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Consultation section: Glaucoma

July consultation #3

Crandall, Alan S. MD

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Journal of Cataract & Refractive Surgery: July 2016 - Volume 42 - Issue 7 - p 1100-1101
doi: 10.1016/j.jcrs.2016.06.012
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Although this type of case is unusual, it is not rare. Pseudoexfoliation syndrome is associated with glaucoma and cataract.1 Cataract surgery in eyes with PXF can be complicated because of poor pupil dilation, zonular weakness, sticky cortex, and fragile capsules that can lead to complications.2,3 Even with uneventful cataract extraction, glaucoma and late spontaneous IOL–bag subluxation or dislocation can occur.2,4 The occurrence of late subluxation averages 8.5 years after uneventful cataract surgery.4

In this case, the glaucoma and the subluxation must be managed. I would plan a trabeculectomy or the placement of a mini-shunt with MMC to manage the glaucoma. Usually, I prepare the site for the trabeculectomy or shunt without entering the eye because I find dissecting the flap easier with normal pressures.

If the pupil does not dilate well, I would use iris hooks to enlarge it to determine how to address the subluxation. Several approaches can work.5 I find the Kirk and Condon6 technique to be the easiest to use.

In the other eye, although not an emergency, I would fixate the bag complex after the first eye has recovered.

The question that still has no complete answer is related to maneuvers that could be performed at the time of cataract to reduce the possibility of the late subluxation. Certainly with PXF, I try to reduce zonular stress with bimanual rotation and tangential cortical stripping rather than radial, and I often use a capsular tension ring (CTR) if there is evidence of zonular weakness. I also use a Singer sweep to remove as much anterior lens cells as possible to prevent capsule phimosis. The CTR does not protect from the subluxation but helps center the IOL and makes it easier to refixate.7,8 Although lens epithelial cell removal does not prevent posterior capsule opacification, it helps reduce late phimosis.9,10

References

1. Seland JH, Chylack LT Jr. Cataracts in the exfoliation syndrome (fibrillopathia epitheliocapsularis). Trans Ophthalmol Soc U K. 1982;102:375-379.
2. Naumann GOH, Schlötzer-Schrehardt U, Küchle M. Pseudoexfoliation syndrome for the comprehensive ophthalmologist; intraocular and systemic manifestations. Ophthalmology. 1998;105:951-968.
3. Shingleton BJ, Crandall AS, Ahmed II. Pseudoexfoliation and the cataract surgeon: preoperative, intraoperative, and postoperative issues related to intraocular pressure, cataract, and intraocular lenses. J Cataract Refract Surg. 2009;35:1101-1120.
4. Jehan FS, Mamalis N, Crandall AS. Spontaneous late dislocation of intraocular lens within the capsular bag in pseudoexfoliation patients. Ophthalmology. 2001;108:1727-1731.
5. Chan CC, Crandall AS, Ahmed II. Ab externo scleral suture loop fixation for posterior chamber intraocular lens decentration: clinical results. J Cataract Refract Surg. 2006;32:121-128.
6. Kirk TQ, Condon GP. Simplified ab externo scleral fixation for late in-the-bag intraocular lens dislocation. J Cataract Refract Surg. 2012;38:1711-1715. erratum, 2013; 39:489.
7. Lee D-H, Shin S-C, Joo C-K. Effect of a capsular tension ring on intraocular lens decentration and tilting after cataract surgery. J Cataract Refract Surg. 2002;28:843-846.
8. Liu E, Cole S, Werner L, Hengerer F, Mamalis N, Kohnen T. Pathological evidence of pseudoexfoliation in cases of in-the-bag intraocular lens subluxation or dislocation. J Cataract Refract Surg. 2015;41:929-935.
9. Bolz M, Menapace R, Findl O, Sacu S, Buehl W, Wirtitsch M, Leydolt C, Kriechbaum K. Effect of anterior capsule polishing on the posterior capsule opacification–inhibiting properties of a sharp-edged, 3-piece, silicone intraocular lens; three- and 5-year results of a randomized trial. J Cataract Refract Surg. 2006;32:1513-1520.
10. Hayashi H, Hayashi K, Nakao F, Hayashi F. Anterior capsule contraction and intraocular lens dislocation in eyes with pseudoexfoliation syndrome. Br J Ophthalmol. 82, 1998, p. 1429-1432, Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1722461/pdf/v082p01429.pdf. Accessed April 28, 2106.
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