Transcript PXF-Phaco-1388

K.Nasrolahi MD
Fiez 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
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
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)
1. Don’t do a vigorous digital massage or
Healon pressure
2. Don’t do over expanding of AC with
viscoelastic
3. Lower bottle height during surgery
4. 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.
1. Placing an endocapsular ring (ECR)
in the bag. Immediately after a CCC
is completed
2. 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.
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