Cataract surgery for patients with PXF

March 22, 2017

Mom has pseudoexfoliation syndrome (PXF) clinically visible in both eyes. She experiences pops of elevated intraocular pressure (IOP) in one eye and uses glaucoma medications.

I am fortunate to be able to share stories about my mother. Many of my article topics have been inspired by experiences and thoughts shared with my mom.

For background, my mother is 79 years old and, except for a bum knee, is in excellent health. She also is very smart, and sassy, having earned a PhD in organic chemistry decades ago.

Mom is a tough old bird whose career included teaching grade school science to performing histocompatability research at Memorial Sloan Kettering Cancer Center in New York. She has a unique perspectives and interests in topics from community gardening to urban planning.

Mom has pseudoexfoliation syndrome (PXF) clinically visible in both eyes. She experiences pops of elevated intraocular pressure (IOP) in one eye and uses glaucoma medications.

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We decided that it was in her best interest to proceed with cataract surgery because she was experiencing difficulty traveling home at night from local community board meetings.

Pre-surgery preparations

Pre-surgery presented a question-and-answer period that included lecture-quality review of the ocular manifestations and potential surgical complications of cataract surgery-especially in patients with PXF. After the pre-surgery preparations, Mom hesitantly agreed to proceed with surgery.

Although PXF is considered a systemic condition,1 its clinical signs are mostly identified in the eye. Most practitioners are familiar with the grey-white material that is deposited on the anterior structures, notably the anterior lens capsule.

This material, consisting of nanometer-sized fibrils within a loose matrix, is generated multifocally within the eye. The fibrils in PXF are thought to be generated by polymorphisms in a gene named LOXL-1(lysyl oxidase like 1) that is responsible for the biogenesis of connective tissue.2

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One must recognize that the aberrant material deposited in PXF impacts many structures of the eye and may compromise its proper function.

 

Disorders associated with PXF

With respect to the ocular surface, patients with PXF appear to have higher predisposition of tear function disorders. One study, using the Schirmer II test and assessment of lid parallel conjunctival folds in PXF patients, demonstrated that there was a statistically significant difference in tear film break-up time compared to controlled patients.3

There is also an up-regulation of the non-specific inflammatory marker MMP-9 (matrix metalloproteinase-9) in tear film in PXF-syndrome.4 Studies show tear osmolarity is higher in both eyes of patients when compared with normal subjects, and  pseudoexfoliation is suggested to alter basic features of goblet cell morphology-thus affecting tear film stability.5,6

PXF can cause zonular weakness that can allow for excessive lens movement, or dislocation, at the time of cataract surgery. Postoperative inflammation and corneal edema associated with cataract surgery may also be increased in eye with PXF.7

Naturally, I discussed all these things with my mother.

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Post-surgery outlook

Fast forward to Mom’s post-operative statement, “I have no pain.”

My mother had no comment about her vision, or her lack of possible PXF-related complications. The comfort of her eye was the key indicator of success in her surgery.

It surprised me that in light of my concerns, it was only lack of discomfort that my mother discussed. This exercise made me re-evaluate my cataract surgery procedures and how I discuss surgery with patients.

Would it be better to start by saying, “We expect minimal postoperative discomfort?”

References

1.Miglior S, Bertuzzi F. Exfoliative glaucoma: new evidence in the pathogenesis and treatment. Prog Brain Res. 2015;221:233-41

2. Wiggs JL, Pasquale LR. Expression and regulation of LOXL1 and elastin-related genes in eyes with exfoliation syndrome. J Glaucoma. 2014 Oct-Nov;23(8 Suppl 1):S62-63

3. Škegro I, Suić SP, Kordić R, Jandroković S, Petriček I, Kuzman M, Perić S, Masnec S. Ocular surface disease in pseudoexfoliation syndrome. Coll Antropol. 2015 Mar;39(1):43-5.

4. Zimmermann N, Erb C. [Immunoassay for matrix metalloproteinase-9 in the tear film of patients with pseudoexfoliation syndrome - a pilot study]. Klin Monbl Augenheilkd. 2013 Aug;230(8):804-7.

5. Öncel BA, Pinarci E, Akova YA. Tear osmolarity in unilateral pseudoexfoliation syndrome. Clin Exp Optom. 2012 Sep;95(5):506-9.

6. Kozobolis VP, Christodoulakis EV, Naoumidi II, Siganos CS, Detorakis ET, Pallikaris LG. Study of conjunctival goblet cell morphology and tear film stability in pseudoexfoliation syndrome. Graefes Arch Clin Exp Ophthalmol. 2004 Jun;242(6):478-83.

7. Shingleton BJ, Crandall AS, Ahmed II. Pseudoexfoliation and the cataract surgeon: preoperative, intraoperative, and postoperative issues related to intraocular pressure, cataract, and intraocular lenses. J Cataract Refract Surg. 2009 Jun;35(6):1101-20.

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