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9/28/2012 1 Post-Operative Retinal Complications 9/28/2012 Presenter Robert E. Benedett, MD Diplomate, American Board of Ophthalmology Co‐Management For The Practicing Optometrist Presented By Missouri Eye Institute, LLC Springfield Branson Joplin Intravitreal Injections •Expect vision to be blurred until medication absorbs Post‐Operative •Avastinand anti‐VEGF meds: overnight • Triamcinolone: 2‐3 days until it drifts inferiorly, but can Retinal Complications last for 6 to 8 weeks Intravitreal Injections Intravitreal Injections • Immediate pain: lasts a few minutes to hours • Transient increase in intraocular pressure • Will decrease after a few minutes • Delayed pain: after anesthesia wears off • ClCorneal abibrasion: severe pain, like welding burn • Triamcinolone can cause long‐term IOP spike –Betadineis the likely culprit •30% will have spike – Pressure patch and oral pain medications are •Risk increases with increasing injections and shorter appropriate time between injections •May require filtering surgery to alleviate 1 9/28/2012 Intravitreal Injections Intravitreal Injections • Endophthalmitis • Posterior Vitreous Detachment •Starts on the first day post‐injection •All patients with multiple injections will eventually •Symptoms include pain, blurry vision, and conjunctival develop posterior vitreous detachments injection • Requires prompt evaluation •Rare Complications •Most do well with treatment, but 20% do not • Vitreous hemorrhage •Retinal tears or detachments • Choroidal hemorrhage –Photophobia –Headache Vitrectomy Vitrectomy •Cornea • Glaucoma – Persistent Corneal Abrasion –Diabetic vitrectomies in 1980s: 20% developed rubeotic • Related to PRP and complete conjunctival periotomy vessels; current risk is 2% • May require corneal transplant •3% of diabetic vitrectomies will require penetrating –Risk Factors for NVI keratoplasty •Pre‐operative NVI • Persistent retinal detachment •Aphakia • Severe proliferative diabetic retinopathy Vitrectomy Vitrectomy •Glaucoma • Cataract –Ghost Cell Glaucoma •Remove all vitreous and blood, and wash out the anterior –72% have significant nuclear sclerosis at two years chamber and angle •No gas/air bubble – Silicone Oil – 100% with prolonged gas • Droplets in angle • Macular hole • Pupillary Block –Inferior iridotomy •6‐12 months –Gas –Lens touch at vitrectomy •26‐57% immediate post‐operative •No air travel •Medic alert wrist band 2 9/28/2012 Vitrectomy Vitrectomy •Post‐operative vitreous hemorrhage •Rare Complications –20% in diabetic vitrectomy – Endophthalmitis •First day to a few weeks •Rate of incidence is 0.07% • Air/fluid exchange in office if it does not clear –Sympathetic ophthalmia •Retinal Detachment •Rate of incidence is 0.06% –Risk is 3‐7% –Can present as tears or proliferative vitreoretinopathy Scleral Buckle Scleral Buckle • Redetachment •Infection –10‐15% occurrence –1% occurrence –Can occur in few days to months to years, but usually two – Usually happens in first three months weeks to two months •Pain –Peak risk is at five weeks • Proliferative vitreoretinopathy (PVR) –Signs: •No prophylaxis •Purulent discharge • Subconjunctival hemorrhage • Ganulomas and fistula formation • Conjunctival retraction • Vitreitis •Proptosis Scleral Buckle Scleral Buckle •Extrusion of buckle element •ChoroidalDetachment –Patient will present with pain and redness – Serous or hemorrhagic – Usually occurs months/years after the procedure – Up to 40% –Must remove element because closure will not work – Hypotony at drainage – Redetachment rate is 33‐34% –Vortex Vein obstruction •More time since procedure to removal lowers rate of redetachment – Increases with age 3 9/28/2012 Scleral Buckle Scleral Buckle • Malaise and low‐grade nausea •Cystoid Macular Edema (CME) • Usually resolves in a few days to weeks • Steroids—topical and oral •25% by angiography at 5 weeks post‐operative • Cycloplegics to rotate iris/lens diaphragm posteriorly to prevent or relieve angle closure •Steroids •Drain choroidals if they remain kissing for more than –Topical, Subtenon’s, oral, or intravitreal a few days –Avastin • Hemorrhagic choroidals –Older and highly myopic eyes – Severe pain and nausea Scleral Buckle Scleral Buckle • Macular Pucker • Motility Abnormalities –80% in the first few weeks –3‐17% incidence –4% long‐term – Pre‐operative PVR • Treatment –Prisms –Total retinal detachment –Muscle surgery • Difficult because of scarring –Pre‐operative vitreous hemorrhage •Noplopiais worse than diplopia Scleral Buckle •Refractive Error – Stabilizes at three months – Usually 2 to 3.5 diopters Photos and Case • Can occasionally be higher than 5 to 6 diopters Discussions 4 9/28/2012 Patient Case #1 Patient Case #1 . 