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Complications of Cataract Surgery in Patients with Pseudoexfoliation

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Complications of Cataract Surgery in Patients with Pseudoexfoliation J Ayub Med Coll Abbottabad 2009;21(2) COMPLICATIONS OF CATARACT SURGERY IN PATIENTS WITH PSEUDOEXFOLIATION SYNDROME Mohammad Jawad, Aqil-ur-Rehman Nadeem, Aleem ul Haq Khan*, Mohammad Aftab Department of Ophthalmology, *Department of Biochemistry, Women Medical College, Abbottabad, Pakistan Background: The weak zonule’s predisposition to complications during conventional cataract surgery is one of the common risk factor for poor visual acuity after surgery. The present study was conducted to determine the frequency and types of complications during cataract surgery in patients with Pseudoexfoliation Syndrome. Methods: A cross sectional descriptive study based on non probability sampling of patients having pseudoexfoliation syndrome admitted for cataract surgery in tertiary care hospitals was carried out spread over 4 years. The data of all variables of interest were entered and analyzed through SPSS version 15.0. Results: A total of 200 eyes of 122 patients having Psuedoexfoliation were included in the study. Vitreal prolapse in 21 (10.5%) and posterior capsular rupture in 18 (9%) patients were the most common complications seen in Pseudoexfoliation. Damage to sphincter pupillae in 16 (8%), iridodialysis in 2 (1%), decentration of IOL in 8 (4%) and hyphaema in 2 (1%) patients was seen. Zonular dialysis in 8 (4%), retained lens matter in 12 (6%) and lens dislocation was seen in 6 (3%) patients. Conclusion: Patients with pseudoexfoliation are at increased risk for development of complications. Ophthalmologists should stress to increase awareness among general public for the proper diagnosis and convince patients for proper and regular follow up visits to the hospital. Keywords: Pseudoexfoliation, Cataract, Complications, Intraocular pressure INTRODUCTION Multiple factors contribute to the development of 1 pseudoexfoliation syndrome. The most common Pseudoexfoliation (PEX) is a senile condition , more association is age and is most common between 60 common in males, familial and seems to be 11 and 70 years. Pseudoexfoliation can cause genetically inherited disease characterized by bluish inflammation in the eye which may lead to white fibrillogranular material in the anterior segment complicated cataract and secondary glaucoma. PEX of eye and conjunctiva. The deposit is most results in increased complications during cataract prominent on the anterior lens capsule at its centre as surgery.12 The objectives of this study are to thick translucent membrane and on periphery of lens 2 determine the frequency and types of complications as granular deposits. during cataract surgery in patients having Pseudoexfoliation was first described by 3 Pseudoexfoliation syndrome and cataract. Lindberg in 1917. He believed that this material was created by earlier inflammation. The main and full MATERIALS AND METHODS description of pseudoexfoliation was made by a This study was carried out from 1st July 2003 to 30th Swiss Ophthalmologist Alfred Vogt.4 In 1918 he June 2007 at Departments of Ophthalmology, District described pseudoexfoliation as a film on the anterior Head Quarter Hospital and Ayub Teaching Hospital lens capsule due to remnants of pupillary membrane. Abbottabad. A total of 200 eyes of 122 cataract In 1925, full description as ‘exfoliation of the lens patients aged 50 years or more were included in the capsule’ and its deposition on lens capsule, iris, back study. Convenience (non probability sampling) was of the cornea and its association with ‘glaucoma 5 used for this prospective and descriptive study. capsulare’ was made. The histological studies done Patients with developmental cataract, traumatic by Davork-Theobald differentiated between true cataract, complicated cataract, high myopia, any exfoliation seen in glass blowers and senile other ocular disease and previous surgery were exfoliation. Senile exfoliation was then termed as excluded. Patients were admitted to the ‘pseudoexfoliation’. Ophthalmology wards of the hospitals. There is slight variation in prevalence for Written consent of all the patients included example it is 6.45% in Pakistan6 and 3.8% in South in the study was taken after fully explaining the India.7 It is quite rare in few populations for example procedure and purpose of the study to the patients. A prevalence rate is 0.4% in Chinese people8, aged detailed proforma was devised containing all above 60 years. The pseudoexfoliation syndrome essential details for each individual. A complete develops at younger age in persons living at lower ophthalmic history was taken. The patients were attitudes9, other possible contributing factors are 10 asked about their name, age, sex, occupation and