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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 14  |  Issue : 3  |  Page : 328-333

Comparison of pseudoexfoliation syndrome and normal cases undergoing manual small-incision cataract surgery in a tertiary health-care center in Eastern India


Department of Ophthalmology, Institute of Medical Sciences and SUM Hospital, SOA (Deemed to be) University, Bhubaneswar, Odisha, India

Date of Submission13-Feb-2021
Date of Acceptance03-May-2021
Date of Web Publication30-Sep-2021

Correspondence Address:
Dr. Pradeep Kumar Panigrahi
Department of Ophthalmology, Institute of Medical Sciences and SUM Hospital, SOA (Deemed to be) University, 8-Kalinga Nagar, Bhubaneswar - 751 003, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kleuhsj.kleuhsj_27_21

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  Abstract 

INTRODUCTION: Pseudoexfoliation (PXF) syndrome has been known to be a genetically inherited syndrome which generally affects the population above 50 years of age. It further increases the chances of complications during cataract surgery.
AIM: In our study, we aim to compare the results of manual small-incision cataract surgery (MSICS) in PXF eyes and controls and report the intraoperative and postoperative outcomes (up to 6 weeks) in both groups.
MATERIALS AND METHODS: This was a prospective, observational, nonrandomized study, which was conducted in the ophthalmology department in a tertiary hospital in Eastern India from February 1, 2018, to December 31, 2019. 50 patients with PXF (Group 1) and 50 controls (Group 2) were included in this study and assigned to undergo MSICS.
RESULTS: Group 1 patients (with PXF) were found to be significantly of older age (P = 0.0315). Mixed cataract, i.e. with cortical and nuclear sclerosis, was present in 22 (44%) eyes in Group 1 and 31 (62%) eyes in Group 2. After attaining maximum dilatation, the 1st group was observed to have significantly smaller mean pupil diameter than 2nd group (P = 0.0001). In Group 1, intraoperative complications were observed: zonular dehiscence in 3 (6%) eyes, posterior capsule tear/rupture in 7 (14%) eyes, and vitreous loss in 6 (12%) eyes (including 3 eyes of zonular dialysis). In the 2nd group, no such complications were encountered during surgery. Postoperatively, anterior chamber cells and flares were significantly more in the 1st group than that in the 2nd group (P = 0.0002). Best-corrected visual acuity of 6/12 or better was found in 43 eyes (86%) of the 1st group and in 46 eyes (92%) of the 2nd group.
CONCLUSION: We conclude that with meticulous preoperative evaluation, vigilant intraoperative measures, and proper surgical expertise, MSICS can be an apparently safe procedure in patients with PXF syndrome.

Keywords: Cataract, manual small incision, pseudoexfoliation, surgery


How to cite this article:
Das S, Samant S, Panigrahi PK, Mehra L. Comparison of pseudoexfoliation syndrome and normal cases undergoing manual small-incision cataract surgery in a tertiary health-care center in Eastern India. Indian J Health Sci Biomed Res 2021;14:328-33

How to cite this URL:
Das S, Samant S, Panigrahi PK, Mehra L. Comparison of pseudoexfoliation syndrome and normal cases undergoing manual small-incision cataract surgery in a tertiary health-care center in Eastern India. Indian J Health Sci Biomed Res [serial online] 2021 [cited 2021 Dec 8];14:328-33. Available from: https://www.ijournalhs.org/text.asp?2021/14/3/328/327256


  Introduction Top


Pseudoexfoliation (PXF) syndrome is characterized by accumulation of greyish white extracellular fibrillar materials in the trabeculum, pupillary margin of iris, lens capsule, and ciliary body of the eye. Some studies have also found whitish flaky deposits of PXF on the corneal endothelium and even the anterior vitreous.[1] Pigment loss from the iris sphincter region and its deposition on anterior chamber structures supports the diagnosis.[2] These materials are produced from the abnormally behaving basement membranes of aging epithelial cells.[3] In Indian population, the prevalence of PXF is 0.69%–3.8%. It is about 0.95% in the rural population in Central India.[4] Eyes with PXF have difficulties during cataract surgery, which is due to structural alteration by PXF material. Thus, the susceptibility to surgical complications, such as zonular dialysis, posterior capsular rupture, vitreous loss, and nuclear drop, increases. A study by Scorolli et al. showed five times greater chance of intraoperative complications during cataract surgery in PXF eyes as compared to normal population.[5] Thus, it becomes necessary to diagnose this condition accurately during preoperative evaluation to be able to take appropriate measures such as use of pupil expanders, viscoelastic agents, and capsular tension ring (CTR) and techniques such as sphincterotomy which will lessen the complication rate.[6] Very few studies are presently available where manual small incision cataract surgeries (MSICSs) in PXF syndrome have been discussed in detail.[7],[8]

