Intraocular lens implantation in exfoliation syndrome and capsular glaucoma

Psychometric analysis of the questionnaires for the assessment of upper limbs available in their Italian version: a systematic review of the structural and psychometric characteristics

INTRODUCTION

There is no systematic review that analyzes the psychometric properties of questionnaires in Italian. Previous studies have analyzed the psychometric characteristics of instruments for the measurement of pathologies of upper limbs and their joints in different languages. The aim of the present study was to analyze the psychometric properties of the questionnaires published in Italian for the evaluation of the entire upper limb or some of its specific regions and related dysfunctions.

EVIDENCE ACQUISITION

For the development of this systematic review, the following databases were used: PubMed, Scopus, Cochrane, Dialnet, Cinahl, Embase and PEDro. The selection criteria used in this study were: studies of transcultural adaptation to Italian of questionnaires oriented to the evaluation of upper limbs or any of their structures (specifically shoulder, elbow and wrist/hand), and contribution of psychometric variables of the questionnaire in its Italian version.

EVIDENCE SYNTHESIS

After reading the titles and applying the inclusion and exclusion criteria to the complete documents, 16 documents were selected: 3 for the upper limb, 8 for the shoulder, 1 for the elbow and 4 for the wrist and hand. The cross-sectional psychometric variables show levels between good and excellent in all the questionnaires. Longitudinal psychometric variables had not been calculated in the vast majority of the analyzed questionnaires.

CONCLUSIONS

Italian versions of the questionnaires show good basic structural and psychometric characteristics for the evaluation of patients with musculoskeletal disorders of the upper limb and its joints (shoulder, elbow and wrist/hand).

A different surgical approach to cases with zonular weakness or dialysis: sutureless transscleral fixated intraocular lens implantation and stabilization of lens capsule

PURPOSE

To evaluate the effect of sutureless transscleral fixated intraocular lens (IOL) implantation and capsule stabilization of IOL optics on postoperative visual outcomes in cases with zonular dialysis in excess of 70°.

METHODS

Fifteen eyes of thirteen patients with > 70° zonular dialysis and endothelial cell counts higher than 1500 cells/mm² who had been followed for at least 6 months were included. A modified surgical approach was applied to these eyes with sutureless transscleral fixated IOL implantation and the IOL was secured to the capsulorhexis to stabilize the lens capsule (optic capture).

RESULTS

The mean best-corrected visual acuity (BCVA) was 0.21 ± 0.2 on the first day, 0.45 ± 0.33 on the first week, 0.60 ± 0.32 on the first month, 0.80 ± 0.26 on the third month, and 0.82 ± 0.27 on the sixth month. When preoperative BCVA and postoperative BCVA were compared, a statistically significant increase was observed in postoperative BCVA beginning from the seventh postoperative day. There was a statistically significant (p = 0.038) decrease in endothelial cell count at postoperative third and sixth months (1895 ± 65, 1872 ± 376, respectively) compared to preoperative values.

CONCLUSIONS

The use of this new surgical modification that utilizes capsular tension rings combined with a procedure that secures the sutureless scleral IOL fixation to the capsulorhexis for the treatment of eyes with zonular dialysis in excess of 70° was found to be very successful in the 6 months of follow-up. More cases and longer follow-up periods are required to provide an idea as to whether different complications will develop in such patients.

Risk Factors for Intraoperative and Early Postoperative Complications in Extracapsular Cataract Surgery

The risk factors for intraoperative and early postoperative complications were evaluated in 351 consecutive cataract operations at the Oulu University Hospital in 1990. Bleeding into the anterior chamber during the operation was recorded in 8.6%, zonular rupture in 6.6%, posterior capsular rupture in 5.4% and vitreous loss in 3.2%, On account of the loss of capsular support an anterior chamber intraocular lens was implanted in 3.1%. Of the early postoperative complications, signs of fibrinous reaction were observed in 24.5%, corneal edema in 53.6% and rise of intraocular pressure to 30 mmHg or more in 27.6%. There was no difference in the complication rate between men and women or in relation to age. The use of anticoagulant (although discontinued before surgery) or antiplatelet medication increased the risk of intraoperative bleeding but no sight-threatening bleeding occurred. The use of acetylsalicylic acid was also associated with an increased risk of postoperative fibrinous reaction. Other systemic diseases like systemic hypertension, diabetes, asthma, or cardiac or mental disorders, or medications, did not increase the complication rate. Of the various ocular parameters, small pupil and exfoliation syndrome were the most important risk factors for both intra- and early postoperative complications, and the presence of glaucoma increased the risk of vitreous loss, postoperative pressure rise and corneal edema. General anesthesia did not seem to reduce the complications rate.

Pressure Control in Glaucoma Patients after Cataract Surgery with Intraocular Lens

In a retrospective study 97 patients with glaucoma and 16 with ocular hypertension were examined with regard to intraocular pressure (IOP) after extracapsular cataract extraction with implantation of a posterior chamber lens. During the follow-up 39 cases dropped out but 63 glaucoma patients and 11 patients with ocular hypertension were followed for three years.

Compared to preoperative IOP 59% of the patients treated previously with Argon laser trabeculoplasty (ALT) had an IOP rise of > 10 mm Hg the day after surgery. The corresponding proportion among medically treated patients was 34% (P=0.01). A pressure rise of > 10 mm Hg was less frequent among patients treated with one drug than among those treated with two or three (P=0.05). During follow-up eight patients had a pressure rise which could not be controlled medically and they had to undergo additional ALT or surgery. All eight had been treated with ALT or with glaucoma filtering surgery prior to the cataract operation.

After three years observation of 63 of the glaucoma patients, 63% were having less medical therapy than preoperatively, 30% an equal amount and 7% more; 49% (31 of 63) were still without any therapy. In the group of patients who preoperatively were only treated medically, no definite increase in therapy was needed in the long term.

