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Postoperative lens exchange complications are best categorized by the timeframe in which they typically occur. At the one-day post-op exam, the major complications to look for are increased IOP and corneal wound leakage (sometimes leading to decreased IOP). Although increased IOP is much more common than wound leakage, it is not viewed as serious due to its self-limiting nature. Endophthalmitis, the most devastating of all complications, typically does not present until three to seven days after cataract surgery.
Although there are several different techniques for performing cataract surgery, modern phaco has––by far––been the most widely adopted. To minimize tissue disruption, most surgeons will use a corneal incision roughly 3mm to 4mm in length. This serves the dual purpose of permitting phaco probe entry and facilitating subsequent intraocular lens delivery. A second, side-port corneal incision is much smaller and undergoes far less manipulation.
Key clinical signs that you may have a wound leak on your hands include poor vision, low eye pressure (below 8mm Hg), complaints of epiphora, shallow anterior chamber, large corneal folds, choroidal effusion and optic nerve edema. If any of these are noted, be especially diligent to ensure good wound closure. Although any full-thickness corneal incision can leak, the vast majority of the time, it will be confined to the phaco incision.
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a narrated video of a wound leakage visualized with fluorescein.
The easiest and best way to identify wound leakage is with the instillation of fluorescein. Generally, close inspection of the wound under cobalt blue light will show leaking intraocular fluid between blink with no special manipulation. If wound leakage is not seen clearly but is still suspected, “paint” the wound with a fluorescein strip, as shown in the video. This deposits substantial amounts of dye around the wound and enhances visualization of any leakage.
Management of wound leakage will vary based on the cause, timing, severity and general appearance. The majority of leaks will be visible in the first day or two after surgery, and will be self-sealing if mild. If wound leakage is moderate but the anterior chamber is still formed, use a bandage contact lens to decrease lid interaction and promote re-epithelialization. Other potential strategies at this point include decreasing steroid use, adding cycloplegia and initiating topical aqueous inhibitors. If the anterior chamber is flat or the IOP is consistently very low, have the patient see the surgeon for surgical repair.
Postoperative wound leakage after cataract surgery is typically a condition that can be managed well by comanaging optometrists. Reassure patients by explaining the condition’s self-resolving nature and excellent visual prognosis. We prefer to see any patient with wound leak on a daily basis until the wound is fully closed, and continue broad-spectrum topical antibiotic therapy for several days after the wound is fully closed. (Note: it is essential to remind the patient about the importance of using their antibiotic eye drops as long as they are functionally exposed to the infection risks of an open globe.)
