OP8.4 | Cataract Surgery: Anaesthesia, ECCE Steps, Complications and Postoperative Treatment — Summary & Reflection

KEY TAKEAWAYS

Four surgical techniques are available for cataract extraction: phacoemulsification (2–3 mm, foldable IOL, current global standard), MSICS (5–7 mm scleral tunnel, rigid PMMA IOL, Indian high-volume standard), ECCE (10–12 mm limbal incision, sutures, largely replaced), and ICCE (entire lens + capsule, cryoprobe, largely obsolete). Anaesthesia options range from topical drops (most modern, no injection) through sub-Tenon, peribulbar (injection outside muscle cone — preferred over retrobulbar), and retrobulbar blocks (inside cone — higher risk: globe perforation, optic nerve injury, retrobulbar haemorrhage) to general anaesthesia (children and uncooperative adults). The ECCE steps proceed: superior rectus suture → conjunctival flap → limbal incision → can-opener anterior capsulotomy → hydrodissection → nucleus expression → cortex I/A → IOL implantation → wound closure with sutures. Major intraoperative complications: posterior capsular rupture (PCR, most common serious complication → anterior vitrectomy ± sulcus IOL), nucleus drop (→ pars plana vitrectomy), expulsive haemorrhage. Post-operative complications: early — raised IOP, corneal oedema, uveitis, endophthalmitis (day 2–7 pain/hypopyon/reduced VA → emergency intravitreal antibiotics ± vitrectomy per EVS); late — PCO (commonest late complication, Nd:YAG capsulotomy), CMO, IOL dislocation, refractive surprise. Post-operative treatment: topical antibiotic + steroid (tapering over 6 weeks) ± NSAID; precautions (no rubbing, no swimming 4 weeks); red flag symptoms requiring same-day emergency referral.

REFLECT

Consider the hook scenario: you are observing phacoemulsification. Halfway through the case, the surgeon pauses and says quietly, 'There's been a small capsular rent.' Reflect on: What does that mean for the rest of the case? What would change — in surgical plan, IOL placement, and what you would say to the patient afterwards? Then shift perspective: six days after a routine ECCE you performed at a camp site, a patient returns to the district hospital in pain. What do you do? What do you NOT do? And when you eventually counsel the pre-operative patient before the next camp surgery, how will you incorporate the endophthalmitis risk honestly, while still communicating that cataract surgery is safe? This reflection sits at the intersection of surgical knowledge, clinical judgement, and ethical communication — the exact intersection that defines good surgical practice.