Optimizing outcomes in phacoemulsification: Addressing intraoperative and postoperative complications in a case series from Iraq

Study design and setting

This study is a retrospective case series combined with a literature review, conducted at a private ophthalmology clinic in Baghdad, Iraq. The aim was to evaluate the incidence, management, and outcomes of complications in patients undergoing phacoemulsification surgery. The literature review complements the case series by contextualizing the findings within the broader scope of existing research.

Study population

The study included 31 patients who underwent phacoemulsification for cataract extraction between August 2021 to June 2024. Inclusion criteria were patients who completed at least one year of postoperative follow-up. Patients with incomplete medical records or those who underwent combined surgical procedures were excluded from the analysis.

Data collection

Data were retrospectively collected from patient medical records. The information gathered included demographic details (age, gender, occupation, and city), post-operative visual acuity, IOP, presenting complaints, intraoperative details, and postoperative outcomes. Complications such as PCR, corneal edema, and increased intraocular pressure were particularly noted and analyzed. Follow-up for patients was conducted post-operatively and then after six months.

Surgical technique

All surgeries were performed by the same experienced surgeon using a standardized phacoemulsification technique. The procedure was conducted under local anesthesia, involving a small corneal incision of approximately 2.2-2.75 mm for the insertion of the phacoemulsification probe. Ultrasound energy was used to emulsify the lens nucleus, and the residual cortical material was aspirated. An intraocular lens (IOL) was implanted in the capsular bag in all cases.

Statistical analysis

Descriptive statistics were used to summarize the demographic and clinical characteristics of the patients. The incidence of complications was reported as frequencies and percentages. Due to the small sample size, no inferential statistical analyses were performed.

Ethical considerations

The study was conducted in accordance with the principles of the Declaration of Helsinki. Informed Written consent was obtained from all patients for the use of their medical data for research purposes. Participants are below the age of 18; informed consent was obtained from parents or guardians. The local ethics committee of the University of Baghdad, College of Medicine waives ethical approval due to the study’s retrospective nature.

Systematic review

A systematic review was conducted to complement the findings from the case series and provide a broader context for managing complications associated with phacoemulsification. Following the PRISMA guidelines⁴ ( Figure 1), a comprehensive search of the PubMed and Scopus databases was performed using the keywords “phacoemulsification” and “complications”, with a focus on studies published between 2014 and 2024. The inclusion criteria for this review were original research articles that discussed intraoperative or postoperative complications of phacoemulsification in human subjects, published in peer-reviewed journals, and written in English. Only studies that reported patient outcomes or management strategies related to phacoemulsification complications were included. Studies involving animal models, conference abstracts, case reports, or those lacking clear outcomes related to complications were excluded.

Figure 1. PRISMA flowchart of the included studies.

The initial article screening was conducted using the Rayyan tool to remove duplicates and assess eligibility. To ensure the quality and reliability of the included studies, the ROBINS-I tool was applied for non-randomized studies⁵ ( Table 1), while the ROB 2 tool was used for randomized controlled trials⁶ ( Table 2). Each study was evaluated for bias in areas such as confounding factors, selection bias, measurement of outcomes, and reporting bias. Only studies that were assessed to have a low or moderate risk of bias were selected for further analysis. The final selection included studies that examined complications such as posterior capsule rupture, elevated intraocular pressure, and corneal edema, with particular attention to patients with comorbidities such as diabetes and high myopia. Data extraction from the included studies focused on identifying the types of complications, risk factors, management strategies, and visual outcomes.

Case series analysis

This case series involved 31 patients who underwent phacoemulsification for cataract extraction, with an average age of 65.4 years ( Table 3). These patients presented with diverse preoperative conditions, including diabetic retinopathy, high myopia, and posterior polar cataracts, all of which posed unique challenges to surgical success.

Visual outcomes

The results demonstrated a significant improvement in postoperative best-corrected visual acuity (BCVA). Specifically, 35.5% of patients achieved a visual acuity of 6/6 in the right eye, and 29% in the left eye. This substantial enhancement underscores the effectiveness of phacoemulsification in restoring visual function, even in patients with complex preoperative conditions. Such outcomes are consistent with the literature, where phacoemulsification is widely recognized for its ability to deliver superior visual acuity improvements ( Tables 4, 5).

Complications

PCR emerged as the most prevalent complication, occurring in 12.9% of cases. Additionally, IOP elevation was observed in 9.7% of patients, while corneal edema was noted in 6.5%. These complications, while significant, were effectively managed through interventions such as anterior vitrectomy for PCR and topical medications for IOP control. The ability to manage these complications effectively is indicative of the surgeon’s expertise and the robustness of the postoperative care protocols employed ( Figure 2, Figure 3).

Figure 2. Presenting complaints and associated IOP.

Figure 3. Complications and outcomes by age group.

Management success

Regardless of the arising complications, visual outcomes were generally universally favorable. The management strategies not only minimized immediate complications but also ensured stability and satisfaction for the patients in the long run. This resolution again finds support from current best practices in phacoemulsification and keeps the position for an individualized surgical and postoperative management.

