In keeping with JAMA Network policy, the author advises that following blog post is fictional and the details within do not refer to an actual patient, but rather represent typical clinical findings of pseudo-exfoliation syndrome.

Fictional Case Scenario
Even from across the room, I could tell that the next patient was not going to be easy. The highly hyperopic spectacles were the first sign. The 20/200 visual acuity and poor dilation were the next clues. Finally, microscopic examination revealed the danger: pseudoexfoliation syndrome.

She was literally a little old lady from Pasadena, incredibly sweet and tolerant. She had let her vision decline over the years because she didn’t want to bother anyone and her vision didn’t seem that bad. But eventually her vision declined and she started having problems with simple daily tasks. Finally, her teenage grandchild decided to do something about it: he researched cataract surgeons in Los Angeles and arranged for an Uber to bring them both to my clinic.

When looking at her anterior segment, there were important clues to be gleaned. Most obvious was the cataract with moderate nuclear density but extensive posterior subcapsular opacities. The weakly dilating pupil and pseudoexfoliation material were the next observations. The anterior chamber was also rather shallow, less than 2 mm, given her 22-mm axial length. This is a clue that the zonular structures are so lax than the entire lens-iris diaphragm is pushing forward and flattening the anterior chamber. Fortunately, her optic nerves showed only mild glaucomatous damage and her intraocular pressures were only mildly elevated. Both eyes had these features, though her left eye was worse.

The approach to cataract surgery in a patient like this is different than that used in a more routine case. Anesthesia is important, particularly if any manipulation of the iris or pupil expansion is planned. It is important to make a relatively large capsulorhexis in these types of eyes, with a goal of having a diameter of about 5 to 5.5 mm. This is enough to overlap the optic edge but aids in the prevention of anterior capsular phimosis, which can occur when the capsulorhexis is too small (typically under 5 mm). In this case, I elected to forgo these iris expansion devices and simply make the capsulorhexis larger than the pupil.

During nucleus removal the goal is to be as gentle as possible on the already weak zonular apparatus. Cortex removal can be done circumferentially rather than radially to help. With the eye now aphakic and the capsular bag empty and expanded, the question is whether to implant a capsular tension ring. Because pseudoexfoliation is a progressive disease that affects all areas of lens support, I do not routinely implant a capsular tension ring, which I believe is better suited to cases with focal zonular loss, such as in trauma, which are not expected to be progressive. If there is a concern about future long-term dislocation of the entire lens-bag complex, a 3-piece IOL can be implanted since it may be easier to suture fixate down the road.

The patient did amazingly well in the immediate postoperative period and was eager to have surgery in the fellow eye. After both eyes were restored, she drove herself to the last postoperative examination in her car that had been sitting dormant for many years. She was so thrilled to have her vision, and her freedom, back that she also bought her grandson a car as a gift for helping her get her sight back.

While this story is fictional and the details do not refer to an actual patient, they represent typical clinical findings of some patients with pseudo-exfoliation syndrome and it reminds me how fortunate I am to be an ophthalmologist and that every one of the 3 million cataract surgeries performed in the United States each year has the potential to transform a life.

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