Phacoemulsification in Pseudoexfoliation Syndrome Akram Rismanchian MD Farabi Hospital Isfahan University of Medical Sciences
Phaco in pseudoexfoliation syndrome In exfoliation syndrome a basement membrane like fibrillogranular white
material is deposited on the lens, cornea , iris , anterior hyaloid face, ciliary processes, zonular fibers , and trabecular meshwork It is known that eyes with PEX are
at higher risk for developing openand closed- angle glaucoma and cataract Patients with exfoliation syndrome may also experience weakness of the zonular
fibers and spontanous lens subluxation and phacodonesis Cataract formation is more pronounced and development at an earlier age in eyes with
pseudoexfoliation syndrome (PXF) Cataract surgery then can be challenging because of a small pupil and a loose zonules an increased risk for complication during surgery.
In many studies cataract surgery in the presence of PEX has been reported to be associated with increased risk of intraoperative and postoperative
complications such as zonular dialysis, vitreous loss, prolonged corneal edema, sustained inflammatory reaction and lens decentration
Zonular instability, poorly dilating pupils, corneal endothelial changes and breakdown of the blood-aqueous barrier are the leading factors in increased intraoperative and postoperative complications in eyes with
PEX PXF is associated with -
Higher incidence of glaucoma Loss of zonular integrity Lens subluxation and phacodonesis Poorly dilating pupil (hyporeactive) Fibrotic capsule
Small pupils It is relative contraindication for the inexperienced phaco-surgeon. Preop evaluations of pupil:
- Dynamic ,direct light. - Static ,mydriatic. Small pupil 4 mm, may be classified as: -hyporeactive pupil, hyperopia, DM,PXF.age
- Fixed pupil ,pilo, PS, neurologic. Small pupils cont
Techniques For intraoperative manipulation of pupil size -Intracameral adrenalin 0.1 cc of 1/10,000 -Viscomydriasis with hyperviscosity,
viscoelastic (Healon GV, Healon 5) Mechanical Mydriasis
Iris hooks Iris protector ring Pupil dilator (Beehler, Moria) Stretch pupilloplasty Bimanual phaco (experts)
Incisional mydriasis Iris Hooks Iris Protector Ring
Hydroview Pupil dilator (Beehler, Moria) Stretch pupilloplasty
Incisional Mydriasis Capsulorhexis (CCC) - Dont do a vigorous digital massage or Healon
pressure - Dont do over expanding of AC with viscoelastic - Lower bottle height during surgery - Using dye for a better visualization
CCC. Cont Difficult to perforate capsule for CCC. Start capsulatomy with pinch type forceps or cystotome forceps .
Difficult to perforate capsule for CCC With loose zonules performed two handed capsulatomy technique by using tangential
forceps described by Nuhann. Ant CCC size: should be at least 6.00 mm CCC. Cont. - Placing an endocapsular ring (ECR) in the bag.
Immediately after a CCC is completed - There is no need for systemic reset to a ECR but if a zonulalysis is observed its use indicated.
(ECR) in the bag Immediately after a CCC is completed Hydrodissection and Hydrodelination
A complete cortical cleaning hydrodissecition should be perform followed by hydrodelination Gentle decompression should be performed each wave of fluid is injected.
Phaco in PXF Extreme caution during manipulation Two handed rotation of the nucleus. Use high cavitation tips such as kelman Tip
Phaco in PXF Stabilized nucleus during phaco.
Phaco in PXF Gimble phaco sweep procedure , Initial groove can be formed; and then without rotating the lens by moving the phaco probe laterally
and with a rotational movement. Phaco in PXF cont. When zonules the already wreaked vacuum ,flow rate and infusion should
lowered is a slow motion fashion. Major zonular disinsertion(>4 clock hours) may necessary to remove the entire capsular bag followed with ant vitx, IOL implantation in the sulcus , ACIOL or Artisan .
Phaco in PXF cont. Minor zonular disinsertion (< 4 clock hours) adequate Vitx, ECR (Ring injector, manually)
Small zonular disinsertion 2 clock hours) large diameter of IOL can be used haptic position on damaged area or with ECR. Phaco in PXF cont.
Cortical clean up not be performed in these cases until after implantation of IOL Bimanual I/A is ideal
for such a situation Recommended tangential traction on the cortex with I/A tip
Phaco in PXF cont. Use PMMA lens or acrylic foldable lens with PMMA haptics and large size to prevent capsule contraction and lens decentration. Plate haptic or accommodative design should
be avoided. A stand by vitrectomy machine and ACIOL should always be Kept ready Angle supported ACIOL are not the first choice
IOL criteria 3 Piece acrylic foldable with open loop PMMA haptics and sufficient size and lens diameter was prepared
Higher incidence of complication
Zonular dialysis Capsular tear Vitreous loss IOL decentration
Capsulorhexis contraction Capsular phymosis Early PCO Post Operative Management
Intensive topical steroid therapy Systemic steroid Ocular hypotensive drugs Mydriatics
