EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/76185
World view A SC RS The official publication of the American Society of Cataract & Refractive Surgery July 2012 Publisher Donald R. Long dlong@eyeworld.org Editorial Associate Editor Stacy Majewicz smajewicz@eyeworld.org EyeWorld Staff Writers Faith Hayden faith@eyeworld.org Jena Passut jena@eyeworld.org Production Graphic Designer Julio Guerrero jguerrero@eyeworld.org Production Manager Cathy Stern cstern@eyeworld.org 703-383-5702 Production Assistant Karen Salerni ksalerni@eyeworld.org Contributing Editors Vanessa Caceres Lakeland, Florida Michelle Dalton Reading, Pennsylvania Rich Daly Arlington, Virginia Volume 17 • No. 7 PUBLISHING STAFF Enette Ngoei Singapore Matt Young Malaysia Senior Contributing Editor Maxine Lipner Nyack, New York Advertising Sales ASCRSMedia 4000 Legato Road Suite 700 Fairfax, VA 22033 703-591-2220 fax: 703-591-0614 eyeworld@eyeworld.org www.eyeworld.org Advertising Sales Managers Jeff Brownstein jbrownstein@eyeworld.org 703-788-5745 Paul Zelin pzelin@eyeworld.org 703-383-5729 Classified Sales Cathy Stern cstern@eyeworld.org 703-383-5702 EyeWorld Special Projects and Events Jessica Donohoe jdonohoe@eyeworld.org 703-591-2220 W Reay Brown, M.D., glaucoma editor hen eye surgeons share stories about their most difficult cataract operations, it's a good bet that some—if not most—of those cases involve pseudoexfoliation (PEX). PEX challenges eye surgeons in a seemingly infi- nite variety of ways. The pupils don't dilate, the zonules are uncertain, the cataracts are dense, and the post-op pressures may spike. All of these issues—alone or in powerful combinations— make PEX cataract surgery highly unpredictable. Our cover focus this month explores some of the continuing questions surrounding PEX. The first mystery is why PEX happens in the first place. One of our articles reviews the genetic issues of PEX and how environmental factors may play an enabling role. It appears that the incidence of PEX goes up the farther north people live from the equator. So colder temperatures seem to be important. But the cold alone doesn't explain why the incidence of PEX is so disproportionately high in Scandinavia. Perhaps reflected sunlight is a contributing factor, and there is some evidence that drinking large quantities of coffee may increase the risk of PEX. Laser trabeculoplasty has always been an important therapy in PEX glaucoma. The use of selective laser trabeculoplasty (SLT) has increased interest in laser therapy; another of our articles reviews this issue. Some advocate beginning treatment in PEX glaucoma with medications and then using laser if there are compliance issues or a lack of response. However, some surgeons feel that initial laser treatment is appropriate. Most surgeons will bring the patient into the decision of where laser fits into the treat- ment paradigm. There are many nuances to laser treatment in PEX. The meshwork may be deeply pigmented, and there may be some angle com- promise due to zonular weakness. The IOP may be quite high pretreatment, and the risk of a post-laser IOP spike is greater than for open-angle patients. The article reviews how to deal with these challenges. Cataract surgery is increasingly performed by itself as another effective ASCRS Publisher: EYEWORLD (ISSN 1089-0084) is published monthly by ASCRS Ophthalmic Services Corp., 4000 Legato Road, Suite 700, Fairfax, VA 22033-4003; telephone: 703-591-2220; fax: 703-591-0614. Printed in the U.S. Editorial Offices: EYEWORLD News Service, 4000 Legato Road, Suite 700, Fairfax, VA 22033-4003; toll-free: 800-451-1339, 703-591-2220; fax: 703-591-0614; email: eyeworld@eyeworld.org. Advertising Offices: ASCRSMedia, 4000 Legato Road, Suite 700, Fairfax, VA 22033-4003; toll-free: 800-451-1339, 703-591-2220; fax: 703-591-0614; email: eyeworld@eyeworld.org. Copyright 2012, ASCRS Ophthalmic Services Corp., 4000 Legato Road, Suite 700, Fairfax, VA 22033-4003. All rights reserved. No part of this publication may be reproduced without written permission from the publisher. Letters to the editor and other unsolicited material are assumed intended for publication and are subject to editorial review and acceptance. Subscriptions: Requests should be addressed to the publisher. Annual subscription prices: Individual: 1 year, $120; 2 years, $220; 3 years, $320. Institutional: 1 year, $250; 2 years, $330; 3 years, $425. Foreign: 1 year, $240, 2 years $470, 3 years, $700. Back copies: Subject to availability. Contact the publisher. Cost per copy is $15; $30 foreign. All orders for individual or back copies must be accompanied by payment. Requests to reprint, use, or republish: Requests to reprint or use material published herein should be made in writing only to Cathy Stern, EYEWORLD, 4000 Legato Road, Suite 700, Fairfax, VA 22033-4003; toll-free: 800-451-1339, 703-591-2220; fax: 703-591-0614; email: eyeworld@eyeworld.org. EYEWORLD reprints: To order reprints of material published in EYEWORLD, contact Cathy Stern, EYEWORLD, 4000 Legato Road, Suite 700, Fairfax, VA 22033-4003; toll-free: 800-451-1339, 703-591-2220; fax: 703-591-0614; email: cstern@eyeworld.org or your salesperson. Change of address: Notice should be sent to the publisher six weeks in advance of effective date. Include old and new addresses and label from recent issue. The publisher cannot accept responsibility for undelivered copies. POSTMASTER: Send change of address to EYEWORLD, 4000 Legato Road, Suite 700, Fairfax, VA 22033. Periodical postage paid at Fairfax, VA 22033 and at additional mailing offices. The ideas and opinions expressed in EYEWORLD do not necessarily reflect those of the editors, publisher, or its advertisers. Reay Brown, M.D., glaucoma editor way to reduce IOP in glaucoma. This can be particularly helpful in PEX glaucoma. However, in some patients, combining cataract surgery with a glaucoma operation is necessary to adequately treat serious glaucoma. Another of this month's articles reviews the controversies of whether to perform cataract surgery alone in PEX or combine it with a glaucoma procedure. The glaucoma procedures that may be combined with cataract surgery include trabeculectomy—perhaps with an EX-PRESS Glaucoma Filtration Device (Alcon, Fort Worth, Texas)—canaloplasty, endocyclophotocoagulation, and trabeculotomy with the Trabectome (NeoMedix, Tustin, Calif.). The options for combined surgery have expanded recently with the FDA approval of the iStent (Glaukos, Laguna Hills, Calif.). The iStent is a breakthrough glaucoma device. It is the first trabecular bypass device and the first device to be implanted within the anterior chamber and directly into Schlemm's canal. The iStent changes the landscape of combined sur- gery by giving cataract surgeons—for the first time—the option of a MIGS (micro-invasive glaucoma surgery) device. No discussion of PEX would be complete without some clinical stories of harrowing cases. The article on unforgettable cases demonstrates the incredible range of what can happen during surgery in PEX. The article provides many pearls on how to assess PEX pre-op and what tricks and devices can be used to complete these difficult cases successfully. PEX may announce its presence dramatically. The patterns of PEX material on the lens, iris, and cornea can be artistic and impressive. But whether the appearance is vivid or subtle, PEX presents us with numerous tests of our judgment and surgical skills. We hope this cover focus gives you some new insights—and courage—as you confront the challenges of PEX. Pseudoexfoliation cataracts: A riddle wrapped in a small pupil inside some loose zonules