Pseudo-Exfoliation

Dr. Anand Sudhalkar

BOS 2009

The understanding

a Finnish ophthalmologist named Lindberg first described pseudoexfoliation syndrome in 1917.

Dvorak-Thebold suggested the term pseudoexfoliation to differentiate it from true exfoliation or lamellar delamination of the lens capsule found in glassblowers. True exfoliation syndrome is due to heat or infrared-related changes in the anterior lens capsule.

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Prevalence

In Europe England: 4.7% Norway: 6.3% Germany: 4% Greece: 1.1% France: 5.5%In South Africa

Bartholomew 8.2% in the Bantu

tribes In Asia Japan 3.4%. Pakistan 6.45%

India 7.4%

Demographics: Sex: F>M Kozart and Yanoff,

3 times more common in women than in men.

Age: >50 Increases steadily with age after

50. In Norway, Aasved reported that the

prevalence of pseudoexfoliation was 0.4% in individuals aged 50-59 years and 7.9% in individuals aged 80-89 years.11 The reported mean age of pseudoexfoliation syndrome ranges from 69-75 years.

Jonasson et al reported a 10% annual increase for both open-angle glaucoma and pseudoexfoliation in persons aged 50 years and older in Iceland.12

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Pathophysiology

Ophthalmic:  In the anterior segment of

the eye, it is characterized by deposition of pseudoexfoliative amyloidlike material on the anterior lens capsule, ciliary body, zonules, pupillary margin of the iris, corneal endothelium, anterior vitreous, and trabecular meshwork. in the walls of the vortex veins and the central retinal artery

Systemic: Extraocular tissues

involved include lung, skin, liver, heart, kidney, gallbladder, blood vessels, extraocular muscle, connective tissue in the orbit, and meninges

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Pseudoexfoliation syndrome is diagnosed clinically by slit lamp examination with an 85%

sensitivity rate and a 100% specificity rate.Flecks at Pupil Margin

Pigment deposition on the iris surface,

Deposition of pigment and pseudoexfoliation material on the corneal endothelium,

Pigment liberation after pupillary dilation, and pseudoexfoliation material covering the ciliary processes and the zonules

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After Dilatation:

The most commonly recognized feature is the 3-ring sign on the anterior lens capsule, formed by a central disk, a peripheral ring, and a clear zone, which separates the two. The clear zone varies in diameter and may exhibit curled edges.

Secondary pigmentary dispersion syndrome, with a loss of melanin from the iris pigment epithelium at the pupillary margin and an accumulation of melanin granules in the trabecular meshwork. Peripupillary iris atrophy is a common finding.

Gonioscopy shows a discontinuous pigmentation of the trabecular meshwork, usually less dense than seen in pigmentary glaucoma. Also, pigment characteristically is deposited on the Schwalbe line or anterior to the Schwalbe line (the Sampaolesi line). A high incidence of narrow, or occludable, angles in eyes with pseudoexfoliation has been reported.

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The Challenges

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Insufficient mydriasis, Posterior synechiae, Anterior insertion of

zonules Phacodonesis, lens

subluxation, Corneal endothelial

decompensation Nuclear cataract GLAUCOMA (3.2%

PER YEAR CONVERSION RATE)

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Next

Cataract With Uveitis

Dr. Anand Sudhalkar

BOS 2009

Iris Inflammation

Situations Concerns

Small, undilating Pupil Posterior Synechia Sub clinical

inflammation Complicated cataract Associated Glaucoma Systemic diseases

Preop medications Iris handling, tears,

bleeding Rhexis & Zonular

stress Choice of IOL Postop care

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Additional Measures

Preop Management Intraop modifications

NSAID, Steroids, Cycloplegics

Systemic management for Autoimmune diseases, DM, HT, UTI

IOP control Counseling for long

term Postop followup

Ciliary block anesthesia

Sub Conj Mydricaine + Steroid

Viscoelastics, Capsular staining

Low Phaco Parameters, MICS

IOL choices: HSM, Hydrophilic

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Video: Iritis with total post synechia

Case of F/32, Rubella Case of F/45, Ch Iritis

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Post Glaucoma Surgery Post SynechiaSituations:

Bleb Leak

Shallow AC

Temp incision

Previous Endothelial damage

Recurrent Iritis

SOLUTION:

GOOD VISCOELASTIC

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Special conditions with small pupils

Atrophic/ floppy Iris NVI

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Thank you