Objective classification of zonular weakness based on lens movement at the start of capsulorhexis

Purpose

To quantify zonular weakness based on lens movement at the start of continuous curvilinear capsulorhexis (CCC) and establish a classification system for it.

Setting

Kozawa Eye Hospital and Diabetes Center, Mito, Japan.

Design

Retrospective interventional case series.

Methods

We examined 402 consecutive eyes of 316 patients who underwent CCC, phacoemulsification and aspiration (PEA), and intraocular lens (IOL) implantation. The movement of the lens capsule was measured using images from video recordings of the CCC procedure. Zonular weakness was classified based on the shifted distance: Grade I, less than 0.20 mm; Grade II, 0.20–0.39 mm; and Grade III, greater than 0.40 mm. For each of these grades, we examined the use of the capsule stabilization device during PEA, the surgical procedure for lens removal, and IOL fixation.

Results

We classified 276 eyes (68.6%) as Grade I, 102 eyes (25.4%) as Grade II, and 24 eyes (6.0%) as Grade III. As the grade increased, the use of the capsule stabilization device in PEA and scleral suture fixation of IOL increased.

Conclusions

Zonular weakness was quantified by measuring the movement of the lens capsule. An objective classification of zonular weakness based on lens movement may be useful for selecting the appropriate device and procedure during cataract surgery.

Is the exfoliation syndrome a contraindication for the use of IOL in cataract surgery?

A questionnaire on the possibility of the use of IOL in cases of cataract with exfoliation syndrome (ES) was sent to several ophthalmic surgeons. The analysis of the answers to the questionnaire shows that the ES is a relative contraindication to the IOL implantation. Posterior chamber and sulcus fixation are recommended.

Light microscopy of the exfoliation syndrome

The exfoliation syndrome affects all structures of the ocular anterior segment, as well as the conjunctiva and occasionally, nonocular structures. The exfoliative material has been shown by a series of light microscopic and gross anatomic studies to be only loosely adherent to the anterior lens capsule, zonules and anterior vitreous face, and firmly adherent to the equatorial lens capsule and posterior epithelium of the iris and the nonpigmented ciliary epithelium. Electron microscopy demonstrates that, in these latter regions, exfoliation material consisting of characteristic, cross-banded fibrils embedded in an amorphous matrix, is present both within the epithelial cells and associated with a disorganized, reduplicated basement membrane. These findings suggest that the material arises from the epithelium of the lens, iris and ciliary body, possibly the result of an underlying metabolic disorder. From these areas, the material enters the aqueous humor and later deposits on the anterior lens capsule, zonules, vitreous face, anterior surface of the iris, and trabecular meshwork. Histochemical studies demonstrate the presence of glycosaminoglycans, which may comprise the interfibrillar portion of the exfoliative material. Other studies demonstrate histochemical similarities between exfoliative material and zonules and are supported by recent work suggesting that the exfoliative fibrils are related to the microfibrillar portion of elastin. Although some reports suggest similarities between exfoliative material and amyloid, a majority of histochemical studies do not support this possibility.

The exfoliation in the Scheimpflug photography

Scheimpflug photography is a very useful method in the diagnosis of exfoliation. It helps to differentiate between tiny subcapsular opacifications and supracapsular appositions. It is a valuable aid in the detection of early stages of exfoliation still unvisible at ordinary slit lamp examination. New phenomenons might be detected in the future like the elevation of a precapsular membrane in one of our patients.

Our experiences in planned extracapsular cataract extraction in the exfoliation syndrome

We noticed a tenfold higher incidence of zonular rupture during planned extracapsular cataract extraction (e.c.c.e.) in patients with exfoliation syndrome compared to patients without this disease. The exfoliation glaucoma is an especially bad precondition for e.c.c.e. The postoperative complication rate (toxic lens syndrome, iridocyclitis) is remarkably high when there is an increased fluorescein leakage of the iris vessels before the operation. Also changes of the vitreous as shown by biomicroscopy or ultrasonography in the case of hazy optical media of the eye are a bad precondition. An intracapsular cataract extraction without lens implantation should be considered in cases of two or more worsening preoperative conditions.

Cataract and glaucoma surgery in pseudoexfoliation syndrome: a review

Pseudoexfoliation syndrome is a risk factor in cataract surgery because of the increased weakness of zonular apparatus and reduced pupillary dilatation. The surgical outcome of using phacoemulsification in the central zone, inducing minimal stress on the zonules, inserting a capsular tension ring in selected cases, and stretching the pupil mechanically in eyes with miotic pupils, may turn out to be uneventful in most cases. Postoperative fibrosis with subsequent shrinkage of the capsule is increased in these eyes, and these centripetal forces will further loosen the zonular fibres. Late in-the-bag intraocular lens dislocation is therefore anticipated to become a growing problem in the future. Despite the dysfunctioning of the blood-aqueous barrier in eyes with pseudoexfoliation syndrome, the frequency of postoperative inflammatory reaction is low due to the improvements made in surgical technique and equipment in recent years. Glaucoma frequently occurs in eyes with pseudoexfoliation syndrome. Compared with primary open-angle glaucoma, optic damage is more pronounced in these eyes at the time of diagnosis and response to medical therapy is poorer. Although responses to argon laser therapy and filtering surgery are roughly similar between the two types of glaucoma, there are indications that primary laser trabeculoplasty has a higher success rate in pseudoexfoliation glaucoma than in primary open-angle glaucoma.

