¹Consultant, ²Post Graduate Resident, ³Jr Consultant, Department of Ophthalmology, BDBA Municipal Hospital, Kandivali West, INDIA.

Email: girish_surlikar@yahoo.com

RESULTS

In present study, maximum numbers of patients were from the age group of 70-79 years (62.5%), followed by age group of 60-69 years (31.25%). Mean age of patients was 71.83 ± 5.80 years. In this study, 56 (70%) patients were males and 24 (30%) were females.

Table 1: Age and gender wise distribution of patients

In this study of 80 patients with Pseudoexfoliation Syndrome, 60 patients had Bilateral Pseudoexfoliation i.e. 120 eyes (85.71%) while 20 patients had Unilateral Pseudoexfoliation i.e. 20 eyes (14.29%).

Table 2: Distribution        of number of eyes with pseudoexfoliation

In majority of the eyes 111 (79.29%) had involvement of lens with Pseudoexfoliation while 109 (77.86%) had pupillary involvement. Pseudoexfoliation involving Iris was seen in 56 (40%) of eyes, while Pseudoexfoliation involved 20 (14.29%) of cornea and 6 (4.29%) of angle.

Table 3: Anterior segment changes

Mean Anterior Chamber Depth in Pseudoexfoliative eyes was 2.50±0.22 mm. majority of the eyes, 81 (57.86 %) with Pseudoexfoliation were of 2 – 2.5 mm dept with mean depth of 2.34±0.11 mm whereas 59 eyes (42.14%) were of 2.6 – 3mm depth with mean depth of 2.72±0.12 mm.

Table 4: Anterior chamber depth

Majority of the eyes i.e. 74 (52.9%) were having IOP between 16 – 20 mm Hg. 61 eyes (43.6%) had IOP between 11 – 15 mm Hg while only 2 eyes (1.4%) had IOP more than 20 mm Hg and 3 eyes (2.1%) had IOP less than equal to 10mmHg. Mean IOP recorded in 140 eyes with Pseudoexfoliation was 15.60±2.21 mm Hg.

Table 5: Intra ocular pressure (IOP) in eyes with pseudoexfoliation

80 eyes of 80 patients underwent MSICS, 17 (21.25%) patients developed Intraoperative Complications. In present study Zonular Dialysis was found in 3 eyes (17.65%) and Zonular Dialysis with Vitreous Loss was seen in 4 eyes (23.53%). Posterior Capsular Rent was found in 2 eyes (11.76%) and PCR with Vitreous Loss was found in 4 eyes (23.53%). Sphincter Tear was noted in 3 eyes (17.65%) and Iridodialysis was seen in one eye (5.88%).Total 8 eyes had Vitreous Loss. Intraoperative use of Capsular Tension Ring and Iris Hooks was done in 4 eyes with small pupils. No Intraoperative Complications were noted in 63 eyes (78.72%).

Table 6: intraoperative complications (n=17)

70 (87.5%) eyes achieved visual acuity of near normal vision postoperative whereas 7 (8.75%) eyes achieved vision of 6/18-6/60 (Visually impaired). 3(3.75%) patients had vision of <6/60-FC 3m (Severe visual impairment). It was observed that there was significant difference (p <0.05) in visual acuity post operatively following MSICS.

Table 7: Postoperative visual outcome

Chi Square value=92.36, p-value=0.0001, Significant

In our study we found that complications occurred frequently in Anterior Chamber Depth of 2 - 2.5 mm. All 17 patients with complications had ACD in the range of 2 – 2.5 mm with mean ACD of 2.33 ± 0.12 mm.

Table 8: Distribution of anterior chamber depth and complications

In our study we found that complications occurred frequently in Dilated pupil size of 5.1-6 mm {11(64.71%)} and this was statistically significant (p < 0.05).

Table 9: Distribution of dilated pupil size and complications

Chi square value=79.59, p=0.0001, Significant

In 80 patients undergoing SICS, 17 patients had complications. Complications rate were maximum in patients having only Nuclear Sclerosis i.e. 6 patients out of 17 (35.29%), followed by 4 patients (17.65%) with Hypermature Cataract, 4 patients (23.53%) with combined Nuclear and Cortical Cataract and 3 patients (23.53%) with Mature Cataract had complications.

