Phaco in post-vitrectomy cataracts

George Kampougeris MD, MRCSEd, PhDConsultant Ophthalmic Surgeon

www.eyedoctorgk.gr

DISCLOSURES

No financial interest in any of the products or techniques mentioned

Post-vitrectomy cataractIncreased frequency of vitrectomiesPrevalence up to 80%, hence very frequentChildren-young adults: Posterior subcapsularAdults: NuclearLens touch with capsule break during vitrectomy:

usually rapid occurrence of total white cataract BE CAREFUL!

SPECIAL PROBLEMSVery hard nuclear cataractSmall pupil Compromised zonules – iridophacodonesis !Posterior capsular plaques (very hard)Possible scleral buckles presentReduced visual potentialSilicone oil in the eye

SPECIAL PROBLEMSANESTHESIA

Can be done with topical anesthetic only (drops) Intracameral lidocaine suggested

Peribulbar or subtenon’s: Preferable by many when surgery is anticipated to be long (very hard cataract, zonular instability, small pupil)

General anesthesia if possible can be a good option

SPECIAL PROBLEMS – IOL

Hydrophobic or hydrophilic acrylic preferable (1- piece or 3- piece)PMMA (rigid)Large optic (at least 5.75mm), no plate haptic

designNo silicone IOLsBeware of IOL calculation when silicone oil present !

SPECIAL PROBLEMS - SURGERYHypotony (use lots of viscoelastics)Very deep A/C (low bottle height, low infusion, low

zoom at microscope)Careful incision (2 or 3-step)Small pupil (iris hooks, Malyugin ring)

SPECIAL PROBLEMS - SURGERY

Capsulorhexis - anterior capsular fibrosis- poor red reflexUse vision blue - no small rhexis (larger than 5-5.5mm)Hydrodissection: Slow-carefulCAREFUL: When in doubt about posterior capsule integrity (white cataract) – hydrodelineation only! (or viscodissection)

SPECIAL PROBLEMS - SURGERYPhaco (most cases straightforward)Preferable to use a technique with fewer manipulations(phaco chop, stop and chop)Excessive fluctuations of anterior chamber depthlow bottle height, keep irrigation goingInfusion deviation syndrome (when fluid escapes

backwards through defective zonules, shallow A/C)raise the iris

SPECIAL PROBLEMS – SURGERY

Posterior capsular plaques (fibrotic tissue) especially when silicone oil was used: posterior capsulorhexis

Careful when inserting IOL (in zonular instability use CTR-capsular tension ring)

Avoid hypotony at the end (suture?)

POSTOPERATIVE CAREAvoid excessive inflammation (steroids, NSAIDs,

cycloplegics) Increased incidence of posterior synechiae and

cystoid macular edema Increased frequency of follow-ups (also consider

that many patients are diabetics)

CONCLUSIONSPlan your surgery in advance Have accessory equipment available (sulcus

IOLs, Malyugin rings, iris hooks, CTR, viscoelastics)

Even for experienced surgeons: SLOWLY-CAREFULLY