Pseudoexfoliation syndrome: pathological manifestations of relevance to intraocular surgery

Pseudoexfoliation syndrome (PEX) is a common ocular condition often associated with the need for intraocular surgery. Although results of cataract and glaucoma filtering surgery in eyes with PEX in the early stages of the disease may be comparable to those in eyes without PEX, in the later stages morbidity is significantly increased due to periocular surgical complications and the outcome is worse. Surgical and postoperative difficulties are often multifactorial and are directly related to the pathological changes of PEX on intraocular structures. Recent years have seen a large increase in the understanding of the effects of PEX on the various ocular tissues. Although the visible areas of the anterior capsule are most obviously involved, this is only a small part of the picture and of least significance. Biomicroscopically invisible changes of the zonules and their attachments are of greatest consequence. There is also distinct, often active, involvement of almost all tissues of the anterior segment of the eye, many of which have important implications for the anterior segment surgeon including iridopathy, iris vasculopathy (including persistent breakdown of the blood-aqueous barrier and anterior segment hypoxia), ciliary body involvement and keratopathy. Trabecular dysfunction is evident by the deposition of PEX material derived from both in situ and extra-trabecular production as well as protein and melanin deposition. These changes should be kept in mind by all intraocular surgeons as a source of potential difficulties in the perioperative period. Additionally, in light of these changes, patients need to be given realistic expectations regarding the increased risk of complications and more prolonged expected recovery time. In this short review, current reports relating to PEX pathological changes of practical interest to the intraocular surgeon are summarized.

Decreased incidence of capsule complications and vitreous loss during phacoemulsification in eyes with pseudoexfoliation syndrome

PURPOSE

To report a series of patients with pseudoexfoliation syndrome who had phacoemulsification without an increased incidence of intraoperative complications or late intraocular lens (IOL) dislocation.

SETTING

Department of Ophthalmology, Kaiser Permanente, Denver, Colorado, USA.

METHODS

Patients were prospectively recruited from a consecutive series of all cases of phacoemulsification performed by 1 surgeon. There were 67 eyes with pseudoexfoliation syndrome and 1670 eyes without pseudoexfoliation. The incidence of vitreous loss, capsule tears, and zonular dialysis was compared between the 2 groups.

RESULTS

The incidence of vitreous loss was 1.5% in eyes with pseudoexfoliation syndrome and 2.3% in eyes without pseudoexfoliation. The difference between the 2 groups was not statistically significant (chi square = 0.203; P =.33). There were no cases of posterior capsule tears or zonular dialysis in pseudoexfoliation eyes without vitreous loss. No IOL dislocated over a mean follow-up of 54.1 months.

CONCLUSION

Although caution is still advised, patients with pseudoexfoliation syndrome who have phacoemulsification can achieve results similar to patients without pseudoexfoliation.

Spontaneous late dislocation of intraocular lens within the capsular bag in pseudoexfoliation patients

PURPOSE

To identify a delayed complication of cataract surgery in patients with zonular weakness caused by pseudoexfoliation syndrome.

DESIGN

Retrospective observational case series.

PARTICIPANTS

Eight eyes in seven patients with clinically diagnosed pseudoexfoliation syndrome who had undergone previous uncomplicated cataract extraction and placement of a posterior chamber intraocular lens.

METHODS

This study evaluated eight cases of late spontaneous dislocation of posterior chamber intraocular lenses within the capsular bag in patients with pseudoexfoliation syndrome. Data were gathered retrospectively from patients' operative reports, medical records, and pathology reports.

MAIN OUTCOME MEASURES

(1) Interval between original surgery and dislocation; (2) final best-corrected visual acuity and ocular outcome.

RESULTS

All patients had a diagnosis of pseudoexfoliation syndrome and had previously undergone uncomplicated cataract surgery. No patient had any other predisposing factors that would lead to zonular dehiscence or weakness. Delayed dislocation of the entire capsular bag containing the intraocular lens (IOL) occurred spontaneously in all cases. Mean time from IOL implantation to dislocation was approximately 85 months (7 years and 1 month; range, 57-115 months) after surgery. Seven eyes were treated successfully with IOL exchange: six with placement of an anterior chamber IOL and one with scleral fixation of a posterior chamber IOL. The remaining case was treated by scleral fixation of the dislocated IOL. Gross pathology analysis of seven cases confirmed the presence of the IOL within the intact capsular bag. Six eyes have achieved final best-corrected visual acuity of 20/40 or better.

CONCLUSION

Patients with pseudoexfoliation syndrome may be at risk for delayed spontaneous dislocation of IOL within the capsular bag after uncomplicated cataract surgery. Awareness of this newly recognized long-term complication may justify a reevaluation of surgical considerations for cataract removal in these patients.

Exfoliation syndrome

Exfoliation syndrome (XFS) is an age-related disease in which abnormal fibrillar extracellular material is produced and accumulates in many ocular tissues. Its ocular manifestations involve all of the structures of the anterior segment, as well as conjunctiva and orbital structures. Glaucoma occurs more commonly in eyes with XFS than in those without it; in fact, XFS has recently been recognized as the most common identifiable cause of glaucoma. Patients with XFS are also predisposed to develop angle-closure glaucoma, and glaucoma in XFS has a more serious clinical course and worse prognosis than primary open-angle glaucoma. There is increasing evidence for an etiological association of XFS with cataract formation, and possibly with retinal vein occlusion. XFS is now suspected to be a systemic disorder and has been associated preliminarily with transient ischemic attacks, stroke, systemic hypertension, and myocardial infarction. Further ramifications await discovery. Deposits of white material on the anterior lens surface are the most consistent and important diagnostic feature of XFS. The classic pattern consists of three distinct zones that become visible when the pupil is fully dilated. Whereas the classic picture of manifest XFS has been often described, the early stages of beginning exfoliation have not been well defined. Next to the lens, exfoliation material is most prominent at the pupillary border. Pigment loss from the iris sphincter region and its deposition on anterior chamber structures is a hallmark of XFS. Despite extensive research, the exact chemical composition of exfoliation material (XFM) remains unknown. An overproduction and abnormal metabolism of glycosaminoglycans have been suggested as one of the key changes in XFS. The protein components of XFM include both noncollagenous basement membrane components and epitopes of the elastic fiber system such as fibrillium. Regardless of etiology, typical exfoliation fibers have been demonstrated electron microscopically in close association with the pre-equatorial lens epithelium, the nonpigmented ciliary epithelium, the iris pigment epithelium, the corneal endothelium, the trabecular endothelium, and with almost all cell types of the iris stroma, such as fibrocytes, melanocytes, vascular endothelial cells, pericytes, and smooth muscle cells. The presence of XFS should alert the physician to the increased risks of intraocular surgery, most commonly zonular dehiscence, capsular rupture, and vitreous loss during cataract extraction. Heightened awareness of this condition and its associated clinical signs are important in the detection and management of glaucoma, and preoperative determination of those patients at increased risk for surgical complications.

