“Cataract surgery gone wrong?”
I underwent cataract surgery in my right eye on May 26, 2020, but, prior to the surgery, the surgeon had averred that the cataract in the eye was quite dense and should never be removed manually and removal by phacoemulsification was the only option. He assured me that he was “highly skilled and experienced in removing dense brunescent cataracts and that to date he had dealt with many such cases successfully”.
To cut a long story short, the surgeon performed the surgery but unfortunately, during the surgery, something went wrong. Midway he aborted the procedure and I was left with excruciating pain in the eye and with no vision in the eye whatsoever. At the time he would not give me details but later in an email averred that he had used “very low power phaco and removed a big portion of the nucleus when the rest fell into the vitreous and that the post capsule was ingrown to the anterior vitreous hualoid”.
Subsequently, he advised me that he had arranged with a retina surgeon to do a “posterior vitrectomy after a week to remove all the fragments of the nucleus that were still in the eye. He averred that, as the capsular bag had been destroyed, there was no other alternative but to attach only one side of the new IOL to the back of the iris due to bleeding. However, further complications have arisen and I will post again in this regard shortly.
From what I read on threads on the internet, it is incumbent upon surgeons to first ascertain to what stage the cataract had progressed and then to set the phaco settings with Ozil accordingly. Just setting the phaco settings extremely low at the outset (without first identifying the type of cataract in question and setting the machine with no Ozil settings), merely results in generating a massive amount of heat and thus destroying the capsular bag and surrounding tissue. That apparently appears to have occurred.
In light of the foregoing, was the surgeon in error to have used very low power phaco at the outset? Your views and comments would be highly appreciated.
To cut a long story short, the surgeon performed the surgery but unfortunately, during the surgery, something went wrong. Midway he aborted the procedure and I was left with excruciating pain in the eye and with no vision in the eye whatsoever. At the time he would not give me details but later in an email averred that he had used “very low power phaco and removed a big portion of the nucleus when the rest fell into the vitreous and that the post capsule was ingrown to the anterior vitreous hualoid”.
Subsequently, he advised me that he had arranged with a retina surgeon to do a “posterior vitrectomy after a week to remove all the fragments of the nucleus that were still in the eye. He averred that, as the capsular bag had been destroyed, there was no other alternative but to attach only one side of the new IOL to the back of the iris due to bleeding. However, further complications have arisen and I will post again in this regard shortly.
From what I read on threads on the internet, it is incumbent upon surgeons to first ascertain to what stage the cataract had progressed and then to set the phaco settings with Ozil accordingly. Just setting the phaco settings extremely low at the outset (without first identifying the type of cataract in question and setting the machine with no Ozil settings), merely results in generating a massive amount of heat and thus destroying the capsular bag and surrounding tissue. That apparently appears to have occurred.
In light of the foregoing, was the surgeon in error to have used very low power phaco at the outset? Your views and comments would be highly appreciated.
Male | 74 years old
Complaint duration: 6 months
Medications: Ganfort, Acular, Optive eye drops
Conditions: Constant pain, burning and stinging in eye
8 Answers
Ophthalmology|RetinaSpecialistOphthalmologist
Literature doesn’t mention that as a side effect of timolol. Meaning losing one's voice.
It doesn’t matter how skilled a surgeon is, dense brunescent cataracts are high risk procedures, and no one should wait to let their cataracts become like that. Even with high power, they are difficult to remove, the zonules are often weak because of the dense nature of the cataracts. So, the chances of the capsule breaking is greater. Also, just small movements in the eye during surgery can cause issues. I do mostly very complicated cataracts and there are times where things are not in the surgeon's control. I have had cases where the lens was just free floating with no support. People should see their ophthalmologists regularly and make sure the cataracts aren’t so dense. We don’t live in a country where the access to care is limited, so the cataracts should never get this large.
This is a tough medical legal case and requires a medical legal opinion. The provider of that opinion is then drawn into the case which could definitely require intense scrutiny into every aspect of the surgeon and the surgery. Medical Legal counsel should be obtained to assist and determine if malpractice occurred or if this was in the realm of risk that can occur when a lens becomes a very opaque dense cataract. This decision needs then requires ophthalmic experts for the defense and prosecution and becomes a costly affair. It cannot be decided without thorough evaluation.
Roger Ohanesian, MD
Roger Ohanesian, MD
I'm sorry you had a less than great outcome with your cataract surgery. In general, cataract surgery is a very common and safe procedure. Complications are rare, but do sometimes occur. More mature lenses, as it sounds like you had, are at a higher risk of complication, and/or longer healing times. The particular complication you had, a posterior capsular break or rupture, is the most common complication to occur with cataract surgery. Sometimes a lens fragment can fall into the posterior segment, also called the vitreous as your surgeon described. It sounds as though he performed the surgery correctly, and similar to what I would have done in those circumstances (i.e., implanting a lens, and referring you to a retina
surgeon a few days or a week later for a vitrectomy).
I hope everything turns out well for you. Even with complications such as yours, many patients still obtain and enjoy good vision afterwards.
Take care,
J. Eric Downing, MD
surgeon a few days or a week later for a vitrectomy).
I hope everything turns out well for you. Even with complications such as yours, many patients still obtain and enjoy good vision afterwards.
Take care,
J. Eric Downing, MD
The phaco power settings are adjustable as we operate, adding more phaco or more oz ol or oscillation. This is usually found on the Alcon machine. I use a Stellaris by B&L. No oZil. And high vac and various pulse rates for low density, high cortical and higher us power and slower pulses or denser lenses. It is set up to start lower power and go to higher power as the lens require more as power.
Dr. LMJ
Dr. LMJ
This case brings up some challenging issues. The ability for a surgeon to safety remove a very dense cataract is continuously evolving with improvements in instrumentation and surgical technique. Cataracts that were considered “too risky” to be removed” by any method years ago are currently routinely removed by extra capsular techniques. The best method and approach is finally determined by the experience and skill of the surgeon, not merely what the cataract looked like preoperatively. Even in the best of hands, complications can occur. If a surgeon’s complication rate of your problem is one in ten thousand, unfortunately for you it is 100%. All that said, your questions are best resolved by personally being evaluated by one or more ophthalmologists with a solid practice and experience in dealing with this type of cataract, not inquiring on the internet about machine settings, as each doctor’s skills vary. Unfortunately, what happened in this eye cannot be undone. However, careful review of your exam records and especially the dictated operative report ( op note) would prove beneficial in planing the surgery of your other eye if had not yet been done. If you did successfully undergo removal of the fragments by a competant retina vitreous surgeon and you still have issues, they should be addressed by that doctor and or you should seek another independent retinovitreous opinion. You may need a change in your current treatment regimen. Best wishes for your improvement.
It is very difficult to comment on the details of the surgery without seeing you in person and reviewing all the information including testing, surgical notes and reports. I am sorry that you had a difficult surgical experience. I recommend that you get a second opinion from an experienced surgeon at an academic teaching hospital such as Wills Eye Hospital in Philadelphia PA USA.
I hope this is helpful to you.
Sincerely,
Mark F. Pyfer, MD
I hope this is helpful to you.
Sincerely,
Mark F. Pyfer, MD
Capsular damage and dropped nucleus are well known complications of surgery involving very dense cataract in any surgeons hands. With luck the retina surgeon can recover remaining nuclear material. You might want to discuss IOL issues with the retina surgeon, who should have the lens calculations from your cataract surgeon on hand in case they need to change the IOL at the time of vitrectomy. Good luck!
