What is the optimal pre‑operative, intra‑operative, and post‑operative management of posterior synechiae in a patient undergoing small‑incision cataract surgery (SICS)?

Management of Posterior Synechiae in Small-Incision Cataract Surgery

In patients with posterior synechiae undergoing small-incision cataract surgery, aggressive perioperative pupil dilation with mydriatic agents is essential to prevent synechiae formation, combined with extended topical corticosteroid therapy (prednisolone acetate 1% four times daily for 4-6 weeks) to minimize postoperative inflammation that drives adhesion formation. 1, 2, 3

Preoperative Management

Assessment and Risk Stratification

• Identify pre-existing posterior synechiae through careful slit-lamp examination, as their presence increases the risk of postoperative synechiae formation by over 12-fold (OR: 12.868) 4
• Document pupil size and reactivity, recognizing that miotic pupils represent a complex surgical feature requiring modified techniques 2
• Perform B-scan ultrasonography to rule out posterior segment pathology that could affect surgical planning 2

Preoperative Pharmacologic Preparation

• Initiate aggressive pupil dilation with mydriatic and cycloplegic agents to break existing synechiae and maximize pupil diameter 1, 3
• Consider preoperative topical corticosteroids if significant inflammation is present to reduce the inflammatory substrate that promotes synechiae formation 1

Intraoperative Management

Surgical Technique Modifications

• Use pupil expansion devices or iris hooks when miosis is present to achieve adequate surgical exposure and prevent iris trauma, which is a major risk factor for postoperative synechiae 2, 5
• Minimize intraoperative trauma to iris tissue, as surgical trauma significantly increases synechiae risk 5
• Perform a carefully sized anterior capsulectomy, as capsulectomy size influences posterior synechiae formation between iris and anterior capsule remnants 5
• Ensure complete removal of viscoelastic material at surgery completion, as retained viscoelastic can promote inflammation and fibrin deposition 6

IOL Selection Considerations

• Prefer three-piece acrylic IOLs over single-piece designs when posterior synechiae risk is elevated, as single-piece IOLs carry 2.7-fold higher odds of postoperative synechiae formation (OR: 2.658) 4
• Target standard monofocal IOL for distance vision rather than premium IOLs, particularly if posterior segment pathology exists 2

Postoperative Management

Aggressive Anti-Inflammatory Protocol

• Prescribe topical prednisolone acetate 1% four times daily with an extended taper over 4-6 weeks, as the American Academy of Ophthalmology emphasizes this is essential for complex cases with increased inflammation risk 1, 2
• Add topical NSAID (ketorolac 0.45%) for the first postoperative month to reduce inflammation and cystoid macular edema risk 2
• Intensify steroid therapy immediately if anterior chamber fibrin deposition develops, as this increases synechiae risk 6-fold (OR: 6.012) 4

Critical Pupil Management

• Dilate the pupil regularly during follow-up to prevent synechiae formation, as the American Academy of Ophthalmology specifically recommends this intervention 1, 3
• Use mydriatic agents (tropicamide or cyclopentolate) at least 4 times daily in the early postoperative period when synechiae risk is highest 7, 8
• Continue mydriatic therapy for several weeks rather than the standard brief course, particularly in high-risk cases 7, 8

Monitoring Protocol

• Examine at postoperative day 1,3,7,14, and 30 with careful slit-lamp assessment for early synechiae formation 1
• Check IOP at each visit, as synechiae can contribute to angle closure and IOP elevation 1
• Perform gonioscopy once corneal clarity permits to assess angle status and identify peripheral anterior synechiae 1, 6

Management of Established Synechiae

Medical Intervention

• Intensify mydriatic therapy immediately upon detecting early synechiae formation, using agents 4-6 times daily 7, 8
• Increase corticosteroid frequency to control the inflammatory component driving adhesion formation 7, 8

Surgical Options for Refractory Cases

• Consider surgical lysis of synechiae (synechiolysis) if performed within 6-12 months, as this timeframe offers the best chance of successfully reopening closed structures 1
• Perform goniosynechialysis if peripheral anterior synechiae compromise aqueous outflow and elevate IOP 1, 6

Critical Pitfalls to Avoid

• Do not underestimate inflammation control: Inadequate or prematurely tapered corticosteroids are a primary driver of synechiae formation 5, 4
• Do not defer pupil dilation: Failure to maintain mydriasis in the early postoperative period allows synechiae to form rapidly 1, 3
• Do not ignore pre-existing synechiae: These dramatically increase postoperative risk and require intensified preventive measures 4
• Do not use gas tamponade unnecessarily: If combined vitrectomy is performed, C₃F₈ gas increases synechiae risk 4-fold (OR: 4.051) compared to balanced salt solution 4
• Do not miss anterior chamber fibrin: Early fibrin deposition requires immediate aggressive intervention to prevent permanent adhesions 4