Cataract extraction complicated by capsular glaucoma

[Late results of phaco-canaloplasty in patients with concomitant advanced pseudoexfoliation glaucoma and cataract]

PURPOSE

To assess the safety and efficacy of phaco-canaloplasty in patients with concomitant advanced pseudoexfoliation glaucoma and cataract.

MATERIAL AND METHODS

The study included 56 patients (57 eyes) who underwent phacoanaloplasty guided by Glaucolight microcatheter. All patients were followed up for 48 months. Visual acuity, changes of intraocular pressure (IOP), use of glaucoma medications, incidence of complications, as well as postsurgical interventions were examined.

RESULTS

Mean preoperative IOP decreased significantly from 29.8 mmHg (15.8-61.6) with a mean of 1.92 (0-3) glaucoma drops to 12.9 mmHg (11.0-19.6) with a mean of 0.12 (0-3) drops respectively 48 months after phacocanaloplasty. Mean visual acuity increased from preoperative 0.15 (0.01-0.8) to 0.6 (0.01-1.2). The most frequent complications included intraoperative perforation of Descemet's membrane (4 eyes, 7%) and hyphema (37 eyes, 65%), IOP spikes (4 eyes, 7%) and inflammation (4 eyes, 7%) in the early postoperative period.

CONCLUSION

Phacocanaloplasty in eyes with concomitant advanced pseudoexfoliation glaucoma and cataract re-establishes the natural outflow system and leads to significant IOP reduction with minimal risk of intra- and postoperative complications.

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.

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.

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.

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.

Pseudoexfoliation syndrome and secondary cataract

AIM/BACKGROUND

The pseudoexfoliation (PEX) syndrome is frequently associated with impairment of the blood-aqueous barrier. This study analysed if this might stimulate secondary cataract following cataract extraction.

METHODS

This historical cohort study included 197 eyes of 197 patients (99 with and 98 without PEX) that underwent extracapsular cataract extraction with posterior chamber lens implantation (PMMA optic) between 1985 and 1991. Secondary cataract was defined as opacification of the axial posterior capsule and decrease of visual acuity by two or more lines. Mean follow up was 23.8 months. For statistical analysis, the Kaplan-Meier method and multivariate Cox regression analysis were used.

RESULTS

Secondary cataract was observed within 24 months in 35% (SD 7%) of all eyes, and was significantly more frequent in eyes with PEX (45 (11)%) than in eyes without PEX (24 (9)%, p < 0.03). Eyes with diabetes mellitus (n = 32) showed a significantly lower frequency of secondary cataract (11 (11)%) than eyes without diabetes mellitus (39 (8)%, p < 0.01). The influences of sex, open angle glaucoma, type of cataract, surgeon, positioning of IOL, and phacoemulsification versus nuclear expression on secondary cataract did not reach statistical significance.

CONCLUSION

The higher frequency of secondary cataract could be considered as another potential complication of cataract surgery in eyes with PEX.

Centration and fixation of posterior chamber intraocular lenses in eyes with pseudoexfoliation syndrome. An analysis of explanted autopsy eyes

Pseudoexfoliation syndrome is an important risk factor in cataract surgery. We examined decentration of posterior chamber intraocular lenses in a series of 24 autopsy eyes with pseudoexfoliation syndrome that had undergone cataract surgery and intraocular lens implantation. The results were compared to a control group of 25 normal autopsy eyes that matched the pseudoexfoliation collection for age distribution, implant duration and further anatomical parameters. The mean lens decentration in all pseudoexfoliation eyes (0.75 +/- 0.38 mm) was significantly higher than in the control group (0.40 +/- 0.29 mm) (p = 0.0008). Analysis of subgroups with symmetrical bag/bag fixated intraocular lenses showed a significantly higher decentration in the pseudoexfoliation group (p = 0.04). The main reason for decentration was a decentration of the entire capsular bag in pseudoexfoliative eyes (p = 0.001), which was related to zonular weakness and damage. The results indicate that in patients with pseudoexfoliation syndrome alternative fixation sites, like sulcus or transscleral fixation, should also be considered.

Pseudoexfoliation syndrome with poorly dilating pupil: a light and electron microscopic study of the sphincter area

BACKGROUND

The study was carried out to examine histological changes in the iris sphincter muscle and surrounding tissue in eyes with pseudoexfoliation syndrome (PXS).

METHODS

Seventeen patients with PXS, 14 of them having capsular glaucoma, were enrolled into the study. Iris biopsies were obtained during extracapsular cataract extractions (ECCE) requiring sphincterotomies. Thirteen biopsy specimens underwent histological examination by light microscopy, and four were examined with the electron microscope. Three iris biopsies from cadaver eyes and one obtained during ECCE from a patient with a miotic pupil (no PXS) served as control specimens on light microscopy. Electron microscopic controls included three iris specimens from cadavers.

