|Year : 2014 | Volume
| Issue : 3 | Page : 137-139
Prevalence of pseudoexfoliation syndrome in patients scheduled for cataract surgery in eye camps in Kashmir
Aalia R Sufi1, Asmat A Mufti1, Nighat Nazir2, Tariq Qureshi2, Rahila Ramzan2
1 Mobile Ophthalmic Unit, Directorate of Health Services, Kashmir, Jammu and Kashmir, India
2 Department of Ophthalmology, Government Medical College, Srinagar, Jammu and Kashmir, India
|Date of Submission||21-Jul-2013|
|Date of Acceptance||15-Apr-2014|
|Date of Web Publication||16-Aug-2014|
Dr. Aalia R Sufi
Government Medical College, Srinagar - 190 010, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Aims: To study the prevalence of pseudoexfoliation syndrome (PEX) in patients scheduled for cataract surgery in eye camps in Kashmir. Materials and Methods: This was a prospective study conducted by the Mobile Ophthalmic Unit holding eye camps in rural areas of Kashmir from December 2010 to July 2011. Total of 1117 patients from 11 areas with age-related cataract scheduled for surgery underwent complete clinical examination. The PEX was diagnosed by the presence of gray flakes on the anterior lens capsule or at the pupillary margin or both. A Chi square test was used for statistical analysis. Results: The prevalence of PEX was 26.32%. The prevalence from the different areas varied from 4 to 36.36%. Males comprised 64.62% of the patients with PEX ranging in age from 49 years to 89 years. Increasing age was associated with increase in prevalence of PEX (P value < 0.001). Prevalence of PEX was higher in patients involved with outdoor activities (P value < 0.001). Most common type of cataract seen in patients with PEX was nuclear sclerosis. Patients with PEX had visual acuity (VA) significantly lower than patients without PEX (P value = 0.0013). Conclusion: The prevalence of PEX in Kashmir is relatively high. This is important from the perspective of mobile eye camps considering the increased frequency of cataract and the surgical complications associated with PEX, and thus the surgery mandates a thorough preoperative clinical examination to ensure good surgical outcome.
Keywords: Cataract, eyecamps, prevalence, pseudoexfoliation syndrome, visual acuity
|How to cite this article:|
Sufi AR, Mufti AA, Nazir N, Qureshi T, Ramzan R. Prevalence of pseudoexfoliation syndrome in patients scheduled for cataract surgery in eye camps in Kashmir. J Clin Ophthalmol Res 2014;2:137-9
|How to cite this URL:|
Sufi AR, Mufti AA, Nazir N, Qureshi T, Ramzan R. Prevalence of pseudoexfoliation syndrome in patients scheduled for cataract surgery in eye camps in Kashmir. J Clin Ophthalmol Res [serial online] 2014 [cited 2020 Jul 6];2:137-9. Available from: http://www.jcor.in/text.asp?2014/2/3/137/138855
The pseudoexfoliation syndrome (PEX) is a condition characterized by widespread intraocular and systemic production and deposition of an abnormal fibrillar extracellular material. , It is clinically diagnosed by the presence of light gray flakes most noticeable on the pupillary margin and also seen on the lens surface, zonules, trabecular meshwork, hyaloid and endothelial surface of cornea.  Globally, the reported prevalence rate of PEX in patients scheduled for cataract surgery shows extensive variations in Ethiopia (39.3%),  Estonia (35.4%),  Finland (30.8%),  Greece (28%),  South Africa (26%),  Portugal (25.3%),  and Turkey (16.4%).  While conducting eye camps in rural Kashmir, our clinical observation led us to believe that the prevalence of PEX among Kashmiri people is relatively high. Therefore, we decided to conduct a prospective study aimed to study the prevalence of PEX among Kashmiri people with age-related cataract, who were scheduled for surgery.
| Material and Methods|| |
A cross-sectional study was conducted from December 2010 to July 2011 by the Mobile Ophthalmic Unit of Kashmir. This Unit works under the Directorate of Health Services of the state of Kashmir and conducts eye camps and performs cataract surgeries in the rural areas of Kashmir. Patients with senile lens change planned for cataract surgery were registered for the study. Approval from the ethics committee of Government Medical College, Kashmir was obtained for the study and it adheres to the tenets of the Declaration of Helsinki.
