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Pi Is 0886335008008481
Pi Is 0886335008008481
complications. The preliminary study also found that IOP decreased in the early postoperative period. In this issue (pages 18341841), the latest report by Shingleton et al. evaluates the long-term effect of phacoemulsification with posterior chamber IOL implantation on IOP in this series of PXF patients. The retrospective study looked at the results in 1122 eyesd882 had no glaucoma and 240 had glaucoma. After approximately 7 years, the PXF with no glaucoma eyes demonstrated a statistically significant reduced mean IOP compared with the preoperative levels. Similarly, the PXF with glaucoma eyes had a reduced mean IOP over this same period of time. A higher mean preoperative IOP was associated with a greater reduction in IOP postoperatively in both groups. The most important outcome noted in the study was that only 2.7% of the PXF with no glaucoma eyes progressed to actual glaucoma requiring medication and only 3.7% of the PXF eyes with glaucoma progressed to needing laser or glaucoma surgery. These numbers are remarkable given the propensity for patients with PXF to convert from ocular hypertension to glaucoma or to progress rapidly when glaucoma develops. Thus, it appears that phacoemulsification with IOL implantation has a protective effect on the development or progression of glaucoma in patients with PXF. This effect seemed to persist throughout the relatively long follow-up in this group of patients. The exact mechanism of decreased IOP after removal of the cataractous lens is unclear; however, growth of the crystalline lens throughout life has been noted to cause a progressive shallowing of the anterior chamber, which may cause some forward traction by the zonules in the anterior ciliary body, displacing the uveal track anteriorly and compressing the outflow of the trabecular meshwork and the canal of Schlemm. Theoretically, removing the thickened crystalline lens and replacing it with a thin IOL should reverse this change and relieve some of the compression of the trabecular meshwork and the canal of Schlemm.8 Extrapolating these findings to eyes with PXF, it is likely that removing the crystalline lens during phacoemulsification and replacing it with an IOL will lead to an increase in outflow through the trabecular meshwork and Schlemm canal despite the buildup of exfoliative material, leading to a decrease in the conversion from ocular hypertension to glaucoma. This may also be instrumental in reducing the number of patients with PXF glaucoma who progress to medication or surgery.
0886-3350/08/$dsee front matter doi:10.1016/j.jcrs.2008.09.002
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Long-term studies that follow a large group of patients are critical when evaluating potential treatment modalities for a progressive, long-term condition such as PXF. Nick Mamalis, MD REFERENCES
tzer-Schrehardt U. Exfoliation syndrome. Surv 1. Ritch R, Schlo Ophthalmol 2001; 45:265315 2. Ritch R. Exfoliation syndromedthe most common identifiable cause of open-angle glaucoma. J Glaucoma 1994; 3:176178 3. Bengtsson B, Heijl A. A long-term prospective study of risk factors for glaucomatous visual field loss in patients with ocular hypertension. J Glaucoma 2005; 14:135138
4. Grdum K, Heijl A, Bengtsson B. Risks of glaucoma in ocular hypertension with and without pseudoexfoliation. Ophthalmology 2005; 112:386390 5. Jeng SM, Karger RA, Hodge DO, Burke JP, Johnson DH, Good MS. The risk of glaucoma in pseudoexfoliation syndrome. J Glaucoma 2007; 16:117121 tzer-Schrehardt U, Naumann GOH. Ocular and systemic 6. Schlo pseudoexfoliation syndrome [perspective]. Am J Ophthalmol 2006; 141:921937 7. Shingleton BJ, Nguyen BK, Eagan EF, Nagao K, ODonoghue MW. Outcomes of phacoemulsification in fellow eyes of patients with unilateral pseudoexfoliation: single surgeon series. J Cataract Refract Surg 2008; 34:274279 8. Poley BJ, Lindstrom RL, Samuelson TW. Long-term effects of phacoemulsification with intraocular lens implantation in normotensive and ocular hypertensive eyes. J Cataract Refract Surg 2008; 34:735742