Cataract Pre-operative Risk Checklist: Spot the Difficult Case
Last updated: October 2026
Spot the difficult case in the clinic, not in theatre. Run through this list at the pre-operative visit, write the plan on the case sheet, and counsel the patient about any extra risk.
History
| Ask about | Why it matters | Plan |
|---|---|---|
| Tamsulosin or other alpha-1 blockers (even stopped years ago) | Intraoperative floppy iris syndrome | Intracameral adrenaline (preservative-free), dispersive viscoelastic, iris hooks or ring, low flow; stopping the drug does not reliably help |
| Anticoagulants and antiplatelets | Bleeding with needle blocks | Usually continue for topical or intracameral anaesthesia; check INR is in range for warfarin; prefer topical or sub-Tenon over sharp-needle blocks |
| Diabetes | Macular oedema, progression of retinopathy | Treat existing DME or PDR first; consider perioperative NSAID or intravitreal therapy; check blood sugar on the day |
| Uveitis | Postoperative flare-up and CME | Quiet for at least 3 months; perioperative steroid cover (topical, oral or intravitreal) |
| Previous refractive surgery | IOL power error | Special formulas (see the biometry checklist) |
| Previous vitrectomy | Deep, fluctuating chamber; posterior capsule plaques; zonular weakness | Lower bottle height, careful hydrodissection, be ready for a lens-iris diaphragm retropulsion |
| Only eye, or poor outcome in the first eye | Higher stakes | Senior surgeon; detailed consent; consider delayed rather than same-day bilateral surgery |
| Back problems, claustrophobia, tremor, deafness, language barrier | Cooperation under the drapes | Positioning aids, sedation or general anaesthesia, an interpreter |
Examination
| Finding | Risk | Plan |
|---|---|---|
| Small pupil (under about 6 mm dilated) | Iris trauma, capsule tear, dropped nucleus | Pupil expansion devices, viscomydriasis, chop technique |
| Pseudoexfoliation | Zonular weakness, small pupil, IOP spikes | Capsular tension ring available, gentle manoeuvres, check IOP after surgery. See PXF cataract surgery. |
| Phacodonesis or iridodonesis | Zonular dehiscence | CTR or capsular hooks; consider a senior surgeon |
| Shallow chamber, short eye (axial length under about 21 mm) | Endothelial damage, iris prolapse, choroidal effusion | Dispersive viscoelastic; consider a pre-operative mannitol or a limited vitreous tap; check for nanophthalmos |
| High myopia (axial length over about 26 mm) | Deep chamber, retinal detachment | Lower bottle height, examine the peripheral retina before and after surgery |
| Dense brown or white cataract | Endothelial loss, Argentinian flag sign (capsule split), long phaco time | Trypan blue, decompress an intumescent lens before the rhexis, chop, soft-shell technique. Consider manual small-incision surgery. |
| Posterior polar cataract | Pre-existing posterior capsule defect | Avoid hydrodissection (use hydrodelineation), low flow, have vitrectomy ready |
| Corneal guttae or low cell count | Corneal decompensation | Specular microscopy (see the specular card); endothelial protection; plan DMEK if needed |
| Blepharitis, lid infection, nasolacrimal obstruction | Endophthalmitis | Treat first; syringe the lacrimal passages when in doubt |
| Glaucoma | IOP spike, worsening of field | Consider combined surgery or MIGS; plan for IOP control after surgery |
| Corneal astigmatism (1–1.25 D or more) | Residual cylinder | Toric IOL or limbal relaxing incisions |
| Macula and retina | Unexpectedly poor outcome | OCT if the view allows; B-scan when the fundus cannot be seen |
On the day
- Recheck the eye mark, biometry, IOL model and power, and a backup IOL.
- Povidone-iodine 5% in the conjunctival sac (at least 3 minutes) and on the lids; intracameral antibiotic at the end of surgery.
- Blood pressure and blood sugar acceptable for surgery; continue usual medicines unless told otherwise.
Write the plan down: "PXF, small pupil: CTR and hooks available, chop" on the case sheet saves time and prevents surprises when a different surgeon or a resident operates.
Related: phaco step by step, posterior capsule tear management, ISBCS and endophthalmitis.
Key sources
- Royal College of Ophthalmologists. Cataract Surgery Guidelines and commissioning guidance (current editions)
- Chang DF, Campbell JR. Intraoperative floppy iris syndrome associated with tamsulosin. J Cataract Refract Surg 2005;31:664–73
- Narendran N et al. The Cataract National Dataset electronic multicentre audit of 55,567 operations: risk stratification for posterior capsule rupture and vitreous loss. Eye 2009;23:31–7
See also: ocular anaesthesia: blocks and complications.
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