“One of the issues with pseudoexfoliation glaucoma is cataract surgery—which will happen to every one of these patients, especially if they live long enough,” said Richard K. Lee, MD. When that happens, patients with exfoliation syndrome (XFS) will need a tailored approach to cataract surgery, he said, speaking during Glaucoma Subspecialty Day.
Cataract challenges. XFS patients are at increased risk of zonular dehiscence, posterior lens prolapse, vitreous loss, poor dilation, and postoperative inflammation.
Surgical Pearls
Dr. Lee recommended the following:
Perform a larger capsulorrhexis. With a smaller capsulorrhexis, pulling on the zonules can occur over time, particularly if capsular phimosis occurs; this can eventually lead to capsular dislocation.
Use phaco prolapse. In this technique, the surgeon takes the lens partially out of the bag. “The key point is ‘out of the bag,’” Dr. Lee emphasized. Phaco prolapse is fast and safe, uses less energy than standard phacoemulsification, and places minimal stress on the zonules, he said. Moreover, the surgeon does not need to flip the whole lens and can, if needed, easily convert to ECCE.
Be prepared for the unstable capsule. “Cataract surgery is a game of pool,” said Dr. Lee. “It’s not what I’m doing at that moment in time, it’s what I’m planning for my second move. You want to leave that cue ball where it will be strategically placed for the next step.”
Thus, the surgeon should check preoperatively for zonular dehiscence—and during surgery, watch the capsulorrhexis for wrinkling, which may indicate areas of zonular dehiscence or zonular weakness.
Dr. Lee uses iris hooks to open up poorly dilated capsules but does not routinely use capsular tension rings (CTRs). Instead, he recommended what he called the “poor man’s CTR,” a 4-haptic, 1-piece intraocular lens (IOL). This is also his preferred IOL for XFS eyes. “This lens always centers. It doesn’t matter what your capsulorrhexis looks like.” Alternatively, he will use a 3-piece IOL, placing the haptics in the axis of the zonular dehiscence.
Expect and treat inflammation. Because of the extracellular matrix disorder associated with XFS, these eyes are prone to vascular leakage, Dr. Lee said. “Even with the smoothest surgical case, you will typically have more flare in these eyes.” Thus, he uses steroids preoperatively, treats postoperative flare aggressively, and uses a longer course of postoperative steroids.—Jean Shaw
Financial disclosures. Bausch + Lomb: L; National Eye Institute: S.
Disclosure key. C = Consultant/Advisor; E = Employee; L = Speakers bureau; O = Equity owner; P = Patents/Royalty; S = Grant support.
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