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Exfoliation Syndrome and Cataract Extraction
Vol. 117, No. 2
Correspondence
and the evolution of diabetic retinopathy and albuminuria. A preliminary multicenter trial. N. Engl. J. Med. 311:365, 1984.
Exfoliation Syndrome and Cataract Extraction EDITOR: We r e a d w i t h interest the article, "Exfolia tion s y n d r o m e a n d cataract e x t r a c t i o n , " by P. L u m m e a n d L. Laatikainen (Am. J. O p h t h a l mol. 116:51, July 1993). The a u t h o r s describe the risk factors in cataract surgery in eyes w i t h exfoliation s y n d r o m e . They state, " W e believe that particularly w i t h less e x p e r i e n c e d cataract s u r g e o n s , this type of anterior c h a m b e r lens is safer in these eyes t h a n s u t u r e fixation of a posterior c h a m b e r l e n s . " O u r o p i n i o n is t h a t in eyes w i t h exfoliation s y n d r o m e the anterior c h a m b e r must b e avoided. A l t h o u g h L u m m e a n d Laatikainen describe the possibility t h a t the anterior c h a m b e r lens can p r o d u c e modifi cations in the c a m e r u l a r a n g l e , they d o n o t m e n t i o n that these lenses can p r o d u c e corneal e d e m a . It is i m p o r t a n t t h a t p a t i e n t s w i t h exfo liation s y n d r o m e b e older, w i t h a d e c r e a s e d e n d o t h e l i u m cell rate, 1 a n d d e p o s i t s of pig m e n t a n d exfoliative material o n the e n d o t h e l i um. 2 These eyes also have b r e a k d o w n of the b l o o d - a q u e o u s barrier, 3 a n d the surgery w i t h miosis may b e of long d u r a t i o n . All of t h e s e factors p r e d i s p o s e to p o s t o p e r a t i v e corneal e d e m a , w h i c h is i n c r e a s e d b y the anterior c h a m b e r lens. We recently a n a l y z e d the risk factors of c a p sular r u p t u r e in the exfoliation s y n d r o m e . 4 In p a t i e n t s at risk we believe it better to r e m o v e the cataract before it b e c o m e s h y p e r m a t u r e . We think that in eyes at risk, cataract surgery must b e p e r f o r m e d b y a s u r g e o n e x p e r i e n c e d in posterior c h a m b e r lens s u t u r e fixation. JAVIER MORENO-MONTANÉS, M.D. DANIEL ALISEDA PÉREZ de MADRID, M.D. JERONIMO LAJARA-BLESA, M.D. Pamplona, Spain
References 1. Miyake, K., Matsuda, M., and Inaba, M.: Corneal endothelial changes in pseudoexfoliationa syn drome. Am. J. Ophthalmol. 108:49, 1989.
273
2. Prince, A. M., and Ritch, R.: Clinical signs of the pseudoexfoliation syndrome. Ophthalmology 93:803, 1986. 3. Küchle, M., Nguyen, N. X., Horn, F., and Nau mann, G. O. H.: Quantitative assessment of aqueous flare and aqueous cells in pseudoexfoliation syn drome. Acta Ophthalmol. 70:201, 1992. 4. Moreno-Montanés, ]., Duch, S., and LajaraBlesa, J.: Pseudoexfoliation syndrome. Clinical fac tors related to the capsular rupture in cataract sur gery. Acta Ophthalmol. 71:181, 1993.
Reply EDITOR: We a p p r e c i a t e the c o m m e n t s of Drs. M o r e n o - M o n t a n é s , Pérez d e Madrid, a n d LajaraBlesa. They have o b s e r v e d i n c r e a s e d risk of corneal e d e m a after cataract surgery in eyes w i t h exfoliation s y n d r o m e a n d therefore prefer the u s e of a posterior c h a m b e r lens w i t h s u t u r e fixation i n s t e a d of an anterior c h a m b e r lens, as r e c o m m e n d e d by u s , in eyes in w h i c h capsular s u p p o r t was lost. We agree t h a t on the first postoperative days corneal e d e m a is m o r e c o m m o n in eyes with exfoliation s y n d r o m e t h a n in t h o s e without. 1 However, the m e a n e n d o t h e l i a l cell loss after cataract surgery a n d i m p l a n t a t i o n of a semiflexible, o n e - p i e c e , o p e n - l o o p anterior c h a m ber lens was n o t i n c r e a s e d by the p r e s e n c e of exfoliation s y n d r o m e . 2 It is better to u s e a posterior c h a m b e r lens t h a n an anterior c h a m b e r lens in exfoliation s y n d r o m e . I n d e e d , in 8 7 % of these eyes (94 of 108), a posterior c h a m b e r lens was i m p l a n t e d , a n d a n anterior c h a m b e r lens w a s u s e d only in eyes w i t h m a r k e d z o n u l a r or posterior capsular tear. Because of the h i g h prevalence of exfolia tion s y n d r o m e in our c o u n t r y ( 3 1 % in this se ries), all of these eyes c a n n o t b e o p e r a t e d on b y the most skilled s u r g e o n s . C o n s i d e r i n g the difficulties a n d risks of s u t u r e fixation of a p o s terior c h a m b e r lens, a n d our experience w i t h the m o d e r n anterior c h a m b e r lens, we believe that a n anterior c h a m b e r lens is safer in these eyes. PIRKKO LUMME, M.D. LEILA LAATIKAININ, M.D. Oulu, Finland
References 1. Lam, P., and Laatikainin, L.: Risk factors for preoperative and early postoperative complications
Correspondence
and the evolution of diabetic retinopathy and albuminuria. A preliminary multicenter trial. N. Engl. J. Med. 311:365, 1984.
