When the lens behaves, but the retina has other plans: prevention, patterns and posterior surprises.
Aging eyes, premium intraocular lens (IOL) expectations and more refractive lens exchange in younger myopes have widened the front door to cataract surgery and, with it, the backdoor risk to the retina.
On Day 3 of the 18th Congress of the Asia-Pacific Vitreo-Retina Society (APVRS 2025), a symposium on posterior segment complications of anterior segment surgery distilled that reality into a set of prevention-minded rules and intraoperative “if-this-then-that” responses.
Chaired by Dr. Nikki Angbue Te (Philippines), Prof. Adrian Fung (Australia) and Dr. Harvey Uy (Philippines), the session threaded eight talks into one message: image early, recognize patterns fast and avoid turning a fixable problem into a traction problem.
Risk stratification and patient counseling
Who is a high-risk eye? Dr. Kenneth Fong (Malaysia) made the clearest case for thinking “vitreous-first” in high myopes. Posterior vitreous detachment (PVD) happens earlier as myopia deepens, and lens surgery accelerates it further. Ultrasound and prospective data show cataract surgery can markedly increase the chance of complete PVD within the first year, and eyes with absent or incomplete PVD pre-op carry the sharper risk edge for pseudophakic retinal detachment (RD).1-3 His advice was to not assume a Weiss ring equals “done.” Grade the vitreous on optical coherence tomography (OCT), counsel on symptoms and treat informed consent like a clinical intervention.
To make risk tangible, Dr. Fong highlighted the Netherlands-developed post-cataract RD risk calculator as a counseling tool, especially for patients under 50 considering refractive lens exchange. It helps translate “higher risk” into a number patients can actually weigh against lifestyle goals.
READ MORE: UGH Syndrome and a Case of Retinal Detachment after Cataract Surgery
Prophylaxis: where guidelines help and where they don’t. On laser for asymptomatic lattice, he stayed aligned with AAO guidance: routine prophylaxis is not generally recommended, with treatment reserved for selected high-risk scenarios.4 His bluntest point got a nod around the room because it’s true. Lasering normal retina often “treats doctor anxiety,” not evidence.
Macula matters too. Dr. Thanapong Somkijrungroj (Thailand) pulled the pre-op conversation toward comorbid macular disease: diabetes, retinal vein occlusion, uveitis and prostaglandin use all raise the odds that post-op blur is not “just slow recovery”.4-5 Without a clear view of the macular baseline and inflammatory context, post-op cystoid macular edema (CME) is often misread and treated with drops, even when the real problem is mechanical.
Recognizing and managing intraoperative red flags
Iris and IOL: mechanical problems you can prevent. Prof. Makoto Inoue (Japan) took a specific complication and made it feel predictable. In Yamane-style sutureless intrascleral fixation, iris capture tends to occur in quadrants without haptic support. Using movie-mode anterior segment OCT, his group documented iris–IOL interactions during eye movements and then proposed a simple mechanical solution: a bridging suture placed 180 degrees from the haptics to prevent posterior iris bowing and recurrent capture.
The suddenly rock-hard eye. Dr. Tai-Chi Lin (Taiwan) separated two entities that look similar but behave differently: chronic aqueous misdirection (malignant glaucoma) versus an acute intraoperative “rock-hard eye” variant during phaco. The key lesson was not to improvise with a needle just because the chamber is collapsing.
“Using the needle to aspirate vitreous may cause…retinal traction [or] retinal tear,” he cautioned. Instead, decompress with a pars plana vitrectomy approach using a high-cut-rate cutter when possible, then complete the case deliberately.
READ MORE: When Retina Meets Glaucoma at APVRS 2025
When the nucleus drops: don’t chase, stabilize. Dr. Uy called dropped nucleus the complication every cataract surgeon eventually meets. His first instruction was: don’t panic. Maintain chamber stability with dispersive viscoelastic, avoid sudden decompression and resist the instinct to “fish” posterior fragments anteriorly. Large nuclear material is inflammatory and pressure-sensitive, so early VR involvement is often the smarter path.
He grounded the timing question in outcomes data. Meta-analyses show that while delayed vitrectomy does not always compromise final visual acuity, earlier pars plana vitrectomy (PPV) can reduce secondary glaucoma and CME, which matters for recovery outside the trial setting.6
Don’t miss a brewing suprachoroidal hemorrhage. Dr. Andrew Tsai (Singapore) focused on the rare catastrophe that demands instant pattern recognition: suprachoroidal hemorrhage (SCH). Intraoperatively, the sequence is classic: sudden shallowing, loss of red reflex and a firm globe. The reflex to “fix” by draining is often wrong in the acute phase.
He boiled it down to three priorities: stop the problem, close the defect and restore pressure. Drainage becomes a later decision guided by ultrasound, clot liquefaction and anatomy, not adrenaline. He added that good management does not guarantee good outcomes and that expectation-setting needs to be part of the discussion.