RESULTS

In the light microscopic examination, blood vessel walls were stained with Congo Red in seven of the 13 PXS specimens. In three of these seven specimens the stromal tissue was extensively fibrotized, and in two specimens fibrosis was moderate. Distinct stromal fibrosis was also observed in one and moderate fibrosis in two PXS specimens negative for amyloid. The control specimens were not positive for Congo Red, but stromal tissue was moderately fibrotized in one specimen. Light microscopy did not reveal differences in muscle tissue between PXS and control specimens. Electron microscopically, however, the muscle tissue was fibrotic or disorganized in three PXS specimens and in one control specimen. Fibrils, similar to the fibrillar component of pseudoexfoliation material described in previous studies, were found in intimate association with the capillary basal lamina in all of the PXS specimens showing muscular fibrosis.

CONCLUSIONS

These findings support the theory that PXS is associated with amyloid, and in some PXS eyes miosis is connected with degenerative changes both in the stromal tissue and in the muscular layer of the iris.

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.

Exfoliation syndrome and occludable angles

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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 the effect of phenylephrine and pilocarpine on pupil size

The horizontal diameter of the pupil was measured on 20 eyes with exfoliation syndrome and 20 control eyes before and after the instillation of 10% phenylephrine and 4% pilocarpine eye drops. Pupil dilation induced by topical application of the alpha 1 adrenoceptor agonist phenylephrine was significantly smaller in eyes with exfoliation syndrome compared to controls. The cholinergic agonist pilocarpine decreased pupil diameter and this effect was significantly less in cases with exfoliation syndrome. We conclude from these data that the pharmacological response to both adrenergic and cholinergic stimulation is weaker in eyes with exfoliation syndrome compared to controls.

Complicated extracapsular cataract surgery in pseudoexfoliation syndrome: a case report

Crystalline lens dislocation and zonular dialysis during intraocular surgery are recognised features of the pseudoexfoliation syndrome (PES). A case is reported in which zonular dialysis occurred in both eyes during extracapsular cataract extraction. In particular surgery was complicated by difficulty in performing anterior capsulotomy. Careful preoperative assessment and peroperative technique may help to reduce the risk of surgical complication in PES.

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.

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.

Precapsular film on the aging human lens: precursor of pseudoexfoliation?

In many older patients we observed a layer of subtle opacification on the anterior lens capsule, appearing as a ground glass film biomicroscopically. This precapsular film (PCF) could be uniform but often had radial grey lines in the mid zone, holes in the paracentral region, and was occasionally rolled up in strings. Lens capsular material obtained at cataract extraction was studied in patients with and without the film. By scanning electron microscopy the PCF appeared as a friable, incomplete fibrillar layer, with rolling of the edges suggesting loose attachment. Ultrastructurally its component fibrils were from 3-6 nm in diameter, similar to the finer fibrils in pseudoexfoliation (PSX) material. Life PSX material the layer stained positively for the elastic microfibril-associated protein, fibrillin, in a lens with radial striations. These similarities suggested that the two conditions have some relationship and that the PCF may be a precursor of PSX. Finding patches of the fibrillar network in some control patients implies that the PCF is common in patients of cataract age, though seldom detected clinically.

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.

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.

Intraocular lens implantation in exfoliation syndrome and capsular glaucoma

The intra-operative difficulties and post-operative complications after posterior chamber lens implantation are described in 30 eyes with exfoliation syndrome (including 19 eyes with capsular glaucoma (CG), 30 age- and sex-matched patients with non-exfoliative eyes comprised a comparison group. Three eyes of the control group had simple glaucoma. The highest risk rate for intra-operative difficulties and post-operative complications was found in the CG group. 8/19 eyes had intra-operative difficulties and 7/19 post-operative complications corresponding 3/11 eyes and 2/11 eyes, respectively, in the exfoliation (E) group. Eyes in the control group had a low rate of complications, 3/30 intra-operatively and 2/30 post-operatively. In 63% of the CG and E eyes the visual acuity was 0.5-1.0 1 month post-operatively compared with 70% in the control group. Exfoliation syndrome is not a contraindication for posterior chamber lens implantation. Special attention should be paid to IOL selection. Complications due to insufficient mydriasis, weak zonules and possible undiagnosed lens subluxation, should be taken into account on planning the operation.

Anterior chamber depth in eyes with pseudoexfoliation

The depth of the anterior chamber was measured in 34 eyes with pseudoexfoliation but without glaucoma and in 334 normal controls. No significant difference was found.