Phacoemulsification in eyes with pseudoexfoliation

PURPOSE

To compare intraoperative and postoperative complications in eyes with and without pseudoexfoliation having cataract surgery by phacoemulsification.

SETTING

Department of Ophthalmology, National Hospital, Oslo, Norway.

METHODS

Of 1152 consecutive phacoemulsification procedures, 164 cases with pseudoexfoliation (Group 1) and 916 cases without (Group 2) were followed for 4 months after cataract surgery in a prospective study. Of all cataract operations performed during that time, 96.2% were phacoemulsification procedures; 90.4 and 97.4% in eyes with and without pseudoexfoliation, respectively (P < .0005).

RESULTS

The frequency of capsular/zonular tear or vitreous loss was 9.6 and 3.7% in Groups 1 and 2, respectively (P = .0002). A visual acuity of 0.5 or better was achieved in 86.5% of eyes in Group 1 and 92.4% in Group 2 (P = .02). There were no statistically significant between-group differences in the frequency of a postoperative inflammatory response 1 day (6.7 versus 4.4%), 1 week (2.4 versus 1.6%), or 4 months (1.8 versus 0.9%) postoperatively.

CONCLUSION

Phacoemulsification was safe in most eyes with pseudoexfoliation even though significantly more complications occurred intraoperatively in these eyes. The low frequency of an inflammatory response indicates that the presence of pseudoexfoliation does not significantly increase the risk of inflammation.

Cataract surgery and lens implantation in eyes with exfoliation syndrome

OBJECTIVE

To evaluate the surgical technique, intraoperative complications, and outcomes of extracapsular cataract extraction (ECCE) and intraocular lens (IOL) implantation in patients with exfoliation syndrome.

SETTING

Department of Ophthalmology, Hippokration Thessaloniki General Hospital, Thessaloniki, Greece.

METHODS

This prospective study comprised 84 patients with exfoliation syndrome who had ECCE and posterior chamber IOL implantation between December 1992 and November 1993. Main outcome measures were poor mydriasis, zonular rupture, vitreous loss, and best corrected visual acuity. Mean follow-up was 9.32 months (range 4 to 16 months).

RESULTS

Pupil diameter was smaller than 5.0 mm in 61.90% of the eyes. Zonular rupture, capsular tear, and vitreous loss occurred in 13.09, 10.71, and 7.14%, respectively. Best corrected visual acuity ranged from 7/10 to 10/10 in 72 eyes (85.71%).

CONCLUSION

Patients with exfoliation who had ECCE and posterior chamber IOL implantation had an increased risk of intraoperative complications. In these patients, surgery must be done by experienced surgeons able to handle all possible complications.

Prevalence and surgical complications of pseudoexfoliation syndrome in Portuguese patients with senile cataract

PURPOSE

To determine the prevalence and surgical complications of pseudoexfoliation syndrome (PES) in a Portuguese population of patients with senile cataract.

SETTING

Department of Ophthalmology, Coimbra University Hospitals, Coimbra, Portugal.

METHODS

In a prospective study, 183 consecutive patients with senile cataract referred to the Implant and Refractive Surgery Section of the Department of Ophthalmology were examined for PES. To determine the occurrence of intraoperative and postoperative complication of extracapsular extraction with posterior chamber intraocular lens implantation in patients with PES, two groups of similar age were compared: one with PES (n = 31) and a control group without PES (n = 31).

RESULTS

The prevalence of PES in the 183 Portuguese patients with senile cataract was 23.5%. There was statistically significant difference between the two groups in the presence of phacodonesis (P < .05), insufficient intraoperative mydriasis (P < .001), need to perform sphincterotomies to facilitate nucleus expression (P < .01), and formation of pupillary fibrin membranes in the postoperative period (P < .01). These complication were more frequent in the PES group. Zonular breaks also occurred more often in patients with PES, although this was not statistically significant.

CONCLUSIONS

Pseudoexfoliation syndrome was a common condition in patients with senile cataract having surgery in Portugal. Inadequate mydriasis was the major intraoperative difficulty; a pupil enlargement procedure should be performed in these cases. In the first days postoperatively, therapy with topical, subconjunctival, and systemic corticosteroids is recommended to reduce the inflammatory reaction in the anterior chamber.

Effect of postoperative mydriatics on the iris

PURPOSE

To assess the role postoperative mydriatics play after extracapsular cataract extraction (ECCE) and posterior chamber intraocular lens (IOL) implantation in causing iris modifications and in controlling inflammation.

SETTING

Outpatients Department, Ninewells Hospital, Dundee, Scotland.

METHODS

The prospective study comprised 136 patients who had standardized ECCE. Half the patients used a mydriatic for 2 weeks postoperatively. Anterior chamber activity, pain, and eye redness were evaluated at 2 weeks postoperatively; pupil shape, peripheral anterior synechias, IOL position, and iris adhesions, at 6 weeks.

RESULTS

Iris-lens adhesions were significantly more common in the group using a mydriatic. There was no difference between the two groups in postoperative inflammation.

CONCLUSION

Mydriatics should not be used routinely after ECCE with posterior chamber IOL implantation.

