Quantification of aqueous flare after phacoemulsification with intraocular lens implantation in eyes with pseudoexfoliation syndrome

Inflammatory reaction in eyes with late in-the-bag intraocular lens dislocation

PURPOSE

To investigate the inflammatory reaction in eyes with late in-the-bag intraocular lens (IOL) dislocation.

METHODS

This prospective clinical study with fellow-eye comparison consists of 76 of the patients (76 eyes) with late in-the-bag IOL dislocation enrolled in the LION trial. The main outcome measure was anterior chamber flare before surgery measured with a laser flare meter in photon counts per millisecond (pc/ms). The dislocation was graded as 1 (small: optic still covering the visual axis), 2 (optic equator close to the visual axis) or 3 (optic decentred beyond the visual axis, but the IOL-capsule complex partly visible in the pupillary area). The secondary aim was to compare intraocular pressure (IOP) before surgery.

RESULTS

Flare levels before surgery were significantly higher in the dislocation eyes than in the fellow eyes with a median flare of 21.5 (range 5.4-135.7) pc/ms versus 14.1 (2.0-42.9) pc/ms, respectively (p ˂ 0.001). A regression analysis of log-transformed flare values showed that the dislocation eyes had a non-significant tendency towards higher flare in dislocation grade 1 with a median flare of 24.6 (5.4-135.7) pc/ms compared to grade 2; 19.6 (6.5-41.5) pc/ms (p = 0.06), and no significant difference compared to grade 3; 19.4 (10.2-53.5) pc/ms (p = 0.47). The IOP was significantly higher in the dislocation eyes than in the fellow eyes (p ˂ 0.001).

CONCLUSIONS

Eyes with late in-the-bag IOL dislocation had increased flare levels compared to their fellow eyes. This suggests that inflammation is part of the clinical picture of late in-the-bag IOL dislocation.

Anterior chamber flare and choroidal vascular index as inflammatory markers after uncomplicated phacoemulsification surgery

PURPOSE

To determine the effect of phacoemulsification surgery, which is one of the types of cataract surgery by using ultrasonic power to break up the crystalline lens and clean it with vacuum, on anterior chamber flare (ACF) and choroidal vascular index (CVI).

METHODS

For this cross-sectional study, patients were included if they had cataract with nucleus hardness grade 2 or 3, no systemic inflammatory disease, and not use of anti-inflammatory drugs/prostaglandins preoperatively. ACF using a laser flare meter and CVI in patients underwent uncomplicated phacoemulsification was recorded preoperatively, on the postoperative 1st day, 1st week, and 1st month.

RESULTS

Fifty-six eyes were included. ACF was 9.00 ± 2.90 ph/ms preoperatively. Although ACF increased significantly on postoperative day-1 (39.38 ± 23.31ph/ms) and decreased gradually until the 1st month (14.03 ± 6.03ph/ms) after the operation, it was still significantly higher at the 1st month (p < 0.001). Macular and peripapillary CVI increased significantly on postoperative day-1 (0.64 ± 0.03/0.63 ± 0.05) and week-1 (0.64 ± 0.04/0.62 ± 0.04) (p = 0.01, p < 0.001); the postoperative 1st month was similar to the preoperative one (0.59 ± 0.06/0.58 ± 0.06). The relationship between the change in ACF and the change in CVI was not significant.

CONCLUSION

Phacoemulsification causes raises in ACF and CVI due to increased intraocular inflammation. The fact that ACF was significantly higher in postoperative month-1 and CVI returned to its preoperative value suggests that the effect of uncomplicated phacoemulsification surgery on the increase in inflammation in the anterior segment lasts longer than in the posterior segment. These results suggest that ACF and CVI follow-up may be clinically important in the follow-up of postoperative inflammation.

Randomised clinical trial for morphological changes of trabecular meshwork between Kahook dual-blade goniotomy and ab interno trabeculotomy with a microhook

We demonstrated whether the difference of trabecular meshwork remodeling occur depending on the incisional cross-sectional area by comparing Kahook dual-blade goniotomy (KDB) and ab interno trabeculotomy with a microhook. Phakic eyes with primary open-angle or exfoliative glaucoma were randomised into a KDB or a microhook group. The primary outcome was an incisional cross-sectional area quantified by anterior segment optical coherence tomography. In subgroup analysis, the number of patients with the unidentifiable incisional area was compared between the groups. Secondary outcomes were the rate of intraocular pressure changes, the laser flare metre values, corneal endothelial cell densities, the number of glaucoma medications, the usage rate per glaucoma medication type and postoperative complications between the two groups. A total of 29 eyes in 29 patients in the KDB and microhook group were included respectively, with an overall mean age of 72.6 ± 8.1 years. The incisional cross-sectional area of the KDB group was significantly larger at 1 week and at 1, 6 and 12 months (p < 0.01) postoperatively. The number of patients with the nonidentified incisional area was higher at 1, 6 and 12 months postoperatively (p ≤ 0.03) in the microhook group. The flare values in the KDB group were higher than those in the microhook group at 12 months postoperatively (p = 0.02). No significant differences were observed in other secondary outcomes. Incisional cross-sectional area remains larger in eyes treated with KDB goniotomy than in those treated with ab interno trabeculotomy with the microhook, whereas KDB goniotomy did not have an advantage in controlling intraocular pressure postoperatively.Trial registration: UMIN000041290 (UMIN, University Hospital Medical Information Network Clinical Trials Registry of Japan; date of access and registration, 03/08/2020).

Blood-Aqueous Barrier Disruption in Penetrating and Posterior Lamellar Keratoplasty: Implications for Clinical Outcome

BACKGROUND

The blood-aqueous barrier (BAB) separates immunoprivileged tissue of the eye from the blood circulation. Disruption of the BAB is therefore a risk factor for rejection after keratoplasty.

PURPOSE

The present work provides a review of the work of our group and others on BAB disruption in penetrating and posterior lamellar keratoplasty and its implications for clinical outcome.

METHODS

A PubMed literature search was performed to generate a review paper.

RESULTS

Laser flare photometry provides an objective and reproducible method to assess the integrity of the BAB. Studies of the flare after penetrating and posterior lamellar keratoplasty demonstrate a mostly regressive disruption of the BAB in the postoperative course, which is influenced in extent and duration by multiple factors. Persistently elevated flare values or an increase in flare after initial postoperative regeneration may indicate an increased risk of rejection.

