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July 2012 Pseudoexfoliation February 2011 EW FEATURE 41 or glaucoma surgery, you have to an- ticipate that there are a lot of things that we don't see clinically in the examination pre-operatively," Dr. Lewis said. "It's hard to prepare for every scenario, but you need to be on guard that this kind of situation can happen." He pointed out that it may not be a bad idea to put the lens in the sulcus or to suture it to the wall of the eye because the pseudoexfolia- tion is going to continue. "You may have stability for a few months or even a few years, but ultimately it still may dislocate," Dr. Lewis said. Counting on "coat hangers" An example of pseudoexfoliation glaucoma Source: "Serum homocysteine, vitamin B 12 and folic acid levels in different types of glaucoma," by Tongabay Cumurcu, Semsettin Sahin, and Erdinc Aydin This inherent zonular laxity is often part-and-parcel with pseu- doexfoliation. "I think for day-to- day activities this patient was doing fine," Dr. Lewis said. "It was such minimal trauma—it shouldn't have happened then but it did." He sees the case as re-emphasizing just how weak such a patient's zonules can be. Dr. Lewis found that he had to move to plan B. "We had to do a lensectomy, vitrectomy, and the glaucoma surgery took a second fid- dle to these other procedures," he said. "The lens was gone so we had to remove it through a vitrectomy and then we had to suture in a pos- terior chamber intraocular lens." The patient ultimately did OK, although Dr. Lewis stressed that the underlying pseudoexfoliation process can be unrelenting. "A lot of these patients may do well for a few years with glaucoma surgery, but it's not unlikely to see them fail later on because of the progressive nature of the disease," he said. Like Dr. Condon, he reminds practitioners of the value of antici- pation with pseudoexfoliation pa- tients. "Whether it's cataract surgery Because of zonular laxity, stabiliza- tion of the capsule is key in pseudoexfoliation patients with cataracts. Dr. Condon recalls a case he had involving a gentleman who had had a catastrophic procedure in his first eye, who was referred to him to handle the second. "Basically the zonules were loosened during the procedure that immediately fol- lowed the capsulorhexis," he said. He pointed out this was prior to the availability of current stabiliza- tion technology, and he found that he had to improvise to stabilize the capsule. "I used a pair of Ahmed capsular tension segments and tem- porarily hooked each one of the eye- lets to an inverted iris retractor and used them like a pair of coat hangers in the capsular bag to support this," he said. These were placed 180 de- grees apart from each other. He found that this made all the differ- ence. "It made the whole case seem routine," Dr. Condon said. "I didn't realize how much zonular laxity I was disguising with that setup until I took them out after putting the lens in the capsular bag, and I could see this tremendous mobility of the capsular bag." Of course, such "coat hangers" are no longer necessary. Technology such as the MST capsule retractor (MicroSurgical Technology, Red- mond, Wash.) or Ahmed capsular tension segments (CTS, Morcher, Stuttgart, Germany) can help to sup- port the capsule during the case. Dr. Condon sees these as superior to a capsular tension ring here. "The dif- ference between those and a stan- dard capsular tension ring, or even the one with the eyelet, is that you know that the capsular tension ring has to be compressed as it's going into the capsule so there is the possi- bility of stressing the zonules more than you would like to get in there," Dr. Condon said. In cases where the capsular bag is profoundly redundant and lax in itself, however, Dr. Condon will consider a capsular tension ring. He does have one caveat. "If you do continued on page 42 Poll Size: 513 EyeWorld Monthly Pulse EyeWorld Monthly Pulse is a reader survey on trends and patterns for the practicing ophthalmologist. Each month we send a 4-6 question online survey covering different topics so our readers can see how they compare to our survey. If you would like to join the current 1,000+ physicians who take a minute a month to share their views, please send us an email and we will add your name. Email ksalerni@eyeworld.org and put EW Pulse in the subject line; that's all it takes. Copyright EyeWorld 2012