teeth, tonsiIs and sinuses. Treatment with heat, atropine, caIcium gluconate and foreign protein wiI1 cIear up a certain number of them. Remova1 of infected areas is usuaIIy necessary. I have seen two severe, intractabIe cases respond quickIy to suIfaniIimide. Some of these patients may be sensitive to Iens protein which has been Ieft within the eye. Trauma to the ciIiary body in attempting to rupture a zonuIe which is unyieIding doubtIess causes uveitis in a considerabIe number of patients. This usuaIIy occurs Late Hemorrhage. upon the fourth or fifth postoperative day. The patient has been doing we11 and suddenIy compIains of a sharp pain in the eye. The surgeon then knows before he opens the eye what he wiI1 find. There may be a smaI1 amount of bIood in the anterior chamber, or it may be fiIIed. WhiIe this deIays convaIescence, it need not cause aIarm because it aIways disappears after a time. This bIood comes from a IimbaI or conjunctiva1 vesse1, sIipping down through the wound into the anterior chamber. The use of caIcium before or just after operation may heIp prevent this hyphemia. Heat heIps hasten its absorption. Separation of the Wound. This usuaIIy occurs during the first few days after operation as a resuIt of retching, coughing or some other strain or by an accidenta bIow. It is generaIIy accompanied.by proIapse of the iris. The patient shouId be prepared at once for operation as carefuIIy as for the previous one. One or two sutures are pIaced in the tough conjunctiva directly at the Iimbus, the proIapsed iris is excised, and the sutures are then passed through the

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episcIera and the wound firmIy approximated. A conjunctiva1 Asp shouId then be drawn over the wound. If a few weeks have eIapsed and the wound has faiIed to hea1, the edges shouId be freshened by touching with trichIoracetic acid. Postoperative Psychosis. EIderIy persons, placed in unfamiIiar surroundings, harassed by the thought of operation upon their eyes, pIagued by the fear of permanent Ioss of vision, and pIaced in bed with both eyes bandaged, are IikeIy to become confused and even irrationa1. Much may be done to prevent this by instiIIing confidence in the patient prior to operation. A nurse we11 trained in caring for these patients is a vaIuabIe asset during the first few days foIIowing operation. The unoperated eye shouId be unbandaged within twenty-four hours foIIowing the operation. Sedatives may be used freeIy, aIthough it must be admitted that some patients do not bear them we11 and they are sometimes responsibIe for menta1 confusion. Very few patients, if properIy prepared and given carefu1 postoperative treatment, wiI1 become vioIent. However, shouId this occur, they must be carefuIIy guarded to prevent injury and if necessary must be restrained. FIuids and sugars shouId be given freeIy, and if the patient refuses them by mouth, they should be given intravenousIy or by rectum. With these precautions the menta1 equiIibrium is re&stabIished within a short time. Eversion of the Cornea. No compIication that we encounter gives the surgeon a more unpIeasant surprise than to open the eye for the first dressing to find the cornea foIded back upon itself with the iris in contact with the upper Iid. This cannot if conjunctival or of course, happen, cornea1 sutures have been used. W. I. LiIIie (quoted by Bothman3) has devised an operation by which this may be corrected with exceIIent rest&s. A conjunctiva1 flap is dissected up from the upper Iimbus and the origina cornea1 incision is Iengthened I or 1.5 mm. below the horizonta1 foId in the cornea. The whole incision is freed with a spatuIa, proIapsed

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iris is excised, and the ffap is puIIed down over the upper two-thirds of the cornea and anchored at four and eight o’cIock. This prevents the high degree of astigmatism that resuIts from repIacing the cornea without Iengthening the origina incision. Postoperative Glaucoma. Many patients who deveIop gIaucoma foIIowing cataract extraction have had it before operation, though it has often been undiscovered. Downgrowth of cornea1 epitheIium into the wound, forming an epitheIia1 Iining of the anterior chamber accounts for a few cases. This may be prevented by making a conjunctiva1 ffap rather than by ending the incision at the upper Iimbus. This compIication is diffrcuIt to diagnose and usuaIIy the cause is estabIished by histoIogic examination. BIocking of the angIe of the anterior chamber from a Iarge amount of cortica1 debris or from the exudate of uveitis may produce secondary giaucoma. An acute rise in tension frequently foIIows too free discission of soft cataracts. If this happens, it is best to remove the cortica1 material by Iinear extraction. It has been generaIIy taught that gIaucoma often is produced by incarceration of a pillar of the iris in the wound. This has been greatly exaggerated as the cause of gIaucoma, and such teaching has prevented many ophthaImic surgeons from accepting iris incIusion operations in primary gIaucoma. In the light of experience, it seems probabIe that piIIar incarceration foIIowing cataract operation in a gIaucomatous eye is a safe therapeutic measure. GLAUCOMA

