What are the recommendations for cataract surgery in patients with pseudoexfoliation (PXF) syndrome and reduced endothelial cell count?

From the Guidelines

Patients with pseudoexfoliation (PXF) syndrome and reduced endothelial cell count undergoing cataract surgery should be managed with specific precautions to minimize endothelial trauma and optimize outcomes, as outlined in the most recent guidelines 1.

Preoperative Measures

Preoperative evaluation and counseling are crucial, as emphasized in the preferred practice pattern for cataract in the adult eye 1. This includes a thorough examination, discussion of risks and benefits, and informed consent. For PXF syndrome patients, preoperative measures should focus on:

• Thorough pupillary dilation using a combination of topical mydriatics (phenylephrine 2.5-10% and tropicamide 1%) starting 1 hour before surgery, with additional cyclopentolate 1% if needed.
• Administration of nonsteroidal anti-inflammatory drops like ketorolac 0.5% 3-4 times daily for 3 days before surgery to maintain pupil dilation.

Intraoperative Considerations

During surgery, the following are recommended:

• Use of viscoelastic devices with higher viscosity such as Healon GV or DisCoVisc to protect the compromised endothelium.
• Employment of mechanical pupil expansion devices (Malyugin ring or iris hooks) if necessary for small pupils.
• Gentle hydrodissection, lower phacoemulsification power settings (approximately 30-40% reduction from standard settings), and shorter phaco time to minimize endothelial trauma.
• Consideration of capsular tension rings to stabilize the weakened zonules characteristic of PXF syndrome.

Postoperative Care

Postoperatively, patients should receive:

• More intensive endothelial protection with preservative-free lubricants 4-6 times daily for 4-6 weeks.
• A potentially longer steroid taper (prednisolone acetate 1% four times daily for one week, then tapering over 4-6 weeks).

These recommendations are based on the most recent and highest quality study available 1, and prioritize minimizing endothelial trauma and optimizing outcomes for patients with PXF syndrome and reduced endothelial cell count undergoing cataract surgery.

From the Research

Preoperative Considerations

• Patients with pseudoexfoliation (PXF) syndrome and reduced endothelial cell count should be carefully evaluated before cataract surgery, as they may be at higher risk for complications 2, 3.
• Preoperative endothelial cell counts are lower in patients with PXF syndrome compared to age-matched controls, with a mean endothelial cell count of 2387 +/- 266 cells/mm2 in PXF patients versus 2648 +/- 349 cells/mm2 in controls 2.

Intraoperative Considerations

• The management of small pupils found in PXF syndrome can be achieved using various pharmacological and mechanical techniques 3.
• Devices are available to support weak zonules that commonly accompany PXF syndrome, and their use can help prevent complications during cataract surgery 3.

Postoperative Considerations

• Postoperative follow-up is crucial to monitor for complications such as intraocular pressure spikes, inflammation, and intraocular lens dislocation in patients with PXF syndrome 3.
• Studies have shown that the corneal endothelial cell loss after cataract surgery in patients with PXF syndrome is similar to that in patients without PXF syndrome, with no significant differences in endothelial cell density, pleomorphism, and polymegathism at 6-7 years after surgery 4.
• Factors associated with decreases in corneal endothelial cell density after cataract surgery in eyes with PXF syndrome include cataract grade and preoperative anterior chamber depth, but not the presence of PXF syndrome itself 5.

Long-term Outcomes

• A 2-year prospective comparative study found no significant differences in corneal endothelial cell density between patients with and without PXF syndrome before and after cataract surgery, although patients with glaucoma had lower preoperative endothelial cell counts 6.
• The endothelial cell loss after cataract surgery in patients with PXF syndrome was not significantly different from that in patients without PXF syndrome, with a mean endothelial cell loss of 2.6% +/- 5.1% at 3 months after surgery 5.