2/27/2015. University of Utah

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Elaine Matthews
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1 Cataract Surgery in Patients Nick Mamalis, MD Professor of Ophthalmology John A. Moran Eye Center e University of Utah Dr. Mamalis serves as a Consultant/Advisor for ARC Laser Corp., Aaren Scientific, Inc., Abbott Medical Optics, Alcon Laboratories, Inc., Allergan, Anew Optics, Inc., Bausch & Lomb, Inc., Calhoun Vision Inc., ClarVista, Genisphere, HOYA, LensGen, Medennium, Inc., Mynosys, Nu-VueTechnologies, Inc., Omega, PowerVision, and Sharklet Definition Disorder of extracellular matrix Production and progressive accumulation of fibrillar extracellular material in ocular tissues 1

2 LOXL1 (Lysyl oxidase-like 1) Gene Mutation Family of genes necessary for formation and maturation of elastic tissue Role in homeostasis of extracellular matrix Induces cross-linking in collagen and elastin Clinical Findings PXF material on anterior lens surface in three zones Clinical Findings Pupillary ruff and iris sphincter changes 2

3 Clinical Findings Pigment Dispersion Cataract Surgical Complications Capsular rupture Zonular dialysis Vitreous loss Blood-aqueous barrier breakdown Capsular Bag Pathology Exfoliative material on anterior surface of lens capsule Iron filing pattern 3

4 Zonular Pathology Alteration of origin and anchorage to the ciliary body by PXF fibers Am J Ophthalmol 1994; 118:732 Zonular Pathology PXF material infiltration of zonular bundles Am J Ophthalmol 1994: 118:733 Zonular Pathology Weakened anterior Attachment t to lens capsule by PXF material Ophthalmol 1998; 105:957 4

5 PXF in pigment epithelial cells of vessels Iris Pathology PXF in fibroblasts and melanocytes in stroma Ophthalmol 1995; 102:1284 Ophthalmol 1998; 105:959 Iris Pathology PXF in sphincter and dilator muscles Poor pupillary dilation Ophthalmol 1995; 102:1285 Corneal Pathology PXF material in endothelium And Descemet s membrane Postsurgical corneal edema Ophthalmol 1998; 105:964 5

6 Trabecular Meshwork Pathology Passive deposit of PXF material leading to mechanical obstruction of the uveal meshwork Possible active involvement of trabecular cells and excessive accumulation of PXF Increased outflow resistance Deposition of melanin granules from iris pigment epithelium Trabecular Meshwork Pathology Pre-op Considerations Manage intraocular pressure Slit lamp evaluation of chamber anatomy Look at depth Look for asymmetry: suggests zonular weakness Make note of the pupil dilation 6

7 Pupil Management in Small pupil was the main indicator for intra- operative complications Visco-dilation may be sufficient Stretch Hooks Malyugin ring Morcher, Graether, Perfect Pupil Devices Capsulorhexis Wrinkling may suggest zonular weakness Use of dyes may be helpful Can use iris hooks to facilitate the rhexis Size should be as large as possible for the IOL to help reduce capsulophimosis Video 7

8 Hydrodissection Cortical cleaving and good gentle hydrodissection is very important The nucleus in PXE is often difficult to rotate Video Nucleus Disassembly Minimize zonular stress Chopping techniques are the most zonular friendly Pre-chop ideal Vertical chopping in smaller pupils If using a debulking technique use enough power to avoid nuclear movement 8

9 Video Irrigation and Aspiration Definitely more difficult Side to side movement prior to stripping will help loosen the cortex Easy to strip zonules during I & A Video 9

10 Use of Capsular Tension Devices Many use them routinely in all PXE cases However they may also cause stress during the placement If in early they can make I&A more difficult They do not protect against late dislocation but there presence may help in suturing to the sclera Late Postoperative Cataract Complications Spontaneous IOL dislocation within the capsular bag 84 cases evaluated at the Moran Eye Center 9.2 years following surgery 50% associated with PXE Late Postoperative Cataract Complications Associated with all types of IOL materials and designs 10

11 Conclusions Widespread deposition of PXF material throughout anterior segment ocular tissue Multiple associated cataract surgical complications Combination of strategies necessary to prevent complications 11

SECONDARY GLAUCOMA: Pseudoexfoliation (PXF), Pigmentary Dispersion Syndrome (PDS), Neovascular (NV), Uveitic

SECONDARY GLAUCOMA: Pseudoexfoliation (PXF), Pigmentary Dispersion Syndrome (PDS), Neovascular (NV), Uveitic Many roads can lead to glaucoma. With the exception of primary open-angle glaucoma (POAG) and