DISCUSSION

In case of persistent or recurrent elevated flare values after keratoplasty, intensified (local) immunosuppression may potentially be useful. This could become important in the future, especially for the monitoring of patients after high-risk keratoplasty. Whether an increase of the laser flare is a reliable early indicator of an impending immune reaction after penetrating or posterior lamellar keratoplasty has to be shown in prospective studies.

The Blood-ocular Barriers and their Dysfunction: Anatomy, Physiology, Pathology

Complex barriers comprise the blood-aqueous (BAB) and the blood-retinal barrier (BRB), and separate anterior and posterior eye chambers, vitreous body, and sensory retina from the circulation. They prevent pathogens and toxins from entering the eye, control movement of fluid, proteins, and metabolites, and contribute to the maintenance of the ocular immune status. Morphological correlates of blood-ocular barriers are tight junctions between neighboring endothelial and epithelial cells, which function as gatekeepers of the paracellular transport of molecules, thereby limiting their uncontrolled access to ocular chambers and tissues. The BAB is composed of tight junctions between endothelial cells of the iris vasculature, endothelial cells of Schlemm's canal inner wall, and cells of the nonpigmented ciliary epithelium. The BRB consists of tight junctions between endothelial cells of the retinal vessels (inner BRB) and epithelial cells of the retinal pigment epithelium (outer BRB). These junctional complexes respond rapidly to pathophysiological changes, thus enabling vascular leakage of blood-derived molecules and inflammatory cells into ocular tissues and chambers. Blood-ocular barrier function, which can be clinically measured by laser flare photometry or fluorophotometry, is compromised in traumatic, inflammatory, or infectious processes, but also frequently contributes to the pathophysiology of chronic diseases of the anterior eye segment and the retina, as exemplified by diabetic retinopathy and age-related macular degeneration.

Factors influencing aqueous flare after cataract surgery and its evaluation with laser flare photometry

Despite the refinement of modern cataract surgery, postoperative inflammation still constitutes a substantial amount of visual morbidity worldwide. A surrogate for intraocular inflammation and blood-aqueous barrier breakdown can be objectively quantified by Laser flare photometry (LFP). This review outlines the utility of LFP in assessing the assessment of post-cataract surgery inflammation. It highlights the impact of preoperative pathological states such as uveitis and diabetes, intraoperative techniques, including efficient phacoemulsification and direct comparisons between postoperative anti-inflammatory regimes. There is a large interobserver variation in the subjective flare measurement after cataract surgery and the continued use of LFP amongst other objective, noninvasive measurements of intraocular inflammation, particularly in the further development of cataract surgery, is recommended.

PreserFlo® MicroShunt: An Overview of This Minimally Invasive Device for Open-Angle Glaucoma

For moderate-to-severe glaucoma, trabeculectomy remains the “gold standard” intraocular pressure (IOP)-lowering treatment; nonetheless, this method requires extensive post-operative maintenance. Microinvasive glaucoma surgery (MIGS) treatments are designed to lessen intra- and post-operative care burden while offering an acceptable IOP decrease for individuals with mild to moderate glaucoma. The PreserFlo® MicroShunt (previously InnFocus MicroShunt) is an 8.5 mm glaucoma drainage device manufactured from poly(styrene-block-isobutylene-block-styrene) (SIBS), an extremely biocompatible and bioinert material. The lumen is narrow enough to prevent hypotony, but big enough to avoid being obstructed by sloughed cells or pigment. The device is implanted ab externo, as a stand-alone procedure or in conjunction with cataract surgery, with intraoperative mitomycin C, and a bleb is produced under the conjunctiva and Tenon’s capsule. The MicroShunt was CE-marked in 2012 and designed for primary open-angle glaucoma, the IOP of which remains uncontrolled after maximally tolerated topical treatment. Several clinical trials evaluating the MicroShunt’s long-term safety and effectiveness have been conducted, highlighting the effectiveness of the device over time, along with a tolerable safety profile. The present review aims to gather evidence of PreserFlo’s effectiveness and safety results almost 10 years after its introduction, and furthermore, to compare it with other MIGS and with the gold-standard trabeculectomy for glaucoma management.

Association of the CYP39A1 G204E genetic variant with increased risk of glaucoma and blindness in patients with exfoliation syndrome

PURPOSE

Carriers of functionally deficient mutations in the CYP39A1 gene have been recently reported to have a 2-fold increased risk of exfoliation syndrome (XFS). The aim of this study was to evaluate the risk of blindness and related clinical phenotypes of XFS patients carrying the loss-of-function CYP39A1 G204E mutation in comparison to XFS patients without any CYP39A1 mutation.

DESIGN

Retrospective case study PARTICIPANTS: 35 patients diagnosed with XFS carrying the CYP39A1 G204E mutation and 150 XFS patients without any CYP39A1 mutation, who were randomly selected from the Japanese XFS cohort.

METHODS

Two-sided Fisher's Exact Test with an α-level <0.05 was used to estimate the significance of the calculated Odds Ratio (OR) for all categorical measures. Comparisons between groups of subjects were performed using linear mixed effect models with group as random effect and taking possible dependence between eyes within a subject into account.

MAIN OUTCOME MEASURES

Primary analysis compared the incidence of blindness (defined as visual acuity [VA]<0.05 decimal), prevalence of exfoliation glaucoma (XFG), history of glaucoma surgery, and indices of glaucoma severity such as visual field mean deviation (MD), intraocular pressure (IOP) and vertical cup-disc ratio (CDR), between CYP39A1 G204E carriers and those without any CYP39A1 mutation.

RESULTS

The overall risk for blindness was significantly higher in XFS patients carrying the CYP39A1 G204E variant (10/35 [28.6%]) compared to XFS patients without any CYP39A1 mutations (8/150 [5.3%]; OR7.1 [95%CI:2.7-20.2]; p<0.001). A higher proportion of XFS patients with the CYP39A1 G204E mutation (23/35 [65.7%]) had evidence of XFG in at least one eye compared to the comparison group (41/150 [27.3%]; OR5.1 [95%CI:2.4-11.4]; p<0.0001). Significantly higher peak IOP, larger vertical CDR and worse visual field MD were also found in CYP39A1 G204E variant carriers (p<0.001). Additionally, patients with the CYP39A1 G204E mutation (18/35 [51.4%]) required more laser or glaucoma surgical interventions compared to those without any CYP39A1 mutation (32/150 [21.3%], p<0.001).

