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Complications

TL;DR — Cataract surgery is safe in absolute terms but performed so often that rare harms dominate the total burden. Posterior capsule rupture (PCR) occurred in 31,749 of 2,853,376 European registry surgeries (1.1%, annual range 0.60–1.65%, declining trend P < .001), with corneal opacities (OR 3.21, 95% CI 3.02–3.41), diabetic retinopathy (2.74, 2.59–2.90), poor preoperative acuity (1.98, 1.88–2.07) and white cataract (1.87, 1.72–2.03) the strongest risk factors (Segers 2022, PMID 34074994). PCR is the pivotal event: it multiplied the odds of acuity loss 5.74-fold in a 55,567-operation UK audit (Sparrow 2012, PMID 22441022) and, in EUREQUO, worsened mean corrected acuity (0.13 vs 0.05 logMAR) and mean absolute prediction error (1.15 vs 0.41 D), with corneal oedema aOR 2.80, endophthalmitis aOR 4.40 and uncontrolled IOP aOR 14.58 (Segers 2022, PMID 35179858). Endophthalmitis is the most feared: pooled 4,502/6,809,732 eyes (0.066%), reduced by intracameral antibiotics (OR 0.19, 99.4% CI 0.12–0.30) with omission of intracameral cefuroxime raising risk 4.92-fold in the only large randomised trial (Kato 2022, PMID 36258003; ESCRS Endophthalmitis Study Group 2007, PMID 17531690). Pseudophakic retinal detachment pooled at 0.66 per 100 patients (95% CI 0.43–1.00) across 5,480,448 patients (Alshammari 2024, PMID 39172224), and clinical pseudophakic cystoid macular oedema at 0.1–2.35% (Zur 2017, PMID 28351047).

The frequency table

Complication Rate Denominator Source
Posterior capsule rupture 1.1% (annual range 0.60–1.65%, declining) 2,853,376 EUREQUO surgeries 2008–2018 PMID 34074994
Dropped nucleus 0.071% (1,221 eyes) 1,715,348 EUREQUO surgeries Lundström 2020, PMID 32126043
Endophthalmitis (pooled observational) 0.066% (4,502/6,809,732) 51 studies, network meta-analysis PMID 36258003
Endophthalmitis (randomised trial) 29/16,603, 20 proven infective ESCRS 2×2 factorial trial PMID 17531690
Endophthalmitis without vs with intracameral antibiotics 1 in 485 vs 1 in 2,855 surgeries; RR 0.12 (0.08–0.18) 1 RCT + 17 observational studies Kessel 2015, PMID 25779209
Endophthalmitis with vs without intracameral vancomycin/moxifloxacin 1 in 1,517 vs pooled reduction RR 0.20 (0.10–0.42) 34 studies, 1,264,797 eyes Huang 2016, PMID 27824933
Retinal detachment 0.66 per 100 patients (0.43–1.00); men OR 1.73 (1.68–1.78) vs women 5,480,448 patients, 36,886 events PMID 39172224
Clinical pseudophakic cystoid macular oedema 0.1–2.35% Modern cataract surgery literature PMID 28351047
Positive dysphotopsia up to 67% early; 2.2% persisting at 1 year; surgery indicated in 0.07% Review Pusnik 2022, PMID 36676002
Negative dysphotopsia up to 26% early; 0.13–3% persisting at 1 year Review PMID 36676002
Late in-the-bag IOL dislocation 0.1% at 5 and 10 y; 0.2% at 15 y; 0.7% at 20 y; 1.7% at 25 y 14,471 extractions, population-based Pueringer 2011, PMID 21683329

Posterior capsule rupture

PCR is the index intraoperative complication because it converts a routine operation into a different one — vitreous loss, altered IOL placement, higher inflammation, higher infection risk, worse refractive prediction.

Risk factors. In 2,853,376 EUREQUO cases, the strongest adjusted associations were corneal opacities (OR 3.21, 3.02–3.41), diabetic retinopathy (2.74, 2.59–2.90), poor preoperative visual acuity (1.98, 1.88–2.07) and white cataract (1.87, 1.72–2.03); the PCR cohort had mean age 74.8 ± 10.5 years and was 55.5% female (PMID 34074994). Anaesthetic technique is associated: topical anaesthesia carried higher PCR risk than sub-Tenon (OR 0.80), regional (0.74), general (0.53) or intracameral (0.76) anaesthesia (Segers 2022, PMID 36449673). Age is an independent factor (Gupta 2023, PMID 37133176). Clopidogrel use was associated with higher PCR (3.23% vs non-users, P = 0.0057) in the UK Cataract National Dataset, though not with sight-threatening haemorrhage (Benzimra 2009, PMID 18259210).