In vitro studies of conjunctival cells from eyes with and without pseudoexfoliation

The aim of the study was to examine for possible differences between cell cultures derived from eye with and without pseudoexfoliation. In both populations, scanning electron microscopy showed flattened epithelial cells and also spindleshaped fibroblast-like cells. The presence of these cell types was further confirmed by immunohistochemical demonstration of cytokeratin and vimentin in the cultured cells. The cells maintained in vitro showed a linear increase in uptake of leucine during a 12-h period. Within this period, the leucine recovered in the TCA precipitable fraction was considerably higher than the nonbound fraction. In cultures maintained in medium with and without L-ascorbic acid, the presence of L-ascorbic acid significantly increase the uptake of leucine into TCA precipitable material, and to a similar extent in cultures from the two populations. In conclusion, cells derived from eyes with and without pseudoexfoliation material and maintained in vitro showed similar morphology, presence of intermediate filaments, as well as uptake of leucine under various culture conditions.

A histopathologic study of zonular instability in pseudoexfoliation syndrome

A weak zonular apparatus has been postulated to account for the high incidence of phacodonesis, lens dislocation, and vitreous complications during extracapsular cataract surgery in eyes with pseudoexfoliation syndrome. To clarify and localize the cause of zonular weakness, we examined 11 eyes with pseudoexfoliation syndrome by using scanning and transmission electron microscopy. The production of pseudoexfoliation material by both the nonpigmented ciliary epithelium and the pre-equatorial lens epithelium resulted in typical alterations of the zonules at three levels. (1) At their origin and anchorage in the ciliary body, the zonular bundles were separated from the disrupted basement membrane of the nonpigmented epithelium by intercalating pseudoexfoliation fibers. (2) In the pars plicata of the ciliary body, pseudoexfoliation material infiltrated the zonular bundles passing alongside the ciliary processes leading to zonular rupture. (3) At their attachment to the anterior lens capsule, the zonular lamella was focally lifted and subsequently ruptured by pseudoexfoliation masses erupting through the capsular surface. The immunohistochemical demonstration of lysosomal enzymes within pseudoexfoliation aggregates indicates that proteolytic mechanisms facilitate zonular disintegration. Ophthalmologists treating eyes with pseudoexfoliation syndrome should be aware of these alterations.

Heparin-surface-modified intraocular lens implantation in eyes with pseudoexfoliation syndrome

Eyes with pseudoexfoliation syndrome have a greater risk of intraoperative and postoperative complications. Clinical and histopathological studies indicate that heparin-surface-modified intraocular lenses (HSM IOLs) can reduce postoperative anterior segment inflammation. Our study evaluated the blood-aqueous barrier permeability in eyes with pseudoexfoliation syndrome and implanted with an HSM IOL. We examined two groups of 20 patients, one comprising patients with pseudoexfoliation syndrome and one a sex- and age-matched control group with senile cataracts. Each group was divided into two subgroups of ten patients each. In one subgroup, an HSM IOL was implanted; in the other, a conventional poly(methyl methacrylate) IOL. We performed a complete ophthalmologic examination and iris angiography preoperatively and at 30, 90, and 180 days after surgery. Fluorophotometry was performed at the 90-day and 180-day postoperative examinations. The patients with pseudoexfoliation syndrome had a higher blood-aqueous barrier permeability than did the control group. Permeability decreased significantly three and six months after surgery, especially in the HSM IOL group.

Extracapsular cataract extraction in eyes previously operated for glaucoma

Extracapsular cataract extraction with IOL implantation was performed in 32 consecutive cases of glaucomatous eyes which previously had undergone trabeculectomy (group A). The only complication seen during surgery was one tear in the posterior capsule. The mean IOP on postoperative day 1 was 17.7 +/- 7.9 mmHg. After extracapsular cataract extraction in 68 glaucomatous eyes with no previous surgery (group B) the corresponding mean IOP was 21.7 +/- 7.5 mmHg (p = 0.015). However, the mean preoperative IOP level was lower in group A (group A: 14.3 +/- 4.0 mmHg, group B: 17.1 +/- 4.3 mmHg), so the increase in IOP was not significantly different in the two groups. In group A, 15.6% of the eyes had an IOP elevation exceeding 24 mmHg, compared to 30.9% of the eyes in group B. Four months postoperatively, the IOP was significantly reduced in group B and unchanged in group A (compared to preoperatively). Seventy-two percent of the eyes in group A and 79% of the eyes in group B achieved a visual acuity of 5/10 or better, respectively.

Results and complications after extracapsular cataract extraction in eyes with pseudoexfoliation syndrome

Postoperative results and complications in 136 eyes with pseudoexfoliation syndrome were compared to 744 eyes without pseudoexfoliation syndrome in a consecutive study. The patients were followed for 4 months postoperatively. Excluding cases with glaucoma, 81.4% of the pseudoexfoliation eyes and 83.0% of the eyes without pseudoexfoliation achieved a corrected visual acuity of 5/8.5 or better. IOL malposition was rare in both groups (1.5% in the pseudoexfoliation group and 1.6% in the group without pseudoexfoliation). IOP elevation the first day postoperatively occurred most often in the pseudoexfoliation eyes. In the pseudoexfoliation eyes, postoperative iritis and cellular precipitates were demonstrated in 16.2% and 11.0%, respectively, compared to 3.8% and 3.2% in the eyes without pseudoexfoliation (p < 0.001). The frequency of an inflammatory reaction was highly correlated to small pupil size during operation in both groups.