CONCLUSIONS

Patients with XFS carrying the CYP39A1 G204E mutation had significantly increased risk of blindness, higher occurrence of XFG and more severe glaucoma compared to patients with XFS without any CYP39A1 mutation.

CYSTOID MACULAR EDEMA AFTER FOUR-POINT SCLERAL FIXATION OF INTRAOCULAR LENS

PURPOSE

To assess the incidence of cystoid macular edema (CME) associated with 4-point Gore-Tex suture intraocular lens (IOL) scleral fixation, before and after institution of routine intravitreal triamcinolone acetonide prophylaxis and long-term topical nonsteroidal anti-inflammatory drug usage.

METHODS

Consecutive patients were included after IOL implantation with concurrent pars plana vitrectomy for spontaneous IOL dislocation due to pseudoexfoliation syndrome. We compared short-term prophylactic nonsteroidal anti-inflammatory drugs only (Group A) to prophylactic intravitreal triamcinolone acetonide and long-term nonsteroidal anti-inflammatory drugs (Group B).

RESULTS

Twenty-six eyes of 26 patients with pseudoexfoliation syndrome and spontaneous IOL dislocation were studied. Mean logMAR visual acuity improved from 1.27 ± 0.80 (20/375 Snellen equivalent) preoperatively to 0.46 ± 0.39 (Snellen 20/43) postoperatively (P < 0.001). Visual outcomes were similar for Groups A and B. In Group A, 10/16 eyes had CME, 4/16 had chronic CME longer than 6 months, and 1 longer than 12 months. In Group B, 1/10 had CME (which was both chronic and refractory).

CONCLUSION

In eyes with pseudoexfoliation syndrome and spontaneous IOL dislocation, 4-point Gore-Tex suture IOL ab externo fixation yielded good visual outcomes, although CME was observed more than reported elsewhere. Prophylactic intravitreal triamcinolone acetonide and long-term nonsteroidal anti-inflammatory drugs seem to reduce the risk of postoperative CME.

Effectiveness of MicroShunt in Patients with Primary Open-Angle and Pseudoexfoliative Glaucoma: A Retrospective European Multicenter Study

PURPOSE

To evaluate the effectiveness and safety of the Preserflo MicroShunt implant (Santen) in patients with primary open-angle glaucoma (POAG) and pseudoexfoliation glaucoma (PXG).

DESIGN

Retrospective, open-label, multicenter study.

PARTICIPANTS

Patients with insufficiently controlled primary POAG or PXG who underwent a standalone MicroShunt implantation procedure.

METHODS

Consecutive patients with POAG and PXG who underwent surgery with the ab externo minimally invasive glaucoma surgery device Preserflo MicroShunt with mitomycin C.

MAIN OUTCOME MEASURES

Primary end points were mean change in intraocular pressure (IOP) and number of hypotensive medications from baseline through month 12. Success was defined as an IOP of 18 mmHg or less and an IOP reduction of 20% or more, with (qualified) or without (complete) any hypotensive medication.

RESULTS

Among the 130 patients who underwent MicroShunt implantation, 104 fulfilled the inclusion and exclusion criteria and were included in the analysis. Eighty-one eyes (77.9%) were diagnosed with POAG and 23 eyes (22.1%) were diagnosed with PXG. The mean age was 71.4 ± 12.6 years, and 45 patients (43.3%) were women. Mean IOP was lowered significantly from 25.1 ± 6.5 mmHg at baseline to 14.1 ± 3.4 mmHg at month 12 (P < 0.0001). At month 12, 27 eyes (26.0%) were categorized as complete successes and 61 eyes (58.7%) were categorized as qualified successes. The mean number of hypotensive medications was reduced significantly from 3.0 ± 1.0 medications at the preoperative visit to 0.77 ± 0.95 medication at month 12 (P < 0.001). Throughout the study, 19 eyes (18.3%) required needling and 14 eyes (13.5%) underwent surgical revision. Eight eyes (7.7%) showed hyphema and 5 eyes (4.8%) showed choroidal detachment. These were resolved with medical therapy without sequelae. Four patients underwent subsequent surgeries, and 2 patients underwent trabeculectomy (at months 3 and 6): One patient underwent transscleral cyclophotocoagulation at month 3 and 1 patient underwent MicroPulse cyclophotocoagulation at month 4.

CONCLUSIONS

In this retrospective study, the MicroShunt effectively lowered IOP and the need for IOP-lowering medications.

Outcomes of cataract surgery in pseudoexfoliation syndrome in England: 10-year retrospective cohort study

PURPOSE

To investigate the outcomes of cataract surgery in eyes with pseudoexfoliation syndrome in a real-world National Health Service setting.

SETTING

Prince Charles Eye Unit, Windsor, United Kingdom.

DESIGN

Single-center retrospective cohort study.

METHODS

All eyes that underwent phacoemulsification cataract surgery from January 2010 to December 2019 were included. Eyes with combined intraocular surgery or with a history of ocular trauma were excluded. Eyes were classified as pseudoexfoliation (n = 280 [1.2%]) or no pseudoexfoliation (n = 23 049). The primary outcome was mean change in logarithm of the minimum angle of resolution (logMAR) visual acuity (VA). Secondary outcomes included intraoperative and postoperative complications.

RESULTS

The study comprised 23 329 eyes of 15 257 patients. Eyes in the pseudoexfoliation group were older and more likely to have multiple co-pathologies. Intraoperatively, they were more likely to experience zonular dialysis and dropped nucleus. Postoperatively, they had significantly higher rates of corneal edema, elevated intraocular pressure, postoperative uveitis, and intraocular lens subluxation and were more likely to require a second operation within 90 days. Although the pseudoexfoliation group had worse preoperative and postoperative logMAR VA, logistic regression analysis confirmed that mean VA improvement was comparable to reference group (mean ± standard deviation -0.49 ± 0.52 vs -0.55 ± 0.66, adjusted mean difference 0.02 [95% CI, -0.01 to 0.06]).

CONCLUSIONS

Although patients with pseudoexfoliation had a significantly higher risk of some complications, they achieved similar VA improvements with cataract surgery compared to the nonpseudoexfoliation group. These findings will help inform the consent process and management of patient expectations.

Does Pseudoexfoliation Syndrome Affect the Choroidal Response After Uneventful Phacoemulsification

Purpose

To examine subfoveal and peripapillary choroidal thickness changes after successful phacoemulsification in cataract cases with nonglaucomatous pseudoexfoliation syndrome (PXS).

