EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/76185
40 EW FEATURE February 2011 Pseudoexfoliation July 2012 Casing out pseudoexfoliation by Maxine Lipner Senior EyeWorld Contributing Editor AT A GLANCE • With pseudoexfoliation patients, zonular laxity makes cataract procedures particularly dicey • Some of these cataracts may "magically disappear" • The most minimal trauma may collapse the works • Going back to the basics may be best Learning from unforget- table real-life scenarios I t's unfortunately par for the course with pseudoexfoliation cases—surgery is anything but routine, according to Garry P. Condon, M.D., associate pro- fessor, College of Medicine, Drexel University, Pittsburgh. "The thing about pseudoexfoliation in general is that you don't know necessarily how it's going to behave in the OR— I call it the proverbial box of choco- lates," Dr. Condon said. "When I get to the OR, the thing that I'm always thinking about is anticipating the worst and hoping for the best." To offer a better idea of just what can arise, EyeWorld asked sev- eral leading practitioners to share some of their more memorable pseu- doexfoliation cases. Here is some of what you might expect to crop up. The disappearing cataract Paul J. Harasymowycz, M.D., chief, Glaucoma Service, University of Montreal, remembers a case that he was referred involving a pseudoexfo- liation patient who, it appeared, had broken the trust of the initial sur- geon. When the initial surgeon went to schedule the patient for cataract surgery, there was no cataract to be found. "He told me that the patient had cataract surgery done elsewhere but was denying the fact," Dr. Harasymowycz said. "I asked, 'Are you sure he had cataract surgery?' And he said, 'It is obvious—the cataract is no longer there.'" Dr. Harasymowycz examined the patient himself. He noted right off the bat that there were no telltale incisions of cataract surgery. When he looked a bit further he discovered the truth. "The patient had no visible cataract, but it had sponta- neously luxated down into the vitreous cavity so he was aphakic through the pupil," he said. "We saw the end of the cataract on the B-scan, so the patient obviously wasn't lying." He took two lessons from the case. "It goes to show that you can have spontaneous lens luxation," Dr. Harasymowycz said. "Also, some- times you can place the lens in the bag and get late luxation—months or years later it can luxate into the vitreous cavity, in which case some- times we have to suture it to the sclera." Nightmare patient One pseudoexfoliation patient left a particular impression on Dr. Condon. This man was a deaf, 92- year-old Russian who had only one eye left, a super dense cataract, and who more than likely had very weak zonules. "His other eye had been lost as a result of complex cataract surgery that resulted in a loss of lens material and retinal detachments," Dr. Condon said. As a rule, Dr. Condon worries about such patients since there is no communicating with them about a situation once in the operating room. For this particular patient who had been referred to him be- cause of the difficulties with the first eye, he was particularly on edge. "I looked and thought, I'm not even going to try to do phaco on this guy," he said. "So I did an extracap- sular cataract procedure on him and he was fine." Dr. Condon sees an important lesson here. "If the scenario looks like the deck is stacked entirely against you with a situation like that, then I think there's nothing wrong with going to the good old extracapsular procedure when you have a patient with terrible vision and a tremendous likelihood of being a complex procedure with ad- ditional down-the-road problems," he said. "Doing an extracapsular procedure where you're much more assured of getting the entire lens contents out of the eye in one sit- ting to me is a perfectly reasonable thing to do." Poking along Meanwhile, Richard A. Lewis, M.D., Sacramento, Calif., recalls a combined cataract/glaucoma case involving a pseudoexfoliation pa- tient with pressures in the mid-30s on full medical therapy. Dr. Lewis elected to do a combined procedure here, beginning with the cataract surgery. "I made the initial incision and was starting the capsulorhexis," he said. For this he takes a little bent needle and pokes a hole in the ante- rior capsule and starts the tear. In most patients this is no problem, but in this case the unexpected occurred. "Just that little nick with a capsulotomy needle caused the entire cataract to collapse into the vitreous," he said. "There was no zonular support even though there was no evidence of that pre-opera- tively." Monthly Pulse Keeping a Pulse on Ophthalmology W hether you are a glaucoma specialist or a comprehensive ophthalmolo- gist, pseudoexfoliation (PEX) tests your clinical skills in myriad ways. This survey asked some basic management questions. It is not surpris- ing that most begin therapy with eye drops, although a significant minority uses laser as frontline treatment. The frequency of PEX is confirmed in question 2 with almost 50% seeing it in more than 5% of patients—and 8% finding it in more than 20%. Question 3 shows how much we worry about the specific issues of PEX. More than half are concerned with zonular laxity, and 15% worry about a dropped nucleus. The actual incidence of a dropped nucleus is certainly much less frequent and demonstrates how PEX forces us to worry about complications that are unlikely to happen. Question 4 shows that most of us review the most serious risks when giving informed consent even though they are rare. However, 16% of surgeons don't even mention PEX. Reay Brown, M.D., glaucoma editor