Lecture 7 Pseudoexfoliation syndrome Flashcards by brooke bonilla

(T/F) Exfoliation syndrome (XFS) and pseudo-exfoliation syndrome are the same thing

True, also, it is caused from the capsular delamination of the lens

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(T/F) XFS (exfoliation syndrome) is common in glass blowers

True bc there is no protection of infrared radiation

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What is the origin of the pigment deposits found in XFS?

a) lens
b) corneal endothelium
c) iris
d) both a and c

d) both a and c (The precise origin is unknown–partly lens and iris)

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Which one of the following is NOT where XFS pigment material is found?

a) lens epithelium and capsule
b) iris pigment epithelium, stroma and blood vessels
c) pupillary margin
d) macula

d) macula

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Which TWO of the following is TRUE regarding XFS?

a) XFS is best detected when pt’s pupil is constricted so you can get a better view of the angle
b) XFS is better detected when pt’s pupil is dilated so you can get a better look at the lens
c) XFS is detected when looking at the corneal endothelium for krukenberg spindle pattern
d) XFS is detected with transillumination of the iris when looking for a moth-eaten appearance

b) XFS is better detected when pt’s pupil is dilated so you can get a better look at the lens (look for a clear zone of removal of material by iris movement)
d) XFS is detected with transillumination of the iris when looking for a moth-eaten appearance

remember krukenberg spindle is found in pigment dispersion syndrome

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(T/F) XFS is a significant risk factor for XFG (exfoliation glaucoma), in fact, 30% of XFS pt’s develop XFG.

true

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Which one of the following is NOT true regarding XFS?

a) incidence is greater in males than in females
b) when the pupil is dilated, an XFS pt will show a central disc that corresponds to the size of the pupil
c) when the pupil is dilated, an XFS pt will show a clear zone-removal of material by the iris
d) when the pupil is dilated, an XFS pt will show a peripheral granular zone due to undisturbed accumulation of material

a) incidence is greater in males than in females (false, the opposite is true, its greater in females)

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(T/F) Prevalence of XFS is highest in Finland (21%) and prevalence of XFG is highest in Australia (14.2%)

true

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In XFS, why would you find phacodonesis (vibration of the lens) and subluxation of the lens (displacement of the lens)?

Because XFS material contains proteolytic enzymes that cause dengenerative changes to the zonules

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(T/F) Regarding pt’s with XFS, in prone (laying on stomach) position, anterior lens movement can occur causing pupillary block and increasing chances of angle closure

true

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(T/F) Production of XFS material continues after cataract extraction

true and also may cause late decentration or even subluxation of lens implant

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Which one of the following is NOT true in regards to XFS

a) iris trans-illumination defects show “moth-eaten” pattern
b) pupillary margin shows white flecks and loss of pigment and loss of “pupillary ruff”
c) The iris dilates better since parts of the iris are thinner
d) The TM shows heavy pigmentation grade 3 or 4

c) iris dilates better since parts of the iris are thinner (false-iris DOESN’T dilate as well in thinner areas because of iris sphincter and dilator muscles have undergone degenerative changes due to the proeolytic nature of the XFS material)

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Which of the following is NOT true in regards to XFS?

a) Dispersion of melanin post pharmacological dilation may cause acute IOP rise, check IOP post dilation
b) gonioscopy shows even 360 degrees pigmentation
c) chamber is narrow due to fwd movement of lens-iris diaphragm
d) pigment deposition on Schwalbe’s line referred to as sampaolesi’s line

b) gonioscopy shows even 360 degrees pigmentation (false-shows uneven pigmentation)

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Which one of the following is not an iris change seen with fluoroscein angiography in XFS pt’s?

a) neovascularization
b) hyperperfusion
c) both a and b

b) hyperperfusion (false-you will see HYPOperfusion. Why? bc vessels blocked with material cause hypoxia)

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Which one of the following is NOT related to XFS?