Pseudoexfoliation syndrome and extracapsular cataract extraction

Extracapsular cataract extraction (ECCE) in 139 eyes with pseudoexfoliation syndrome was compared to 762 eyes without pseudoexfoliation syndrome in a consecutive study. Preoperative findings, operative procedure and problems were registered, stored and analyzed in a computer program package. Of the patients with pseudoexfoliation syndrome 88.5% were 70 years or older, compared to 67.2% of the patients without pseudoexfoliation syndrome (p < 0.001). Glaucoma occurred in 48.9% of eyes with pseudoexfoliation syndrome and in 6.8% of eyes without pseudoexfoliation syndrome, respectively. Poorly dilated pupil was demonstrated in 46.8% and in 5.8% of eyes with and without pseudoexfoliation syndrome, respectively. Capsule/zonulae tears (without vitreous loss) occurred in 4.3% of the pseudoexfoliation syndrome eyes, compared to 1.3% in eyes without pseudoexfoliation syndrome (p < 0.05). The incidence of vitreous loss was similar in both groups. We found no correlation between the pupil size and capsule/zonulae tears or vitreous loss in either group. In conclusion, when appropriate care is undertaken, ECCE with posterior chamber IOL implantation is a safe procedure in pseudoexfoliation syndrome eyes.

Exfoliation syndrome and cataract extraction

In a prospective study of 351 consecutive cataract operations performed on Finnish patients, the prevalence of exfoliation syndrome was 31% (108 of 351 eyes), increasing from 0% (zero of 54 eyes) in patients younger than 60 years to 15% (12 of 78 eyes) in patients aged 60 to 69 years, 42% (57 of 137 eyes) in patients aged 70 to 79 years, and 48% (39 of 82 eyes) in those aged 80 years or more, than has previously been reported in general populations of the same age in Finland. Exfoliation syndrome was more common in patients aged 70 years or more. Glaucoma was found in 41 of 108 eyes with exfoliation syndrome (38%). Exfoliation syndrome increased the risk of intraoperative complications in extracapsular cataract extraction either directly (rupture of the zonules) or through poor dilation of the pupil (rupture of the posterior lens capsule). The occurrence of vitreous loss was fourfold, and the need to use an anterior chamber intraocular lens instead of a posterior chamber lens because of loss of capsular support was tenfold in eyes with exfoliation as compared to those without exfoliation.

Intraocular pressure after extracapsular cataract extraction with implantation of posterior chamber lenses

To determine factors which influence postoperative intraocular pressure (IOP) we retrospectively reviewed changes in pressure during the first postoperative week in 633 consecutive eyes undergoing extracapsular cataract extraction (ECCE) with implantation of a posterior chamber lens. The material was restricted to four surgeons and two types of lenses. IOP was measured preoperatively, one day and one week after surgery. Glaucomatous eyes (n = 113) as well as exfoliative non-glaucomatous eyes (n = 79) had a higher mean IOP (27.8 and 26.1 mmHg) the first postoperative day compared to 'simple' cataract eyes (20.1 mmHg). After one week mean IOP in glaucomatous eyes still remained elevated while exfoliative non-glaucomatous eyes had regained preoperative values. Mean IOP on the first postoperative day (18.8, 24.5, 23.1 and 13.2 mmHg respectively) was also dependent on surgeon. To some extent the IOP could be correlated to tightness of suturing as estimated by keratometry. Only one surgeon had significant difference between irrigated and non-irrigated visco-elastic substance. Postoperative pressure was not only dependent on the status of the patient's eye, but factors for the individual surgeons seemed to be as important.

Incidence of posterior capsule opacification in eyes with exfoliation syndrome and heparin-surface-modified intraocular lenses

Conventional poly(methyl methacrylate) (PMMA) intraocular lenses (IOLs) and heparin-surface-modified (HSM) IOLs were implanted after extracapsular cataract extraction in 40 human eyes with exfoliation syndrome. The study was double-masked and randomized. Two years after surgery 17 cases with HSM IOLs and 15 with PMMA IOLs were examined. We observed that pigment and cell deposits were more frequent on the PMMA than on the HSM IOLs. The incidence of posterior synechia formation was similar in both groups. However, the incidence of neodymium:YAG laser posterior capsulotomy and posterior capsule opacification was more frequent in the PMMA IOL group. Visual acuity did not differ between the two groups before or two years after surgery. The results suggest that in eyes with exfoliation syndrome, implanting an HSM IOL reduces the incidence of posterior capsule opacification often associated with extracapsular cataract extraction.

Pseudoexfoliation syndrome as a risk factor for acute ciliary block angle closure glaucoma

Two patients presented with unilateral ciliary block angle closure glaucoma and bilateral pseudoexfoliation (PSX) syndrome and were treated successfully with posterior sclerotomy (one case), extracapsular cataract extraction and posterior chamber lens implantation. None of the eyes had undergone previous ocular surgery except Nd: YAG-laser iridotomy. Axial lengths as measured with A-scan ultrasonography were 22.48 mm and 24.30 mm. During follow-up of 5 and 12 months, intraocular pressure was well controlled without antiglaucoma medication in both patients. We suspect that the well-known changes of the zonula origin at the ciliary epithelium in PSX syndrome lead to anterior subluxation of the lens with consecutive ciliary block angle closure glaucoma. Ciliary block angle closure glaucoma seems to be another serious complication in PSX syndrome. Therefore, miotics should probably be used with care in PSX eyes with signs of zonular alterations because they may trigger this mechanism.

