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 open- and 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) Don’t do a vigorous digital massage or Healon pressure Don’t 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