a) increased IOP due to increased outflow resistance?
b) XFS material appears on corneal endothelium
c) specular microscopy of of corneal endothelium shows low cell density
d) Morphological changes are seen in the sclera

d) ) Morphological changes are seen in the sclera (false–there are morphological changes to the cornea)

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Which one of the following does NOT describe exfoliation keratopathy?

a) reduced endothelial count with changes in cell shape and size
b) increased corneal guttata
c) thickening of descemet’s membrane
d) pronounced melanin deposits on corneal endothelium
e) retrocorneal flakes

b) increased corneal guttata (false–there is no corneal guttata associated with exfoliation keratopathy)

Which one of the following does NOT describe exfoliation keratopathy?

a) corneal decompensation may develop in both normotensive and hypertensive eyes
b) lowering IOP may reverse decompensation effects in early stages
c) later stages may need penetrating keratoplasty
d) edematous cornea has higher risk of infection and ulceration
e) post-operative counseling is suggested

e) post-operative counseling is suggested (technically, his slide said “pre-operative” counseling)

Which one of the following does NOT describe exfoliation keratopathy?

a) often appears bilaterally
b) the first signs (small flakes) to typical presentation (central ring) can take 5 to 10 years
c) XFS could possibly be asymmetric rather than unilateral
d) all of the above are true

a) often appears bilaterally (false–often appears unilaterally and remain unilateral for many years. In some cases it can then become a bilateral disease)

(T/F) impaired blood flow has been seen in XFS and XFG pt’s

true (blood flow could be low because of high IOP)

Could exfoliation syndrome be a systemic disease, rather than only an ocular disease?

a) It can be since exfoliation material is not restricted to intraocular tissues
b) It can not be because exfoliation material is produced only by the lens and iris

a) It can be since exfoliation material is not restricted to intraocular tissues (this statement is correct, exfoliation material is found on ocular tissues, such as: conj, orbital tissue, extraocular muscles, optic nerve, and ciliary arteries. It is also found systemically in skin, lungs, heart muscle, vessel walls, liver, kidney, gall bladder, and cerebral meninges)–
* in conclusion, XFS is a systemic disease but the role of exfoliation material in causing or exaggerating the systemic diseases remains to be clarified

Which one of the following does NOT describe exfoliation syndrome (XFS) and exfoliation glaucoma (XFG)?

a) There is an increased risk of morbidity of cardiovascular, cerebrovascular, and alzheimer’s diseases associated with XFS
b) there is an increase in mortality rates associated with XFS and XFG
c) there are elevated plasma homocystein levels related to increased risk of venous occlusion
d) there is mild sensory hearing loss reported

b) there is an increase in mortality rates associated with XFS and XFG (false–there is no increases in mortality rates associated with XFS or XFG)

(T/F) XFS increases the risk of XFG by up to 9.8 fold. IOP may or may not be high. Sometimes a disturbance in perfusion in posterior ocular tissues is seen along with exfoliation material found in posterior ciliary artery and vortex veins.

true

Which one of the following does NOT describe exfoliation syndrome (XFS) or exfoliation glaucoma (XFG)?

a) Ocular hypertension alone increases the risk of developing glaucoma by 3.7 fold. XFS and ocular hypertension increase that risk even further (twice the risk).
b) XFG has greater pigment accumulation in the angle compared to XFS
c) normotensive eyes with XFS show decreased IOP over time
d) degree of pigmentation and exfoliation material in angle correlates positively with IOP

c) normotensive eyes with XFS show decreased IOP over time (false–they show IOP elevation over time)

Which one of the following does NOT describe exfoliation syndrome (XFS) or exfoliation glaucoma (XFG)?

a) Likelihood of a normotensive XFS pt developing ocular hypertension (OHT) is 5.3% over 5 years and 15.4% over 10 years
b) conversion rate of XFS to XFG is 32% over 10 years (most convert in 5 years)
c) XFS shows greater diurnal variations
d) almost all unilateral XFG became bilateral over time
e) all of the above are correct

e) all of the above are correct

Which one of the following does NOT describe XFG? a) Pts with XFG had a higher mean IOP than POAG pt's (often exceeding 35 mmHg) b) There are less 24 hour IOP fluctuations with XFS compared to XFG c) significant diurnal fluctuations may differentiate XFG from POAG d) greater IOP fluctuations may account for faster progression in XFG

b) There are less 24 hour IOP fluctuations with XFS compared to XFG (false--there is greater 24 hour IOP fluctuations in both XFS and XFG)