Exfoliation syndrome in patients scheduled for cataract surgery

A series of 305 consecutive patients 30 years of age or older scheduled for cataract surgery was examined to find out the frequency of exfoliation syndrome, the predominant type of cataract, and the intraocular pressure status. The mean age of 222 (72.8%) females and 83 (27.2%) males was 71.7 (+/- 11.1) years (range 32 to 91 years). Exfoliation was detected in 77 (25.2%) patients. It was unilateral in 37 (48.0%) patients, the affected eye being in 29 (78.4%) cases scheduled for cataract surgery, and bilateral in 40 (52.0%) patients. Exfoliation was increased steadily with age. It was most often seen on the anterior lens capsule (88.9%). Krukenberg's spindle was seen in 31 (20.4%) eyes of patients with and in 12 (2.6%) eyes of patients without exfoliation (p less than 0.001). Nuclear sclerosis predominated in eyes with (83.8%) as compared to those without (61.9%) exfoliation (p less than 0.01). Posterior subcapsular cataract was less common in eyes with exfoliation (1.5%) than in eyes (21.1%) without it (p less than 0.001). A tendency to slightly higher preoperative intraocular pressure was measured in eyes with exfoliation as compared to those without it, and glaucoma occurred much more frequently (33.8% vs 10.8%) in the former group (p less than 0.001). Exfoliation and capsular glaucoma, which must be promptly detected to avoid surgical complications, are frequent in patients scheduled for cataract surgery.

Clinical features of capsular glaucoma in comparison with primary open-angle glaucoma in Japan

Clinical features of capsular glaucoma during a recent 15-year period were compared with those of primary open-angle glaucoma (POAG). Out of 1623 new glaucoma patients, 263 patients (16.2%) were capsular glaucoma and 268 (16.5%) were POAG. The patients with capsular glaucoma were older than the patients with POAG. The former had higher intraocular pressure, lower visual acuity, more advanced visual field change and heavier trabecular pigmentation than POAG patients at the time of initial examination. These findings suggest that capsular glaucoma is more difficult to manage than POAG and that the prognosis is poorer than for POAG. Pseudoexfoliative material was found on the pupillary border in 98.3%, on the central lens surface in 46.1%, and on the peripheral lens surface in 72.3%. Though 190 of 263 patients with capsular glaucoma (73.9%) were unilateral cases, 38.9% of the fellow eyes had some abnormalities related to glaucoma. Phakodonesis was found in 10% of patients with capsular glaucoma. This finding suggests that the presence of capsular glaucoma might be a risk factor in cataract surgery.

Exfoliation syndrome and extracapsular cataract extraction with implantation of posterior chamber lens

Extracapsular cataract extraction followed by implantation of a one-piece posterior chamber polymethylmethacrylate intraocular lens (IOL) into the capsular bag was performed in 25 eyes with exfoliation syndrome and 20 control eyes. The patients were investigated preoperatively and then 1 day, 1 week, 3, 6 and 12 months after surgery. Preoperatively, maximal pupil dilatation was significantly smaller in eyes with exfoliation syndrome compared to controls. During surgery the incidence of complications such as ruptures of the zonule or posterior lens capsule, were higher in eyes with exfoliation syndrome. Furthermore, postoperative complications, such as fibrinoid reaction anterior to the IOL followed by posterior synechias and cell deposits, were more common in eyes with exfoliation syndrome compared to control eyes. The results imply that compared to control eyes, eyes with exfoliation syndrome are likely to present more complications both during extracapsular cataract extraction with implantation of intraocular lenses and postoperatively.

Exfoliation syndrome and heparin surface modified intraocular lenses

Either heparin surface modified (HSM) or regular polymethyl methacrylate (PMMA) intraocular lenses (IOLs) were implanted after extracapsular cataract extraction in 40 human eyes with exfoliation syndrome in a double-masked, randomized study. The patients were investigated preoperatively, and then 1 day, 1 week, 3, 6 and 12 months postoperatively. In eyes implanted with the HSM IOL, 26% had a fibrinoid reaction anterior to the IOL, while this complication was found in 50% of eyes implanted with the regular IOL. Pigment and cell deposits were more frequent on the regular IOLs than on the HSM lenses postoperatively. Posterior synechia formation between the iris and the implant or lens capsule was more common in the eyes with regular IOL compared to HSM IOL. No difference in visual acuity between the two groups was found either before or after surgery. The results suggest that in eyes with exfoliation syndrome, a heparin surface modified IOL reduces clinical complications associated with cataract surgery.

Gonioscopic findings in Greek patients with exfoliation glaucoma

A prospective gonioscopic evaluation was carried out upon a cohort of Greek patients who had undergone trabeculectomy for open-angle glaucoma. Sixty-five patients were found to show clinical evidence of exfoliation glaucoma (EXG), whilst nine patients were deemed to have primary open angle glaucoma (POAG). The gonioscopic features of these eyes and of 43 non-operated eyes from the same patients with either exfoliation syndrome (EXS) or EXG are presented. The median degree of angle pigmentation was significantly higher in the operated eyes with EXG when compared with the POAG cases. In the operated eyes, deposition of exfoliation was found on the ciliary processes in 82% of cases and on the zonules in 52%.

Phacoemulsification and intraocular lens implantation in patients with cataract. Experiences of a beginning 'phacoemulsification surgeon'

Phacoemulsification was performed in 125 eyes (123 patients) selected from 145 eyes (143 patients) referred for planned extracapsular cataract extractions and intended posterior chamber intraocular lens implantations. These procedures were the first clinical phacoemulsification operations performed by the author. In the total material, lesion of the posterior capsule or zonules occurred in 7 eyes (4.9%). Vitreous loss occurred in 3 of these eyes (2.1%). In cases with vitreous loss the operative strategy was changed to implantations of anterior chamber lenses. Five of the 7 eyes that experienced intraoperative complications, had preoperative complicating conditions other than cataract. Visual acuity 6 to 12 weeks postoperatively was 6/12 or better in 87% (126/145) of the eyes. Excluding preoperative posterior segment pathology, 98.4% (126/128) achieved this visual acuity. This study demonstrates that it is possible to include phacoemulsification as the main treatment modality in planned ECCE operations without significant increase in complication rates even for a 'beginning phacoemulsification surgeon'.

Pseudoexfoliation glaucoma in Greece

Pseudoexfoliation glaucoma is commonly seen in Greece, however there is little data concerning the prevalence and characteristics of this disorder. Patients undergoing trabeculectomy for open angle glaucoma were investigated both by the appraisal of the case notes and by re-examination. The prevalence of pseudoexfoliation glaucoma in this population was found to be 87.8%. The characteristics of this disease process in the population studied are discussed. These findings indicate that pseudoexfoliation is a major contributor to severe glaucoma in the population of Northern Greece.