This study evaluates the intraoperative complications of MSICS with posterior chamber intraocular lens (PCIOL) implantation in patients with PXF syndrome and their effect on postoperative visual acuity and compares them with the surgical consequences obtained in normal individuals. Different approaches to minimize the likelihood of these complications have also been discussed.


  Materials and Methods Top


This prospective, observational study was carried out in the department of ophthalmology in a tertiary eye care hospital in Eastern India from February 1, 2018, to December 31, 2019. Hundred patients who were assigned to undergo MSICS with or without PXF were included in this study and were divided into two groups. The population under Group 1 comprised 50 consecutive eyes having cataract with PXF, and Group 2 comprised 50 consecutive eyes having cataract without PXF as control for our study. The study adhered to the basic tenets of Declaration of Helsinki, 1975. All patients included in the study provided informed consent. Institutional ethical committee clearance was obtained before starting the study.

All diagnosed cases above 50 years of age were examined under slit lamp, before and after dilatation. Patients with miotic use, high myopia, cataract with preexisting glaucoma, complicated cataract, traumatic cataract or any other history of ocular trauma, or history of previous ocular surgery were excluded from our study. All patients were admitted to the hospital 1 day before surgery, and detailed history was taken. Visual acuity testing was done and best-corrected visual acuity (BCVA) was recorded for both distance and near vision. Noncontact tonometer and Goldmann applanation tonometer were used for intraocular pressure (IOP) measurement. Gonioscopy with Sussmann's 4 gonio mirror was done to access the angle, and grading was done using Shaffer's grading system. A thorough anterior segment evaluation was done using slit lamp to assess relevant preoperative findings before and after mydriasis, which included pupil size, pattern of PXF, i.e. greyish white fibrillar materials found at the pupillary margin, and/or the presence of classic PXF pattern on the anterior lens capsule [Figure 1]a. The presence of phakodonesis, type and grade of cataract according to LOCS II criteria, and zonular dehiscence/lens subluxation was noted. ROPLAS test and lacrimal passage irrigation were also done. Furthermore, indirect ophthalmoscopy and slit-lamp biomicroscopy were used to assess the state of fundus. Keratometry and A-scan biometry were performed to calculate the PCIOL power. Vitals were recorded, and blood analysis for fasting blood sugar, postprandial blood sugar, HIV, and hepatitis-B and C was done. The pupil was dilated with a combination of 1% tropicamide and 10% phenylephrine on the day of the surgery.
Figure 1: (a) Clinical photograph showing pseudoexfoliation material in pupillary margin. (b) Small rigid pupil in pseudoexfoliation. (c) Multiple sphincterotomies during cataract surgeries. (d) Grade V nuclear sclerosis in pseudoexfoliation syndrome

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Surgical technique and intraoperative measures

All the operations were done by a single experienced surgeon under local peribulbar anesthesia. The eye to be operated was painted with povidone iodine (10%) and was draped, and proper sterilization was maintained during the whole procedure. A wire speculum was placed, and a superior rectus bridle suture was passed underneath the muscle and secured. A conjunctival flap, based on fornix, was made using conjunctival scissors, and through bipolar cautery, hemostasis was achieved. A straight/frown incision of about 6–7 mm was made at about 2 mm posterior to surgical limbus superiorly. Scleral tunnel was made with a crescent-shaped knife and dissection continued 1 mm into clear cornea. A 3.2-mm keratome was used for entering into the anterior chamber followed by paracentesis, which was made at 3 o'clock position in the right eye and in the left eye at 9 o'clock position with a 15° side port knife. After that, trypan blue dye was injected to stain the anterior capsule. A 26-G bent needle was used for capsulorrhexis. Next, the inner opening of tunnel was extended by a 5.5-mm extension keratome. With the help of balanced saline solution, hydrodissection was accomplished. After that, nucleus was prolapsed and delivered out with irrigating wire Vectis. Then, using classical Simcoe cannula, cortical matter was aspirated. All these steps were safe guarded by copious use of viscoelastic material. A single-piece, rigid, biconvex PCIOL of polymethyl methacrylate material was implanted in the bag. Conjunctiva and Tenon's capsule were reposited back over the wound. Subconjunctival injection of antibiotic and steroid was used after completion of surgery.

