This article is more than 5 years old. Information may no longer be current.

Carefully evaluate the pseudoexfoliation patient before cataract surgery

ByUday Devgan, MD

Add topic to email alerts

Receive an email when new articles are posted on

Please provide your email address to receive an email when new articles are posted on .

Subscribe

Added to email alerts

You've successfully added to your alerts. You will receive an email when new content is published.

Click Here to Manage Email Alerts

You've successfully added to your alerts. You will receive an email when new content is published.

Click Here to Manage Email Alerts

Back to Healio

We were unable to process your request. Please try again later. If you continue to have this issue please contact customerservice@slackinc.com.

Back to Healio

We know that pseudoexfoliation makes cataract surgery more difficult by causing zonular weakness and intraoperative miosis. The weaker zonules make every step of the surgery more challenging, from capsulorrhexis creation to nucleus removal to IOL insertion.

A central posterior subcapsular cataract in a younger patient.

When starting the capsulorrhexis, an ominous sign is excessive wrinkling of the anterior capsule. This happens because the zonular laxity causes the anterior capsule to be more mobile, and it is no longer taut like a drum. Excessive force during cataract surgery can result in breakage of the zonules, vitreous prolapse, subluxation of the cataract and a host of other problems. With a high degree of zonular weakness, it may be difficult to achieve centration of the IOL, and there may even be long-term dislocation of the entire IOL-capsule complex in the future. The small pupil issues due to pseudoexfoliation can pose additional challenges by making access to the cataract more difficult. Clearly, these are not easy cases. Wouldn't it be good to know ahead of time the extent of the zonular weakness and miosis that you'll be encountering?

Slit lamp examination can show the degree of pseudoexfoliative material on the anterior lens capsule, and it will also show you the level of pupillary dilation. But how can you tell the degree of zonular laxity? Alan Crandall, MD, taught me to compare the anterior chamber depth to the axial length. If the anterior chamber depth is very shallow in an eye with a normal or long axial length, then there is likely zonular laxity that is causing the entire cataract to come forward and flatten the anterior chamber.

For example, a preop patient has an axial length of 25.5 mm and a refraction of –3.25 D, but his anterior chamber depth is just 1.8 mm, indicating that there is likely a high degree of zonular weakness causing anterior displacement of the cataract and a shallowing of the anterior chamber depth. This one pearl has made my life much easier - it's nice to know ahead of time that the surgery may be particularly challenging.