Operating with a poor view. Dr. Nimesh Patel (USA) tackled cases where the retina can be saved but the cornea gets in the way. He walked through practical options, starting with wide-angle viewing when visibility allows, moving to temporary keratoprosthesis for planned combined procedures and turning to endoscopic vitrectomy when the real question is whether the eye can be salvaged at all.
He returned to training as the real takeaway, urging surgeons to practice endoscopic vitrectomy before they are forced to rely on it.
Inflammation, infection & macula
Day 1 vs day 3–7: TASS, infection or hemorrhage? Dr. R. Unnikrishnan Nair (India) built his entire talk around one reality: modern endophthalmitis care is less EVS-era binary and more speed, severity and media clarity. Prevention still has two heavyweight pillars: povidone–iodine antisepsis (contact time matters) and intracameral antibiotics.7 He called it the “three 3s,” a reminder grounded in data that prevention still hinges on getting the unglamorous details right.
On diagnosis, he stressed timing and anatomy. Severe inflammation on day 1 is more suggestive of toxic anterior segment syndrome (TASS) than infection, while infectious endophthalmitis more often presents days later and involves vitritis. When uncertain, treat presumed cases urgently, because organism and inflammatory load drive outcomes.
He emphasized acting earlier and with less hesitation. When retinal details are hard to see, he said, early vitrectomy is often the more controlled option. In other words, do not let Snellen acuity alone decide; let retinal visualization and inflammatory burden guide escalation.
Macular threats and the “mechanical masquerade.” When vision fails to clear, OCT often reveals the classic “Fuji Mountain” pattern of Irvine-Gass CME. Dr. Somkijrungroj noted its generally good prognosis but urged surgeons to look deeper. “When you look at the cases that have the post-op CME, you look a little bit more detail into the anterior chamber,” he said.
Pigmented cells in the AC are a tell-tale sign of IOL-iris chafe, a mechanical cause requiring surgical repositioning, not more drops. This echoes Dr. Uy’s point that retained lens material can drive persistent inflammation and CME, necessitating PPV.
READ MORE: Retina on the Ropes: Tackling the Toughest Debates in Medical Retina at APVRS 2025
When things still go wrong
Some complications are slow burns, demanding long-term VR partnership. Chronic aqueous misdirection after trabeculectomy, as described by Dr. Lin, may ultimately require vitrectomy with an irido-zonulo-hyaloidectomy to permanently uncouple the posterior pressure gradient.
Dr. Tsai discussed the slow resolution of suprachoroidal hemorrhages, where drainage, if needed, is best delayed 7-14 days for clot liquefaction, sometimes aided by suprachoroidal tPA.
For the most devastated eyes, Dr. Patel’s armamentarium of permanent keratoprosthesis and endoscopic vitrectomy are the final salvage options.
And for that stubborn, refractory CME, Dr. Somkijrungroj highlighted that vitrectomy for epiretinal membrane or vitreomacular traction may be the definitive solution where pharmacotherapy has failed.
Rebuilding the bridge between chambers
This session showed that cases tend to go better when anterior and posterior segment surgeons are thinking about the same eye from the start. New tools help, from risk calculators to endoscopic workarounds, but technology only goes so far without shared expectations.
In cataract and refractive surgery, the retina is not a backup plan. It is part of the case from the start. The sessions kept circling the same idea in different ways. Look past the lens, plan for what happens behind it and talk early when things drift off course. What stuck was how often the basics, done early and done well, change everything that follows.
Editor’s Note: This content is intended exclusively for healthcare professionals. It is not intended for the general public. Products or therapies discussed may not be registered or approved in all jurisdictions, including Singapore. Reporting for this story took place during the 18th Congress of the Asia-Pacific Vitreo-Retina Society (APVRS 2025) from 12-14 December in Manila, Philippines.
References
- Yonemoto J, Ideta H, Sasaki K, et al. The age of onset of posterior vitreous detachment. Graefes Arch Clin Exp Ophthalmol. 1994;232(2):67-70.
- Hayashi S, Yoshida M, Hayashi K, et al. Progression of posterior vitreous detachment after cataract surgery. Eye (Lond). 2022;36(10):1872-1877.
- Ripandelli G, Coppé AM, Parisi V, et al. Posterior vitreous detachment and retinal detachment after cataract surgery. Ophthalmology. 2007;114(4):692-697.
- Flaxel CJ, Adelman RA, Bailey ST, et al. Posterior vitreous detachment, retinal breaks, and lattice degeneration Preferred Practice Pattern. Ophthalmology. 2020;127(1):P146-181.
- Taubenslag KJ, Kim SJ, Grzybowski A. Anti-inflammatory pharmacotherapy for the prevention of cystoid macular edema after cataract surgery. Am J Ophthalmol. 2021;232:1-8.
- Lim M, Sverdlichenko I, Wei EY, et al. Time to pars plana vitrectomy in adults with retained lens fragments: a systematic review and meta-analysis. Can J Ophthalmol. 2025;60(3):e451-465.
- Das T, Dave VP, Dogra A, et al; EMS working group. Endophthalmitis management study. Report 1: protocol. Indian J Ophthalmol. 2021;69(7):1936-1941.