Surgeon variation. Across 55,567 operations by 406 surgeons in 12 NHS trusts, variation in PCR rate was highest among the most junior surgeons and among those contributing few cases, and lowest among experienced high-volume surgeons; the authors concluded that acceptable limits for this benchmark cannot be set until outcomes are adjusted for case-mix complexity (Johnston 2010, PMID 19680280).

Consequences. In EUREQUO, 12,196 of 1,371,743 cases (0.9%) with complete follow-up had PCR. Those patients more often received a PMMA IOL (5.2% vs 0.4%) or no IOL (1.1% vs 0.02%); mean corrected acuity was 0.13 ± 0.21 vs 0.05 ± 0.16 logMAR and mean absolute biometry prediction error 1.15 ± 1.60 vs 0.41 ± 0.45 D (both P < .001, and both confirmed on multivariate adjustment at 0.04 logMAR and 0.70 D). Postoperative complications rose: corneal oedema 0.88% vs 0.17% (aOR 2.80, 2.27–3.45), endophthalmitis 0.11% vs 0.02% (aOR 4.40, 2.48–7.81), uncontrolled IOP 0.55% vs 0.03% (aOR 14.58, 11.16–19.06). Most PCR patients nevertheless ended with better acuity than before surgery (PMID 35179858). PCR was the only modifiable adverse risk indicator for acuity loss in the UK audit, with OR 5.74 (PMID 22441022).

Prophylaxis after PCR. Because PCR raises endophthalmitis risk more than six-fold, intracameral antibiotic prophylaxis in this subgroup has been examined specifically: across 9 studies (2 RCTs, 7 observational; 153,690 patients, 50,207 receiving intracameral antibiotic), endophthalmitis incidence was significantly lower with prophylaxis (OR 0.41, 95% CI 0.26–0.65, P < .001, I² = 9%), and for intracameral moxifloxacin specifically OR 0.33 (0.19–0.57) (Arteche 2026, PMID 40958158).

Dropped nucleus and retained lens fragments

Dropped nucleus occurred in 1,221 of 1,715,348 EUREQUO eyes (0.071%), significantly associated with white cataract, previous vitrectomy, poor preoperative acuity, small pupil, pseudoexfoliation, diabetic retinopathy and male sex, with a significant decrease over time; affected eyes had poorer visual and refractive outcomes than eyes with the same risk factors but no dropped nucleus (PMID 32126043). Prior intravitreal anti-VEGF injection raised the risk of retained lens fragment removal within 28 days (HR 2.26, 95% CI 1.19–4.30) in 203,643 Medicare beneficiaries (Hahn 2016, PMID 26278863).

Endophthalmitis

Incidence and prophylaxis. The ESCRS multicentre 2×2 factorial trial recruited 16,603 patients across 24 units in 9 countries; 29 developed endophthalmitis, of whom 20 were proven infective. Absence of intracameral cefuroxime 1 mg in 0.1 mL was associated with a 4.92-fold risk increase (95% CI 1.87–12.9); clear-corneal incisions carried 5.88-fold higher risk than scleral tunnels (1.34–25.9); silicone IOL optic material 3.13-fold higher than acrylic (1.47–6.67); the presence of surgical complications 4.95-fold (1.68–14.6); and men were more predisposed among proven cases (OR 2.70, 1.07–6.8) (PMID 17531690).

Subsequent syntheses agree on the route and disagree on the agent ranking. A network meta-analysis of 51 studies (6,809,732 eyes) ranked intracameral vancomycin best (OR 0.03, 99.6% CI 0.00–0.53), then cefazolin (0.09, 0.02–0.42), cefuroxime (0.18, 0.09–0.35) and moxifloxacin (0.36, 0.16–0.79) — but only cefuroxime and moxifloxacin have randomised support, and route-level sensitivity analysis showed that only intracameral injection significantly reduced risk (OR 0.19, 99.4% CI 0.12–0.30) (PMID 36258003). A 17-study meta-analysis of >900,000 eyes favoured intracameral antibiotics overall (OR 0.20, 95% CI 0.13–0.32, P < 0.00001), with weighted incidences of 0.0332% (cefuroxime), 0.0153% (moxifloxacin) and 0.0106% (vancomycin); moxifloxacin showed minimal toxicity, most cefuroxime toxicity arose from dosing errors, and vancomycin was rarely associated with toxic retinal events (Bowen 2018, PMID 29326317). Kessel's meta-analysis found endophthalmitis in 1 of 485 surgeries without and 1 of 2,855 with intracameral antibiotics (RR 0.12, 0.08–0.18) and found no evidence that topical antibiotics prevent endophthalmitis (PMID 25779209).