In case of small pupil (<5 mm), microsphincterotomies [Figure 1]b and [Figure 1]c by Vannas scissors and viscomydriasis by dispersive viscoelastics were done. During capsulorhexis, the incision was made with a fresh, sharp 26 G cystitome. In case of unsuccessful attempt of capsulorhexis, can-opener capsulotomy was attempted. Strict attention to shearing forces on the capsule and reduction of capsular tension in weak zonules was maintained. From the capsule, lens was separated with “slow and moderate” hydrodissection with the help of a hydrocannula. In PXF with weak zonules, nucleus was gently lifted into the anterior chamber by a bent cystitome without rotation. In case of vitreous loss, anterior vitrectomy was done thoroughly. CTR ring was used in cases of zonular dehiscence after capsulorhexis. The protocol sheet was well documented with all intraoperative observation procedures.

Postoperatively, visual acuity was recorded on the 1st day, 1st week, and 6th week following surgery. IOP was measured with a noncontact tonometer. Anterior chamber flare and cell response were measured using slit lamp. Postoperative follow up check-ups were done on 1st day, 1st week, 6 weeks after the discharge of patient. All patients were treated with antibiotics and steroid eye drops with tapering over a period of 4 weeks.

Statistical analysis

The data were entered into a Microsoft Excel sheet. Mean and standard deviation calculation was done for quantitative characters, and percentage and frequency were obtained for all qualitative characters. The significant difference in results obtained in test and control groups was calculated applying the unpaired t-test. P < 0.05 was considered statistically significant. Data were analyzed using IBM SPSS software version 21 (Chicago, IL, USA).


  Results Top


Our study sample consisted of 35 (70%) males and 15 (30%) females in Group 1 and 26 (52%) males and 24 (48%) females in Group 2. The mean age of the Group 1 patients was 67.76 ± 3.24 years, while the mean age in the control group was 61.12 ± 2.58 with majority of patients in their seventh decade of life. No significant difference in gender-related prevalence was seen in either group (P = 0.1001). We observed that PXF was bilateral in 29 patients (58%) and unilateral in 21 patients (42%). Patients in the 1st group (PXF) had a comparable axial length with those in the 2nd group (control). Patients having phakodonesis, however, had greater anterior chamber depth.

In both the groups, the preoperative IOP fell under normal range, but the IOP level in Group I was found to be higher than Group II (P = 0.0125), which was statistically significant. Incidence of mixed cataract, i.e., with cortical and nuclear sclerosis, was present in 22 (44%) eyes in the 1st group and 31 (62%) eyes in the 2nd group. In Group I, total 23 (46%) patients had only nuclear sclerosis [Figure 1]d. This pure nuclear sclerosis was the 2nd most common cataract in Group II. Similarly, in the 1st group, more eyes had nuclear sclerosis of grade 4 or 5 (P = 0.008), and in the 2nd group, more eyes had cataract with nuclear sclerosis of the Grade 1–3 (P = 0.008). 3 (6%) eyes were reported having phakodonesis. Salient preoperative clinical findings are highlighted in [Table 1].
Table 1: Preoperative clinical observations

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After attaining maximum dilatation, the 1st group was observed to have significantly smaller mean pupil diameter than the 2nd group (P = 0.0001). Thus, in the 1st group, 52% of eyes were with 6.0 mm or more of pupil diameter, whereas in the 2nd group, this constituted 92%. The smallest pupillary diameter was 4.8 mm and this was observed in 2 (4%) eyes of the 1st group. In Group 1, intraoperative complications were observed: Zonular dehiscence in 3 (6%) eyes, posterior capsular tear/rupture in 7 (14%) eyes, and vitreous loss in 6 (12%) eyes (including 3 eyes of zonular dialysis). There were no such intraoperative complications in Group 2. There was no dropped nucleus/fragment in any eye in either group. Decentered IOL was seen in 2 (4%) cases in Group 1. The results for IOP >22 mm Hg in eyes for both the units are statistically insignificant.