Fibrinoid reaction after extracapsular cataract extraction and relationship to exfoliation syndrome

A transitory deposit of a fibrin-like material in the anterior chamber following extracapsular cataract extraction and intraocular lens (IOL) implantation is described. In two studies, one retrospective of 352 operations and one prospective of 189 operations, the fibrinoid reaction was observed in 17% and 11% of the eyes, respectively. The reaction appeared in the early postoperative period in an otherwise quiet eye and the signs varied from a few threads in the pupil area to a dense pupillary membrane in front of the IOL. The deposit disappeared one day to three weeks postoperatively, usually without any remnants. The majority of eyes with the fibrinoid reaction had received a posterior chamber IOL. A strong association with the exfoliation syndrome was found and an increased vascular permeability is suggested as a probable cause of the reaction.

Results of the intercapsular technique with the IOGEL lens

Standard biconvex 12 mm diameter IOGEL PC-1 hydrogel intraocular lenses were inserted into the eyes of 55 patients using intercapsular in-the-bag placement and extracapsular ciliary sulcus placement. All patients had senile cataracts. Endothelial specular microscopic assessment was performed preoperatively and postoperatively at six and 12 months. Viscoelastic agents were not used in any of the cases and upper haptic positioning was achieved with dialing and irrigation and iris retraction in each group, respectively. Major complications in both groups were iridocapsular synechias. This resulted in dislocation of a single haptic into the anterior chamber angle in one ciliary-sulcus-placed lens and in an updrawn pupil in one of the intercapsular cases. Pigment dispersion syndrome occurred in one case with a ciliary-sulcus-placed lens. In one case in each group a Nd:YAG laser posterior capsulotomy was performed. Whereas the visual results in each group were similar, the percentage cell loss was significantly greater in the group with lenses in the ciliary sulcus at six months postoperatively. The lower cell loss in the intercapsular group was attributed to the protective effect of the anterior capsule on the endothelium during the major intraocular manipulations.

Topical indomethacin in extracapsular cataract surgery. A photographic study

A photography-based single-blind study was conducted to evaluate the effect of topical indomethacin on the per-operative pupil of 52 consecutive patients undergoing an extracapsular cataract extraction with or without an intraocular lens. Each operation was done by the author. Per-operative miosis was significantly smaller in the group receiving indomethacin as compared with the control group (P = 0.06-0.13). A reproducible photographic method for evaluating the per-operative behavior of the pupil is described.

Considerations on posterior chamber intraocular lens implantation in patients with pseudoexfoliation syndrome

The authors describe the principal difficulties and intra and post-operative complications frequently encountered in IOL implantation surgery in P.C. in patients with pseudoexfoliation syndrome (SPE); particular attention is given to incomplete mydriasis, the facilitation of expulsion by sphyncterotomy or radial iridotomy, zonule rupture, uveal retraction, endothelial involvement, hyphema and lens dislocation. These complications were more numerous in patients with SPE plus glaucoma. The authors conclude that, with adequate pre-operative investigation and appropriate measures during surgery, SPE with or without glaucoma is not to be considered an absolute contraindication to IOL implantation in P.C.

Combined procedure for the management of glaucoma and cataract

Thirty eyes of 29 patients (12 male and 17 female) with an age range 50-86 years (mean 76 years) were operated by combined technique for cataract and glaucoma with a follow-up ranging between 6-18 months (mean 6.8 months). Seventeen eyes had capsular glaucoma and 13 eyes simple glaucoma. The surgical technique of trabeculectomy, extracapsular cataract extraction and posterior chamber lens implantation is described. The pre-operative IOP was 31.5 mmHg +/- 7.8 on maximum tolerated medical therapy and the post-operative IOP 17.8 mmHg +/- 3.9. Fourteen eyes had to be treated with topical timolol X 2 daily after the operation. Twenty-eight eyes had a pre-operative visual acuity of less than or equal to 0.3. Of these, 17 had a visual acuity of less than or equal to 0.1, and were severely visually handicapped. Visual acuity improved markedly in 24 eyes and remained unchanged in 6 eyes. Every patient but one (with vitrectomy and no lens implantation) experienced considerable subjective visual increase. The main complications consisted of vitreous loss in one eye and fibrinous effusion into the anterior chamber in 7 capsular glaucoma eyes. Pre-operative precautions and post-operative care are important. The combined triple procedure is recommended for the management of patients with uncontrolled glaucoma and cataract.

Capsule thickness of cataractous lenses with and without exfoliation syndrome

Lens capsule thickness was measured in 105 cataractous lenses with and without exfoliation syndrome. The lenses were removed by intracapsular cryoextraction. Forty lenses (38%) showed exfoliation, while 65 (62%) were exfoliation negative. Thickness values were measured by light microscopy from the central anterior capsule, central posterior capsule and from the equator. The mean thickness values were for the central anterior capsule 8.2 +/- 3.2 mu, for the central posterior capsule 3.2 +/- 1.4 and for the equator 3.9 +/- 1.3. There was no statistical difference between the exfoliation-positive and exfoliation-negative lenses. The capsule thickness varied greatly throughout the present material. The highest value, 22.4 mu, was measured from an exfoliation-negative central anterior lens capsule of a male patient aged 33 years. The lowest value, 0.6 mu, was measured from an exfoliation-positive central posterior capsule of a male patient aged 64 years. The central posterior capsule is the thinnest area of the lens capsule. The findings call for great caution in polishing the posterior capsule during extracapsular cataract surgery. The higher complication rate in eyes with exfoliation syndrome cannot be explained by thinner lens capsules but rather on the more friable zonules.