There are some compIications of gIaucoma surgery that I do not fee1 capabIe of discussing since I no Ionger do the types of operation in which they occur. A good many years ago I abandoned the trephine operation for the reason that the prochamber longed absence of anterior formation and occasionaIIy a subsequent opacification of the Iens did not appea1 to me as an idea1 resuIt. In recent years I have confined my operative procedure to four

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operations, viz.: (I) broad iridectomy if forced to operate during an acute attack; (2) basa1 iridectomy; (3) CycIodiaIysis; and (4) iris incIusion. For compensated gIaucoma (glaucoma simpIex) and as an interva1 operation in acute gIaucoma, iridencleisis has served me we11 for many years. If done as I shaI1 describe brieffy, it constitutes aImost a fooI-proof operation and there shouId be no compIications. A retrobuIbar injection of procaine and adrenaIin is given a few minutes ahead, both for anesthesia and to soften the gIobe. In case the intraocuIar tension is unduIy high, 50 C.C. of 50 per cent sucrose soIution is given intravenously an hour before operation. A generous ffap is dissected to the Iimbus as in the trephine operation. Then a scratch incision about 6 mm. Iong is made just behind the Iimbus in the same manner as Elschnig’s ” iridectomia ab externo.” After the aqueous is evacuated, provided miotics have been discontinued for a while and the iris is not too atrophic or bound by periphera1 synechia, the iris wiI1 prolapse into the wound when the upper Iip is depressed. The iris is now withdrawn to the pigmented border and spIit verticaIIy. One piIIar is retained beneath the conjunctiva and the other returns to the anterior chamber. In case the episcIera1 vesseIs bIeed freeIy, a pIedget of cotton is soaked in adrenaIin and aIIowed to remain beneath the flap a short time before scratching through the scIera. This operation has two features to recommend it over that of the usua1 operation by keratome incision: (I) it eIiminates the danger of scratching the anterior Iens capsuIe with the Iance point-in an unusuaIIy shaIIow anterior chamber this may readily occur even in skiIIfu1 hands; (2) this incision reaches the iris at its base instead of we11 below it, as occurs when the customary incision is made. The onIy compIications I have ever encountered in this operation have been: (I > retina1 hemorrhages-these are due to the comparativeIy sudden Iowering of

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tension in an eye with extremeIy scIerotic vesseIs, and may occur during any intra0cuIar operation; (2) hyphemia, which often occurs at the time of operation and disappears within a few days; (3) hemorrhage into the vitreous, which occurs if the incision is made too far back so that after the anterior chamber is evacuated, a bead of vitreous presents, and if the patient is a free bleeder, bIood seeps into the anterior vitreous; (4) iritis, probabIy traumatic in origin and to be combated with atropine and heat. Iritis usuaIIy subsides quickly. It is safe to use atropine after iris inclusion operations. FoIIowing this operation the anterior chamber reforms within twentyfour hours, massage is started earIy and continued for some weeks and the resuIts are exceIIent. I have never seen sympathetic ophthaImia nor Iate infection deveIop after this operation, and I -beIieve it is the safest and best Mtering procedure yet devised.

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This by no means covers a11 the complications that the ophthaImic surgeon faIIs heir to as a part of the hazards of his chosen profession. It has been my purpose to point out ways to avoid compIications rather than to stress treatment after they occur. The best way to get out of trouble is not to get into it. An oId sage once remarked that “the man who makes no mistakes does no business.” Just as surely, the man who has no compIications does Iittle surgery. Some of them are unavoidable; most are preventabIe. The surgeon who seiects his cases wiseIy, prepares them properIy, uses the technique that is safest in his hands and the postoperative care with supervises minute attention to detail, wiI1 escape much of the troubIe that arises to pIague his more careIess coIIeagues. REFERENCES I. DYAR and MATTHEW. Arch Opbtb., 18: 57, 1937. 2. VAIL, D. Am. J. Opbtb., 21: 256, 1938. 3. BOTHMAN, L. Arch. Opbtb., 17: 1073, 1937.