As discussed in the companion article (“Preoperative considerations in patients with cataracts and pseudoexfoliation syndrome,” December 2013), patients with pseudoexfoliation (PXF) have an accelerated incidence of cataract formation,1,2 and the surgery for cataract removal may be more complicated. These patients may require extensive preoperative testing, and they also demand increased postoperative vigilance, even after an uneventful phacoemulsification with endocapsular intraocular lens (IOL) placement.
More from Dr. Fabrykowski: Pre-op consideration in patients with cataracts, PFX
Postoperative patients with PXF pose both short- and long-term concerns due to the underlying pathological changes that occur from the fibrillar deposition with some complications arising years after the surgery. This review provides a time-oriented approach to comprehensively assess patients with PXF who have undergone cataract surgery, beginning with immediately 24-hours after surgery.
Short-term complication watch
It has been reported that intraocular pressure (IOP) spikes, within 24 hours, can reach over 30 mm Hg in 7 percent of patients.3 Postoperative IOP spikes are more common and may be higher than non-PXF eyes. Acutely high IOPs may necessitate topical hypotensive therapy, or oral diuretics such as acetazolamide or methazolamide may need to be used. In rare cases, when IOP becomes dangerously high, some practitioners advocate for release of aqueous from the paracentesis.3 Any of the above cases require diligent in-office follow up.
Due to the decrease in integrity of corneal endothelial cells found in PXF eyes, often there is more intense and prolonged postoperative anterior segment inflammation.4,5 This potentially includes higher levels of aqueous flare with accompanied fibrinoid reaction, even leading to posterior synechiaes. Such an increase in inflammation may necessitate a more frequent topical steroid dosing schedule, a stronger topical steroid, or, in rare cases, adjunctive cycloplegia. Of course, this follows with increased surveillance of the IOP and may require more visits. Some cases of significant postoperative corneal edema may benefit from adjunctive topical sodium chloride solution or ointment in addition to increased steroid use (see Figure 1). Thankfully, corneal decompensation requiring surgical intervention after routine phacoemulsification in eyes with PXF is exceedingly rare.3
Anterior capsular phimosis is another potential early postoperative phenomenon, slightly more common in eyes with PXF.6 It is characterized by contraction of the anterior capsule and potential decentration or tilt of the IOL in the X, Y, or Z plane. It may be beneficial to perform Nd:YAG laser relaxing incisions to the phimotic area of the capsule at the earliest sign.3
Posterior capsular opacification (PCO) has also been reported in higher frequency in eyes with PXF (Shingleton & Crandall).6 One study found that after two years, 45 percent of PXF eyes had posterior capsular opacification vs. 24 percent of non-PXF.7 If visually significant, this may require prompt Nd:YAG laser to the posterior capsule.