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) 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

6. SPECIAL PROBLEMS – IOL Hydrophobic or hydrophilic acrylic preferable (1- piece or 3- 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 or 3-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) – hydrodelineation only! (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