Applying a cautious approach can increase the chance for successful outcomes
Patients with pseudoexfoliation glaucoma can have good outcomes from cataract surgery with a careful approach.
Reviewed by Amy D. Zhang, MD
Performing cataract surgery in the pseudoexfoliation (PFX) glaucoma patient requires special care from the preoperative to postoperative periods, according to Amy D. Zhang, MD, assistant professor, Kellogg Eye Center, University of Michigan, Ann Arbor, MI.
As a first step, take some extra time during the preop evaluation to identify patients with pseudoexfoliation.
“Often, they are patients with very small pupils with white exfoliated material around the pupillary margin,” Dr. Zhang said. “You have to find those patients and note the degree of pupillary dilation. This will correlate with how difficult your case will be.”
The next step, according to Dr. Zhang, is to assess the degree of zonular laxity. You can assess for phacodonesis or look for an increase in the anterior chamber depth that suggests a forward shift of the lens.
One study found that an anterior chamber depth of less than 2.5 mm was associated with a four-time increased risk of zonular instability and vitreous loss, Dr. Zhang said.
With your preop evaluation results, you’ll want to consider the kind of procedure you want to perform-whether it is phacoemulsification alone or phacoemulsification plus glaucoma. Consider IOP, glaucoma stability, and degree of glaucoma change as you make your choice.
Dr. Zhang typically performs phaco-only in patients with well-controlled mild glaucoma who are using one or a maximum of two medications.
“For all the rest, I’d recommend combining with the use of microinvasive glaucoma surgery,” Dr. Zhang said. “I’ve had success with. For patients with severe glaucoma, the gold standard is still phaco and trabeculectomy.”
Intraoperatively, start with the soft-shell technique. Coat the endothelium with a viscodispersive ophthalmic viscosurgical device (OVD) and further flatten the anterior lens capsule with a viscocohesive OVD such as Healon.
“The key when doing this is to be careful not to overinflate the anterior chamber,” she said. “If you inflate it, it can add more stress to the zonules.”
Pupillary expansion devices such as Malyugin hooks may be needed to create a 5- to 6-m rhexis.
“It’s important to create a well-centered capsulorhexis so you have enough room to work without creating more stress for the zonules,” Dr. Zhang said.
If the nucleus is still not rotating, Dr. Zhang recommends performing a viscodissection. Capsular retractors also can be helpful with these patients as they help with hydrodissection and cataract fragmentation.
Capsular tension rings also are useful in cases of zonular dehiscence. For the phaco technique in pseudoexfoliation patients, a horizontal chop, prechop, or ultrachopper are all good choices, Dr. Zhang said.
You also might consider prolapsing the lens partially out of the bag by tilting it partially forward and phacoing outside to decrease the amount of stress. There has been some debate about using a oneversus three-piece IOL. Dr. Zhang favors a three-piece in patients who have any zonular instability, but a one-piece is reasonable if there are no zonular issues.
Plan to perform an anterior vitrectomy if there is the presence of vitreous. When removing instruments out of the eye, make sure to put in a viscocohesive OVD beforehand to stabilize the bag as much as you can. Dr. Zhang also recommends extensive irrigation/aspiration and injecting dilute Miostat at the end of the case.
Postoperatively, this patient group should use steroids and nonsteroidal anti-inflammatory drugs for an extended time period. These patients should be kept on steroids longer than with a routine case. Observe the patient for IOP spikes and check the IOP after 4 to 8 hours.
Amy D. Zhang, MD
This article was adapted from Dr. Zhang’s presentation at the American Glaucoma Society annual meeting. Dr. Zhang has no related disclosures.