Materials and Methods

Nineteen cataract patients with PXS and 19 without PXS were included in this prospective and interventional controlled study. Subfoveal and peripapillary choroidal thicknesses were measured before surgery and on the postoperative first day (D1), first week (W1), first month (M1), second month (M2), and third month (M3). Subfoveal choroidal thickness measurement included total subfoveal choroidal thickness (tSFCT), the small choroidal vessel layer (SF-SCVL) thickness, and the large choroidal vessel layer (SF-LCVL) thickness.

Results

The greatest increase in mean tSFCT compared to baseline was observed between W1 and M1 with values of 23.33 ± 2.96 µm and 31.84 ± 2.88 µm, respectively, for the PXS and non-PXS groups (P = 0.014). The greatest increase in SF-SCVL thickness compared with baseline occurred at M1 with values of 6.66 ± 1.97 µm and 26.52 ± 1.92 µm, respectively, for the PXS and non-PXS groups (P < 0.001). The peripapillary choroidal thickness only showed a significant difference between the groups at the inferior measurement point with values of 117.94 ± 14.15 µm and 137.52 ± 34.53 µm, respectively, for the PXS and non-PXS groups (P = 0.032).

Conclusions

Cataract cases with PXS exhibited a different choroidal thickness response compared to non-PXS eyes after successful phacoemulsification. The increased choroidal thickness was particularly observed in Haller's layer in the eyes with PXS and in the choriocapillaris and Sattler's layer in the eyes without PXS.

Comparison of macular thickness change by optical coherence tomography after uncomplicated cataract surgery in eyes with and without exfoliation syndrome

PURPOSE

To evaluate the effect of exfoliation syndrome (ES) on macular thickness after uncomplicated cataract surgery.

METHODS

87 patients (87 eyes) who underwent uncomplicated cataract surgery were included in the study. Optical coherence tomography (OCT) films were taken in addition to the routine ophthalmologic examination before the surgery and at postoperative 1st week, 1st, 3rd and 6th months. Mean macular thickness, central macular thickness and macular volume values obtained from the 6 × 6 mm macular map in the OCT measurements were recorded. The cases were divided into two groups as Group 1: cases without ES and Group 2: cases with ES. The macular values obtained from the OCT measurements of the two groups were compared with statistical methods.

RESULTS

Eighty-seven eyes were included in the study; while 51 had no ES (Group 1), 36 had ES (Group 2). The mean age of all cases was 66.70 ± 9.13 years. While the mean macular thickness, central macular thickness and macular volume were similar at the preoperative visit and the postoperative 1st week of all cases (each p value > 0.05); these values were higher at the postoperative 1st, 3rd and 6th month compared to the preoperative and the postoperative 1st week values (each p value < 0.05). The highest values were obtained at the postoperative 1st month; while the values of 1st, 3rd and 6th months were statistically similar (each p value > 0.05). No statistically significant difference was observed between Group 1 and Group 2 in terms of macular volume, central macular thickness and average macular thickness in these periods.

CONCLUSION

Exfoliation syndrome has not been evaluated as a risk factor for an increase in macular thickness after uncomplicated cataract surgery.

Integral role for lysyl oxidase-like-1 in conventional outflow tissue function and behavior

Lysyl oxidase-like-1 (LOXL1), a vital crosslinking enzyme in elastin fiber maintenance, is essential for the stability and strength of elastic vessels and tissues. Variants in the LOXL1 locus associate with a dramatic increase in risk of exfoliation syndrome (XFS), a systemic fibrillopathy, which often presents with ocular hypertension and exfoliation glaucoma (XFG). We examined the role of LOXL1 in conventional outflow function, the prime regulator of intraocular pressure (IOP). Using Loxl1^-/- , Loxl1^+/- , and Loxl1^+/+ mice, we observed an inverse relationship between LOXL1 expression and IOP, which worsened with age. Elevated IOP in Loxl1^-/- mice was associated with a larger globe, decreased ocular compliance, increased outflow facility, extracellular matrix (ECM) abnormalities, and dilated intrascleral veins, yet, no dilation of arteries or capillaries. Interestingly, in living Loxl1^-/- mouse eyes, Schlemm's canal (SC) was less susceptible to collapse when challenged with acute elevations in IOP, suggesting elevated episcleral venous pressure (EVP). Thus, LOXL1 expression is required for normal IOP control, while ablation results in altered ECM repair/homeostasis and conventional outflow physiology. Dilation of SC and distal veins, but not arteries, is consistent with key structural and functional roles for elastin in low-pressure vessels subjected to cyclical mechanical stress.

Prospective cohort study of risk factors for choroidal detachment after trabeculectomy

PURPOSE

To investigate risk factors for choroidal detachment after trabeculectomy.

METHODS

We prospectively evaluated 97 patients with open-angle glaucoma who underwent primary trabeculectomy to investigate risk factors for choroidal detachment after trabeculectomy. The primary outcome measure was risk factors for the occurrence and severity of choroidal detachment after trabeculectomy. Choroidal detachment severity was quantified as the number of fundus quadrants with choroidal detachment.

RESULTS

Sixteen patients (16.5%) had choroidal detachment. Mean period between surgery and occurrence of choroidal detachment was 7.9 ± 5.7 days. Mean intraocular pressure (IOP) on the first day of choroidal detachment was 6.1 ± 3.0 mm Hg. Multivariable analyses revealed that the exfoliation glaucoma, greater ΔIOP between preoperative and lowest postoperative IOPs, and thicker cornea were associated with choroidal detachment (P = 0.022, P = 0.002, and P = 0.013, respectively). These factors were also associated with the severity of choroidal detachment (exfoliation glaucoma; P = 0.013, greater ΔIOP; P < 0.001, and thicker cornea; P = 0.006).

CONCLUSIONS

Exfoliation glaucoma, more IOP reduction, and thicker cornea are associated with the occurrence and severity of choroidal detachment after trabeculectomy.

Anti-inflammatory Medication of Cataract Surgery in Pseudoexfoliation Syndrome - NSAID Is Needed

BACKGROUND

To optimize the anti-inflammatory treatment of cataract surgery in pseudoexfoliation syndrome (PXF) eyes.

METHODS

A prospective randomized double-masked trial. Sixty eyes of 60 patients with PXF undergoing routine cataract surgery were randomized for potent topical postoperative anti-inflammatory medication either with prednisolone acetate (10mg/ml), nepafenac (1mg/ml) or their combination. Clinical outcome parameters were recorded at 28 days and 3 months. Recovery from surgery was recorded by a structured home questionnaire.