Table 10: Distribution of lens morphology and complications

Chi square value=7.98, p=0.046, Significant

DISCUSSION

In present study, maximum number of patients were in the age group of 70-79 years (62.50%). In a study done by C N Gupta et al.,⁶ majority of patients were of age group 61-70 (47.5%) and from 71-80 years age group (37.5%). The prevalence of Pseudoexfoliation syndrome was increased and found to be statistically significant (p<0.01) with age of the patients. In study by M Nazarul Islam et al.,⁷ out of 512 patients of cataract with Pseudoexfoliation undergoing MSICS, maximum of number of patients in age group of 71 – 80 years (41.11%), which is corresponding with our results. In study done by Anmol et al.,⁸ and Bojan Kovac et al.,⁹ mean age of patients was found to be 67.95 years and 79.70 years respectively. These results are consistent with our study (mean age 71.83years) Thus, it can be seen that there is increase prevalence of PXF with increase in age all over the globe. In our study of 80 patients, 56 (70%) patients were males and 24 (30%) were females with Male to Female ratio of 2.3:1. Similar results were found in studies done by Bairy SN et al.,¹⁰ among 90 cases of Pseudoexfoliation, males were 63 (70%) and females, 27 (30%). Our study is similar to study done by B Ramalakshmi et al.,¹¹ has found 23 patients (37.09%) to have unilateral involvement while 39 patients (62.90%) to have bilateral involvement, which statistically significant. In another study done by Arvind et al.,¹² 108 (3.8%) were found to have PXF syndrome, with unilateral disease in 53 (49.1%) and bilateral in 55 (50.9%) subjects and is not statistically significant. This is expected as the disease process is invariably bilateral pathologically but clinical bilateral involvement is evidenced after 5-10 years of unilateral clinical presence. Meanwhile unilateral presence cannot be confirmed only with clinical finding since the histopathological are confirmative of the condition of whether it is unilateral or bilateral which is not done in our study and only clinical presence is take into consideration for classification of laterality. According to WHO criteria of Visual status, 35 (25%) eyes had Near Normal vision, 72 eyes (51.43%) were included in Visually Impaired, 10 eyes (7.14%) had severe visual impairment, 12 (8.57%) eyes had Social Blindness and 11 (7.86%) patients were included in Legal Blind category. Aalia R Sufi et al.,¹³ found that decrease in visual acuity in patients with PXF. Study done by Thomas et al.,¹⁴ has found the prevalence of blindness with PXF to be 15.1%. Result of both the study are consistent with our study. Visual impairment in patients with PXF may be attributed to several possible mechanisms. Pericellular accumulating PXF material disrupts and destroys the basement membrane and the cells involved. The cell-matrix interaction may adversely affect the cells leading to cellular dysfunction and eventually cell degeneration known as degenerative fibrillopathy. In some cases of PXF, the patient may complain of impaired visual acuity or changes in their perceived visual field. This visual problem occurs when the granular flakes become enmeshed in trabecular meshwork and block normal drainage of aqueous humor leading to increased intraocular pressure and loss of vision. Pseudoexfoliation syndrome is also known to weaken ciliary muscle and adversely affect lens zonules. Rubbing off PXF material from the lens may result in loss of iris pigment, which can lead to transillumination defects. Poor pupillary response to dilatation is a subtle finding in PXF patients, which may adversely affect vision.