Pseudoexfoliation syndrome
 

The iris and the lens contain dandruff-like flakes. The flakes on the lens are arranged in a bull eye fashion with an  intermediate clear zone. The corneal endothelium shows pigment deposition. On retroillumination, the iris shows  peripupillary iris transillumination. The condition is usually bilateral. Look for: trabeculectomy  fundus for optic disc cupping (glaucoma caused by pseudoexfoliation syndrome is also termed capsular  glaucoma) lens subluxation or phacodonesis. As the eye is usually dilated for examination, iridodonesis is  usually not apparent if there is lens subluxation.

Questions:
1. What is the risk of glaucoma in pseudoexfoliation syndrome?

Answer
About 60% of patients with pseudoexfoliation syndrome develop secondary open angle glaucoma. Compared with primary open angle glaucoma, this type of glaucoma is less responsive to medical therapy. Argon laser trabeculoplasty is useful initially to control the pressure but this is eventually lost sometimes abruptly. Trabeculectomy is useful and has the same success rate as primary open angle glaucoma.

2. What may you see on gonioscopy?

Answer
Sampaolesis' line which is a line of pigment deposition anterior to Schwalbe's line.

3. What is the source of the flakes seen in this condition?

Answer
The exact source is unknown. It may be produced by the epithelium of the lens and other tissues because the material is not confined to the eyes. The condition is thought to be a generalized disorder of the basement membrane. Biochemically, the material is made up of proteoglycan materials and has features of basement membrane. Cataract operation does not stop its production.

4. What is the risk of cataract extraction in this patient?

Answer
Poor pupillary dilatation
Weak zonules predisposes zonular dehiscence. This risk is increased with vigorous hydrodissection or excessive nucleus manipulation during phacoemulsification.
Increased risk of posterior capsular rupture

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