RESULTS

Patient age and gender distribution, and all baseline ophthalmic and surgical parameters were comparable between the study groups. At 28 days, change in central subfield macular thickness was +11.4 ± 11.9 µm in prednisolone acetate group compared to +1.7 ± 16.8 µm in nepafenac (P = .017), and -0.3 ± 8.7 µm in combination therapy (P = .010) groups. At 3 months, the values were +11.8 ± 18.1 µm, +1.8 ± 17.5 µm (P = .055), and -1.3 ± 6.4 µm (P = .055), respectively. Pseudophakic cystoid macular edema (PCME) was reported in two eyes, both with prednisolone acetate monotherapy. After surgery, conjunctival injection lasted 6.5 ± 5.0 days and irritation of the eye 9.5 ± 8.5 days in prednisolone acetate group compared with nepafenac (2.6 ± 2.2 days; P = .037 and 4.3 ± 5.2 days; P = NS, respectively) and combination therapy (3.3 ± 1.9 days; P = NS and 3.0 ± 4.0 days; P = .025, respectively).

CONCLUSIONS

Routine cataract surgery of PXF eyes with nonsteroidal anti-inflammatory drugs (NSAID) alone, or in combination with steroids resulted in faster recovery from surgery and avoidance of PCME compared to steroids alone.

ABBREVIATIONS

BAB: blood-aqueous barrier; CDVA: corrected distance visual acuity; CDE: cumulative dissipated energy; CSMT: central subfield macular thickness; HRQoL: Health-related quality of life; IOP: intraocular pressure; logMAR: log of the minimum angle of resolution; NSAID: nonsteroidal anti-inflammatory drug; PCME: pseudophakic cystoid macular edema; PXF: pseudoexfoliation syndrome; OCT: optical coherence tomography; t.i.d.: three times a day; VA: visual acuity.

Association of Postoperative Topical Prostaglandin Analog or Beta-Blocker Use and Incidence of Pseudophakic Cystoid Macular Edema

PURPOSE

The purpose of this article is to determine the association of postoperative topical prostaglandin analog (PGA) or topical beta-blocker use and the incidence of pseudophakic cystoid macular edema (CME).

METHODS

This was a nested case-control study. All adult patients who underwent cataract surgery between January 1, 2006 and December 31, 2016 and who were enrolled in the PharMetrics Plus database were eligible for inclusion. The association between postoperative topical PGAs (bimatoprost, latanoprost, and travoprost/travoprost-z) or beta-blocker (betaxolol, levobunolol, and timolol) use and the incidence of pseudophakic CME was assessed by conditional logistic regression.

RESULTS

Five hundred eight cases and 5080 controls were included in the analyses. Incidence of pseudophakic CME was found to be statistically significantly associated with the current postoperative use of both topical PGAs [relative risk (RR), 1.86; 95% confidence interval (CI), 1.04-3.32] and topical beta-blockers (RR, 2.64; 95% CI, 1.08-6.49). Postoperative use of each of bimatoprost (RR, 2.73; 95% CI, 1.35%-5.53%) and travoprost/travoprost-z (RR, 3.16; 95% CI, 1.42-7.03) in the year before diagnosis was demonstrated to be statistically significantly associated with the incidence of pseudophakic CME. This association was not observed to be statistically significant with the postoperative use of latanoprost (RR, 1.55; 95% CI, 0.84-2.88).

CONCLUSIONS

To the best of our knowledge this is the largest study that has investigated the association between postoperative topical PGA or topical beta-blocker use and the incidence of pseudophakic CME. Postoperative use of both topical PGAs and topical beta-blockers was found to be associated with the incidence of pseudophakic CME.

Cataract surgery and nonsteroidal antiinflammatory drugs

Nonsteroidal antiinflammatory drugs (NSAIDs) have become an important adjunctive tool for surgeons performing routine and complicated cataract surgery. These medications have been found to reduce pain, prevent intraoperative miosis, modulate postoperative inflammation, and reduce the incidence of cystoid macular edema (CME). Whether used alone, synergistically with steroids, or for specific high-risk eyes prone to the development of CME, the effectiveness of these medications is compelling. This review describes the potential preoperative, intraoperative, and postoperative uses of NSAIDs, including the potency, indications and treatment paradigms and adverse effects and contraindications. A thorough understanding of these issues will help surgeons maximize the therapeutic benefits of these agents and improve surgical outcomes.

FINANCIAL DISCLOSURE

Proprietary or commercial disclosures are listed after the references.

Macular edema after cataract surgery in eyes with and without pseudoexfoliation syndrome

BACKGROUND

The purpose of the study was to identify macular edema after cataract surgery in eyes with and without pseudoexfoliation syndrome. The study was a post-hoc analysis of a randomized, double-blind, prospective single-center study. Patients were enrolled between January 2016 and October 2016 as per the national guidelines for the management of cataract in the Department of Ophthalmology, Kymenlaakso Central Hospital, Kotka, Finland.

METHODS

One hundred and fifty-six eyes of 149 patients undergoing routine cataract surgery. Postoperatively anti-inflammatory medication was either dexamethasone (N = 78) or diclofenac (N = 78). Spectral domain optical coherence tomography imaging and laser flare meter measurement of the anterior chamber were conducted before surgery and at the control visit 28 days postoperatively.

RESULTS

Baseline variables were comparable between eyes with pseudoexfoliation syndrome (N = 32) and those without (N = 124), except for intraocular pressure (P = 0.002) and glaucoma medication (P < 0.001). In patients having pseudoexfoliation syndrome, central retinal thickness increase (mean ± standard error of the mean) was 63.3 ± 35.5 μm for dexamethasone and 17.6 ± 5.8 μm for diclofenac, compared to 28.9 ± 8.0 μm (P = NS) and 6.9 ± 1.3 μm (P = 0.014) in eyes without pseudoexfoliation syndrome, respectively. Aqueous flare at 28 days was 25.8 ± 5.4 pu/ms for patients with pseudoexfoliation syndrome and 18.3 ± 1.8 pu/ms for those without (P = 0.030). Best corrected visual acuity gain and best corrected visual acuity at 28 days were less in patients having pseudoexfoliation syndrome compared to those without (0.39 ± 0.07 vs 0.59 ± 0.03 decimals, P = 0.007; and 0.77 ± 0.06 vs 0.92 ± 0.03 decimals, P = 0.008, respectively).