After informed consent, complete clinical evaluation was done including age, sex, visual acuity (VA) with Snellen chart, intra-ocular pressure (IOP) by Schiotz tonometry, fundus examination. Detailed slit lamp biomicroscopy under maximal mydriasis with tropicamide 1% was performed to assess the type and grade of cataract according to the Lens Opacities Classification System II (LOCS II). Cataracts were classified morphologically as nuclear sclerosis (NS), cortical and posterior subcapsular (PSC). Diagnosis of PEX was based on the presence of gray flakes of PEX material on the anterior lens capsule or at the pupillary margin or both. Associated anatomical features looked for included pupillary ruff atrophy and pigment dispersion. Glaucoma was also excluded from our study as our eye camps only assess and perform cataract surgery and glaucoma needs long-term follow-up, which is not possible with mobile eye camps that shift base. We studied the association of visual status with PEX alone without glaucoma. Statistical analysis of the data was done by using Chi square test (χ2 test). The level of significance was fixed at P-value less than 0.05 i.e. P < 0.05 was taken to be statistically significant.
| Results|| |
A total of 1117 patients from 11 different areas of Kashmir were included in this study. Prevalence of PEX was 26.32%. Prevalence of PEX was highest in Beeru and lowest in Sogam [Table 1]. 64.62% of the patients with PEX were males and 35.37% were females, ranging in age from 49 years to 89 years. Mean age of patients with PEX was 72.61 years as compared to patients without PEX with mean age 62.92 years. Increasing age was associated with increase in prevalence of PEX [Table 2]. PEX was present unilaterally in 47.96% of patients and 52.04% bilaterally. PEX was seen at the pupillary border in 62.92% of patients and on the anterior lens capsule in 26.20%, and on both in 10.88%. More patients with PEX were involved with outdoor activity [Table 3]. Most common type of cataract seen in patients with PEX was nuclear sclerosis 78.91% [Table 4]. Patients with PEX had VA significantly lower than patients without PEX with majority of patients with PEX with VA less than 3/60 compared to patients without PEX having VA greater than 3/60 [Table 5].
| Discussion|| |
The PEX occurs worldwide although reported prevalence rates vary extensively. Several prevalence studies have been conducted in other parts of India and neighboring Pakistan. The prevalence of PEX based on hospital reports from India varies between 1.87% and 13.5%.  However, our study provides information from a region where data is scarce and varied from the data provided by previous studies. The prevalence of PEX in patients attending eye camps in Kashmir was 26.32%. Though this prevalence was similar to other countries but this prevalence was high as compared to prevalence studies conducted in southern parts of the country. Kashmir, being the northernmost state of India, this difference can be attributed to a number of factors ranging from differences in the climatic and geographical conditions, ethnic origin and genetic factors. Variations also occur due to age and sex distribution of patients or population group examined; the clinical criteria used to diagnose PEX; the thoroughness of the examination and the ability of the examiner to detect early stages.
In our study, increasing age was associated with increase in prevalence of PEX. Although the reason for this age-related increase is unknown, it has been speculated that the changes in gene expression that occur with age may be responsible. 
Our study showed increased prevalence of PEX in people exposed to outdoor activity. Majority of people in rural Kashmir depend on agriculture as source of income and thus would be exposed to outdoor activities. This supports the association between environmental factors (possibly solar radiation, UV exposure) and PEX as documented by other studies. 
Cataracts are known to be more common in PEX, with nuclear sclerosis being the predominant type of cataract. Similar result was obtained in our study. Ascorbic acid is significantly reduced in the aqueous of cataract patients with PEX. , One may therefore consider the possible association between oxidative stress  and ocular ischemia in PEX and, hence the reason for the association between the two.
We found that patients with PEX had lower visual acuity (VA) compared with patients without PEX. Similar data was reported in the Andhra Pradesh eye disease (APED) Study that found prevalence of blindness in eyes with PEX to be 15.1%. 
Eyes with PEX have a greater frequency of complications such as poor pupillary dilatation, zonular dialysis, capsular rupture, and vitreous loss at the time of cataract extraction. Postoperative complications of acute increase in intra ocular pressure, posterior capsular opacification, capsule contraction syndrome, intraocular lens decentration, and inflammation are also greater in eyes with PEX. 
