Improving cataract surgery in eyes with pseudoexfoliation

Cataract surgery in eyes with pseudoexfoliation syndrome is associated with increased intraoperative and postoperative risks. Strategies for improving outcomes include attention to IOL selection, and one surgeon describes why he is using a particular IOL.

Take-home: Cataract surgery in eyes with pseudoexfoliation syndrome is associated with increased intraoperative and postoperative risks. Strategies for improving outcomes include attention to IOL selection, and one surgeon describes why he is using a particular IOL.

Brooklyn, NY—Eyes with pseudoexfoliation syndrome (PXF) present multiple challenges for cataract surgery as they are at increased risk for a number of complications during and after the procedure. Zonular weakness is a key issue in these cases as it affects both intraoperative safety and postoperative IOL stability.

According to Leonard M. Bley, MD, multiple features of a particular single-piece hydrophobic acrylic IOL (enVista, Bausch+Lomb) make it an excellent choice for implantation in eyes with PXF.

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Dr. Bley is Surgical Director, NYLASIK Laser & Microsurgery Institute, New York, NY, and sees many patients of eastern European and Russian heritage among whom PXF is common. After switching to using the enVista IOL for eyes with PXF about 12 months ago, Dr. Bley estimates he has implanted it in about 200 cases either alone or with a capsular tension ring. So far, he is very satisfied with the outcomes.

“Longer follow-up is needed because eyes with PXF are at risk for late IOL dislocation due to progressive zonular weakness and anterior capsule phimosis. However, I believe the unique material of the enVista IOL will help limit these complications, and its performance has been very promising,” he told Ophthalmology Times.

Dr. Bley said that in eyes with PXF, placement of a capsular tension ring to expand the capsular bag intraoperatively is important for increasing the safety of cataract removal in eyes with frank zonular dehiscence. Leaving the CTR in the eye can also help maintain capsule stability, although it does not prevent late IOL dislocation.

The benefit of using the enVista IOL in eyes with PXF relates to the fact that the lens is constructed of a relatively stiff hydrophobic acrylic material. Consequently, it can act to keep the capsular bag expanded and help to resist the forces created through capsular bag contraction that can lead to zonular dehiscence.

“Especially in cases where a CTR is not used, an IOL that is made of a very stiff material essentially acts like a CTR to help to keep the bag open,” Dr. Bley said.



The aberration-free aspheric optic of the enVista IOL is another one of its advantages, according to Dr. Bley.

He explained that this feature makes the optical performance of the lens more forgiving to changes in alignment, centration, or axial position that can occur with time in eyes with PXF considering the potential for progressive zonular weakness and increased risk of capsular phimosis.

The potential for late in-the-bag IOL dislocation in eyes with PXF underlies another reason why Dr. Bley likes to implant the enVista IOL in these cases. He explained that the implant features holes at the junction of the haptic and optic that enable repositioning by iris or scleral suture fixation.

Additional tips for safe and successful surgery

Careful preoperative examination is important for identifying PXF if it has not been diagnosed already so that surgeons will be prepared to use techniques and technologies that can reduce the risk of complications.

Dr. Bley said it is important to determine preoperatively whether the case can be done with a standard technique or will require placement of a device for capsular support.
“Surgeons should look for movement or shimmering of the lens during the examination in the office preoperatively, but also need to look carefully at how the capsule behaves during capsulotomy,” he said.

Dr. Bley also recommended approaching nucleus and cortex removal using techniques that will minimize any pressure exerted on the capsular bag.

“It is important to have good hydrodissection and hydrodelineation, and surgeons might also consider placing an expansion device or lens in the bag prior to cortex removal,” he said.

In addition to zonular weakness and capsular complications, eyes with PXF are prone to poor pupil dilation, prolonged inflammation, and postoperative IOP spikes.

If pupil expansion is needed, Dr. Bley said it is best to place rings or hooks as an early step, before performing the capsulotomy.

“In case capsular support is required, it is recommended that capsular tension hooks be placed prior to hydrodissection and hydrodelineation because performing the two latter maneuvers in the absence of capsular support often leads to further weakening of the zonules and even frank bag dehiscence,” he noted.

Meticulous removal of viscoelastic is especially critical in eyes with PXF because they are more susceptible to IOP spikes postoperatively. Because they are at risk for greater postoperative inflammation, surgeons may also consider a more intensive corticosteroid regimen, and eyes with PXF are also more likely to be steroid-responders.

“Watch these patients carefully for IOP elevations after cataract surgery, and don’t forget the need for continued monitoring for IOL dislocation that can happen months to years later,” Dr. Bley said.


Leonard M. Bley, MD

Dr. Bley has no relevant financial interests to disclose.

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