Phaco experience in 1,000 pseudoexfoliation patients underlines pearls for success

Pseudoexfoliation is a common disorder that mandates special attention when cataract surgery is indicated, said Bradford J. Shingleton, MD, who delivered the Stephen A. Obstbaum, MD Honored Lecture at ASCRS Glaucoma Day 2007.

“We need to be aware of pseudoexfoliation, and we need to be wary of it because intraoperative and postoperative complications of cataract surgery are greater in eyes with this disorder,” said Dr. Shingleton, assistant clinical professor, Harvard Medical School, and clinical instructor of ophthalmology, Tufts University School of Medicine, Boston.

Dr. Shingleton told attendees that he considers pseudoexfoliation the most common problematic issue in his practice that embraces both cataract and glaucoma. He reported findings from analyses of his single surgeon, consecutive series of phacoemulsification in 1,000 patients (1,500 eyes) with pseudoexfoliation and reviewed considerations for surgical success.

His retrospective analyses included comparisons of outcomes of cataract surgery in patients with unilateral pseudoexfoliation who underwent bilateral phacoemulsification, patients with pseudoexfoliation with and without glaucoma, and patients with pseudoexfoliation and glaucoma undergoing combined surgery versus phacoemulsification alone.

Regarding IOP outcomes, the results showed IOP is lower after cataract surgery in eyes without pseudoexfoliation than in affected eyes. The pseudoexfoliation eyes achieve a greater mean decrease in IOP and have stable glaucoma medication requirements until 3 to 5 years. Pseudoexfoliation eyes with and without glaucoma both show sustained IOP reduction after cataract surgery, while combined surgery can afford an even greater reduction in IOP. The findings from his review also highlighted the role of zonular weakness rather than capsule tears as the greatest risk factor for intraoperative complications.

Outlining keys for success, Dr. Shingleton emphasized the importance of identifying patients at high risk preoperatively by looking for frank phacodinesis and more subtly, anterior depth asymmetry between eyes. Intraoperatively, it is important to achieve free nucleus rotation and use phaco chop because it avoids directing aspiration forces to the peripheral capsule. Dr. Shingleton advocated liberal use of capsular retractors or capsule tension segments, and he emphasized suturing the capsule tension ring if there is concern about progressive zonule weakness. Implantation of an acrylic posterior chamber IOL may be preferred because it may minimize phimosis, and surgeons should be prepared to convert to planned extracapsular or pars plana lensectomy/virectomy approaches as necessary.

Postoperatively, patients need to be followed carefully to detect and treat anterior capsular fibrosis early in order to reduce progressive capsular contraction that can result in IOL subluxation, he said.