CONCLUSION

Eyes with pseudoexfoliation syndrome may be predisposed to an increased aqueous flare and macular edema after cataract surgery. This study outlines the need to determine the optimal anti-inflammatory medication after cataract surgery in patients with pseudoexfoliation syndrome.

Effectiveness and safety of combined cataract surgery and microhook ab interno trabeculotomy in Japanese eyes with glaucoma: report of an initial case series

PURPOSE

To report the early postoperative results and safety profile of ab interno microhook trabeculotomy (μLOT) combined with cataract surgery.

PATIENTS AND METHODS

This retrospective observational case series included 68 consecutive glaucomatous eyes of 23 Japanese men and 25 Japanese women [mean (SD) age, 76.0 ± 8.5 years] who underwent μLOT for intraocular pressure (IOP) and visually relevant cataracts. The LOT site/extent, perioperative complications, and complication treatments were collected from the medical and surgical records. The preoperative and postoperative IOP, numbers of antiglaucoma medications, logarithm of the minimum angle of resolution visual acuity (VA), anterior chamber (AC) flare, and corneal endothelial cell density (CECD) were compared.

RESULTS

After small incisional cataract surgery, the trabecular meshwork was incised in the nasal (6 eyes, 3.6 ± 0.5 clock hours), temporal (6 eyes, 3.8 ± 0.8 clock hours), or both nasal and temporal (56 eyes, 6.5 ± 0.6 clock hours) angles. The mean preoperative IOP (16.4 ± 2.9 mmHg) and number of antiglaucoma medications (2.4 ± 1.2) decreased significantly (P < 0.0001 and P = 0.0039, respectively) to 11.8 ± 4.5 and 2.1 ± 1.0 mmHg at 9.5 months postoperatively. Compared with the preoperative conditions, the final VA improved (P = 0.0002), the AC flare increased by 6.3 pc/ms (P = 0.0157), and the CECD decreased by 6% (P = 0.0005). Hyphema with niveau formation (28 eyes, 41%) and hyphema washout (6 eyes, 9%) were the most common postoperative complication and intervention, respectively. At the final visit, 54 eyes (79%) had achieved successful IOP control of 15 mmHg or less and IOP reduction of 15% or greater.

CONCLUSION

Combined μLOT and cataract surgery improves IOP and VA during the early postoperative period in patients with glaucoma and cataract.

Pseudophakic Macular Edema in Primary Open-Angle Glaucoma: A Prospective Study Using Spectral-Domain Optical Coherence Tomography

PURPOSE

To determine the incidence of and risk factors for pseudophakic macular edema (PME) after uncomplicated cataract surgery in primary open-angle glaucoma (POAG) using spectral-domain optical coherence tomography (SDOCT).

DESIGN

Cohort study.

METHODS

Macular retinal thickness was evaluated using SDOCT at 1 week before surgery and at 1, 3, 6, and 12 months postoperatively, in 70 POAG and 68 control eyes. Forty-three healthy subjects without impaired vision or cystoid PME were recruited separately as pilot samples to define significant PME. Significant PME was defined as an increase in the average thickness exceeding the mean + 3 standard deviations of the increase shown in the pilot samples.

RESULTS

Significant PME (increase in the foveal 3-mm zone thickness of >19.5 μm) was observed in 31 (44%) eyes with POAG and in 14 (21%) control eyes (P = .003). The extent of PME was maximal at 3 months postoperatively and decreased gradually until 12 months. Regression tree analysis revealed that the risk of PME was the greatest in the POAG group using prostaglandin analogue (PGA) (odds ratio [OR] = 5.51), followed by POAG not using PGA (OR = 1.70), and control group (OR = 1.0). Risk factors for PME were younger age in all groups (OR = 1.07), systemic hypertension in PGA users (OR = 6.42), higher untreated IOP in PGA nonusers (OR = 1.09) and male sex (OR = 14.06) and diabetes mellitus (OR = 16.71) in the control group.

CONCLUSIONS

The incidence of PME as observed by SDOCT was higher than previously reported after uncomplicated cataract surgery. Eyes with POAG were at greater risk for PME, which was mainly associated with perioperative PGA use.

Laser flare-cell photometer: principle and significance in clinical and basic ophthalmology

A slit-lamp examination is an indispensable and essential clinical evaluation method in ophthalmology, but, it is qualitative subjective. To complement its weaknesses in making a quantitative evaluation of flare intensity and number of cells in the aqueous humor in the eye, we invented the laser flare-cell photometer in 1988. The instrument enables a non-invasive quantitative evaluation of flare intensity and number of cells in the aqueous with good accuracy and repeatability as well as maneuverability equal to slit-lamp microscopy. The instrument can elucidate the pathophysiology in the blood-aqueous barrier (BAB) function in a variety of ocular disorders. The accuracy of the instrument makes it possible to investigate not only the pathophysiology of intraocular disorders but also the effects of various drugs and surgical procedures in BAB. The instrument does not only lighten the burden on patients in clinical examinations and study but it also helps minimize the sacrifice of experimental animals and improves the reliability of the results by minimizing inter-individual variations through its good repeatability. Here I shall relate how the instrument has been applied to clinical and basic studies in ophthalmology and what novel knowledge its application contributed to pathophysiology in ophthalmology.

Disturbed oxidant/antioxidant balance in aqueous humour of patients with exfoliation syndrome

PURPOSE

To establish the total oxidant status (TOS), total antioxidant capacity (TAC) and oxidative stress index (OSI) of the aqueous humour in patients presenting exfoliation syndrome (EXS) without glaucoma.

METHODS

The TOS, TAC and OSI of the aqueous humour of patients with EXS (group 1, n = 17) and patients without EXS (group 2, n = 25) who underwent cataract surgery were evaluated. Samples were measured spectrophotometrically using a colourimetric method. The Mann-Whitney U, independent-samples t tests, Pearson correlation and analysis of covariance tests were used in the statistical analyses.

RESULTS

The mean TOS in group 1 and 2 patients was 57.6 ± 32.4 and 30.4 ± 22.6 mmol/L, respectively, which is a statistically significant difference (p = 0.001). The mean TAC level in group 1 and 2 patients was 2.3 ± 0.7 and 2.5 ± 0.7 mmol/L, respectively, and although TAC was decreased in group 1 relative to group 2, the difference was not statistically significant (p = 0.55). The mean OSI in group 1 and 2 patients was 27.4 ± 17.1 and 12.5 ± 8.3 mmol/L, respectively, with the mean OSI level statistically higher in group 1 (p = 0.03).