Topical antibiotics add little. Adding postoperative topical antibiotic to intracameral prophylaxis changed endophthalmitis rates from 0.017% to 0.016% across 42,466 eyes in 15 rural Indian centres (Rathi 2020, PMID 33120637); intracameral alone was as effective as intracameral plus topical (P > 0.3) in the comparative meta-analysis (PMID 29326317).

Practice and barriers. Adoption of intracameral prophylaxis has risen steadily; among American Society of Cataract and Refractive Surgery respondents intracameral injection use rose 16% between 2014 and 2021, vancomycin fell to 6% and moxifloxacin became dominant at 83%; about 2,500 patients need treatment to prevent one case of endophthalmitis, and 500 μg intracameral moxifloxacin at $22 per dose is cost-effective including after PCR (Lieu 2024, PMID 37877364). Barriers are availability, compounding safety, cost and antimicrobial-resistance concerns, plus the association of vancomycin with haemorrhagic occlusive retinal vasculitis (Haripriya 2018, PMID 29095716; Haripriya 2017, PMID 29208819; George 2018, PMID 29974362; Grzybowski 2021, PMID 32343980; Linertová 2014, PMID 25152613; Röck 2014, PMID 25333241; Haripriya 2017, PMID 28780782). Recognition and treatment are covered in red flags and safety concerns.

Cystoid macular oedema

Pseudophakic CME is the commonest cause of suboptimal vision after uncomplicated surgery. Clinical (as opposed to OCT-only) incidence is 0.1–2.35%; most cases resolve spontaneously, prophylactic treatment is of doubtful value, and first-line treatment is topical NSAID plus corticosteroid with oral carbonic anhydrase inhibitors as an adjunct and periocular or intraocular steroid for resistant cases (PMID 28351047). Established risk factors are intraoperative complications — especially PCR — and preoperative diabetes, uveitis, retinal vein occlusion, epiretinal membrane and macular hole; the role of topical glaucoma medication remains debated, and high-quality trials are notably lacking for periocular and intravitreal steroid, intravitreal bevacizumab and vitrectomy (Han 2019, PMID 30953417; Wielders 2018, PMID 28914687). A recurring methodological problem is that different studies define and resolve CME differently, which is why large systematic reviews reach contradictory conclusions (PMID 30953417). Topical NSAIDs reduce pain, prevent intraoperative miosis, modulate inflammation and reduce CME incidence, alone or synergistically with steroids (Hoffman 2016, PMID 27697257); prior pars plana vitrectomy raises CME risk after otherwise uneventful surgery (Du 2023, PMID 36384754). Which NSAID is unresolved: a network meta-analysis of 11 RCTs and 2,175 subjects, using nepafenac 0.1% as reference, found bromfenac significantly better for one-month visual acuity (p < 0.001), nepafenac 0.3% with the least increase in foveal thickness (p = 0.09), diclofenac with the lowest IOP, and ketorolac worst for acuity and IOP — with no significant results for foveal thickness or IOP overall (Almasri 2024, PMID 39095467). The clinical course is usually benign: clinical PCME appears 2–10 weeks after surgery in 1–2% of eyes after an initial improvement in vision, with biomicroscopically visible macular cysts, while angiographic and OCT changes without functional consequence are much commoner; risk factors are complicated surgery, diabetes, uveitis, epiretinal gliosis and previous retinal vein occlusion, and most cases recover spontaneously over months, though treatment is started to avoid irreversible loss (Radeck 2020, PMID 32468102). Editorial and comment literature on prevention spans four decades (Jampol 1988, PMID 3390049; Mamalis 2018, PMID 29778103; Kohnen 2018, PMID 30055688).

Corneal decompensation, IOP and other early problems

Corneal oedema after PCR ran at 0.88% versus 0.17% without (aOR 2.80) in EUREQUO (PMID 35179858). Eyes with Fuchs endothelial corneal dystrophy are at elevated risk of decompensation and may need combined or sequenced endothelial keratoplasty (Ali 2023, PMID 36637659; Ahad 2025, PMID 39423013) — see surgery with coexisting eye disease. Endothelial cell loss is comparable between phacoemulsification and MSICS (543 vs 506 cells/mm² at 6 weeks, P = 0.44) (Gogate 2010, PMID 20152605).

