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A Clinical Study Pseudoexfoliat M.S.Ophtha A CLINICAL STUDY OF GLAUCOMA IN PSEUDOEXFOLIATION SYNDROME. Dissertation submitted to THE TAMILNADU Dr.M.G.R MEDICAL UNIVERSITY In partial fulfilment of the regulations for the award of the degree of M.S.OPHTHALMOLOGY BRANCH – III Thanjavur Medical College and Hospital The Tamilnadu Dr. M.G.R Medical University Chennai,India APRIL 2016 1 CERTIFICATE This is to certify that this Dissertation entitled “ A CLINICAL STUDY OF GLAUCOMA IN PSEUDOEXFOLIATION SYNDROME” is a bonafide original work done by Dr.P.ANURADHA , under my guidance and supervision in the Department of ophthalmology, Thanjavur Medical College, Thanjavur doing her Postgraduate course from 2013 -2016. Dr. M, SINGARAVELU M.D., DCH., Dr.J.GNANASELVAN M.S., D.O., The Dean, The Professor and HOD, Thanjavur Medical College, Department of Ophthalmology, Thanjavur – 613004. Thanjavur Medical College, Thanjavur – 613004. 2 CERTIFICATE This is to certify that this Dissertation entitled “ A CLINICAL STUDY OF GLAUCOMA IN PSEUDOEXFOLIATION SYNDROME” is a bonafide original work done by Dr.P.ANURADHA, under my guidance and supervision in the Department of Ophthalmology, Thanjavur Medical College, Thanjavur doing her Postgraduate course from 2013 -2016. Dr.J.GNANASELVAN M.S.,D.O., The Professor and HOD, Department of Ophthalmology, Thanjavur Medical College, Thanjavur – 613004. 3 DECLARATION I Dr.P.ANURADHA solemnly declare that this Dissertation “ A CLINICAL STUDY OF GLAUCOMA IN PSEUDOEXFOLIATION SYNDROME” is a bonafide record of work done by me in the Department of Ophthalmology, Thanjavur Medical College, and Hospital, Thanjavur under the Guidance and Supervision of my Professor Dr.J.GNANASELVAN M.S.,D.O., The Head of the Department, Department of Ophthalmology, Thanjavur Medical College, Thanjavur between 2013 and 2016. This Dissertation is submitted to The Tamilnadu Dr. M.G.R Medical University , Chennai in partial fulfilment of University regulations for the award of M.S Degree (Branch – III) in Ophthalmology to be held in April 2016. Dr.P.ANURADHA, Postgraduate Student, Thanjavur Medical College. Thanjavur. 4 5 6 7 ACKNOWLEDGEMENT I thank the All Mighty God for the abundant grace & Blessings and making me successful in every field to complete my dissertation work. I would like to thank the Dean, Thanjavur Medical College, Thanjavur for granting me permission to conduct this study at Thanjavur Medical College , Thanjavur . It is my bounden duty to offer my sincere gratitude to my Professor & HOD Dr.J.GNANASELVAN M.S.,D.O., Head of the department of Ophthalmology for his motivation, meticulous guidance and encouragement throughout the period of study. I express my heartful thanks and gratitude to my teachers Dr.R.Raja M.S., Dr.S.Amudhavadivu M.S., Dr.T.Anbuselvi.M.S., Dr.Thaialnayagi.M.S., Dr.K.Rajasekaran.M.S.,D.O., for the constant guidance, immense support, suggestions and for being a great source of inspiration throughout the study. I acknowledge the support from all my colleagues and friends in completing this study. I am thankful to my family for their support and help throughout this study. I am deeply indebted to the cogwheels of my study, the patients without whom the study would not have been completed for their participation and cooperation to conduct this study. 8 CONTENTS SI.No. TITLE PAGE NO PART I 1 INTRODUCTION 1 2 REVIEW OF LITERATURE 2 3 AQUEOUS HUMOUR DYNAMICS 8 4 PSEUDOEXFOLIATION SYNDROME 24 5 GLAUCOMA AND PSEUDOEXFOLIATION 33 MANAGEMENT OF PSEUDOEXFOLIATION 6 42 GLAUCOMA PART II 7 AIM OF THE STUDY 50 8 MATERIALS AND METHODS 51 9 OBSERVATION AND RESULTS 54 10 DISCUSSION 82 11 CONCLUSION 85 PART III 12 BIBLIOGRAPHY 87 13 APPENDIX I,II 14 KEY TO MASTER CHART 15 MASTER CHART 9 INTRODUCTION Glaucoma is one of the leading causes of irreversible blindness worldwide. Pseudoexfoliation is one of the common causes of secondary open angle glaucoma worldwide. It is noted to be a more aggressive disease with a mean progression rate higher than primary open angle glaucoma. Pseudoexfoliation syndrome is a systemic micro fibrillopathy which targets ocular tissues through gradual deposition of proteinaceous material. This fibrillar material is produced by cells in the anterior segment in response to oxidative stress. Clumps of fibrillar material released into extracellular spaces gets deposited into corneal endothelium, ciliary epithelium, trabecular meshwork, iris, anterior capsule of lens, zonules, anterior vitreous face and conjunctiva. Clinically these appear as greyish white flakes. This pseudoexfoliative material gets accumulated in the trabecular meshwork and leads to elevated intra ocular pressure which leads to glaucoma. Systemically this exfoliative fibrillopathy has also been reported in skin, visceral organs and associated with an increasing number of vascular disorders, sensori neural hearing loss and Alzheimer disease. 