Which one of the following is NOT a clinical feature of XFG? a) high IOP with poor response to meds b) narrow angles c) IOP spikes, significant diurnal fluctuations, and acute IOP rise after dilation d) pigment dispersion e) rapid progression f) exfoliative trabeculopathy, iridopathy, phacopathy, and zonulopathy g) need for surgery is common

b) narrow angles (false--XFG is associated with open angles)

(T/F) Constantly fluctuating IOP is more damaging than constantly high IOP

true

Which one of the following is NOT a cataract surgery complication/consideration in pt's with XFS? a) weak zonules due to proteolytic enzymes in exfoliation material and dislocation of IOL b) poor dilation due to moth-eaten patterns, evidence of iris muscle degeneration c) capsular tear and vitreous loss d) all of the above are valid concerns

d) all of the above are valid concerns

Which of the following is not true regarding medical therapy in XFS and XFG? a) generally medical therapy is the best option b) XFG pt's have higher IOP than POAG pt's c) XFG pt's have greater IOP fluctuations than POAG pt's d) all of the above are correct

a) generally medical therapy is the best option (false--Medical therapy is not very effective for XFG pt's. This is because IOP in XFG pt's is abnormally high with greater IOP fluctuations, making it a hard form of glaucoma to manage, need for surgery is common)

(T/F) Lowering IOP in any form of glaucoma decreases chances of progression in most pt's. However, studies showed that 28% of XFG pt's with a mean IOP less than 17mmHg showed progression and 70% of XFG pt's showed progression with a mean IOP over 20mmHg.

true

Which one of the following is NOT true regarding the treatment of XFG? a) XFG is similar to POAG, however, monotherapy is not always successful b) you never want to use a miotic such as pilocarpine c) XFG pt's tend to need surgery earlier than POAG pt's d) medications that increase outflow are preferred to aqueous suppressants.

b) you never want to use a miotic such as pilocarpine (false-it is preferable to add a miotic such as pilocarpine because it constricts the pupil and stops hippus that causes the iris to constantly rub against the lens which creates exfolitaion material)

(T/F) What are the 2 laser treatment options mentioned for XFG pt's?

ALT (argon laser trabeculoplasty) and SLT (selective laser trabeculoplasty)

Between ALT and SLT, which one is the repeatable one and which can only be performed once?

ALT is not-repeatable, where as SLT is repeatable.

Which one of the following is NOT true regarding ALT laser treatment in XFG pt's? a) It is a well tolerated and well established procedure b) considerable pressure lowering effect c) ALT should be always be considered as a first line treatment before medical treatment in XFG d) A degree of pigmentation must be present for ALT to be effective e) ALT shows a better response in XFG pt's than in POAG pt's f) all of the above are true

c) ALT should be always be considered as a first line treatment before medical treatment (false-ALT is a choice after medical therapy failure, however, it may be a first choice in older or non-compliant pt's)

Which one of the following is NOT true regarding SLT laser treatment in XFG pt's? a) Similar principle to ALT but selectively targets intracellular melanin in trabecular meshwork b) SLT is non-destructive and doesn't burn TM, so it is repeatable c) SLT is more favorable to ALT d) all of the above are true

d) all of the above are true

Which one of the following is NOT true regarding surgical treatment in XFG pt's? a) In cases of very low target IOP, trabeculectomy is the surgery of choice b) surgical treatment is rare in XFG pt's c) the more invasive the surgery, the higher the risk of cataract d) trabecular aspiration may be considered in XFG if cataract surgery is performed

b) surgical treatment is rare in XFG pt's (false--it is frequently needed)