1. Phacoemulsification in Pseudoexfoliation Dr.Hamid Khakshoor Mashhad University Of Medical Sciences

2. Exfoliation Syndromes True exfoliation: True exfoliation of the lens capsule is rare, occurring primarily in glassblowers and blast furnace operators. Presumably, intense exposure to infrared radiation and heat causes the superficial lens capsule to delaminate and peel off in scrolls.

3. Pseudoexfoliation 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. These deposits, believed to arise from basement membranes within the eye, appear as grayish white flecks that are prominent at the pupillary margin and on the lens capsule.

4. Pseudoexfoliation Associated with this condition are atrophy of the iris at the pupillary margin, deposition of pigment on the anterior surface of the iris, poorly dilating pupil, increased pigmentation of the trabecular meshwork, capsular fragility, zonular weakness, and open-angle glaucoma. Exfoliation syndrome is a unilateral or bilateral disorder that becomes more apparent with increasing age.

5. Pseudoexfoliation Some investigators have reported an increased prevalence of senescent cataracts in patients with Pseudoexfoliation. Patients with this syndrome may also experience weakness of the zonular fibers and spontaneous lens subluxation and phacodonesis. Poor zonular integrity may affect cataract surgery techniques and IOL implantation. The exfoliative material may be elaborated even after the crystalline lens is removed.

6. Pupil management Pupillary sphincter is stretched with instruments, applying gentle force 180º apart. Multiple sphincterotomies are created with intraocular scissors. Iris hooks are placed in four quadrants to retract iris.

7. Pupil Management During Operation The use of iris hooks for pupillary dilatation and lens stabilization.

8. Pupil Management During Operation The use of a pupil-strecher Using two hooks to stretch the pupil.

9. IOL Selection In PXF Without complications Zonular dehiscence Phacodonesis (lens subluxation) Lens dislocation Loss of anterior and posterior capsule

10. Complications During Operation Grades of zonular dehiscence Grade 11-2 clock hours of ZD Grade 22-6 clock hours of ZD without vitreous presentation Grade 32-6 clock hours of ZD with vitreous presentation Grade 4Greater than 6 clock hours of ZD

11. Complications During Operation Grade 1 zonular dehiscence.

12. Complications During Operation Inserting a capsule tension ring using a bimanual technique.

13. Surgical treatment of a dislocated intraocular lens-capsular bag-capsular tension ring complex Slitlamp view of superotemporal dislocation of the IOL-CB-CTR complex. The haptic of AcrySof and 1 end of the CTR are seen. Suturing the CTR during surgery. Left: a 30-gauge needle is introduced into the ciliary sulcus. One needle with a 10-0 polypropylene suture is passed through the opposite incision and captured in the barrel of a 30-gauge needle over the IOL and CB. Right: the second needle is introduced through the same incision and passed through the anterior and posterior capsules under the CTR. For this maneuver, the CTR is immobilized with a forceps through the temporal incision.

14. Surgical treatment of a dislocated intraocular lens-capsular bag-capsular tension ring complex Two polypropylene suture are positioned over and under the CTR.

15. Surgical treatment of a dislocated intraocular lens-capsular bag-capsular tension ring complex Suturing the CTR transsclerally. Left: the 10-0 polypropylene suture is pulled to provide adequate tension and sutured to the sclera. Right: the same procedure is done at 180 degrees, and the knot is tied. After the second suture is placed to anchor the IOL-CB-CTR complex, centration is good. One day after surgery, the IOL is well centered. The posterior capsule is clear, and the size (red line) and diameters (yellow lines) of the capsulorhexis are normal.

16. There were 67 eyes with pseudoexfoliation syndrome and 1670 eyes without pseudoexfoliation. The incidence of vitreous loss, capsule tears, and zonular dialysis was compared between the 2 groups. The incidence of vitreous loss was 1.5% in eyes with pseudoexfoliation syndrome and 2.3% in eyes without pseudoexfoliation. Although caution is still advised, patients with pseudoexfoliation syndrome who have phacoemulsification can achieve results similar to patients without pseudoexfoliation.

