Dense cataract with pseudoexfoliation, a small pupil and a patient on apixaban
A 79-year-old retired teacher is listed for phacoemulsification of the right eye. He takes apixaban 5 mg twice daily for atrial fibrillation (CHA2DS2-VASc 4), aspirin 81 mg, tamsulosin 0.4 mg nightly for three years, and latanoprost in both eyes. Best-corrected acuity is 6/60 right and 6/12 left. The right lens shows dense nuclear sclerosis with pseudoexfoliation and phacodonesis on dynamic examination; the pupil dilates to only 4.0 mm after tropicamide and phenylephrine. Endothelial cell count is 1,850/mm², there is no vitreous in the anterior chamber, and intraocular pressure is 18 mmHg on latanoprost. Axial length is 23.1 mm and anterior chamber depth 3.0 mm. He lives alone, drives himself to appointments, and asks whether he can 'just stop the blood thinner for a few days' and be operated under a block so he does not have to lie still.
1. How would you manage his anticoagulation and the choice of anesthesia, and why?
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Continue apixaban and aspirin. Atrial fibrillation with a CHA2DS2-VASc of 4 carries a substantial annual stroke risk, and there is no evidence that continuing a direct oral anticoagulant increases sight-threatening haemorrhage in small-incision phacoemulsification. Stopping it for two or three days creates a stroke risk window far larger than the bleeding risk of cataract surgery, and bridging with heparin adds its own hazards. Current guidance for cataract surgery under topical or sub-Tenon anesthesia is to continue the drug.
What should change is the anesthesia technique. A sharp-needle retrobulbar or peribulbar block in a fully anticoagulated patient risks a retrobulbar haemorrhage that can be sight-threatening and is difficult to manage in a patient who cannot lie flat for pressure. Offer topical anesthesia with intracameral preservative-free lidocaine, which is well tolerated for phaco and requires no needle. If he cannot tolerate topical, a blunt sub-Tenon cannula is a reasonable compromise, but topical should be the first plan.
The other counselling point is that his 6/12 left eye means the surgery is for function and quality of life rather than absolute necessity; the discussion should include the higher-than-average risk profile (pseudoexfoliation, small pupil, low endothelial reserve) so consent is realistic. His expectation of 'lying still' should be reframed: he needs to keep his head still, not his eye, and topical anesthesia is easier for a nervous patient than a block.
2. Describe your intraoperative strategy for the small pupil, pseudoexfoliation and tamsulosin exposure, and what you would do if 4 clock hours of zonular dialysis appeared with vitreous in the wound.
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Preparing for a soft eye, a small pupil and loose zonules:
- Tamsulosin guarantees some degree of intraoperative floppy iris syndrome; stopping it for a week does not reliably abolish the effect, so plan for it rather than delay surgery.
- Two paracenteses, generous cohesive viscoelastic to tamponade the iris, and mechanical dilation with iris hooks or a pupil-expanding device rather than heroic viscoelastic alone at 4 mm.
- Stain the capsule with trypan blue (poor red reflex in dense nuclear sclerosis), make a slightly smaller capsulorhexis than usual, and perform gentle, staged hydrodissection.
- Use low bottle height and low flow, divide-and-conquer or stop-and-chop to limit stress on the zonule, and have capsule hooks and a capsular tension ring ready.
- Intracameral phenylephrine 1% or epinephrine in BSS helps keep the pupil open. Minimise iris trauma, since pigment release and breakdown of the blood-aqueous barrier worsen postoperative inflammation.
If 4 clock hours of dialysis appear with vitreous in the wound: stop phacoemulsification immediately, do not withdraw the phaco tip through vitreous, and perform a limited anterior vitrectomy with a low infusion and a dispersive viscoelastic to keep the vitreous posterior. Reassess capsular support: place capsule hooks or a CTR if the residual zonule allows; if the bag is unstable, implant a three-piece IOL in the sulcus with optic capture through the rhexis. If nuclear material has dropped, do a thorough anterior vitrectomy, close the eye and refer for pars plana vitrectomy rather than fishing for fragments. Document and warn about cystoid macular oedema, IOL decentration and retinal detachment.
3. On the first postoperative day the intraocular pressure is 34 mmHg with corneal oedema and a well-centred in-the-bag IOL; there is no vitreous in the anterior chamber. How do you manage this, and what do you tell him about long-term risk?
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Immediate management. A pressure of 34 mmHg with corneal oedema on day one is usually retained viscoelastic, blood, or pigment-related trabecular blockage in a pseudoexfoliative eye; it is not yet pseudoexfoliation glaucoma. Treat with a topical beta-blocker and a topical carbonic anhydrase inhibitor, consider oral acetazolamide if the pressure does not fall or the cornea is too oedematous for a reliable view, and review within 24–48 hours. Do not start a prostaglandin analogue in the immediate postoperative period if he is not already on one; he is, so continue latanoprost, but recognise that its contribution to any cystoid macular oedema risk should be weighed if inflammation persists.
Look specifically for the causes that matter: retained viscoelastic, a pupil block from a tight capsulorhexis, intraocular lens tilt, or significant inflammation. Gonioscopy at this stage is usually unhelpful; the anterior segment examination and response to treatment are more informative. Steroid frequency should be increased if there is marked inflammation, and the patient warned about the symptoms of acute pressure rise.
Long-term counselling. Pseudoexfoliation is a systemic elastopathy with bilateral, asymmetric progression. Even with a good surgical result he has a materially increased lifetime risk of raised pressure, glaucoma and optic nerve damage, of late IOL decentration from progressive zonular weakness, and of capsule phimosis. He needs annual pressure and optic disc review with the local ophthalmologist, and should understand that after this operation the 'other eye' may behave differently at surgery. Document the discussion.