Each and every eye with exceptional IOP, i.e., ≥22 mm Hg, was treated with timolol maleate 0.5% eye drops two times daily for a whole week. After the treatment for a week, the IOP returned to its normal limits. Anterior chamber cells and flares were significantly more in the 1st group than in the 2nd group (P = 0.0002). The inflammatory response seen in few eyes were reduced after 1 week of topical steroid treatment [Table 2]. The BCVA after 6 weeks was 6/12 or better in 43 (86%) eyes of the 1st group and in 46 (92%) eyes of the 2nd group [Table 3]. One patient in the 1st group was diagnosed with macular pathology (full thickness macular hole) postoperatively. Other patients who had BCVA <6/12 were found to have myopic degeneration and amblyopia. Thus, the BCVA after 6 weeks was comparable in both groups.
Table 2: Postoperative complications (day 1)

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Table 3: Best corrected visual acuity after 6 weeks

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  Discussion Top


The PXF syndrome was first reported in 1917 by Lindberg. As per the syndrome, most of the intraocular tissues were adversely affected, from the endothelium of cornea to the optic nerve.[3],[9] The intraoperative difficulties and complications followed by considerably reformed postoperative behavior in affected eyes were reported by cataract surgeons worldwide.[10] As per epidemiology, PXF syndrome is a common occurrence with varying frequency worldwide.[11] Predominantly, PXF increases with increasing mean age of the population.[12] As per our study, the average age of PXF-affected patient is higher than the control. This result is similar to the results obtained in epidemiological studies of PXF conducted by Alfaiate et al.[13] and Jawad et al.,[14] which have shown that it is more common in patients older than 60 years, and prevalence further increases with increase in age of patient.

Our study reported a slightly higher incidence of PXF in males, which was not statistically significant. Conflicting reports related to sex predilection have been seen in PXF studies. While a study conducted by Arvind et al.[15] showed no sex predilection, the study by Avramides et al.[16] observed a higher incidence in females. In our study, in the PXF group, only nuclear sclerosis was seen in 23 cases (46%) followed by mixed cataract 22 cases (44%), but in the control group, 31 cases (62%) showed up with mixed cataract, while only 13 cases (26%) had pure nuclear sclerosis. Thus, our study showed a clear predominance of pure nuclear sclerosis in PXF cases as compared to controls. Although IOP in all cases of our study fell within the normal range, the mean IOP was toward the higher side of the normal in PXF group (18.85 ± 4.26) in comparison to the non-PXF group (12.94 ± 3.02). Poor mydriasis is the characteristic of PXF syndrome.[5],[17] Thus, we got considerably smaller pupillary diameter of about 6.0 mm or less on mydriasis in 68% of eyes. A similar study by Hemalatha and Shetty reported pupillary dilation of <7 mm in about 64% of PXF cases,[18] while Alfaiate et al. reported a prevalence of 48.4%.[13]

Preoperative evaluation under slit-lamp biomicroscopy showed 3 (6%) cases of phakodonesis or zonular dialysis. Significantly high prevalence of phakodonesis in PXF eyes was reported earlier.[19],[20] In pseudoexfoliated eyes with light-colored irides, a higher incidence of iridophakodonesis was observed than those with dark irides, indicating lesser possible damage of eyes with dark irides, which can also be seen in the studied population.[21] Previous studies reported that the zonules of PXF eyes were delicate compared to normal eyes in similar age groups.[22] After 1-month results in terms of BCVA were comparable in both groups. This study recorded an intraoperative complication in 10 out of 50 (20%) PXF cases, while there were no complications in all the non PXF cases. Three cases showed zonular dehiscence, while 7 cases had PC tear. Out of these 10 cases, 6 had vitreous loss and 2 cases had total zonulodialysis. Similar intraoperative posterior capsular complications of MSICS were noted in 18 out of 99 PXF eyes (18%) and 7 out of 120 (5.5%) non-PXF eyes in a study conducted by Bayramlar et al.[7] However, according to a previous study by Ariga et al.,[23] which performed MSICS in 100 patients of PXF, it was observed that there was intra- and postoperative complications in 6 and 26 eyes (23%), respectively. In PXF eyes, iris vessels are pathological, which are more permeable to protein. During IOL implantation in cataract surgery, the blood–aqueous barriers were broken-down temporarily. This explains the higher flare response by the cohort group after 1 day and 1 week of surgery, despite an uneventful procedure.


