we did an 8-year retrospective analysis of all patients who had intraoperative complications during cataract surgery in melaka hospital . permission to conduct the study was granted by the medical research ethics committee . the age , gender , and side of eye operated on were noted . the age groups were divided into < 40 years , 4150 years , 5160 years , 7180 years , and above 80 years . ocular comorbidities such as pterygium involving the cornea , corneal opacity , glaucoma , chronic uveitis , and pseudoexfoliation were noted . lens - related complications such as phacomorphic , phacolytic , and subluxated / dislocated lenses were noted . the type of cataract surgery done whether lens aspiration using a simcoe cannula , extracapsular cataract extraction ( ecce ) , phacoemulsification ( phaco ) , phaco converted to ecce or intracapsular cataract extraction ( icce ) was all noted down . whether the surgery was done alone or in combination with other procedures such as pterygium excision , filtering surgery , vitreoretinal surgery , and penetrating keratoplasty the grade of the surgeon doing the surgery whether specialist , gazetting specialist or medical officer ( mo ) was all noted down . a specialist is one who has been assessed after having passed the postgraduate examination and is found to be able to work independently . a gazetting specialist is one who has passed the postgraduate examination in ophthalmology ( ms or frcs ) but has to work under the supervision of a consultant senior specialist . a mo is one who has passed mbbs and has to be supervised by a specialist during surgery . the types of intraoperative complications such as posterior capsular rupture ( pcr ) without vitreous loss , pcr with vitreous loss , central corneal edema , zonular dehiscence , dropped nucleus , and suprachoroidal hemorrhage were all recorded . we looked to see if certain demographic features and presence of ocular comorbidities resulted in more complications . we studied the relationship between types of cataract surgery , whether done alone or in combination and the grade of a surgeon operating with the occurrence of an intraoperative complication . good vision ( 6/66/12 ) , impaired vision ( 6/186/36 ) , and poor vision ( 6/60 and worse ) . these included high astigmatism , posterior capsule opacification , cystoid macular edema ( cme ) , endophthalmitis , preexisting ocular comorbidity , corneal decompensation , intraocular lens ( iol ) decentration and retinal detachment ( rd ) . the data were analyzed with ibm spss statistics for windows , version 20.0 ( ibm corp . global chi - square and fisher 's exact tests were used to determine the possible relation between two categorical variables . the data were analyzed with ibm spss statistics for windows , version 20.0 ( ibm corp . global chi - square and fisher 's exact tests were used to determine the possible relation between two categorical variables . a total of 12,992 eyes underwent cataract surgery from 2007 to 2014 with 6.1% registering intraoperative complications . some had > 1 intraoperative complication during surgery as shown in table 1 . due to some missing data , the highest number of intraoperative complications was recorded in 2013 ( 18.3% ) followed by 13.9% in 2014 , the lowest number of intraoperative complications was recorded in 2012 ( 9.2% ) . 2 shows that there was a drop in the number of mos and gazetting specialist handling cataract surgery in 2012 ( n = 190 ) with the number doubling in 2013 ( n = 366 ) . number of medical officers / gazetting specialist and specialists handling cataract surgery as seen in fig . 3 , pcr was the main cause of intraoperative complications from 2007 to 2014 with the highest number of cases recorded in 2013 ( 114 cases ) . a large number of cases of vitreous loss and zonular dehiscence were also seen from 2007 to 2014 . fewer cases of dropped nucleus , suprachoroidal hemorrhage , and corneal edema occurred during cataract surgery . types of intraoperative complications by year table 2 shows that gender ( p < 0.05 ) and age below 40 years old ( p < 0.05 ) were significantly associated with intraoperative complications while ethnicity was not significantly associated with intraoperative complications ( p > 0.05 ) . the highest percentage of intraoperative complications was seen in those aged below 40 years ( 9.5% ) followed by those above 80 years old ( 6.7% ) . association between sociodemographic status and intraoperative complications pseudoexfoliation was the only ocular comorbidity significantly associated with intraoperative complications ( p < 0.05 ) and accounted for 12.1% of complications from 2007 to 