Pseudoexfoliation has important implications for cataract and glaucoma patients, long-term study shows

SAN DIEGO — Pseudoexfoliation is a "ubiquitous disorder" that requires special care and attention in patients with both cataract and glaucoma, the results of large-scale retrospective study have found.

Bradford J. Shingleton

Bradford J. Shingleton, MD, reviewed more than 1,500 cataract surgery cases involving patients with pseudoexfoliation over nearly 2 decades. He delivered the Stephen A. Obstbaum, MD, Honored Lecture during Glaucoma Day of the American Society of Cataract and Refractive Surgery meeting.

All 1,500 eyes (1,000 patients) were operated on by Dr. Shingleton between 1987 and 2006. The review, which included every eye with pseudoexfoliation in one or both eyes, examined visual improvement, IOP reduction, glaucoma medication requirements, intraoperative complications and postoperative complications, Dr. Shingleton said.

"What is the most common problematic issue I have had to deal with that deals with both cataract and glaucoma? Without question, for common and problematic issues, it is clearly pseudoexfoliation," he said.

According to Dr. Shingleton, pseudoexfoliation affects 70 million people worldwide, and is probably "the most identifiable cause of open-angle glaucoma."

Looking at two eyes of the same patient, Dr. Shingleton found that the eye with pseudoexfoliation has higher IOP — and experiences a greater mean decrease in IOP postoperatively — than its normal fellow eye. The fellow eye tends to require less medication after surgery over an extended period of time, while the pseudoexfoliative eyes require more medication in a 3- to 5-year interval, he said.

Postoperative visual improvement, as well as the rate of intraoperative and postoperative complications, appears to be about the same in eyes with pseudoexfoliation and their normal fellow eyes. Overall, the fellow eye appears to be a "hybrid," or somewhere between a pseudoexfoliative eye and a normal eye, he said.

When Dr. Shingleton compared eyes with pseudoexfoliation with glaucoma to those without glaucoma, he found about an equal level of IOP reduction in both eyes for an extended period of time. In patients who underwent combined cataract and glaucoma surgery, surgery reduced postoperative IOP and improved vision in eyes with pseudoexfoliation as well as eyes without.

However, he cautioned that intraoperative complications in patients with pseudoexfoliation are more prevalent than in patients without this disorder, and the problems are typically related to zonular issues.

To maximize intraoperative success, Dr. Shingleton recommended identifying high-risk patients early on and preparing them for possible adverse outcomes. He suggested employing hydrodissection and delineation and using capsule retractors and sutured capsular tension rings for additional zonular support. He also stressed that using acrylic IOLs can help reduce phimosis.

While acknowledging that his study was limited by its retrospective nature, the fact that he was the only surgeon involved and the variability of technologies during the 20-year study period, he also said he felt the unique design provided "a certain value."

Having just one surgeon perform all the surgeries ensured consistency in technique, and the large number of eyes with long-term follow up has offered him the chance to modify his approach to the problem.

"I really exhort every one of you to follow your results. It helps guide, focus, tailor and individualize your care," Dr. Shingleton concluded.