Phacoemulsification in true exfoliation of the lens capsule: a case series

Current Concepts in True Exfoliation Syndrome

True exfoliation syndrome is characterized by the peeling of a translucent membrane from the anterior lens capsule. The condition increases with age and despite the classic association with occupations involving intense heat, most cases are idiopathic. We have proposed a new clinical classification system dividing true exfoliation syndrome into 4 successive stages based on characteristic changes in the anterior capsule. We have also proposed a new mechanism related to iris movement and aqueous flow accounting for the capsular delamination. We have found that a detached flap occurs exclusively in areas that lack the anterior zonules. In our series of 259 consecutive patients, 47 (19.5%) patients developed primary open-angle glaucoma, 26 (10.0%) had primary angle-closure glaucoma, and 15 (5.8%) were primary angle-closure suspects. Twenty-six (10.0%) patients demonstrated spontaneous phacodonesis or anterior lens dislocation, of whom 14 also had secondary angle-closure and 2 had open-angle glaucoma. Histologic studies have shown that the lens dislocation is associated with a lack of anterior zonular support. All patients developed cataracts, predominantly nuclear sclerosis. The double-ring sign frequently occurs during capsulorhexis.

The Clinical Spectrum and a New Theory of Pathogenesis of True Exfoliation Syndrome

PURPOSE

To describe the clinical spectrum and a new theory of pathogenesis of true exfoliation syndrome.

DESIGN

Cross-sectional and prospective, observational case series.

PARTICIPANTS

Consecutive patients with characteristic peeling of the anterior lens capsule.

METHODS

After maximal mydriasis, slit-lamp biomicroscopy, and photography, imaging of the anterior capsule and zonules was performed. The condition was classified into 4 clinical stages: annular anterior capsule thickening with a distinct splitting margin (stage 1), an inward detached crescentic flap lying on the anterior lens (stage 2), a floating and folding translucent membrane behind the iris (stage 3), and a broad membrane within the pupil (stage 4). Serial photography was performed at each 3-month follow-up visit. Ultrastructural examination of dislocated lenses and excised anterior capsules was performed.

MAIN OUTCOME MEASURES

Detached membrane morphologic features, zonular defects, pigment deposition, glaucoma, phacodonesis, and cataract.

RESULTS

We enrolled 259 patients (424 eyes). Ages ranged from 52 to 97 years (mean age, 75.2±7.1 years). Eleven patients were associated with trauma (n = 1) or intense heat (n = 10), whereas 248 were idiopathic. Two hundred ten patients were followed up every 3 months, with a mean follow-up of 9.6±6.1 months (range, 3-50 months). The detachment started along the anterior zonular insertions in association with zonular disruption. It progressed centrally to higher stages, manifesting a spectrum of disease. Several stages coexisted in a single eye. At the final visit, including 49 patients who were examined once, there were 70, 87, 85, and 17 patients in stages 1, 2, 3, and 4, respectively. All stages shared common histologic findings consisting of diffuse capsular lamellar separation and anterior zonular disruption. All developed cataract. Pigment deposition on the membrane was present in 178 patients (68.7%). Twenty-six patients (10%) had spontaneous phacodonesis. Eighteen eyes (4.2%) demonstrated secondary delamination.

CONCLUSIONS

Capsular lamellar separation and anterior zonular disruption are characteristic findings. Aging, heat exposure, and trauma are risk factors. Initial capsular splits occur along the insertions of disrupted anterior zonules. The peeling progresses centrally in association with iris movement and aqueous flow. A second detachment can occur.

Age-Related True Exfoliation of the Lens Capsule: Phacoemulsification Surgery Results

Historically associated with glassblowers, true exfoliation of the crystalline lens involves a splitting or delamination of the capsule. We reviewed the phacoemulsification records of a single surgeon for patients with true exfoliation of the lens capsule. The incidence in our series was 2.2% (6 in 278 cases). The average age was 85.0 years. All patients had successful phacoemulsification outcomes, which may have been due to accurate recognition of the condition and appropriate surgical planning. Our findings support the notion that true exfoliation may be more often associated with advanced age rather than infrared radiation.

The use of Pentacam in the Assessment of True Exfoliation of the Lens Capsule

Purpose

To highlight the use of Pentacam in the identification of true exfoliation of the lens capsule.

Methods

A 72-year-old woman presented for assessment of bilateral cataracts. An unusual appearance was noted in the right eye. A scrolled membrane was seen floating in the anterior chamber.

Results

Imaging with Pentacam showed its origin to be from the anterior lens capsule, suggesting the diagnosis of true exfoliation of the lens capsule. The patient went on to have uncomplicated cataract surgery and the lens capsule was sent for histopathology.

Conclusions

This case highlights the use of anterior segment imaging, the classic histopathology findings, and the management of cataract surgery in these rare cases.

Electron microscopic investigation of anterior lens capsule in an individual with true exfoliation

AIM

To determine the changes which occur in the anterior capsule in true exfoliation which is a very rare condition.

METHODS

The anterior capsule from a 93 year-old patient and 6 other patients with age-related cataract during capsulorhexis was examined via transmission electron microscopy (TEM).

RESULTS

TEM revealed apoptosis of lens epithelial cells in both two groups. Moreover, we observed lamellar delamination, granular belts in the anterior capsular zone and loss of the subcapsular epithelium cells in the posterior capsular zone, as well as abnormal fibrils located in the central capsular layer only in the sample from the patient with true exfoliation.

CONCLUSION

We suggest that loss of lens epithelial cells and appearance of abnormal fibrils is important in disease developing, and our study supported age-related degeneration is one of causative factors in true exfoliation.

Multiple layers lens capsule true exfoliation in patient with primary angle closure glaucoma

Introduction

True exfoliation of lens capsule is a relatively rare disorder that has a thin, fluttering membrane in the anterior chamber, mainly located in the pupil area, which is believed to have split from the anterior lens capsule.

Case Report

The authors present here a patient with true exfoliation and primary angle closure glaucoma in both eyes, the ultrastructure of one eye revealed that the delaminated membrane was composed of more than two layers in itself.

Conclusion

Lens capsule true exfoliation could happen in patient with primary angle closure glaucoma, with more than two layers in itself.