Good outcomes possible in eyes with PXF -

Good outcomes possible in eyes with PXF - - ModernMedicine

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San Diego—Pseudoexfoliation (PXF) is a common disorder that mandates special attention when cataract surgery is indicated, said Bradford J. Shingleton, MD, in his delivery of the Stephen A. Obstbaum, MD Honored Lecture at the glaucoma subspecialty day during the American Society of Cataract and Refractive Surgery annual meeting.

"We need to be aware of PXF, and we need to be wary of it because intra- and postoperative complications of cataract surgery are greater in eyes with this disorder," said Dr. Shingleton, assistant clinical professor, Harvard Medical School, and clinical instructor of ophthalmology, Tufts University School of Medicine, Boston.

Dr. Shingleton said he considers PXF the most common problematic issue in his practice, which embraces both cataract and glaucoma.

He reported findings from analyses of his single-surgeon, consecutive series of phacoemulsification in 1,000 patients (1,500 eyes) with PXF and reviewed considerations for surgical success.

Patients in the group had a mean age of 75 years and were about three-fourths females. Follow-up ranged from 1 day to 19 years, with a mean exceeding 3 years.

Dr. Shingleton presented retrospective analyses comparing outcomes in 1) fellow eyes of patients with unilateral PXF who underwent bilateral phacoemul-sification and 2) eyes with PXF, and without glaucoma. He also presented the results from eyes with PXF and glaucoma undergoing combined surgery.

Overall, the results showed that cataract surgery in PXF eyes with or without glaucoma is associated with good visual outcomes and long-term IOP control, and combined surgery results in even greater IOP reduction. The analyses also highlighted the fact that eyes with PXF are at increased risk for intraoperative and postoperative complications that are directly related to zonular weakness, however.

Phaco in fellow eyes

Figure 1 IOL subluxation in the presence of pseudoexfoliation. (Photo courtesy of Bradford J. Shingleton, MD)

The fellow eye study of patients with unilateral PXF included 137 subjects. Results showed that both the PXF and fellow eyes achieved significant vision improvement after phaco, and no significant difference was seen between them in terms of intraoperative or postoperative complications. A greater mean IOP reduction was seen in the eyes with PXF compared with the fellow eyes, and the decrease from baseline in the eyes with PXF (mean, 2.3 mm Hg) remained statistically significant at 1 year after surgery. Although the patients with PXF were able to decrease use of glaucoma medications initially, a shift occurred between 1 and 3 years, and between 3 and 5 years, the average number of medications used had returned to baseline.

"It is well documented that IOP decreases after cataract surgery in normal eyes, but the magnitude of the decrease in the eyes with PXF was even greater than that," Dr. Shingleton said. "The fellow eyes do not do as well as the normal [eyes] and may be thought of as a hybrid between normal and eyes with PXF."

Phaco in eyes with PXF

This comparison included 217 eyes with glaucoma and 690 eyes without glaucoma. Both groups exhibited a reduction in IOP after cataract surgery that was sustained among eyes followed beyond 5 years. The change from baseline was greater in the eyes with glaucoma, although glaucoma medication use remained fairly stable, Dr. Shingleton noted.

Especially notable from this analysis was the finding that IOP spikes occurred fairly frequently on the first day after surgery in both the eyes with and without glaucoma (38% and 17%, respectively).

"These events were more common than I would have expected and occurred despite effective removal of viscoelastic and routine treatment with a topical beta-blocker and alpha-agonist or an oral carbonic anhydrase inhibitor," Dr. Shingleton said. "The message is to beware of IOP spikes after phaco in patients with PXF."