Improving detection of pseudoexfoliation syndrome

This editorial’s authors discuss the challenges of managing pseudoexfoliation syndrome, including the difficulty of diagnosis. They emphasize the importance of always having a keen eye and a high index of suspicion when examining a patient, looking for the often subtle findings that may lead to prompt diagnosis and treatment.

They note that the presence of pseudoexfoliation material can represent a spectrum of intraocular diseases, including glaucomatous optic neuropathy, cataract formation, phacodonesis, lens subluxation, iris atrophy, poor mydriasis and a Fuchs’ like keratopathy.

They say that pseudoexfoliation syndrome is a general disorder of extracellular matrix, although it remains unclear whether the changes within the extracellular matrix can lead to any systemic disease. Some small-scale retrospective case–control studies have linked pseudoexfoliation syndrome to various diseases of aging, demonstrating associations with cardiovascular and cerebrovascular diseases, sensory neural hearing loss and Alzheimer disease.

Detection of pseudoexfoliation syndrome is based on clinical findings, the authors note, so the diagnosis can be missed, especially in the its early stages. The classic features of pseudoexfoliation syndrome include loss of pupillary ruff, iris transillumination defects, the presence of a Sampaolesi’s line and fluffy white anterior lens capsule deposits. These are all clinical observations made at the slit lamp and can often be quite subtle. There is also most often unilateral clinical disease despite bilateral pathology.

They say that improving early detection of pseudoexfoliation syndrome could boost the ability to connect this disease to other systemic problems. However, reports have shown that the first changes from pseudoexfoliation syndrome are fine deposits on the ciliary processes and zonules, as well as elastotic alterations at the lamina cribrosa, findings that cannot be detected with clinical slit lamp evaluation. Future advances in imaging may help to identify these changes more reliably, they say. Studying the lamina cribrosa changes in more detail with more sensitive imaging methods may also increase our understanding of the connection between pseudoexfoliation and the development of glaucoma.

They recommend:

• Being observant of comorbid disease in all patients older than age 60.
• Using capsular support hooks or a capsular tension ring (CTR) when zonular weakness is found, which can turn a high-risk cataract extraction into a straightforward case.
• Using a suturable three-piece lens placed into the capsular bag to provide the best outcome should a dislocation occur. Accommodating or multfocal lenses should not be used.
• Performing frequent reassessment of gonioscopy in phakic patients, as these patients are prone to develop angle closure as the zonules loosen and lens complex shifts anteriorly.
• Taking advantage of anterior segment imaging to help in assessing a patient with pseudoexfoliation and narrow angles.