2. Phacoemulsification in Pseudoexfoliation Syndrome
Akram Rismanchian MD
Farabi Hospital
Isfahan University of Medical Sciences

3. 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

4. It is known that eyes with PEX are at higher risk for developing open- and closed- angle glaucoma and cataract

5. Patients with exfoliation syndrome may also experience weakness of the zonular fibers and spontanous lens subluxation and phacodonesis

6. 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.

7. 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

8. 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

9. PXF is associated with Higher incidence of glaucoma
Loss of zonular integrity
Lens subluxation and phacodonesis
Poorly dilating pupil (hyporeactive)
Fibrotic capsule

10. 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.

11. 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)

12. Mechanical Mydriasis Iris hooks Iris protector ring
Pupil dilator (Beehler, Moria)
Stretch pupilloplasty
Bimanual phaco (experts)
Incisional mydriasis

13. Iris Hooks

14. Iris Protector Ring Hydroview

15. Pupil dilator (Beehler, Moria)

16. Stretch pupilloplasty

17. Incisional Mydriasis

23. 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

24. CCC. Cont Difficult to perforate capsule for CCC.
Start capsulatomy with pinch type forceps or cystotome forceps .

25. Difficult to perforate capsule for CCC

27. 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

29. 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.

30. (ECR) in the bag Immediately after a CCC is completed

36. 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.

37. Phaco in PXF Extreme caution during manipulation
Two handed rotation of the nucleus.
Use high cavitation tips such as kelman Tip

38. Phaco in PXF
Stabilized nucleus during phaco.

39. 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.

40. 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 .

41. 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.

42. 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

43. 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

47. IOL criteria
3 Piece acrylic foldable with open loop PMMA haptics and sufficient size and lens diameter was prepared

48. Higher incidence of complication
Zonular dialysis
Capsular tear
Vitreous loss
IOL decentration
Capsulorhexis contraction
Capsular phymosis
Early PCO

50. Post Operative Management
Intensive topical steroid therapy
Systemic steroid
Ocular hypotensive drugs
Mydriatics