2014 [ table 3 ] . association between sociodemographic status and intraoperative complications when adjusted for age group and gender , phacolytic lens , phacomorphic lens , and subluxated lens were noted to have odds of 8.118 , 4.494 , and 3.212 respectively of acquiring intraoperative complications as compared to other lens ( p < 0.05 ) [ table 4 ] . association between lens and intraoperative complication by logistic regression all types of surgery were significantly associated with intraoperative complications ( p < 0.05 ) [ table 5 ] . icce ( 52.6% ) and phaco converted to ecce ( 50.3% ) were the most common techniques of cataract surgeries that caused intraoperative complications followed by lens aspiration ( 9.9% ) , ecce ( 58.9% ) , and phaco ( 4.4% ) as shown in table 5 . the association between type of cataract surgery and intraoperative complication surgeon grade was significantly associated with intraoperative complications . mos ( 11.7% ) had more intraoperative complications compared to gazetting specialists ( 10.1% ) and specialist ( 5.1% ) as seen in table 6 . the association between grade of surgeon and intraoperative complication intraoperative complications were significantly associated with visual outcomes as shown in table 7 . more patients who had intraoperative complications got impaired / poor vision outcome ( 12.4% ) . patients with intraoperative complication had 3.3 times likelihood of having impaired / poor vision outcome compared to patients without intraoperative complication ( 3.033 , 2.5543.601 ) . the association between intraoperative complication and visual outcome table 8 shows that there was a significant association between surgeon grade and visual outcomes . it was noted that patients who were operated upon by specialists had 1.25 odds of having good visual outcome as compared to patients who were operated on by gazetting / mos ( p < 0.001 ) . the association between grade of surgeon and visual outcome among cases with intraoperative complications reasons for not obtaining good acuity were analyzed after excluding the cases with preexisting ocular comorbidities . 4 shows that high astigmatism ( 4.9% ) was the main reason for not obtaining good visual acuity after surgery . the other reasons were cme ( 1.3% ) , corneal decompensation ( 0.6% ) , posterior capsular opacity ( 0.6% ) , rd ( 0.3% ) , infective endophthalmitis ( 0.1% ) , and iol decentration / discolation ( 0.1% ) . in this retrospective study of the ned , we focused on the intra- and post - operative complications of cataract surgery over 8 years in a malaysian tertiary hospital . out of 12,992 eyes undergoing cataract surgery , only 6.1% had a variety of intraoperative complications , some of which had > 1 complication . other centers recorded fewer complications of 1.4% , 1.9% , but higher rates than ours were also found ( 8.5% ) . there was a drop in complications in 2012 followed by a rapid rise in 2013 after which it got back to almost to the usual rate of complications . this trend of complications was seen in the three major types of complications , namely , pcr , vitreous loss , and zonular dehiscence . throughout the 8 years , the pattern of complications correlated with the increase and decrease in the number gazetting specialists and mos . females and extremes of ages ( below 40 years and above 80 years ) had more complications . females and those above 70 were found to have more complications in other studies too . other studies do not show an association between the presence of pseudoexfoliation and intraoperative complications . and sufi found no correlation was found between pcr and the presence of pxm during phacoemulsification . pterygium involving the cornea , corneal opacity , glaucoma , and chronic uveitis were not associated with intraoperative complications in our study . pterygium and corneal opacities extending to the visual axis may hamper the view for capsulorhexis and phacoemulsification , but this did not cause an increase in complications . . any sort of abnormal lens status , be it phacomorphic , phacolytic , subluxated , or dislocated lenses , is a nightmare for a cataract surgeon . phacolytic lenses had the highest rate of complications followed by subluxated / dislocated lenses and least of all were the phacomorphic lenses . a point to note is that , after adjusting for age and abnormal status of lenses , we found that men had a higher rate of the odds of getting an intraoperative complication . ecce or icce are the preferred technique for cataract extraction of subluxated lenses in our center . no significant difference in intraoperative complications was found between