ACTA OPHTHALMOLOGICA 66 (1988) SUPPI. 184, 129-131

EXFOLIATION SYNDROME AS A RISK FACTOR FOR VITREOUS LOSS IN EXTRACAPSULAR CATARACT SURGERY

(Preliminary report)

G. 0. H. Naumann and the “Erlanger Augenblatter-Group”

Department of Ophthalmology (Head: G. 0. H. Naumann), University of Erlangen-Nurnberg, Erlangen, West- Germany

Key words: Exfoliation - pseudoexfoliation - cataract surgery, complications - vitreous loss

Introduction

Exfoliation syndrome (EX) is a puzzling disease of the anterior segment of the eye. Aside from the secondary open angle glaucomas a weaken- ing of the zonular apparatus of the lens causes the main complications (see Naumann, Apple and coworkers, 1986). Purpose of this prelimi- nary communication is to document the signifi- cantly increased incidence of defects of the pos- terior lens capsule and vitreous loss in extracap- sular cataract surgery.

Patients and methods of examination

Since October 1, 1986 all intraocular surgical proce- dures for cataract and glaucoma as well as kerato- plasties are documented in a prospective fashion (“Er- langer Augenblatter”, see Naumann et al. 1987). From that date to September 25, 1987 among others un- selected 1707 intraocular operations in 1424 patients were evaluated (T’able 1 ) . These have been performed by 9 different surgeons.

The details of the documented intraoperative com- plications were evaluated by a computer-programme.

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Results

Vitreous loss during extracapsular cataract sur- gery was significantly increased in eyes with the exfoliation syndrome (Table 2 ) .

Discussion

Exfoliation syndrome is a disease of the anterior segment of the eye of unknown etiology occuring with variable frequency worldwide. It is frequent- ly overlooked clinically and in the laboratory.

50 070 of unilateral cases showed EX deposits on the zonula and ciliary body of the fellow eye (Mizuno & Muroi 1979). In our clinic population in Northern Bavaria we found an incidence of 0,4 070 (Ruprecht et a1 1985); in eyes enucleated for intraocular tumors in 0,7 070 in those for pain- ful absolute secondary glaucoma the incidence is 3,4 070 (Henke & Naumann 1987) (Table 3 ) . The etiology i? obscure. Most obvious are the changes visible at the lens capsule (Seland 1979, 1982).

However, by our own clinical and ophthalmic

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Table I . Unselected intraocular surgical procedures and incidence cf EX, Eye Hospital, University Erlangen-Nurnberg October I ,

1986 - September 25th, 1987.

Incidence of EX

Cataract surgery 1325 46 (3.3 To) extracapsular 1251 intracapsular 74

Perf. keratoplasty 183 1 (0.5 ‘70) Filtrating glaucomaproced. 199 27 (13.5 070)

Total 1707 74 (4.15 070)

Table 2. Incidence of vitreous loss in e.c. cataract surgery Eye Hospital, University Erlangen-Nurnberg, October 1, 1986 - Septem-

ber 25th, 1987.

Extracapsular cataract extraction without EX 1205 23 (1,s 070) Extracapsular cataract extraction with EX 46 4 (9 ‘70)

pathology observation, we are most impressed by the changes of the pars plicata of the ciliary body. We therefore share the observation by Tarkka- nen (1962), that “the material appears to derive from the ciliary body”.

There are some superficial similarities to the changes of the non-pigmented ciliary epithelium in homocystinuria. Studies of the aqueous for amino acids did not reveal any significant changes in comparison to a control population of cataract patients - in contrast to the signifi- cant increased concentration of a// ammuno acid in the primary open angle glaucoma (Hannap- pel et al. 1985 a & b).

The five fold increase in the incidence of vit- reous loss during extracapsular cataract extrac- tion is very striking and confirms our long stand- ing clinical impression by statistical means.

Causes for this increased risk for vitreous loss need further study. Some obvious factors are dif- ficulties in dilatation of the pupil in these pa- tients, the zonular weakening with discreet sub- luxation of the lens and the decreased firmness of the zonula attachments.

Extracapsular cataract extraction in patients with pseudoexfoliation syndrome carry a sig- nificantly increased risk for the complication of vitreous loss. They are certainly not suitable for the relatively little experienced surgeon or begin-

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Table 3. Incidence of EX in Northern Bavaria.

Clinic population (26825)

Surgically enucleated eyes for tumors (142 x)

for second glaucoma (323 x)

Eyes for cataract surgery (1325 x) Eyes for filtrating glaucoma surgery (199 x)

0.4 070 (rough estimate) (Ruprecht et al. 1985)

0.7 070 (Henke &

3.4 070 (Henke & Naumann, 1987)

Naumann, 1987)

3.3 070

13.5 %

ner. As prophylactic measures to avoid this complication, we recommend: (1) Flieringa-Rings to stabilize the exterior of the globe. ( 2 ) In case of non-dilating pupil doubt sector iridectomy or iridotomy. ( 3 ) Very gentle manipulations within the lens. (4) If the nucleus is relatively hard, pha- coemulsification may carry a higher risk than nucleus expression.

Summary

Exfoliation syndrome is a major risk factor for extracapsular cataract surgery. In a series of un- selected prospectively evaluated extracapsular cataract extractions performed by 9 surgeons the incidence of vitreous loss was 1,s 070 in 1205 cataracts without EX; in those with EX 9 %. This fivefold increased incidence of vitreous loss ap- pears related to the difficulties to obtain a satis- factory mydriasis, to the fragility of the zonula and potential, subluxation of the lens. As pre- cautionary measures we recommend Flieringaring, in case of doubt sector iridotomy and sector iri- dectomy.

Exfoliation syndrome is not a harmless anom- aly but a potentially disastrous disease of the an- terior segment of the eye.

References

Hannappel E, Ruprecht K W, Pankow G, Grass1 F. Brand K & Naumann G 0 H: Amino acid pattern in hunian aqueous humour of patients with senile cataract; Primary open angle claucoma and pseudo- exfoliation of the lens. Proc VIIth Congr European Society of Ophthalmology, Helsinki 1985.

Hannappel E, Pankow G, Grass1 F, Brand K & Nau- mann G 0 H (1985): Amino acid pattern in human aqueous humor of patients with senile cataract and primary open-angle glaucoma. Ophthalmic Res 17: 343.

Henke V & Naumann G 0 H (1987): Zur Haufigkeit des Pseudo-Exfoliations-Syndroms in enukleierten Augen. Klin Mbl Augenhkd 190: 173-175.

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Seland J H & Chylack Jr L T (1982): Cataracts in the exfoliation syndrome (fibrillopathia epitheliocap- sularis). Transactions Ophthalmol SOC UK 102: 375-379.

Seland J H (1979): Histopathology of the lens capsule in fibrillopathia epitheliocapsularis (FEC) or so- called senile exfoliation or pseudoexfoliation. Acta Ophthalmol (Copenh) 57: 477-499.

Svedbergh B & Sherwood M (1985): Argon laser trabe- culoplasty in exfoliation glaucoma. A retrospective analysis. Dev Ophthalmol 11: 116-123.

Svedbergh B, Alm A, Amer B, Jerndal T & Thorburn W (1986): Goniodysgenesis in elderly glaucoma and non-glaucoma patients. A masked slit-lamp and gonioscopy study. Acta Ophthalmol (Copenh) 64:

Tarkkanen A (1962): Pseudo-exfoliation of the lens capsule. Acta Ophthalmol (Copenh) Suppl. 71.

45-51.

Author’s address: G. 0. H. Naumann, Department of Ophthalmology, University of Erlangen, Erlangen, West-Germany.

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