Jebmh.com Original Research Article ANALYTICAL STUDY OF PSEUDOEXFOLIATION SYNDROME, ITS ASSOCIATION WITH GLAUCOMA AND ITS SURGICAL COMPLICATIONS M. S. Gokila1, R. Saravanan2, P. S. Maheswari3, M. R. Chitra4 1Senior Assistant Professor, Department of Ophthalmology, Regional Institute of Ophthalmology, Government Ophthalmic Hospital, Madras Medical College, Egmore, Chennai. 2Senior Assistant Professor, Department of Ophthalmology, Regional Institute of Ophthalmology, Government Ophthalmic Hospital, Madras Medical College, Egmore, Chennai. 3Professor, Department of Ophthalmology, Regional Institute of Ophthalmology, Government Ophthalmic Hospital, Madras Medical College, Egmore, Chennai. 4Associate Professor, Department of Ophthalmology, Regional Institute of Ophthalmology, Government Ophthalmic Hospital, Madras Medical College, Egmore, Chennai. ABSTRACT BACKGROUND Pseudoexfoliation syndrome is commonly associated with Glaucoma. Surgical complications occur frequently in this clinical setting, the incidence of which needs to be analysed. MATERIALS AND METHODS 100 patients with Pseudoexfoliation syndrome attending Glaucoma services of a tertiary care hospital over a period of two years starting from November 2012 were included in the study. All were subjected to detailed Anterior Segment examination, Fundus examination and Glaucoma workup. Surgical complications were analysed in patients undergoing Cataract and combined surgery and followed up periodically. RESULTS 74% patients had bilateral and 24% had unilateral Pseudoexfoliation. 48% patients had Glaucoma, most common being Open Angle Glaucoma (32 cases). Poor pupillary dilatation was noted in 58%. Cataract surgery was required for 50 eyes in which following complications were noted: 16% corneal Endothelial Touch, 16% Posterior Capsular Rent and Vitreous Loss and 14% Zonular Dehiscence. PCIOL was placed in 43 (86%) eyes after sufficient surgical modifications. 58% had visual acuity in the range between 6/60 - 6/18. In 18 eyes which underwent combined surgery, 6 eyes developed Corneal Endothelial Touch, 2 had Posterior Capsular Rent and 3 had Zonular Dialysis. PCIOL was implanted in 16 eyes. Post-op vision was <6/60 in 38.8% eyes. 72% eyes had IOP <20 mmHg after surgery. CONCLUSION Pseudoexfoliation is more common in males and usually bilateral. It is associated with Open Angle Glaucoma. Surgical complications occur more in cases with poor dilatation. Necessary surgical modifications will give good visual outcome. Combined surgery is a good option in Pseudoexfoliation with Glaucoma. KEYWORDS Pseudoexfoliation Syndrome, Open Angle Glaucoma, Zonular Dehiscence. HOW TO CITE THIS ARTICLE: Gokila MS, Saravanan R, Maheswari PS, et al. Analytical study of pseudoexfoliation syndrome, its association with glaucoma and its surgical complications. J. Evid. Based Med. Healthc. 2017; 4(43), 2615-2618. DOI: 10.18410/jebmh/2017/518 BACKGROUND of exon 1 of LOXL1 gene has been found in patients with Pseudoexfoliation syndrome is an age-related disease in Pseudoexfoliation syndrome.2 It is now suspected to be a which abnormal fibrillar extracellular material of uncertain systemic disorder and has been associated with Transient origin accumulates in many ocular tissues.1 Polymorphism Ischaemic Attacks, Stroke, Systemic Hypertension, and Myocardial Infarction.3 It is recognised as a common cause Financial or Other, Competing Interest: None. 4 Submission 08-05-2017, Peer Review 13-05-2017, of secondary Open Angle Glaucoma. Acceptance 25-05-2017, Published 26-05-2017. Deposition of amorphous grey dandruff like material on Corresponding Author: the anterior lens surface is the most consistent and Dr. M. S. Gokila, important diagnostic feature of Pseudoexfoliation No. 5, G.1, Sapthagiri Flats, 5 Sapthagiri Colony, Jafferkhanpet, Chennai. syndrome. Exfoliative material is also deposited on E-mail: [email protected] Corneal endothelium, Trabecular meshwork, Iris, Pupillary DOI: 10.18410/jebmh/2017/518 margins, Zonules, Ciliary processes, Anterior Hyaloid phase.6 J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 4/Issue 43/May 29, 2017 Page 2615 Jebmh.com Original Research Article Pseudoexfoliation is associated with increased risks pupillary dilatation. In cases with advanced Glaucoma, during intraocular surgery, most commonly Zonular Cataract surgery was combined with Trabeculectomy. Dehiscence, Capsular Rupture, and Vitreous Loss during Postoperatively all patients received topical antibiotic Cataract extraction.7 steroid eye drops 6 times a day initially which was tapered Secondary Open Angle Glaucoma occurs in 50% cases.8 every week. Systemic antibiotics were given for 3 post- Exact mechanism of rise of IOP is not clear but it is operative days. Patients were