nutrition, climate, radiation and ultraviolet light . address. The questions and inquiries about the http://www.ayubmed.edu.pk/JAMC/PAST/21-2/Jawad.pdf 33 J Ayub Med Coll Abbottabad 2009;21(2) complaints were made which included dimness of Different procedures were conducted during vision, headache, pain in the eyes, watering of the cataract surgery. Peripheral iridectomy was done in eyes, discharge from the eyes, sticking of the lids, all the cases. Sphincterotomy was done in 46% photophobia, history of injury and past history. patients with poor pupillary dilatation. Fifty-four A thorough examination including visual (54%) patients received posterior chamber IOL and acuity, anterior segment, posterior segment and 92 (46%) had planned cataract extraction. Table-1 measurement of intraocular pressure (IOL) was shows distribution of surgical complications during performed before the cataract surgery. Intraocular cataract surgery. A total of 93 (46.5%) complications pressure was recorded with applanation tonometer. were recorded. The diameter of pupil of each patient was measured. Routine follow up visits were done for 12 Intra-operative maximum pupillary dilatation was weeks in all the patients. On each follow up, visual obtained and its size measured. This pupil size was acuity and slit lamp examination was done. Final graded as poor, fair and satisfactory/good. Poor visual acuity was recorded after 12 weeks, which is pupillary dilatation meant 2–4 mm, fair pupillary shown in Figure-1. dilatation meant 5–6 mm, satisfactory/good pupillary Table 1: Surgical complications during Cataract dilatation meant 7–9 mm. surgery (n=93) Standard extracapsular cataract extraction Pseudoexfoliation with PMMA intraocular lens implantation was done. Surgical complications patients (n=200) Topical antibiotic ointment was applied. Eye was Damage to sphincter pupillae 16 (8%) padded and patients were put on oral analgesics. The Irididialysis 2 (1%) patients were examined with slit lamp on 1st post Lens dislocation 6 (3%) operative day. The follow up of the patients was Posterior capsule rupture 18 (9%) th Vitreous prolapse 21 (10.5%) carried out on 8 day, 4 weeks, 8 weeks and finally Retained lens material 12 (6%) 12 weeks. All the patients received oral analgesics Decentration of IOL 8 (4 %) and topical Polymyxin, Neomycin, Dexamethasone Zonular dialysis 8 (4%) and Ofloxacin/Ciprofloxacin. The data were entered Hyphaema 2 (1%) and analysed using SPSS version 15.0. Analysis was Total: 93 (46.5%) done for quantitative and qualitative measures. 69% RESULTS 70% Two hundred (200) cataract patients with 60% 50% pseudoexfoliation syndrome were included in this P study. Patients lost during follow up were excluded a t 40% from the study. The ages of these 200 patients ranged i e 27% from 50 years to 87 years with 12% patients in age n 30% t group of 80–89, 35% patients in the age group of 70– s 79, 37% patients in age group of 60–69 years and 20% 16% patients in age group of 50–59 years. The 10% 4% distribution by gender shows that 84% of patients 0% were males, while the remaining 16% of the patients 6/6-6/12 6/18-6/36 6/60-C.F were females; the male and female ratio was 5.25:1. Visual acuity Distribution of frequency and percentage of right and Figure-1: Distribution of post-operative visual left eyes shows that 12% were right, 10% were left acuity in patients (n=200) and 78% were bilateral. Preoperative features show that 22% DISCUSSION patients had zonular fragility, 6% had iridodonesis This study explored the peroperative outcomes and and 14% had phacodonesis. In 6% patients, pigment complications of cataract patients with dispersion was seen, out of these 4% was present on pseudoexfoliation in tertiary care setting. lens and 2% was present on cornea. Subluxation of Pseudoexfoliation was more commonly seen lens was seen in 4% patients. in males as compared to females in the present study, Mean IOP was 19.682.30 mmHg. i.e., 84% in males and 16% in females. This ratio is Intraoperative pupillary diameter measurements approximately 5:1. More frequent occurrence of showed that poor pupillary dilatation was seen in pseudoexfoliation in males can be explained by two 48% patients, fair pupillary dilatation was seen in factors. The first factor is that most of the patients 42% patients while satisfactory/good pupillary undergoing cataract surgery are males. Secondly, dilatation was seen in 10% patients. males are more commonly involved in outdoor 34 http://www.ayubmed.edu.pk/JAMC/PAST/21-2/Jawad.pdf J Ayub Med Coll Abbottabad 2009;21(2) activities while most of the females are restricted to Pseudoexfoliation is a source of severe homes as traditional housewives. This particular complications in cataract surgery.19 The increased aspect of restriction to houses partly explains frequency of intraoperative complications stem from environmental factors,
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