Systematic review

In this review, data from 32 clinical studies involving complications and outcomes of phacoemulsification have been analyzed. The series vary in population techniques, and complication rates ( Table 5 – underlying data).^7–38

Intraoperative complications

Intraoperative complications were one of the major themes that emerged among the reviewed studies, with the major frequent issue being PCR. In a series of patients with pseudoexfoliation syndrome, Veselinović et al.⁷ reported that PCR developed in 9.26% of the patients, versus only 1.88% in the group without PEX, demonstrating an increased risk in PEX patients. Similar results were presented in a study by Nagar et al. (2022),¹⁰ which identified previous intravitreal anti-VEGF injections as one of the significant risk factors for PCR, and the dose-response relationship between the numbers of injections and the risk of rupture. Other complications like zonular dialysis, vitreous loss, and suprachoroidal hemorrhage were infrequent but important. Savastano et al. (2015)⁸ reported an incidence of 0.094% for SCH, underlining that despite the rarity of this complication, SCH represents a serious risk in the course of nucleolus phacoemulsification. In their study, early detection and the use of reverse Trendelenburg positioning prevented expulsive hemorrhage, allowing for successful completion of surgery.

In studies involving a larger sample size, such as Li et al. (2019),⁹ where 32,526 eyes were reviewed, the introduction of intracameral antibiotics significantly reduced the incidence of postoperative endophthalmitis by 62%. Their findings emphasized that effective intraoperative management, particularly the use of prophylactic antibiotics, can greatly minimize the risk of complications.

Postoperative complications

Postoperative complications varied among the studies but remained a crucial aspect of phacoemulsification outcomes. CME was particularly prevalent among diabetic patients. Samanta et al. (2014)¹¹ reported that 47% of diabetic patients without retinopathy and 55% of those with diabetic retinopathy developed CME postoperatively, compared to only 21% in non-diabetic controls. These findings highlight the importance of managing systemic comorbidities to reduce the risk of postoperative complications.

Corneal edema was another common complication. Among postoperative complications, transient corneal edema was reported by Kausar et al. (2015)¹² in 44% of cases, which was greater in cases with dense nuclear cataracts. They also noticed that systemic hypertension and longer duration of phacoemulsification were the important contributing factors to postoperative corneal edema. In a series, Nagar et al. (2022)¹⁰ demonstrated greater complication rates among eyes receiving previous anti-VEGF injections: posterior capsule rupture and corneal edema. In these patients, immediate anterior vitrectomy combined with same-day referral for pars plana vitrectomy were the required management strategies that significantly improved the postoperative outcomes.

Visual outcomes

The improvement in visual acuity was consistent across all the studies. In the large cohort study by Lee et al. (2020)¹⁵ with 2,162,191 eyes, the overwhelming majority of patients achieved postoperative BCVA of 6/6 or better. Though there were some complications, the general feeling regarding the visual outcome was positive, especially for those patients who had posterior capsulotomy, which was instituted basically to reduce the risk of IOL dislocation. In such studies as Dzhaber et al. (2020),¹³ comparing different surgical techniques, visual outcomes were similar between FLACS and conventional phacoemulsification, with both groups having similar UDVA and CDVA scores at the postoperative 3 months. FLACS slightly showed a lower rate of transient IOP spikes on postoperative day 1 compared to that of the conventional surgery.

Other studies, such as those by Han et al. (2020),²¹ focused on the importance of early intervention in the management of postoperative complications and found that the employment of a risk stratification system, such as the NZCRS, significantly lowered overall complication rates and offered better visual acuity outcomes. Such might involve the stratification of high-risk scores—for example, those with dense cataract or monocular vision—to more career surgeons in order to minimize the chances of adverse events.

Key risk factors

Commonly shared risk factors for intraoperative and postoperative complications include PEX, a small diameter of the pupil, previous intravitreal anti-VEGF injections, and systemic diseases such as diabetes and hypertension. Diabetes as an influencing factor in increasing complication risks of CME and corneal edema was independently emphasized by Veselinović et al. (2017)⁷ and Samanta et al. (2014).¹¹ An interesting finding, however, was documented by Helayel et al. (2022),¹⁷ who included patients in their series with patients who had retained lens fragments. Such scenarios were most likely to result in complications by trainee surgeons. In such cases, timely intervention through the use of pars plana vitrectomy greatly improves the visual outcomes, with 73.4% of patients maintaining or improving their preoperative visual acuity.

Management strategies

The management strategies were varied, each suited to the particular complications encountered. For eyes with PCR, anterior vitrectomy and sulcus IOL fixation represented common interventions. In the series of Carifi et al. (2014),¹⁶ for example, these techniques remained imperative in sight preservation in that 77% of the eyes demonstrated improvement in visual acuity during the postoperative period.

In postoperative CME, Samanta et al. (2014)¹¹ mentioned that the treatment with topical corticosteroids and NSAIDs, particularly in diabetic patients, had a good outcome in maintaining the condition and visual acuity. In cases of endophthalmitis, Ting et al. (2024)²⁶ mentioned that intravitreal antibiotics, namely, vancomycin and amikacin, were promptly given; the majority received BCVA of 6/36 or better.

Summary of findings

This systematic review, therefore, underlines the complexity of dealing with phacoemulsification surgeries, especially in a high-risk population. All the reviewed studies have consistently pointed out that though the complications like PCR, CME, and corneal edema are not uncommon, effective intraoperative management and postoperative care could improve the final outcomes to a large extent. Improvement in visual acuity was recorded in the majority of cases, even in patients with systemic or ocular comorbidities, thereby establishing the modern phacoemulsification techniques.

Ethical approval and consent statement

This is a retrospective observational analysis, and formal ethical approval was not required. Informed consent was obtained from all participants or their legal guardians before data collection. Participants are below the age of 18; informed consent was obtained from parents or guardians. Data used in this study were anonymized to ensure confidentiality and maintain ethical standards in accordance with the principles of the Declaration of Helsinki. The local ethics committee waives ethical approval due to the retrospective nature of the study.