Ophthalmology
Volume 99, Number 11, November 1992
Exfoliation Material on IOLs Dear Editor: We read with interest the recent article by Chen and Blumenthal entitled, "Exfoliation Syndrome after Cataract Extraction" (Ophthalmology 1992;99:445-7). The authors describe three cases in which exfoliation material was noted on the posterior surface of intraocular lenses, some years after extracapsular cataract extraction and lens implantation. This report raises a num~r of matters th~t we would like to address. The authors mcorrectly state 10 their article that "the phenomenon has not been previously presented in the literature" and "there are still no reports on exfoliation material on artificial lenses. " There have been at least two reports in the literature on the same subject. 1,2 The authors state that "n? exfoliatio~ ~ateri~l was seen preoperatively on the pupIllary margm 10 theIr three cases." This comment is surprising. It is well documented in the literature that the diagnosis of exfoliation syndrome is frequently missed, unless specifically sought under mydriasis by an experienced observer. The data the authors present are retrospective (these cases were operated on 10, 12, and 13 years previously) and th~refore the diagnosis may have been missed. We agree With the authors that the appearance of exfoliation material on the surface of plastic intraocular lenses indicates th~t ~he crystalline lens is not the principal so.urce o~ exfoha~I~n material. Indeed, the view of the exclUSIve lentIcular ongm of the exfoliation material started to lose favor only when clinical and ultrastructural studies supplied comprehensive evidence of exfoliation material synthesis in the absence of the crystalline lens. 3 We also would be intrigued to know the pattern of exfoliation material distributio~ in their cases. Finally, while it is true that the pathogenesIs of exfoliation syndrome remains uncertain, the statement ofthe authors that it may be related to the "aging process of the pigment layer" although again not original4 is now deemed to be obsolete. 3 ANASTASIOS G. P. KONSTAS, MD, PhD GORDON N. DUTTON, MD Glasgow, Scotland References I. Krause U. Intraocular lens with pseudo-exfoliation material on its surface. Eur J Implant Refract Surg 1989; 1:211.
2. Ringvold A, Bore J. Pseudo-exfoliation pattern on posterior IOL. Acta Ophthalmol 1990;68:353-5. 3. Konstas AGP. Morphological and clinical studies on the exfoliation syndrome and open angle glaucoma. PhD Thesis; Glasgow 1992.
1644
4. Etienne R. L'atrophie essentieJle des couches epitMliales de l'iris et du corps ciliaire, ses relations avec Ie glaucome. Ann Ocul 1960;193:224-44.
Authors' reply
Dear Editor: We thank Drs. Konstas and Dutton for their comments on our article, in which we described three case~ with late appearance of exfoliative material on the postenor surf~ce of artificial lenses in the presence of an open postenor capsule. To the best of our knowledge, at the time of preparing the manuscript, there was no previous report in the !iterature regarding exfoliative material on the postenor surface of intraocular lenses. The European Journal of Implant and Refractive Surgery does not appear in the Medline, which is probably why we did not cite it. Indeed we stated that no exfoliative material was seen in those p~tients preoperatively. We do not find this comment surprising. Exfoliation material is not difficul.t t.o detect; every patient is carefully examined under mydnas~s by the surgeon as well as by our residen~s. The examInation also includes gonioscopy. Our reSIdents are very well trained to detect exfoliation material on the pupil, anterior capsule of the lens, or in the anterior chamber angle. Of course the diagnosis may have ~een ~issed, but the probability for that in all three cases IS qUite low. Exfoliation syndrome was described in the literature long before those patients were operated on. The pattern of exfoliation material distribution on the intraocular lens (IOL) in our cases varied and was different from that seen on the crystalline lens. It seemed like sheets and strands of white fluffy material on the posterior surface of the IOL and not the typical central disc and peripheral band on the anterior capsule. However, on the pupillary border it had the same appearance as in phakic eyes. The pathogenesis of exfoliation syndrome remains uncertain. As we mentioned, it was suggested that it might be related to some kind of aging process of ocular tissue (i.e., there were no reports of exfoliation syndrome in the first decades oflife and the prevalence increases with age). We congratulate Dr. Konstas on his doctoral thesis and would be happy to read it. VARDA CHEN, MD MICHAEL BLUMENTHAL, MD Tel-Hashomer, Israel