⁶ In study done by Vijayalakshmi et al.,³ pseudoexfoliative material was found on the pupillary margin of iris in 13 patients (22.03%) and on anterior surface of lens in 20 patients (33.89%). In 26 patients (44.06%) material was found on both the areas. Thomas et al.,¹⁴ it was present on the pupillary margins of 65 (58.0%) eyes and on the lens of 71(63.4%), only on the lens surface in 48 (42.9%), only on the pupillary margins in 38 (33.9%), and in both locations combined in 26 (23.2%). Similar findings were noted in present study. In study done by C N Gupta⁶, out of 120 patients, the range of IOP was 11.2 mm Hg to 26.1 mm Hg with an average IOP reading of 17.38 mmHg. In study by Vijayalakshmi et al.,³ 42 patients (71%) had IOP less than 20 mm Hg, 11 patients (18.6%) had IOP more than 21 mm Hg. 6 patients (10%) presented with glaucomatous disc changes in patients Pseudoexfoliation. Our study findings are also consistent with above studies. Satish et al.,¹⁵ studied 500 eyes with Pseudoexfoliation with cataract underwent MSICS with IOL implantation. They found PCR was seen in 50 patients (27.6%), vitreous loss was seen in 40 patients (22.09%) and Iridodialysis was seen in 4 patients (2.20%). In study of Jawad et al.,¹⁶ most common Intraoperative complication was Vitreous loss (10.5 %), PCR (9%), Damage to sphincter pupillae (8%), Retained lens material (6%) Zonular dialysis (4%) present. These results are consistent with the results of our study. Similar results were seen in present study. In study of Praveen et al.,¹⁷ the commonest intra-operative complication was Zonular dialysis in 10% and Posterior capsular rupture in 2%. In a study connected by B Ramalakshmi et al.,¹¹ out of 62 patients who underwent cataract extraction with IOL implantation, 5 patients (8.06%) had post op vision of >3/60,14 patients (22.58) had visual acuity between <6/18 – 3/60, 43 patients had postop visual acuity of ≥6/18 which is similar to our study. In a study done by Prachee et al.,¹⁸ out of 156 patients of Pseudoexfoliation who underwent cataract surgery, the post-operative visual acuity was ≥ 6/18 in 126 patients (80.76%), 6/18 - 6/36 in 24 patients (15.38%) and ≤ 6/60 in 6 patients (3.84%) which is similar to our study. In the current study, among 140 Pseudoexfoliative eyes, 81 eyes (57.86%) had anterior chamber depth in the range of 2 – 2.5 mm and 59 eyes (42.14%) eyes had anterior chamber depth in the range of 2.6 – 3 mm.We found that complications occurred frequently in Anterior Chamber Depth of 2 - 2.5 mm. All 17 patients with intraoperative complications had ACD in the range of 2 – 2.5 mm with mean ACD of 2.33±0.12mm. Similar results were found by Kuchle et al.,^19] that in eyes with Pseudoexfoliation syndrome and anterior chamber depth of less than 2.5mm, the risk of intraoperative complications was 13.4% when compared to eyes in which the anterior chamber depth is 2.5mm or more the risk of intraoperative complications is significantly reduced to 2.8%. The mean anterior chamber depth in eyes with complications is 2.36 ± 0.44 SD compared to eyes without complications in which the mean ACD was 2.74 ± 0.52mm. In study done by Gulsum et al.,²⁰ patient with poor pupil dilation intraoperative complications was seen in 60 (75%) of the patients with Pseudoexfoliation and 17 (11.7%) of the control patients. Thus, frequency of poor intraoperative pupillary dilation was significantly higher in the PXF group compared to controls (p<0.001). In another study done by Chevuturu et al.,²¹, out of 76 patients, 27 (35.5%) had poor pupillary dilatation and higher intraoperatively complications. In study done by Ramalakshmi et al.,¹¹ higher incidence of intraoperative complications like zonular dehiscence in 5 cases (8.06%), PCR (9.67%) and vitreous loss in 8.06% were more where pupil diameter between 3-5mm which was found to be statistically significant (<0.05%) Reduction of stromal elasticity by accumulation of Pseudoexfoliation material plays important role in poor mydriasis and poor postoperative outcomes. Limitations of present study was small sample size; findings of present study need to be confirmed with a larger study population.

CONCLUSION

There is significant association between Pseudoexfoliation syndrome and age, male preponderance and bilateral involvement of eyes. Pseudoexfoliative material is most commonly seen involving lens followed by other anterior eye structures. MSICS provides significant improvement in visual outcome in patients with Pseudoexfoliation syndrome with cataract. Detection of Pseudoexfoliation preoperatively prepares us for the intraoperative complications and allows for prevention of these complications. Thus, it is recommended that each eye with Pseudoexfoliation must be individually approached.

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