Exfoliation Syndrome and Cataract Extraction EDITOR: We r e a d w i t h interest the article, "Exfolia tion s y n d r o m e a n d cataract e x t r a c t i o n , " by P. L u m m e a n d L. Laatikainen (Am. J. O p h t h a l mol. 116:51, July 1993). The a u t h o r s describe the risk factors in cataract surgery in eyes w i t h exfoliation s y n d r o m e . They state, " W e believe that particularly w i t h less e x p e r i e n c e d cataract s u r g e o n s , this type of anterior c h a m b e r lens is safer in these eyes t h a n s u t u r e fixation of a posterior c h a m b e r l e n s . " O u r o p i n i o n is t h a t in eyes w i t h exfoliation s y n d r o m e the anterior c h a m b e r must b e avoided. A l t h o u g h L u m m e a n d Laatikainen describe the possibility t h a t the anterior c h a m b e r lens can p r o d u c e modifi cations in the c a m e r u l a r a n g l e , they d o n o t m e n t i o n that these lenses can p r o d u c e corneal e d e m a . It is i m p o r t a n t t h a t p a t i e n t s w i t h exfo liation s y n d r o m e b e older, w i t h a d e c r e a s e d e n d o t h e l i u m cell rate, 1 a n d d e p o s i t s of pig m e n t a n d exfoliative material o n the e n d o t h e l i um. 2 These eyes also have b r e a k d o w n of the b l o o d - a q u e o u s barrier, 3 a n d the surgery w i t h miosis may b e of long d u r a t i o n . All of t h e s e factors p r e d i s p o s e to p o s t o p e r a t i v e corneal e d e m a , w h i c h is i n c r e a s e d b y the anterior c h a m b e r lens. We recently a n a l y z e d the risk factors of c a p sular r u p t u r e in the exfoliation s y n d r o m e . 4 In p a t i e n t s at risk we believe it better to r e m o v e the cataract before it b e c o m e s h y p e r m a t u r e . We think that in eyes at risk, cataract surgery must b e p e r f o r m e d b y a s u r g e o n e x p e r i e n c e d in posterior c h a m b e r lens s u t u r e fixation. JAVIER MORENO-MONTANÉS, M.D. DANIEL ALISEDA PÉREZ de MADRID, M.D. JERONIMO LAJARA-BLESA, M.D. Pamplona, Spain
References 1. Miyake, K., Matsuda, M., and Inaba, M.: Corneal endothelial changes in pseudoexfoliationa syn drome. Am. J. Ophthalmol. 108:49, 1989.
273
2. Prince, A. M., and Ritch, R.: Clinical signs of the pseudoexfoliation syndrome. Ophthalmology 93:803, 1986. 3. Küchle, M., Nguyen, N. X., Horn, F., and Nau mann, G. O. H.: Quantitative assessment of aqueous flare and aqueous cells in pseudoexfoliation syn drome. Acta Ophthalmol. 70:201, 1992. 4. Moreno-Montanés, ]., Duch, S., and LajaraBlesa, J.: Pseudoexfoliation syndrome. Clinical fac tors related to the capsular rupture in cataract sur gery. Acta Ophthalmol. 71:181, 1993.
Reply EDITOR: We a p p r e c i a t e the c o m m e n t s of Drs. M o r e n o - M o n t a n é s , Pérez d e Madrid, a n d LajaraBlesa. They have o b s e r v e d i n c r e a s e d risk of corneal e d e m a after cataract surgery in eyes w i t h exfoliation s y n d r o m e a n d therefore prefer the u s e of a posterior c h a m b e r lens w i t h s u t u r e fixation i n s t e a d of an anterior c h a m b e r lens, as r e c o m m e n d e d by u s , in eyes in w h i c h capsular s u p p o r t was lost. We agree t h a t on the first postoperative days corneal e d e m a is m o r e c o m m o n in eyes with exfoliation s y n d r o m e t h a n in t h o s e without. 1 However, the m e a n e n d o t h e l i a l cell loss after cataract surgery a n d i m p l a n t a t i o n of a semiflexible, o n e - p i e c e , o p e n - l o o p anterior c h a m ber lens was n o t i n c r e a s e d by the p r e s e n c e of exfoliation s y n d r o m e . 2 It is better to u s e a posterior c h a m b e r lens t h a n an anterior c h a m b e r lens in exfoliation s y n d r o m e . I n d e e d , in 8 7 % of these eyes (94 of 108), a posterior c h a m b e r lens was i m p l a n t e d , a n d a n anterior c h a m b e r lens w a s u s e d only in eyes w i t h m a r k e d z o n u l a r or posterior capsular tear. Because of the h i g h prevalence of exfolia tion s y n d r o m e in our c o u n t r y ( 3 1 % in this se ries), all of these eyes c a n n o t b e o p e r a t e d on b y the most skilled s u r g e o n s . C o n s i d e r i n g the difficulties a n d risks of s u t u r e fixation of a p o s terior c h a m b e r lens, a n d our experience w i t h the m o d e r n anterior c h a m b e r lens, we believe that a n anterior c h a m b e r lens is safer in these eyes. PIRKKO LUMME, M.D. LEILA LAATIKAININ, M.D. Oulu, Finland
References 1. Lam, P., and Laatikainin, L.: Risk factors for preoperative and early postoperative complications