10 REVIEW OF LITERATURE In1917, Lindberg described as pseudoexfoliation for the first time in a finish population. He believed that this material was created by earlier inflammation. The main and full description of pseudoexfoliation was made by a swiss ophthalmologist ALFRED VOGT. In 1918 he described pseudoexfoliation as a film on the anterior lens capsule due to remnants of pupillary membrane. In 1925 full description as exfoliation of the lens capsule and its deposition over lens capsule, iris, back of the cornea and its association with glaucoma capsulare was made. The histological studies done by DAVOK-THEOBALD differentiated between true exfoliation seen in glass blowers and senile exfoliation. Senile exfoliation was then termed as pseudoexfoliation. Prevalence of pseudoexfoliation: Prevalence of pseudoexfoliation ranges from 0 in Eskimos to 21% in Icelanders. In India prevalence rate of pseudoexfoliation is around 2 % (Hiller et al). In South India the prevalence rate is 6 % in >40years of age as per Krishnadas et al in 2003. 11 In 2003 study by Aravind H Raju B, Paul B G showed there was a significant increase in prevalence with age but no sex predilection 1. There was a Significantly higher prevalence of cataract among the people with pseudoexfoliation .The prevalence of glaucoma is among 30% in patients with pseudoexfoliation. In a study by Shazly et al in Egypt glaucoma was found in 30.31% of patients with pseudoexfoliation. AGE: According to Framingham study, 52-64 years 0.6% 65-74 years 2.6% 75-85 years 5.0% Aasved study reported 0.4% of prevalence in the age of 50-59, and 7-9 % of prevalence in the age of 80-89. In South India Aravind et al 2 reported 3.8% rate in patients of more than 40 years of age. 12 HEREDITY: Pseudoexfoliation syndrome appears to be sporadic mostly, but Allingham and associates found X linked inheritance pattern in Icelandic families. They identified one out of three members in a family over 70 years of age having pseudoexfoliation and in each of these families, at least one in next generation had exfoliation and glaucoma. In all cases the parent always is the mother. A study by Hewitt and co-workers suggests that the LOXL 1 family of proteins are associated with extra cellular matrix formation and stability, so the formation of abnormal protein by genetic variants might affect trabecular outflow and the lens epithelium. Glaucoma in pseudoexfoliation syndrome: Prevalence of glaucoma in pseudoexfoliation syndrome was 30 % according to Indian studies by Lamba and Giridhar 2. Marium and Aurora reported prevalence rate of 22.6% and Sood and Rathnaraj reported prevalence rate of 34 % in pseudoexfoliation syndrome patients. According to Blue Mountains Eye Study, The prevalence of glaucoma in exfoliation syndrome was 14.7%. 13 In south India, Krishna Das et al reported 7.5% of patients having glaucoma in pseudoexfoliation syndrome in 2003. In pseudoexfoliation syndrome 12% of patients presenting with glaucoma at diagnosis.5% of patients having no glaucoma at initial presentation, they develop increase in IOP after 5 years and 15% of them develop elevated IOP after 10 years. In Blue mountain study, pseudoexfoliation glaucoma was seen in 14.2% of patients. A study by Henry JC, Kruplin et al reported patients with pseudoexfoliation having greater incidence of raised IOP against control group. IOP AND PSEUDOEXFOLIATION: In pseudoexfoliative eyes without glaucoma having mean IOP is usually higher than the age matched controls. Davenger et al found that mean IOP of primary open angle glaucoma cases were 25.5mmHg and that of pseudoexfoliative patients were as high as 31.5mmHg 3. Futa et al reported that 25.5% of pseudoexfoliation glaucoma cases with intraocular pressure of 30mmHg as compared to POAG only 15% of them having IOP of more than 30mm Hg. 14 Optic nerve head damage: Laden and Shaffer reported Patient with unilateral pseudoexfoliation patient without exfoliation 64% of patients had CD ratio of 0.4, 85% had CD ratio of 0.4 36% of patients had CD ratio of 0.7; 15% had CD ratio of 0.7 KUCHLE et al found that aqueous protein concentration in pseudoexfoliation syndrome was higher than normal and POAG patients. He also quantified flare using Laser Flare Cell Meter (LFCM) and found it to be significantly increased in pseudoexfoliation patients 4. A study by RINGVOLD et al showed 74% of pseudoexfoliation syndrome is not associated with glaucoma. If glaucoma is present, it is usually unilateral in18%and bilateral in 8%.SZKLAI et al reported that 34% of pseudoexfoliation glaucoma are unilateral and 66% are bilateral. Unilateral was always in the eye with pseudoexfoliation. LAMBA and GIRIDHAR reported that 46%
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