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 Table of Contents  
Year : 2022  |  Volume : 34  |  Issue : 1  |  Page : 74-75

A white daisy on intraocular lens

Department of Community Ophthalmology, Global Hospital Institute of Ophthalmology, Sirohi, Rajasthan, India

Date of Submission25-Aug-2021
Date of Decision30-Aug-2021
Date of Acceptance10-Sep-2021
Date of Web Publication21-Apr-2022

Correspondence Address:
Dr. Prateek Jain
Global Hospital Institute of Ophthalmology, Abu Road, Sirohi - 307 510, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/kjo.kjo_184_21

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We report two patients with precipitation of Pseudo-exfoliative material (PXF) material on intraocular lens (IOL), a rare entity, years after uneventful cataract surgery. The PXF material was present on the anterior surface of the IOL optic in a characteristic radiating spoke-like manner, a pattern resembling shape of a white daisy flower. Emphasis is given on differentiating features between PXF deposition on natural lens and PXF deposition on IOL. Furthermore, how opacification of IOL is different from PXF on IOL is briefly explained. In the first case, PXF deposits were not found elsewhere except on anterior IOL surface and in the second patient, pupillary involvement was also noted along with settling on IOL optic. The fellow eyes in both the patients did not have PXF. PXF on IOL is a vital sign and should not be overlooked as it can be the only clue warranting thorough glaucoma evaluation.

Keywords: Intraocular lens opacification, pseudoexfoliation, PXF glaucoma

How to cite this article:
Jain P, Sah P, Pattnaik A. A white daisy on intraocular lens. Kerala J Ophthalmol 2022;34:74-5

How to cite this URL:
Jain P, Sah P, Pattnaik A. A white daisy on intraocular lens. Kerala J Ophthalmol [serial online] 2022 [cited 2022 Dec 4];34:74-5. Available from: http://www.kjophthal.com/text.asp?2022/34/1/74/343673

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Case 1 involves a 73-year-old male with a history of right eye (RE) cataract surgery in 2016. Best corrected visual acuity (BCVA) was 20/20 and IOP was16 mmHg. Slit-lamp biomicroscopy revealed radial striations of pseudo-exfoliative (PXF) deposits on the anterior surface of intraocular lens (IOL) [Figure 1] and [Figure 2].
Figure 1: Slit-lamp image of case 1 in direct diffuse illumination showing pseudo-exfoliation deposits in a concentric ring of radiating spoke-like pattern inferiorly and scattered dot-like pattern superiorly in the intermediate zone of anterior surface of hydrophilic-acrylic intraocular lens optic, resembling petals of a white daisy flower

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Figure 2: Slit-lamp images of case 1. (a) Direct focal illumination (b) Retro-illumination

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Case 2 involves a 68-year-old male with a history of RE cataract surgery in 2014. BCVA and IOP were 20/200 and 20 mmHg, respectively. Slit-lamp examination revealed PXF deposits on IOL similar to case 1 [Figure 3].
Figure 3: Slit-lamp image of case 2 showing loss of pupillary ruff, mid-peripheral radiating spoke-like PXF deposits (similar to case 1) on anterior surface of PMMA intraocular lens. Residual cortex can be noted lying in the bag. (a) Image at ×10, (b) Image at ×16 magnification

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Both the cases had open-angle on gonioscopy, with a cup-to-disc ratio of 0.3:1 and 0.7:1, respectively. Only case 2 had PXF at pupillary margins. Left eye examination was unremarkable in both the patients. They were diagnosed as pseudo-exfoliative syndrome (PXFS) and pseudo-exfoliative open-angle glaucoma, respectively.

PXFS has a prevalence of about 5% after 40 years of age. The incidence of glaucoma at diagnosis of PXFS is 26%.[1] The PXF material is synthesized by nonpigmented ciliary epithelial cells, trabecular endothelial cells, vascular endothelial cells of iris, and preequatorial lens epithelial cells.[2]

The settling of PXF on natural lens occurs in “target-sign” pattern with deposits at the central and peripheral zones.[3] The friction between iris and lens prevents its deposition in intermediate zone. Exactly, a reverse pattern is noted in the pseudophakic eye. Only intermediate zone carries PXF owing to greater iris to IOL distance and PXF being washed away by aqueous from central and peripheral zones.[2] Conditions like IOL in the sulcus or zonular weakness bring IOL close to iris and stimulate PXF production by ciliary body followed by its precipitation over IOL.[4] Both of our patients had IOL placed in the bag, thus making this report unique.

It is vital to differentiate PXF on IOL from the opacification of IOL. IOL opacification involves alteration of IOL material whereas PXF deposition occurs on IOL surface only.[5]

PXF on IOL is a rare entity and can be the only sign in diagnosing glaucoma before it progresses to the “point of no-return.”


The authors acknowledge the guidance of Dr. V C Bhatnagar, Head of Department and Medical Superintendent, Global Hospital Institute of Ophthalmology.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Yasar E, Yildirim N, Gursoy E, Colak H. Prevalence of pseudoexfoliation syndrome and its association with ocular and systemic diseases. Int J Ophthalmol 2017;10:128-34.  Back to cited text no. 1
Bonafonte Marquez E, Bonafonte Royo S. Bilateral pseudoexfoliation deposits on intraocular lens implants. Case Rep Ophthalmol Med 2015;2015:560508.  Back to cited text no. 2
Laul A, Fabrykowsi M. Tailor your Approach to PXG Management. Review of Optometry; July 15, 2014. Availablefrom: https://www.reviewofoptometry.com/article/tailor-your-approach-to-pxg-management. [Last accessed on 2021May 21].  Back to cited text no. 3
Park KA, Kee C. Pseudoexfoliative material on the IOL surface and development of glaucoma after cataract surgery in patients with pseudoexfoliation syndrome. J Cataract Refract Surg 2007;33:1815-8.  Back to cited text no. 4
Jain P, Pattnaik A, Purohit NB. Appraisal of two fuzzy intraocular lens. Indian J Ophthalmol Case Rep 2021;1:196-7.  Back to cited text no. 5
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  [Figure 1], [Figure 2], [Figure 3]


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