phaco and manual small incision surgery for subluxated lenses . we should have perhaps used devices such as capsular tension rings which have been shown to reduce complications for subluxated lenses . most studies describe the postoperative outcomes of abnormal lens status but not about the intraoperative complications . we found that all types of cataract surgeries had complications but the highest was for phaco convert to ecce and the least was for phaco . phaco convert to ecce are cases where phaco was commenced , but at some point during the procedure , the surgeon had noticed some abnormality that could lead to further problems . these include a tear or extension of the anterior capsule , a cataract which is found to be hard , a lens which is not stable or even recognition of vitreous in the anterior chamber . other studies have also found that the type of cataract surgery was also associated with complications . however , there are also studies that found no association between the occurrences of intraoperative complications with the type of cataract surgery done . mos had more complications compared to the gazetting specialists who in turn had more complications than the specialists . vitreous loss , dropped nucleus , pcr rates all dropped with increased experience as more cases were done by the same surgeon . other studies have disproved this concept as they found that experience of the surgeon did not affect the occurrence of complications . the data did not have the point of occurrence of the intraoperative complication . this would have been interesting to see if there was a variation in the point at which complications occurred or were recognized . one study showed that consultants got pcr during cortex removal and specialists got it more during segment removal . after excluding eyes with preexisting comorbidities , we found that the occurrence of intraoperative complications was detrimental to vision as they resulted in impaired and poor vision . in our study , the grade of the surgeon operating also affected the visual outcomes among the complicated cases . the main reasons for the poorer outcomes were high astigmatism , cme , and corneal decompensation . most patients with pcr had a favorable visual outcome with meticulous vitrectomy and insertion of a foldable iol to prevent astigmatism . in a 5-year audit of pcr , age > 65 years , dropped nuclei , and postoperative retinal , corneal , and iol complications were found to cause poor outcomes . poor visual outcomes following vitreous loss were associated with poor preoperative vision , age - related macular degeneration , cme , and anterior ppv for nuclear fragment loss . however , the results reflect the practice in only one center and do not reflect the practice patterns and outcomes of the entire nation .
introduction : as in all surgeries , complications during cataract surgery are unavoidable and cause distress to the surgeon and the patient . 
 this study was conducted to know the factors contributing to complications in our settings , to be able to counsel patients about complications and outcomes and to reduce litigations.materials and methods : the secondary data analysis was conducted using the national eye database from 2007 to 2014 . 
 demographic features , ocular comorbidities , technique of surgery , grade of surgeons , types of intraoperative complications , and reasons for not obtaining good visual acuity following intraoperative complications were studied . 
 statistics was done using statistical package for social sciences version 20.results:out of 12,992 eyes , 6.1% had intraoperative complications . 
 the highest rate of complications was when more trainees ( medical officers [ mos ] and gazetting specialists ) operated . 
 posterior capsule rupture ( pcr ) was the most common complication followed by vitreous loss and zonular dehiscence . 
 those aged below 40 years had more complications ( p < 0.05 ) , and females had more complications . 
 ethnicity did not affect complications . 
 pseudoexfoliation was the only comorbidity causing complications ( p < 0.05 ) . 
 phacolytic lenses had 8.118 times the odds of getting intraoperative complications . 
 mos and gazetting specialists got more complications . 
 good outcomes were obtained in cases without complications and those operated by specialists . 
 high astigmatism was the main reason for poorer outcomes.conclusion:intraoperative complications were caused mostly by less experienced doctors and had poorer outcomes . 
 age below 40 years , females , the presence of pseudoexfoliation and phacolytic lenses had more complications . 
 pcr was the most common complication .