  Conclusion Top


Even though significant preoperative, intraoperative, and postoperative challenges have been reported in cases of cataract surgery of PXF patients, adequate preoperative workup can detect potential problems such as zonulopathy, decompensation of cornea, glaucoma, and small size of pupils, which will help in proper planning for surgery, such as probable need of viscoelastic agents, capsular support devices, and pupil expanders. Furthermore, safety margin can be significantly increased by technical modifications of the tools used during the intraoperative procedures. It can be concluded that with meticulous preoperative assessment, careful intraoperative procedures, and appropriate management of complications, the postoperative results of Indian eyes with PXF have a good visual outcome, which is nearly comparable to eyes without PXF.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Bušic M, Kaštelan S. Pseudoexfoliation syndrome and cataract surgery by Phacoemulsification. Coll Antropol 2005;29:163-66.  Back to cited text no. 1
    
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Streeten BW, Li ZY, Wallace RN, Eagle RC Jr, Keshgegian AA. Pseudoexfoliative fibrillopathy in visceral organs of a patient with pseudoexfoliation syndrome. Arch Ophthalmol 1992;110:1757-62.  Back to cited text no. 3
    
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Stein JD, Pasquale LR, Talwar N, Kim DS, Reed DM, Nan B, et al. Geographic and climatic factors associated with exfoliation syndrome. Arch Ophthalmol 2011;129:1053-60.  Back to cited text no. 4
    
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Scorolli L, Scorolli L, Campos EC, Bassein L, Meduri RA. Pseudoexfoliation syndrome: A cohort study on intraoperative complications in cataract surgery. Ophthalmologica 1998;212:278-80.  Back to cited text no. 5
    
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Bayramlar H, Hepsen IF, Yilmaz H. Mature cataracts increase risk of capsular complications in manual small-incision cataract surgery of pseudoexfoliative eyes. Can J Ophthalmol 2007;42:46-50.  Back to cited text no. 7
    
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Joshi RS, Singanwad SV. Frequency and surgical difficulties associated with pseudoexfoliation syndrome among Indian rural population scheduled for cataract surgery: Hospital-based data. Indian J Ophthalmol 2019;67:221-6.  Back to cited text no. 8
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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. 10
    
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Hyams M, Mathalone N, Herskovitz M, Hod Y, Israeli D, Geyer O. Intraoperative complications of phacoemulsification in eyes with and without pseudoexfoliation. J Cataract Refract Surg 2005;31:1002-5.  Back to cited text no. 11
    
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Jehan FS, Mamalis N, Crandall AS. Spontaneous late dislocation of intraocular lens within the capsular bag in pseudoexfoliation patients. Ophthalmology 2001;108:1727-31.  Back to cited text no. 12
    
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Alfaiate M, Leite E, Mira J, Cunha-Vaz JG. Prevalence and surgical complications of pseudoexfoliation syndrome in Portuguese patients with senile cataract. J Cataract Refract Surg 1996;22:972-6.  Back to cited text no. 13
    
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Jawad M, Nadeem AU, Khan Au, Aftab M. Complications of cataract surgery in patients with pseudoexfoliation syndrome. J Ayub Med Coll Abbottabad 2009;21:33-6.  Back to cited text no. 14
    
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Arvind H, Raju P, Paul PG, Baskaran M, Ramesh SV, George RJ, et al. Pseudoexfoliation in South India. Br J Ophthalmol 2003;87:1321-3.  Back to cited text no. 15
    
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Avramides S, Traianidis P, Sakkias G. Cataract surgery and lens implantation in eyes with exfoliation syndrome. J Cataract Refract Surg 1997;23:583-7.  Back to cited text no. 16
    
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Küchle M, Viestenz A, Martus P, Händel A, Jünemann A, Naumann GO. Anterior chamber depth and complications during cataract surgery in eyes with pseudoexfoliation syndrome. Am J Ophthalmol 2000;129:281-5.  Back to cited text no. 17
    
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Hemalatha BC, Shetty SB. Analysis of intraoperative and postoperative complications in pseudoexfoliation eyes undergoing cataract surgery. J Clin Diagn Res 2016;10:C05-8.  Back to cited text no. 18
    
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Moreno J, Duch S, Lajara J. Pseudoexfoliation syndrome: clinical factors related to capsular rupture in cataract surgery. Acta Ophthalmol (Copenh) 1993;71:181-4.  Back to cited text no. 21
    
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