Population of this study includes patients who were planned for cataract surgery in eye camps and so would not be representative of the general population. This is the limitation of our study an d further studies involving the whole population of Kashmir may be needed.
| Conclusion|| |
India, in particular the state of Kashmir has a high burden of cataract, with cataract being the leading cause of blindness. Mobile eye camps such as ours are mainly focussed at reducing the burden of blindness attributed to cataract by performing cataract surgeries. Our study is important as the prevalence noted in our study is much higher than the previous studies conducted in other parts of India. This high prevalence of PEX and the lower VA seen in patients with PEX has public health implication. Also considering the higher frequency of complications in patients with PEX, preoperative diagnosis by a thorough clinical examination is imperative and precautions during surgery may help improve the surgical outcome.
| Acknowledgment|| |
Mr. Syed Mustafa Bhat provided statistical help and Ms. Arshi Sufi for drafting the manuscript.
| References|| |
|1.||Naumann GO, Schlotzer-Schrehardt U, Kuchle M. Pseudoexfoliation syndrome for the comprehensive ophthalmologist. Intraocular and systemic manifestations. Ophthalmology 1998;105:951-68. |
|2.||Ritch R. Exfoliation syndrome. In: Ritch R, Shields MB, Krupin T, editors. The Glaucomas. 2 nd ed., Vol. 2., Ch. 47. St Louis: Mosby; 1996. p. 993-1022. |
|3.||Lamba PA, Giridhar A. Pseudoexfoliation syndrome (prevalence based on random survey hospital data). Indian J Ophthalmol 1984;32:169-73. |
|4.||Tiliksew T, Kefyalew R. Prevalence of pseudoexfoliation syndrome in Ethiopian patients scheduled for cataract surgery. Acta Ophthalmol Scand 2004;82:253-8. |
|5.||Kaljurand K, Paivi P. Exfoliation syndrome in Estonian patients scheduled for cataract surgery. Acta Ophthalmol Scand 2004;82:259-63. |
|6.||Lumme P, Laatikainen L. Exfoliation syndrome and cataract extraction. Am J Ophthalmol 1993;116:51-5. |
|7.||Konstas AG, Dimitrakoulias N, Kourtizidon O, Filidis K, Bufidis T, Benos A. Frequency of exfoliation syndrome in Greek cataract patients. Acta Ophthalmol Scand 1996;74:478-82. |
|8.||Bartholomew RS. Pseudocapsular exfoliation in the Bantu of South Africa. II. Occurrence and prevalence. Br J Ophthalmol 1973;57:41-5. |
|9.||Alfaite 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. |
|10.||Sekeroglu MA, Bozkurt B, Irkec M, Ustunel S, Orhan M, Saracbasi O. Systemic associations and prevalence of exfoliation syndrome in patients scheduled for cataract surgery. Eur J Ophthalmol 2008;18:551-5. |
|11.||Thomas R, Paul P, Muliyil J. Glaucoma in India. J Glaucoma 2003;12:81-7. |
|12.||Karger RA, Jeng SM, Johnson DH, Hodge DO, Good MS. Estimated incidence of pseudoexfoliation syndrome and pseudoexfoliation glaucoma in Olmsted Country, Minnesota. J Glaucoma 2003;12:193-7. |
|13.||Taylor HR. The environment and the lens. Br J Ophthalmol 1980;64:303-10. |
|14.||Koliakos GG, Konstas AG, Schlotzer-Schrehardt U, Hollo G, Katsimbris IE, Georgiadis N, et al. 8-Isoprostaglandin F2a and ascorbic acid concentration in the aqueous humour of patients with exfoliation syndrome. Br J Ophthalmol 2003;87:353-6. |
|15.||Koliakos GG, Konstas AG, Schlotzer-Schrehardt U, Bufidis T, Georgiadis N, Ringvold A, et al. Ascorbic acid concentration is reduced in the aqueous humor of patients with exfoliation syndrome. Am J Ophthalmol 2002;134:879-83. |
|16.||Ritch R, Schlotzer-Scherhardt U. Exfoliation syndrome. Surv Ophthalmol 2001;45:265-315. |
|17.||Thomas R, Nirmalan PK, Krishnaiah S. Pseudoexfoliation in southern India: The Andhra Pradesh Eye Disease Study. Invest Ophthalmol Vis Sci 2005;46:1170-6. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]