presentation 1 exfoliation and uveitis
TRANSCRIPT
Pseudo-Exfoliation
Dr. Anand Sudhalkar
BOS 2009
The understanding
a Finnish ophthalmologist named Lindberg first described pseudoexfoliation syndrome in 1917.
Dvorak-Thebold suggested the term pseudoexfoliation to differentiate it from true exfoliation or lamellar delamination of the lens capsule found in glassblowers. True exfoliation syndrome is due to heat or infrared-related changes in the anterior lens capsule.
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Prevalence
In Europe England: 4.7% Norway: 6.3% Germany: 4% Greece: 1.1% France: 5.5%In South Africa
Bartholomew 8.2% in the Bantu
tribes In Asia Japan 3.4%. Pakistan 6.45%
India 7.4%
Demographics: Sex: F>M Kozart and Yanoff,
3 times more common in women than in men.
Age: >50 Increases steadily with age after
50. In Norway, Aasved reported that the
prevalence of pseudoexfoliation was 0.4% in individuals aged 50-59 years and 7.9% in individuals aged 80-89 years.11 The reported mean age of pseudoexfoliation syndrome ranges from 69-75 years.
Jonasson et al reported a 10% annual increase for both open-angle glaucoma and pseudoexfoliation in persons aged 50 years and older in Iceland.12
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Pathophysiology
Ophthalmic: In the anterior segment of
the eye, it is characterized by deposition of pseudoexfoliative amyloidlike material on the anterior lens capsule, ciliary body, zonules, pupillary margin of the iris, corneal endothelium, anterior vitreous, and trabecular meshwork. in the walls of the vortex veins and the central retinal artery
Systemic: Extraocular tissues
involved include lung, skin, liver, heart, kidney, gallbladder, blood vessels, extraocular muscle, connective tissue in the orbit, and meninges
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Pseudoexfoliation syndrome is diagnosed clinically by slit lamp examination with an 85%
sensitivity rate and a 100% specificity rate.Flecks at Pupil Margin
Pigment deposition on the iris surface,
Deposition of pigment and pseudoexfoliation material on the corneal endothelium,
Pigment liberation after pupillary dilation, and pseudoexfoliation material covering the ciliary processes and the zonules
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After Dilatation:
The most commonly recognized feature is the 3-ring sign on the anterior lens capsule, formed by a central disk, a peripheral ring, and a clear zone, which separates the two. The clear zone varies in diameter and may exhibit curled edges.
Secondary pigmentary dispersion syndrome, with a loss of melanin from the iris pigment epithelium at the pupillary margin and an accumulation of melanin granules in the trabecular meshwork. Peripupillary iris atrophy is a common finding.
Gonioscopy shows a discontinuous pigmentation of the trabecular meshwork, usually less dense than seen in pigmentary glaucoma. Also, pigment characteristically is deposited on the Schwalbe line or anterior to the Schwalbe line (the Sampaolesi line). A high incidence of narrow, or occludable, angles in eyes with pseudoexfoliation has been reported.
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The Challenges
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Insufficient mydriasis, Posterior synechiae, Anterior insertion of
zonules Phacodonesis, lens
subluxation, Corneal endothelial
decompensation Nuclear cataract GLAUCOMA (3.2%
PER YEAR CONVERSION RATE)
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Next
Cataract With Uveitis
Dr. Anand Sudhalkar
BOS 2009
Iris Inflammation
Situations Concerns
Small, undilating Pupil Posterior Synechia Sub clinical
inflammation Complicated cataract Associated Glaucoma Systemic diseases
Preop medications Iris handling, tears,
bleeding Rhexis & Zonular
stress Choice of IOL Postop care
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Additional Measures
Preop Management Intraop modifications
NSAID, Steroids, Cycloplegics
Systemic management for Autoimmune diseases, DM, HT, UTI
IOP control Counseling for long
term Postop followup
Ciliary block anesthesia
Sub Conj Mydricaine + Steroid
Viscoelastics, Capsular staining
Low Phaco Parameters, MICS
IOL choices: HSM, Hydrophilic
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Video: Iritis with total post synechia
Case of F/32, Rubella Case of F/45, Ch Iritis
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Post Glaucoma Surgery Post SynechiaSituations:
Bleb Leak
Shallow AC
Temp incision
Previous Endothelial damage
Recurrent Iritis
SOLUTION:
GOOD VISCOELASTIC
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Special conditions with small pupils
Atrophic/ floppy Iris NVI
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Thank you