Long-Term Outcome of Cataract Surgery in Eyes with Pseudoexfoliation Syndrome Associated with Weak Zonules: A Case Report

Aqueous humor metabolomic profiling identifies a distinct signature in pseudoexfoliation syndrome

Purpose

PEXS was first described in 1917, yet its etiology still needs clarification. An imbalance between oxidants and antioxidants plays a significant role. PEXS leads to various ocular complications, including increased risk during cataract surgery due to weak zonules, lens dislocation, and reduced visual outcomes. Our study investigates whether metabolomics can provide insights into this ocular pathology.

Methods

The study included 183 patients undergoing cataract surgery at Pauls Stradins Clinical University Hospital. 104 patients did not have PEXS, while 79 were diagnosed with the condition. Intraocular fluid samples from these patients were analyzed using targeted metabolite analysis, performed through HILIC liquid chromatography coupled with mass spectrometry detection.

Results

The aqueous humor of PEXS patients contains statistically significant higher levels of cystine (p < 0.001), citrulline (p < 0.001), phenylalanine (p = 0.041), tyrosine (p = 0.025), serine (p = 0.030), arginine (p = 0.017), lactic acid (p = 0.055), tryptophan (p = 0.055), and creatinine (p = 0.022). These results suggest a potential link to ferroptosis.

Conclusion

Ferroptosis is a form of programmed cell death characterized by iron-dependent LPO. The inhibition of the antiporter system Xc - leads to increased oxidative stress, suggesting that the changes seen in PEXS could be linked to ferroptosis. Our findings indicate that cysteine synthesis occurs via the transsulfation pathway, attributable to inhibiting the antiporter system Xc -. Treatment of pseudoexfoliation should lower the oxidative stress inside the anterior chamber by reducing the uptake of PUFAs, lower iron levels, and cysteine supplementation.

Three-piece intraocular lens in the sulcus with optic capture in patients with mild to moderate zonular weakness in exfoliation

Purpose

To study the use of sulcus placement of a 3-piece intraocular lens (IOL) with optic capture in patients with exfoliation with zonular weakness.

Methods

Data on all exfoliation patients who had direct or indirect evidence of zonular weakness and had a 3-piece IOL implanted in the sulcus with optic capture over a 5-year period between January 2017 and January 2022 were included in this retrospective case series.

Results

The study comprised of 35 eyes of 35 patients. The mean age at surgery of the 20 male and 13 female patients was 75.21 years ± 5.74 (standard deviation (SD)). The mean pupillary diameter was 5.77 ± 2.23 mm (range: 10 to 3 mm). A capsular tension ring (CTR) was used in 17 cases and iris hooks as a pupil-expanding device were used in 15 cases. No patients had an increase in inflammation after surgery and there were no late subluxation or dislocation of "in the bag" posterior chamber IOL or major complications. There was a significant improvement in visual acuity.

Conclusion

The sulcus placement of 3-piece IOL with optic capture is the ideal technique in patients with clinical or intraoperative evidence of mild to moderate zonular weakness. It may also be more appropriate in relatively younger patients (in the fifties or sixties) with exfoliation with no overt zonulopathy to prevent late subluxation or dislocation of "in the bag" IOL.

Anterior Capsule Opening Contraction and Late Intraocular Lens Dislocation after Cataract Surgery in Patients with Weak or Partially Absent Zonular Support

Background and Objectives: To evaluate anterior capsule opening (ACO) contraction and late intraocular lens (IOL) dislocation after cataract surgery in patients with weak or partially absent zonular support and assess methods of reducing these complications. Materials and Methods: For this prospective study, we enlisted cataract surgery patients in our hospital with preoperative diagnoses of weak zonules. All patients received phacoemulsification surgery with implantation of a hydrophobic acrylic IOL and capsular tension ring (CTR). ACO reductions were measured for six months after enrolment. Data on late IOL dislocations were collected five years after enrolment of the last patient. Results: Fifty-three patients were enrolled from 2011 to 2015. Over the six-month active follow-up period, ACO area reduction was 23% in patients receiving CTRs of 11 mm diameter and 8% for patients with CTRs of 12 mm, with an overall mean of 15% reduction. Five years after the last patient was enrolled, seven patients (13%) had experienced late IOL-CTR-capsular bag dislocation. For these patients, the mean ACO reduction in the first six months of follow-up was 33%, including for those who had received neodymium-doped yttrium aluminum garnet (Nd: YAG) anterior capsulotomies. Conclusion: Use of hydrophobic acrylic lenses and CTR reduces ACO contraction, with rates comparable to those after cataract surgery without ocular comorbidity. Our patients experienced a relatively high rate of late IOL-CTR-capsular bag dislocation. However, dislocated complexes were easily repositioned and few patients required IOL exchange. Frequent visits are warranted to promptly detect late complications of cataract surgery in patients with weak zonular support.