followed up for 6 weeks proposed due to clogging of trabecular meshwork with Post-operatively; once weekly for first 2 weeks and once exfoliation material and pigments.9 Glaucoma in every 2 weeks for the next one month. At each visit, Visual Pseudoexfoliation syndrome has worse prognosis due to Acuity measurement, Anterior Segment examination, Intra- poor response to medications and complications involved in Ocular Pressure measurement and fundus examination surgical management. It responds to Argon Laser were done. Patients without any evidence of Glaucoma Trabeculoplasty and Trabeculectomy.8 were advised yearly followup. Patients with Glaucoma were under regular followup every 3-6 months depending on the MATERIALS AND METHODS IOP levels and Optic nerve status. A prospective study of 100 patients with Pseudoexfoliation syndrome who attended the Regional Institute of RESULTS Ophthalmology and Government Ophthalmic Hospital, A total of 100 patients (n =100: M=66, F=34) with mean Chennai, India between November 2012 and September age of 63.71 years had Pseudoexfoliation (74 bilateral and 2014 was carried out. 26 unilateral). 48 patients had Glaucoma while 52 had no Glaucoma. 32 had Open Angle Glaucoma (20 bilateral & 12 Inclusion Criteria- Patients diagnosed with the presence unilateral) and 16 had Angle Closure Glaucoma (9 bilateral of exfoliation material on the pupillary margin and/or lens. & 7 unilateral). Out of the 52 eyes with Open Angle Glaucoma, no optic nerve damage was seen in 9 eyes; Exclusion Criteria- Patients with previous history of early glaucomatous damage was seen in 24 and advanced trauma, anterior uveitis, secondary cataract, primary open glaucomatous damage in 22. Out of the 25 eyes with Angle and closed angle glaucoma, other secondary glaucoma, Closure Glaucoma, 11 showed no damage, 7 showed early uncontrolled hypertension and ischaemic heart disease. damage and 7 eyes showed advanced glaucomatous damage. Evaluation- All patients were subjected to a detailed Slit- Out of the total 174 eyes of 100 patients, 68 eyes were lamp examination for Conjunctival congestion; Cornea - operated upon. 50 eyes were operated for cataract and 18 oedema, pigmentation; Anterior Chamber - depth, flare, underwent combined surgery. Out of 50 eyes subjected to cells, pigment dispersion; Iris - pattern, trans-illumination Cataract surgery, 6 suffered Corneal Endothelial Touch, 2 defects, iridodonesis; Pupil - size, reaction to light, eyes had Posterior Capsular Rent and 3 eyes developed dilatation with mydriatics; Lens - cataract, phacodonesis, Zonular Dehiscence mainly due to poor pupillary dilatation. subluxation or dislocation and exfoliation material in all Out of 18 eyes subjected to Combined surgery, 13 eyes areas. Pupil was dilated to note the three zones of had open angle glaucoma and 5 had angle closure exfoliation material on the lens capsule. Fundus was glaucoma. 10 had advanced glaucomatous damage of the examined with direct ophthalmoscopy and slit-lamp optic nerve. 10 eyes had poor pupillary dilatation. 2 eyes biomicroscopy to look for glaucomatous changes in the suffered posterior capsular rent with vitreous loss and 3 disc. Glaucoma workup was done for all patients including developed zonular dehiscence. All these cases with Gonioscopy with Goldmann single mirror lens and complications had poor pupillary dilatation. In post-op Tonometry using Goldmann applanation tonometer. followup, 17 (94.44%) eyes had IOP less than 20 mmHg of Automated Perimetry was done in selected cases. During which 4 eyes were on adjuvant topical anti-glaucoma Gonioscopy the presence of exfoliation material and medication while 13 were under surgical control without increased trabecular pigmentation were also noted. any medication. One (5.55%) case had IOP between 20-30 mmHg with anti-glaucoma medication. Thus, in 13 Surgery- For patients undergoing surgery, routine lab (72.22%) eyes, IOP was less than 20 mmHg without any investigations like Blood Sugar, Urine Albumin, Sugar and anti-glaucoma medication. Blood Pressure measurement were done. A-scan, K- reading were noted and IOL power was calculated by SRK 2 formula. The patients were given topical antibiotic eye drops 6 times a day on pre-operative day. On the day of surgery pupils were dilated adequately with 0.8% Tropicamide and 5% Phenylephrine eye drops every 15 minutes, 1 hour before surgery. Manual Small Incision Cataract Surgery under local anaesthesia was carried out with PCIOL implantation. Mechanical stretching or Sphincterotomy were carried out for cases with poor Chart 1. Age Distributions (n=100) J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 4/Issue 43/May 29, 2017 Page 2616 Jebmh.com Original Research Article Number of Type of Glaucoma