How is endothelial cell density managed in eyes with pseudoexfoliation syndrome?

From the Guidelines

Endothelial cell density in eyes with pseudoexfoliation syndrome should be managed through careful monitoring and maintenance of a stable cell count, with a trigger for concern at a 20% endothelial cell loss or an endothelial cell count of <1500 cells/mm2, as recommended by the American Academy of Ophthalmology Task Force 1. To manage endothelial cell density in eyes with pseudoexfoliation syndrome, the following strategies can be employed:

• Preoperative assessment using specular microscopy to establish baseline endothelial cell density and morphology
• Minimally traumatic surgical techniques, such as using dispersive viscoelastic agents and gentle hydrodissection, to minimize endothelial trauma during surgery
• Vigilant postoperative monitoring, with serial specular microscopies performed every 4 to 6 months to evaluate cell density stability, and consideration of implant removal if an accelerated annual cell loss rate above 1%/year is observed 1
• Use of topical corticosteroids and hypotonic solutions to control inflammation and support endothelial function Key considerations in managing endothelial cell density in eyes with pseudoexfoliation syndrome include:
• The importance of minimizing artifacts caused by dry eye or poorly focused images during specular microscopy 1
• The need for regular reporting of endothelial cell counts to the sponsor of a clinical investigation, with notification of the investigator if the endothelial cell density decreases 20% or more from the preoperative value or falls below 1500 cells/mm2 1
• The potential for pseudoexfoliation syndrome to cause abnormal fibrillar material deposition, weakening zonular support and increasing surgical complexity, while the associated endothelial compromise reduces the eye's ability to recover from surgical trauma.

From the Research

Endothelial Cell Density in Normal and Pseudoexfoliation Syndrome Eyes

• Endothelial cell density (ECD) in eyes with pseudoexfoliation syndrome is lower compared to normal eyes, with a study finding ECD values of 2297 ± 359 cells/mm² in eyes with pseudoexfoliation syndrome without glaucoma and 2241 ± 363 cells/mm² in eyes with pseudoexfoliation glaucoma, compared to 2503 ± 262 cells/mm² in the control group 2.
• Another study found a significant reduction in ECD in eyes with pseudoexfoliation syndrome, with an average cell count of 1812 ± 297 cells/mm², compared to 2302 ± 394 cells/mm² in control eyes 3.
• The correlation between the stage of pseudoexfoliation and ECD has also been studied, with results showing a significant decrease in ECD with increasing pseudoexfoliation stage, regardless of the presence of glaucoma 4.

Management of Endothelial Cell Density in Pseudoexfoliation Syndrome Eyes

• The management of pseudoexfoliation syndrome and pseudoexfoliation glaucoma often involves surgical techniques, such as Argon Laser or Selective Laser Trabeculoplasty, due to poor results with topical medical treatment 5.
• Indications for surgery are more common in patients with pseudoexfoliation glaucoma than primary open-angle glaucoma, highlighting the importance of proper management of endothelial cell density in these patients 6.
• The goal of treatment is to reduce intraocular pressure and prevent further damage to the optic nerve, with surgical options being considered when medical treatment is insufficient 5, 6.