CONCLUSION

Our findings provide evidence that the aqueous humour of EXS patients is characterised by increased oxidative stress and a disturbed oxidant/antioxidant balance. The increased oxidative stress and decreased levels of antioxidants in ocular fluids of EXS patients may play a significant role in the pathogenesis and complications of EXS.

Disruption of the blood-aqueous barrier and lens abnormalities in mice lacking lysyl oxidase-like 1 (LOXL1)

PURPOSE

Exfoliation syndrome (ES) is commonly associated with glaucoma, premature cataracts, and other ocular and systemic pathologies. LOXL1 gene variants are significantly associated with ES; however, the role of the protein in ES development remains unclear. The purpose of this study was to characterize the ocular phenotype in Loxl1(-/-) (null) mice.

METHODS

Loxl1 null mice and strain-matched controls (C57BL) were evaluated by clinical and histologic analyses.

RESULTS

Anterior segment histology showed a pronounced vesiculation of the anterior lens in the null mice. The lesions were subcapsular and in direct apposition with the posterior iris surface. Fluorescein angiography showed increased diffusion of fluorescein into the anterior chamber of the null mice compared with age-matched controls (P = 0.003, two-tailed, unequal variance t-test), suggesting compromise of the blood-aqueous barrier. Intraocular pressure measurements were within the normal range (16.5 ± 2.0 mm Hg) in null mice up to 1 year of age. Immunohistochemistry showed decreased elastin in the iris and ciliary body in the null mouse compared with controls.

CONCLUSIONS

Elimination of LOXL1 in mice impairs the blood-aqueous humor barrier in the ocular anterior segment and causes lens abnormalities consistent with cataract formation, but does not result in deposition of macromolecular material or glaucoma. These results show that mice lacking LOXL1 have some ES features but that complete disease manifestation requires other factors that could be genetic and/or environmental.

[PEX syndrome. Clinical diagnosis and systemic manifestations]

As a result of demographic changes pseudoexfoliation (PEX) syndrome, an age-related systemic disorder of the extracellular matrix, will become an increasingly important issue in clinical practice. Apart from its well-known association with cataract and glaucoma, PEX syndrome predisposes to a broad spectrum of spontaneous and surgical ocular complications due to characteristic alterations of all anterior segment tissues. In view of the high risk of glaucoma development and potential complications during cataract surgery, an accurate and early diagnosis of PEX syndrome is of considerable clinical relevance. Since the characteristic central PEX deposits are lacking in up to 50 % of patients, a reliable diagnosis requires pupillary dilation. Early stages of the disease may be recognized on the basis of subtle alterations of the lens surface in addition to poor pupillary dilation and pigment-related signs including pigment dispersion and peripupillary atrophy. Any asymmetric clinical signs, e.g., regarding pupil width, pigmentation, cataract and intraocular pressure, should alert the ophthalmologist to the potential presence of PEX syndrome. Although the description of PEX syndrome as a systemic disorder of the extracellular matrix associated with the deposition of PEX material in the skin, blood vessel walls and various organ systems dates back to the early 1990s, a causal relationship between the abnormal material deposits and systemic diseases has not yet been clearly established. A growing number of smaller studies have found suggestive evidence for associations between PEX syndrome and cardiovascular/cerebrovascular diseases. The current evidence, however, is ambiguous and requires further investigation through multicenter or population-based, prospective, randomized clinical studies.

Influence of prostaglandin analogue on outcome after combined cataract surgery and trabecular aspiration in pseudoexfoliative glaucoma

PURPOSE

The aim of this study was to analyze the postoperative outcome and risk profile after combined clear cornea phacoemulsification and trabecular aspiration in the treatment of pseudoexfoliative glaucoma (PEX) associated with cataract. 


METHODS

In this retrospective study, 69 eyes of 60 patients with visually significant cataract and PEX were treated with small-incision cataract surgery combined with trabecular aspiration. The intraocular pressure (IOP), number of antiglaucoma eyedrops before and after surgery, as well as complications were measured at all postoperative visits (1 day, 7 days, 6 weeks, 6 months, 12 months). 


RESULTS

There was a statistically significant decrease in postoperative IOP during the follow-up 
period. There was no significant difference in the number of medications being used after 6 weeks follow-up. Six months and 12 months after surgery, the number of antiglaucoma eyedrops decreased significantly. Complications were fibrinotic iritis in 4 eyes (5.9%), cystoid macular edema in 3 eyes (4.4%), and hyphema in 1 eye (1.4%). Fibrinotic iritis and macular edema were present in only 37 of 
69 eyes that were treated with prostaglandin analogues.


CONCLUSIONS

Small-incision cataract surgery combined with trabecular aspiration in cases of PEX associated with cataract is effective in IOP reduction over a 1-year follow-up. Prostaglandin analogues may increase the risk of postoperative macular edema and fibrinotic iritis. Preoperative medication exchange may be considered.

Outcome of phacoemulsification in patients with and without Pseudoexfoliation syndrome in Kashmir

Background

The aim of the study is to compare the outcome of phacoemulsification in patients with and without pseudoexfoliation syndrome in Kashmir.

Methods

200 patients were prospectively evaluated and divided into 2 groups. Group 1 comprised 100 cases with pseudoexfoliation and Group 2 (control) 100 cases without pseudoexfoliation. Phacoemulsification with posterior chamber intraocular lens implantation was performed by 3 surgeons. Intraoperative and postoperative observations were made in both the groups at regular intervals upto 6 months. A chi square test was used for statistical analysis.

Results

Patients with pseudoexfoliation were significantly older (P = 0.000), had harder cataract(P = 0.030) and smaller mean pupil diameter(P = 0.000) than the control group. Intraoperative complications were comparable between the 2 groups except the occurrence of zonular dehiscence which was seen in 7% patients of Group 1 compared to 0% in Group 2. Higher postoperative inflammatory response was seen in Group 1(P = 0.000). Decrease in intraocular pressure (IOP) at all postoperative measurements was more in Group 1(P = 0.000). The visual acuity was better in the control group in the early postoperative period (P = 0.029), however the final visual acuity at 6 months was comparable between the 2 groups.

Conclusions

Phacoemulsification in presence of pseudoexfoliation necessitates appropriate surgical technique to avoid intraoperative complications. Pseudoexfoliation is associated with higher inflammatory response, significant postoperative IOP drop and satisfactory visual outcome.

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.