74 year old female underwent phacoemulsification with posterior chamber intraocular lens placement to the left eye on 08‐01‐12 . No complications but case was made more difficult by poorly dilating pupil (no breaks in capsule) . 1‐day post‐op visit, incision intact, moderate corneal edema with uncorrected visual acuity 20/300, PCIOL well centered, anterior chamber deep and quiet, IOP 18 mmHg . 1‐week post‐op visit – seen by her optometrist ‐ corneal incision healing well, edema resolved, VA uncorrected 20/150, IOP 14mm Hg – “something strange in the eye” Patient Case #1 Patient Case #1 . Diagnosis? . Further Studies? . Treatment options? Patient Case #1 Patient Case #1 . Retained lens cortex temporally behind iris . 3 week post‐op visit but anterior to the IOL . VA (corrected) improved to 20/50 . Extending about ½ to 2/3rds of the way . IOP stable at 14 mmHg, anterior segment across the pupil, obibscuring the pupil and quiet vision . Cornea clear and incision well‐healed . IOP was within normal limits, no significant . Patient stated vision still obscured and anterior chamber inflammation “blurry” in parts . Patient was kept on prednisolone qid and . Residual cortex still present across ½ of pupil ketorolac qid 5 9/28/2012 Patient Case #1 Patient Case #1 . Further Treatment? . YAG laser ablation of residual cortex performed, patient tolerated procedure well . 1 week post‐laser VA(corrected) improved to 20/20 . IOP stable at 9 mmHg . Anterior chamber deep and quiet . Patient happy Retained Cortex in AC Retained Cortex in AC Retained Cortex in AC Management of Retained Lens Material in the Anterior Chamber . Does not necessarily need surgical removal . Size and type (cortex versus nucleus) of material important . In general cortical material better tolerated and more likely to resorb than nuclear material; also less likely to incite inflammation and elevation of IOP . Smaller fragments better tolerated . Observation is warranted for smaller amounts of retained material 6 9/28/2012 Management of Retained Lens Management of Retained Lens Material in the Anterior Material in the Anterior Chamber Chamber . Control inflammation with steroids or Surgical Intervention may be necessary if: NSAIDs . Presence of large amounts of material or . Add cyclliloplegics if necessary obstruction of the visual axis . Control elevated IOP with appropriate . Uncontrolled mediations medications . Uncontrolled ocular hypertension . If inflammation and/or elevated IOP not well . Uncontrolled corneal edema controlled or if significant corneal edema develops, then consider surgical removal . Associated other problems (endophthalmitis, retinal problems) . Can takes many weeks to resorb Patient Case #2 Patient Case #2 . 75 year old male presented to his optometrist . Visual Acuity (best corrected) OD CF@4 feet, for “blurred” vision –right eye worse than left OS 20/60 . Underwent uncomplicated cataract surgery . Anterior Segment WNL OU OU in 2010 (tid(outside fac ility ) . PCIOL well centered OU . Underwent YAG posterior capsulotomy (OD . Open posterior Capsule OD only only) some time later for “blurred” vision –no . Fundus Exam –dense Asteroid Hyalosis OU improvement. According to the patient . Macula –WNL OU previous surgeon then told him “nothing more can be done.” Patient Case #2 Patient Case #2 7 9/28/2012 Patient Case #2 Patient Case #2 . Marked white granular/calcific deposits on . Diagnosis? the posterior surface of the IOL OU . Further Workup? . Right posterior capsulotomy present . Treatment options? . Left posterior capsule intact . Next step(s)? . Dense asteroid hyalosis OU . Remainder of exam unremarkable OU Asteroid Hyalosis Calcification of Silicone IOLs in Presence of Asteroid . Minute white, granular opacities composed Hyalosis of calcium‐containing phosopholipids in an . Stringham et al. Ophthalmology Aug. 2010 otherwise normal vitreous . Reviewed 22 cases of calcification of silicone IOLs (8 different designs from different silicone materials) . AitiAssociation with dia be tes reportdted . Presence of asteroid hyalosis was confirmed in . Overall Incidence of 1 in 200 persons 86.4% of cases . Unilateral in 75% of cases . Deposits were only found on the posterior surface of the IOL . Rarely causes a significant decrease in visual . Well‐described correlation, however not all patients acuity with asteroid hyalosis and silicone IOLs develop calcification . ? If YAG capsulotomy increases risks of calcification Calcification of Silicone IOLs Patient # 2 – Continued . Patient referred for evaluation of the IOL opacification/calcification and asteroid hyalosis, possible IOL exchange +/‐ vitrectomy . Acrylic IOLs 8 9/28/2012 Questions or Comments? Sources: . Problem patients and when should they be sent . American Academy of Ophthalmology – back to operation surgeon Basic and Clinical Science Course (2002‐2003 . Usually best not to pre‐determine with your patient
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