17. In the difficult cases of cataract associated with pseudoexfoliation syndrome, small pupil and phacodonesis, the modern small-incision cataract surgery provides better results with a low rate of intraoperative and postoperative complications when compared with the extracapsular cataract extraction technique(17.0 % versus 4.2 %, P < 0.05).

18. Cataract extraction in X-linked megalocornea with Pseudoexfoliation: Corneal enlargement and mosaic dystrophy are obvious features of XLM. Anomalies involving the anterior structures of the eye and in particular the lens capsule and zonule are also frequent. Cataract extraction with phacoemulsification and PC IOL implantation can be successful, but special attention must be paid to both surgical technique and IOL selection.

19. Intraoperative complications of phacoemulsification in eyes with and without pseudoexfoliation. Phacoemulsification by experienced surgeons is safe in eyes with pseudoexfoliation without marked phacodonesis or lens subluxation.

20. Posteriorly dislocated capsular tension ring. If CTR were in vitreus after cataract surgery (phacoemulsification)

21. Extraction of endocapsular tension ring after phacoemulsification in eyes with pseudoexfoliation. One 10-0 polypropylene suture needle is passed through the hole at one end of the CTR. If the posterior capsule ruptures, the CTR can be removed by pulling the suture toward the corneal incision and rotating the CTR to remove it. We recommend this procedure in eyes with risk of zonular dialysis and posterior capsule rupture, especially in advanced pseudoexfoliative cataracts or if the surgeon has limited experience with these cases.

22. Late complications with intraocular lens dislocation after capsulorhexis in pseudoexfoliation syndrome. We report 3 cases of significant late intraocular lens/capsular bag subluxation after uneventful capsulorhexis, endolenticular phacoemulsification, and capsular bag implantation in patients with pseudoexfoliation syndrome.

23. Anterior capsular phimosis in eyes with a capsular tension ring in pseudoexfoliation

24. Complete anterior capsule contraction after phacoemulsification with acrylic intraocular lens and endocapsular ring implantation in phacoemulsification. This case shows that endocapsular ring implantation does not prevent anterior capsule contraction syndrome but can prevent IOL decentration.

25. Capsular tension ring implantation after capsulorhexis in phacoemulsification of cataracts associated with pseudoexfoliation syndrome. Intraoperative complications and early postoperative findings. In cases of cataract associated with pseudoexfoliation syndrome, implanting a CTR before phacoemulsification of the nucleus reduced intraoperative zonular separation, increased the rate of capsular IOL fixation, and improved UCVA.

26. Intraocular pressure decrease after phacoemulsification in patients with pseudoexfoliation syndrome. Patients with pseudoexfoliation syndrome had a postoperative IOP reduction from baseline at all measurements and a significantly greater reduction than patients in the POAG and cataract control groups at 6 and 12 months. Phacoemulsification cataract surgery with PC IOL implantation may be effective in managing patients with pseudoexfoliation syndrome who have elevated IOP and visually significant cataract but no advanced optic nerve damage.

27. Quantification of aqueous flare after phacoemulsification with intraocular lens implantation in eyes with pseudoexfoliation syndrome. Breakdown of the blood-aqueous barrier is significantly more extensive in eyes with PEX and may be an important risk factor for early postoperative complications. The altered response to surgery should be considered in eyes with PEX.

28. Combined clear cornea phacoemulsification and trabecular aspiration in the treatment of pseudoexfoliative glaucoma associated with cataract. It seems that the combined clear cornea phaco and trabecular aspiration procedure in cases of PEX glaucoma associated with cataract is a safe and effective method. This technique controls IOP more effectively and with fewer postoperative medications than clear cornea phaco alone.

29. Phacoemulsification in eyes with pseudoexfoliation. Phacoemulsification was safe in most eyes with pseudoexfoliation even though significantly more complications occurred intraoperatively in these eyes. The low frequency of an inflammatory response indicates that the presence of pseudoexfoliation does not significantly increase the risk of inflammation.

30. Anterior capsule contraction and intraocular lens dislocation in eyes with pseudoexfoliation syndrome. The contraction of the anterior capsule opening was more extensive in the PE eyes than in the control eyes, thus resulting in a high Nd:YAG laser anterior capsulotomy rate. The IOL tilt was also greater in the PE eyes than in the control eyes.