Ocular and systemic pseudoexfoliation syndrome

PURPOSE

To provide an update on most recent developments regarding ocular and systemic manifestations and complications, clinical diagnosis and management, and molecular pathophysiology of pseudoexfoliation (PEX) syndrome, and to discuss future tasks and challenges in this field.

DESIGN

Perspective.

METHODS

Review of recent literature and authors' own clinical and laboratory studies.

RESULTS

PEX syndrome is a common age-related generalized fibrotic matrix process of worldwide significance, which may not only cause severe chronic open-angle glaucoma and cataract, but also a spectrum of other serious spontaneous and surgical intraocular complications. Recent progress and advances have led to (1) improvements in clinical management by understanding the effects of the PEX process on ocular tissues, by refining diagnostic criteria, by applying new treatment regimes, and by developing preventive strategies to reduce surgical complications; (2) increasing evidence for systemic associations of PEX with cardiovascular and cerebrovascular morbidity; and (3) new insights into the molecular pathophysiology by analyzing the composition of PEX material, the differential gene expression of affected tissues, and key factors involved in pathogenesis. The current pathogenetic concept describes PEX syndrome as an elastic microfibrillopathy involving transforming growth factor-beta1, oxidative stress, and impaired cellular protection mechanisms as key pathogenetic factors.

CONCLUSIONS

Future tasks and challenges comprise epidemiologic prevalence and genetic studies of PEX syndrome, prospective randomized clinical and histopathological screening studies on its systemic manifestations and associations, and intensified basic research on differential protein and gene expression, animal and in vitro models, as well as potential biomarkers for PEX syndrome and its associated glaucoma.

Quantification of blood-aqueous barrier breakdown after phacoemulsification in Fuchs' heterochromic uveitis

PURPOSE

To quantify the breakdown of the blood-aqueous barrier (BAB) following phacoemulsification with posterior chamber lens implantation in eyes with Fuchs' heterochromic uveitis (FHU).

PATIENTS AND METHODS

In this retrospective study, 19 eyes of 19 patients with FHU (mean age 38 +/- 14 years) and 35 eyes of 35 patients with senile cataracts (mean age 63 +/- 9 years) underwent phacoemulsification with one-piece PMMA posterior chamber lens implantation. Aqueous flare was quantified using the laser flare-cell meter (LFCM, Kowa FC-1000) following medical pupillary dilation preoperatively and 1, 3, and 5 days, then 1 and 6 weeks and 6 months postoperatively.

RESULTS

Mean preoperative aqueous flare (in photon counts per millisecond) in FHU vs. controls was 11.7 +/- 3.5 vs. 5.8 +/- 1.7. Following cataract surgery, mean aqueous flare increased to 27.8 +/- 4.4 vs. 16.0 +/- 4.5 on day 1, decreased to 23.6 +/- 4.0 vs. 11.8 +/- 3.5 on day 3, and to 18.0 +/- 3.0 vs. 9.5 +/- 1.7 on day 5. In FHU eyes, it was 13.9 +/- 2.7 after 1 week, and had returned to preoperative levels after 6 weeks (10.9 +/- 2.5) and remained stable for up to 6 months (mean 10.3 +/- 2.2). Pre- and postoperatively, aqueous flare values were 2-3 times higher in FHU eyes than in control eyes with senile cataract (p = 0.01). No postoperative complications such as fibrin formation, synechiae, macrophages on the intraocular lens optic or endophthalmitis were observed in any of the patients.

CONCLUSIONS

BAB breakdown following phacoemulsification with posterior chamber lens implantation is relatively mild in eyes with FHU and the BAB appears to be fully reestablished to preoperative levels 6 weeks postoperatively, explaining the usually good outcome of cataract surgery in this condition.

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.

Capsular tension ring implantation after capsulorhexis in phacoemulsification of cataracts associated with pseudoexfoliation syndrome. Intraoperative complications and early postoperative findings

PURPOSE

To evaluate the effect of an endocapsular tension ring in preventing zonular complications during phacoemulsification of cataracts associated with pseudoexfoliation syndrome.

SETTING

Eye Clinic of Beyoğlu Education and Research Hospital, Istanbul, Turkey.

METHODS

A prospective randomized study comprised 78 eyes with cataract and pseudoexfoliation syndrome that were randomly divided into 2 groups. The age, sex, cataract density, iridodonesis, axial length, anterior chamber depth, best corrected visual acuity (BCVA), and intraocular pressure (IOP) were matched between groups. In 39 eyes, a capsular tension ring (CTR) was implanted after capsulorhexis and hydrodissection but before nucleus emulsification. Thirty-nine eyes that did not have a CTR implanted served as a control. The main outcome measures were the rates of intraoperative zonular separation and capsular fixation of a foldable intraocular lens (IOL). Posterior capsule rupture without zonular dialysis, vitreous loss, corneal edema, fibrin in the anterior chamber, BCVA, and IOP in the immediate postoperative period were also compared between the 2 groups.

RESULTS

Five eyes (12.8%) in the control group and no eye in the CTR group had intraoperative zonular separation (P =.02). Posterior capsule rupture without zonular separation occurred in 3 eyes (7.7%) in the control group and 2 (5.2%) in the CTR group. Capsular IOL fixation was achieved in 37 eyes (94.9%) in the CTR group and 31 eyes (74.3%) in the control group (P =.012). The difference in BCVA was not statistically significant between the 2 groups (P =.44); however, uncorrected visual acuity (UCVA) was significantly better in the CTR group (P =.026).

CONCLUSION

In cases of cataract associated with pseudoexfoliation syndrome, implanting a CTR before phacoemulsification of the nucleus reduced intraoperative zonular separation, increased the rate of capsular IOL fixation, and improved UCVA.

Exfoliation syndrome

Exfoliation syndrome (XFS) is an age-related disorder of the extracellular matrix characterized by production and progressive accumulation of small, white deposits of a fibrillar extracellular material in many ocular tissues, most commonly seen on the pupillary border and anterior lens capsule. Characteristic signs of pigment liberation and deposition throughout the anterior segment aid in the diagnosis. Exfoliation syndrome predisposes to both open-angle and angle-closure glaucoma, and to capsular rupture, zonular dehiscence, and vitreous loss during cataract extraction. Exfoliation syndrome is associated with ocular and perhaps systemic ischemia. The exact chemical composition of exfoliation material remains unknown. Medical, laser, and surgical therapy are similar to treatment of primary open-angle glaucoma.

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.