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Phaco in post- vitrectomy cataracts

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Phaco in post- vitrectomy cataracts. George Kampougeris MD , MRCSEd , PhD Consultant Ophthalmic Surgeon www.eyedoctorgk.gr. DISCLOSURES. No financial interest in any of the products or techniques mentioned. Post- vitrectomy cataract. Increased frequency of vitrectomies

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  1. Phaco in post-vitrectomy cataracts George Kampougeris MD, MRCSEd, PhD Consultant Ophthalmic Surgeon www.eyedoctorgk.gr

  2. DISCLOSURES No financial interest in any of the products or techniques mentioned

  3. Post-vitrectomy cataract • Increased frequency of vitrectomies • Prevalence up to 80%, hence very frequent • Children-young adults: Posterior subcapsular • Adults: Nuclear • Lens touch with capsule break during vitrectomy: usually rapid occurrence of total white cataract BE CAREFUL!

  4. SPECIAL PROBLEMS • Very hard nuclear cataract • Small pupil • Compromised zonules– iridophacodonesis ! • Posterior capsular plaques (very hard) • Possible scleral buckles present • Reduced visual potential • Silicone oil in the eye

  5. SPECIAL PROBLEMS ANESTHESIA • Can be done with topical anesthetic only (drops) Intracamerallidocaine 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

  6. SPECIAL PROBLEMS –IOL • Hydrophobic or hydrophilic acrylic preferable (1- piece or3- piece) • PMMA (rigid) • Large optic (at least 5.75mm), no plate haptic design • No silicone IOLs Beware of IOL calculation when silicone oil present !

  7. SPECIAL PROBLEMS - SURGERY • Hypotony (use lots of viscoelastics) • Very deep A/C (low bottle height, low infusion, low zoom at microscope) • Careful incision (2 or3-step) • Small pupil (iris hooks, Malyugin ring)

  8. SPECIAL PROBLEMS - SURGERY • Capsulorhexis • anterior capsular fibrosis • poor red reflex Use vision blue - no small rhexis (larger than 5-5.5mm) • Hydrodissection: Slow-careful CAREFUL: When in doubt about posterior capsule integrity (white cataract) – hydrodelineationonly! (or viscodissection)

  9. SPECIAL PROBLEMS - SURGERY • Phaco (most cases straightforward) Preferable to use a technique with fewer manipulations (phaco chop, stop and chop) • Excessive fluctuations of anterior chamber depth low bottle height, keep irrigation going • Infusion deviation syndrome (when fluid escapes backwards through defective zonules, shallow A/C) raise the iris

  10. 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?)

  11. POSTOPERATIVE CARE • Avoid 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)

  12. CONCLUSIONS • Plan your surgery in advance • Have accessory equipment available (sulcus IOLs, Malyugin rings, iris hooks, CTR, viscoelastics) • Even for experienced surgeons: SLOWLY-CAREFULLY