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Extra caution needed in cataract surgery for retinitis pigmentosa cases
Patients with retinitis pigmentosa develop cataracts earlier in life and surgery for these patients presents some challenges. While these patients have relatively soft cataracts, primarily with posterior subcapsular changes, there are other aspects which make their surgery more difficult.
The zonular apparatus tends to be weaker in these patients and have a higher incidence of developing anterior capsule phimosis. In addition, the risk of cystoid macular edema is higher and these patients often do have an underlying level of chronic inflammation in the retina.
Figure. Anterior capsule phimosis.
Pearls for cataract surgery include implanting a three-piece IOL in case future suture fixation is required, making a large capsulorrhexis of 5 mm diameter or more, and aggressive treatment of postoperative inflammation using steroids and NSAIDS. Also important is the postop follow-up where the anterior capsular rim should be checked at regular intervals so that capsular phimosis can be caught early. It can then be addressed by using a YAG laser to make radial relaxing incisions at the cardinal meridians (12, 3, 6, and 9 o'clock) in order to disrupt the phimotic ring.
The picture here shows severe anterior capsular phimosis in a patient with retinitis pigmentosa. She had uncomplicated cataract surgery 5 years ago with a three-piece IOL placed in the capsular bag, a 5.5 mm capsulorrhexis, and aggressive treatment of her postoperative inflammation. She was, however, lost to follow-up for 5 years and then presented with this degree of capsular phimosis. At this point, would doing relaxing incisions of the anterior capsule with the YAG laser be of benefit, or would you leave it be?
I look forward to reading your experiences and suggestions.