Early postoperative IOP elevation may account for up to 88% of early postoperative complications; risk factors include residual viscoelastic, resident-performed surgery, glaucoma, pseudoexfoliation, axial length >25 mm, tamsulosin and steroid responsiveness, and peak IOP occurs 3–4 hours postoperatively. No agent completely prevents spikes; a dorzolamide/timolol plus brinzolamide combination is recommended for high-risk eyes with pre-existing optic nerve damage (Grzybowski 2019, PMID 30489361; Katz 2024, PMID 39503401).

Retinal detachment

Pooled incidence was 0.66 per 100 patients (95% CI 0.43–1.00) across 36,886 detachments in 5,480,448 patients, with male sex conferring higher odds (OR 1.73, 95% CI 1.68–1.78, P < 0.001) and no significant difference in incidence rate across locations (PMID 39172224). Risk concentrates in long eyes: only 63% of myopic patients with axial length >26 mm achieve acuity of at least 20/40, and refractive surprises, IOP spikes and capsular contraction syndrome all remain higher in myopic eyes (Elhusseiny 2023, PMID 36473016).

Refractive surprise and dissatisfaction

Refractive error after otherwise successful surgery is a complication in patient terms. Benchmarks: 71% of eyes within ±0.5 D and 92–93% within ±1.0 D in the FACT randomised trial (Day 2020, PMID 32386810). Prediction error more than doubles after PCR (1.15 vs 0.41 D) (PMID 35179858). Management is by enhancement — LASIK is the most accurate route, with toric IOL rotation for excess residual cylinder and IOL exchange for multifocal dissatisfaction or dislocation being less predictable (Alio 2015, PMID 25321444). Dysphotopsia is the other major driver of dissatisfaction after technically perfect surgery (PMID 36676002; Mamalis 2010, PMID 20202530).

Risk-adjusted audit

Because complication rates depend heavily on case mix, unadjusted comparisons between surgeons or units are misleading. The UK Cataract National Dataset was built to enable adjusted comparison and demonstrated that variation is greatest where case numbers are smallest (PMID 19680280); the same dataset identified the preoperative indicators — age, short axial length, ocular comorbidity, AMD, diabetic retinopathy, amblyopia, corneal pathology, previous vitrectomy — that any fair comparison must adjust for (PMID 22441022). EUREQUO plays the same role in Europe, spanning 15–18 countries and enabling evidence-based benchmarks derived from over half a million operations (Lundström 2012, PMID 22541829; Lundström 2015, PMID 26613089; Lundström 2021, PMID 33086294). Registry tracking of outcomes is described as a powerful tool for improving outcomes and reducing costs (Qin 2018, PMID 28937505). Surgeon-volume effects have been debated without resolution (Hatch 2008, PMID 18982026), and existing preoperative risk-stratification models lack multivariable modelling, standardised outcomes and external validation (Kang 2025, PMID 39900805).

Open questions

  • What is the causal contribution of anaesthetic technique to PCR? The registry associations are large and consistent (OR 0.53–0.80 versus topical) (PMID 36449673) but confounded by case selection; no randomised trial powered for PCR by anaesthetic technique exists in this evidence set.
  • Which intracameral agent is best? Only cefuroxime and moxifloxacin have randomised support, while vancomycin and cefazolin rank highest on observational network evidence and vancomycin carries a distinctive retinal-vasculitis hazard (PMID 36258003; PMID 29326317; PMID 32343980). A head-to-head randomised comparison would need enormous numbers; no such trial was identified in the searches behind this page.
  • Can CME evidence be made comparable? Contradictory systematic-review conclusions are attributed directly to inconsistent definitions and resolution criteria (PMID 30953417); no core outcome set for pseudophakic CME is in use across this literature.
  • What is a fair PCR benchmark? The dataset that showed surgeon-level variation explicitly states that acceptable limits cannot be defined without case-mix adjustment (PMID 19680280), and no validated adjustment model has been published since.
  • Are rare bilateral harms bounded? Endophthalmitis rates of 0.066% (PMID 36258003) mean that even 865-patient randomised trials observe zero events (Spekreijse 2023, PMID 37201546) — the question of bilateral risk after immediate sequential surgery requires federated registry data that do not yet exist.

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