Optical Trocar Causing Aortic Injury: A Potentially Fatal Complication of Minimal Access Surgery (original) (raw)
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Aortic Arch Laceration: A Lethal Complication After Percutaneous Tracheostomy
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16 Complications Associated with Cataract Surgery
2017
This chapter reviews complications associated wth cataract surgery and includes discussion of their risk factors, clinical presentation, prevention and management strategies. For the sake of discussion these complications are classified into intraoperative, early postoperative and late postoperative complications. 2. Anaesthesia-related complications Ocular anaesthesia may be complicated by both ophthalmic and systemic factors. There have been reports of potentially life-threatening complications, including optic nerve damage, globe perforation as well as brainstem anaesthesia, dysrhythmias and cardiovascular depression. These complications are mainly seen with sharp needle techniques and are rarely encountered nowadays as cataract surgery is usually performed under topical or sub-Tenon's anaesthesia (1). 2.1 Optic nerve damage If a sharp needle accidently penetrates the dural sheath of the optic nerve (2), the anaesthetic can track back to the brainstem, causing unconsciousness and severe cardiorespiratory collapse/arrest with a potentially lethal outcome. This complication is rare, with some studies suggesting an incidence of between 0.09% and 0.79% for brainstem depression (3). Needle trauma to the optic nerve tissue can lead to significant loss of vision (4). 2.2 Globe perforation Globe perforation is a rare complication of sharp needle anaesthesia and has been reported with both retrobulbar and peribulbar approaches with an incidence of 0.009% to 0.13% (3). This complication has potential for causing severe injury to the retina and is more frequently encountered in highly myopic eyes and eyes that underwent scleral buckling for retinal detachment (2). Globe perforation should be suspected if hypotony is encountered after administering sharp needle anaesthesia. However, this could be absent if a large volume of anaesthetic has been injected intraocularly. Another sign is a dim red reflex and sometimes blood may be seen Cataract Surgery 222 behind the crystalline lens by the operating surgeon at the start of the operation. Management includes examination of the fundus to assess the extent of retinal damage and to apply argon laser photocoagulation or cryopexy to retinal breaks, if necessary(5). However, in most cases, examination of the fundus is usually difficult due to the presence of vitreous haemorrhage complicating the perforation. B scan ultrasonography is helpful in this context but vitrectomy surgery is usually indicated to remove the haemorrhage and deal with the retinal damage. Of note, in addition to the physical damage that could be caused by the needle injury to the globe, injection of the anaesthetic into the vitreous can also result in retinal toxicity and poor vision (6). 2.3 Retrobulbar haemorrhage Retrobulbar haemorrhage is an uncommon complication of ocular anaesthesia with an incidence of 0.032 to 3%. The condition is more common with sharp needle techniques (retrobulbar and peribulbar) compared to blunt needle anaesthesia (sub-Tenon's) (1) , and is more common in patients on antiplatelet medications and anticoagulants with elevated an International Normalised Ratio (INR) (5). Retrobulbar haemorrhage is an emergency condition that needs to be promptly dealt with to save vision. It usually presents shortly after administration of the anaesthetic injection with increasing proptosis, tightness of the lids, subconjunctival haemorrhage and elevated intraocular pressure (IOP) that can lead to occlusion in the central retinal artery or short post ciliary arteries and blindness (5). Initially mild intermittent compression on the globe can be helpful to stop further bleeding and limit progression of the haemorrhage. If this fails to resolve the condition, then pressure on the globe has to be relieved by performing a lateral canthotomy and cantholysis of the inferior crus of the lateral tarsal ligament. This is usually sufficient to decompress the orbit around the globe in most cases. IOP-lowering medications may be considered but these are usually not sufficient of their own to resolve pressure on the retinal circulation. Elective cataract surgery must be cancelled but may be rescheduled after at least a few weeks. While no immediate laboratory test is essential, patients must be reassessed to exclude underlying blood dyscrasias. Subsequent cataract surgery is better performed under topical anaesthesia and attention should be given to normalizing the INR level if elevated and stopping antiplatelet medications in liaison with a physician. 3. Surgery-related complications 3.1 Positive vitreous pressure Positive vitreous pressure can occur due to poor akinesia, inadvertent pressure on the globe from a tight lid speculum, proptosis, retrobulbar haemorrhage, eyelid abnormalities, as well as high hypermetropia. In this situation the iris-lens-diaphragm is pushed forward making surgery difficult and increasing the risk of more serious complications including iris damage, posterior capsule rupture and suprachoroidal haemorrhage (5). Positive vitreous pressure is best dealt with by early recognition. In many cases a tight lid speculum is the culprit and minor adjustment of the speculum can correct the problem. Should this fail, attention needs to be directed to other causes including retrobulbar haemorrhage that usually manifests before the start of the surgery or aqueous misdirection and suprachoroidal haemorrhage that will present later on during the surgery. In the absence of retrobulbar