Volume 99, Number 11, November 1992
Exfoliation Material on IOLs Dear Editor: We read with interest the recent article by Chen and Blumenthal entitled, "Exfoliation Syndrome after Cataract Extraction" (Ophthalmology 1992;99:445-7). The authors describe three cases in which exfoliation material was noted on the posterior surface of intraocular lenses, some years after extracapsular cataract extraction and lens implantation. This report raises a num~r of matters th~t we would like to address. The authors mcorrectly state 10 their article that "the phenomenon has not been previously presented in the literature" and "there are still no reports on exfoliation material on artificial lenses. " There have been at least two reports in the literature on the same subject. 1,2 The authors state that "n? exfoliatio~ ~ateri~l was seen preoperatively on the pupIllary margm 10 theIr three cases." This comment is surprising. It is well documented in the literature that the diagnosis of exfoliation syndrome is frequently missed, unless specifically sought under mydriasis by an experienced observer. The data the authors present are retrospective (these cases were operated on 10, 12, and 13 years previously) and th~refore the diagnosis may have been missed. We agree With the authors that the appearance of exfoliation material on the surface of plastic intraocular lenses indicates th~t ~he crystalline lens is not the principal so.urce o~ exfoha~I~n material. Indeed, the view of the exclUSIve lentIcular ongm of the exfoliation material started to lose favor only when clinical and ultrastructural studies supplied comprehensive evidence of exfoliation material synthesis in the absence of the crystalline lens. 3 We also would be intrigued to know the pattern of exfoliation material distributio~ in their cases. Finally, while it is true that the pathogenesIs of exfoliation syndrome remains uncertain, the statement ofthe authors that it may be related to the "aging process of the pigment layer" although again not original4 is now deemed to be obsolete. 3 ANASTASIOS G. P. KONSTAS, MD, PhD GORDON N. DUTTON, MD Glasgow, Scotland References I. Krause U. Intraocular lens with pseudo-exfoliation material on its surface. Eur J Implant Refract Surg 1989; 1:211.
2. Ringvold A, Bore J. Pseudo-exfoliation pattern on posterior IOL. Acta Ophthalmol 1990;68:353-5. 3. Konstas AGP. Morphological and clinical studies on the exfoliation syndrome and open angle glaucoma. PhD Thesis; Glasgow 1992.
1644
4. Etienne R. L'atrophie essentieJle des couches epitMliales de l'iris et du corps ciliaire, ses relations avec Ie glaucome. Ann Ocul 1960;193:224-44.
Authors' reply
Dear Editor: We thank Drs. Konstas and Dutton for their comments on our article, in which we described three case~ with late appearance of exfoliative material on the postenor surf~ce of artificial lenses in the presence of an open postenor capsule. To the best of our knowledge, at the time of preparing the manuscript, there was no previous report in the !iterature regarding exfoliative material on the postenor surface of intraocular lenses. The European Journal of Implant and Refractive Surgery does not appear in the Medline, which is probably why we did not cite it. Indeed we stated that no exfoliative material was seen in those p~tients preoperatively. We do not find this comment surprising. Exfoliation material is not difficul.t t.o detect; every patient is carefully examined under mydnas~s by the surgeon as well as by our residen~s. The examInation also includes gonioscopy. Our reSIdents are very well trained to detect exfoliation material on the pupil, anterior capsule of the lens, or in the anterior chamber angle. Of course the diagnosis may have ~een ~issed, but the probability for that in all three cases IS qUite low. Exfoliation syndrome was described in the literature long before those patients were operated on. The pattern of exfoliation material distribution on the intraocular lens (IOL) in our cases varied and was different from that seen on the crystalline lens. It seemed like sheets and strands of white fluffy material on the posterior surface of the IOL and not the typical central disc and peripheral band on the anterior capsule. However, on the pupillary border it had the same appearance as in phakic eyes. The pathogenesis of exfoliation syndrome remains uncertain. As we mentioned, it was suggested that it might be related to some kind of aging process of ocular tissue (i.e., there were no reports of exfoliation syndrome in the first decades oflife and the prevalence increases with age). We congratulate Dr. Konstas on his doctoral thesis and would be happy to read it. VARDA CHEN, MD MICHAEL BLUMENTHAL, MD Tel-Hashomer, Israel
