|Year : 2014 | Volume
| Issue : 1 | Page : 7-11
A study of complications during cataract surgery in patients with pseudoexfoliation syndrome
K Pranathi, Renu M Magdum, Rupali Maheshgauri, Khevna Patel, S Patra
Department of Ophthalmology, Padmashree Dr. D. Y. Patil Medical College, Hospital and Research Centre (Dr. D. Y. Patil Vidyapeeth), Pimpri, Pune, Maharashtra, India
|Date of Submission||17-Jan-2013|
|Date of Acceptance||12-Aug-2013|
|Date of Web Publication||3-Dec-2013|
Renu M Magdum
7 Panchsheel Park, Near Softlink International, Opp. Anandhban Club, Aundh Baner Road, Pune - 411 007, Maharashtra
Source of Support: None, Conflict of Interest: None
Aim: Pseudoexfoliation (PXE) is a common and clinically important systemic condition that affects elderly people, who are also likely to undergo cataract surgery. It can cause serious complications during cataract surgery due to the pupillary rigidity and zonular weakness and instability. The purpose of this study was to study the frequency and types of complications of small incision cataract surgery (SICS) and phacoemulsification surgery in patients with cataract and PXE. Materials and Methods: This cross-sectional descriptive study was carried out on 52 eyes of 52 patients with cataract and PXE who underwent SICS or phacoemulsification surgery in a tertiary care hospital. Their perioperative and post-operative complications were documented and analyzed through statistical package for social sciences version 15.0 (IBM). Results: Poor pupillary dilatation in spite of use of standard mydriatic drops and non-steroidal anti-inflammatory drugs was the most common finding. This single factor made subsequent steps of surgery very difficult due to poor peripheral visualization. Pupillotomy was done in 25% cases. Other problems encountered were accidental iridodialysis, posterior capsule rupture, vitreous loss, retained cortical matter, decentered intraocular lens and zonular dialysis. Conclusion: Presence of associated PXE in cataract patients significantly increases the risk of vision threatening complications. Use of flexible iris hooks for small pupils and for capsular stability, capsular tension rings and high viscosity viscoelastics are useful modifications of surgical technique for good visual outcome.
Keywords: Iridopathy, miosis, phacopathy, pseudoexfoliation, zonular weakness
|How to cite this article:|
Pranathi K, Magdum RM, Maheshgauri R, Patel K, Patra S. A study of complications during cataract surgery in patients with pseudoexfoliation syndrome. J Clin Ophthalmol Res 2014;2:7-11
|How to cite this URL:|
Pranathi K, Magdum RM, Maheshgauri R, Patel K, Patra S. A study of complications during cataract surgery in patients with pseudoexfoliation syndrome. J Clin Ophthalmol Res [serial online] 2014 [cited 2020 Oct 28];2:7-11. Available from: https://www.jcor.in/text.asp?2014/2/1/7/122627
Pseudoexfoliation (PXE) was first described by Lindberg in 1917.  He believed that this material was created by earlier inflammation. The main and full description was made by a Swiss Ophthalmologist Alfred Vogt  in 1918. He described it as a film on the anterior lens capsule as a remanent of the pupillary membrane. PXE is now recognized as an accumulation of grey white fibrogranular extracellular pseudoexfoliative material produced by abnormal basement membranes of ageing epithelial cells in trabeculum, equatorial lens capsule, pupillary margin of iris and ciliary body of the eye.  Moreover, exfoliative fibrillopathy has been reported in the skin and visceral organs  as well, thereby suggesting that it may be an ocular manifestation of a systemic disorder.
A study carried out in South India reported prevalence of PXE as 3.8%, while the Andhra Pradesh Eye Disease Study reported it as 3.01%. ,
PXE usually presents in the elderly age group and it is this very group of patients who are likely to undergo cataract surgery. The clinical changes are most readily apparent on the lens capsule on which a grey amorphous material is layered in the pupillary region and along the pre-equatorial region of the lens. These two areas are initially connected, but later get separated by the iris brushing against the lens. Pre-operative diagnosis can be made by examining the pupillary margin for deposits of grey dandruff like flakes along with a moth eaten appearance of iris sphincter on transillumination. The cornea may show diffuse pigment deposition or sometimes a Krukenberg spindle. Mild aqueous flare may be seen. On dilating the pupil, the characteristic double ring appearance can be seen with a central disc and peripheral band of PXE and clear area in between. On gonioscopy, trabecular meshwork shows pigmentation, sometimes with a pigmented sampaolesi line anterior to schwalbes line and dandruff like flakes on the trabecular meshwork. It may be associated with secondary open angle glaucoma due to blockage of trabeculum by exfoliative material and pigment.
Histologically, the material is produced by ageing epithelial cells of basement membranes of the ciliary body, iris and lens epithelium. It is also associated with the basement membranes of endothelial cells of iris and conjunctival vessels and with trabecular endothelial cells. It consists of fibrillar extracellular material consisting of a protein core surrounded by glycoaminoglycans. There can be iris infiltration and fibrosis and deposition in zonules as well.
PXE induced iridopathy and phacopathy with zonular instability make routine cataract surgery a challenging task. Scorolli et al.  found that such patients have 5 times greater likelihood of intraoperative complications in cataract surgery compared with normal cases. Recognition of this condition is hence very important before commencing surgery on such patients.
Surgical and post-operative difficulties are often multifactorial and directly related to pathological changes of pseudoexfoliative materials on intraocular structures. Many cases may go undetected due to failure to dilate the pupil or examine the lens surface with the slit lamp before surgery. Hence, rational diagnostic, preventive and therapeutic strategies need to be developed and utilized. This study was done with the aim of studying the intra-operative and post-operative complications during the cataract surgery in patients with PXE and to suggest measures to minimize the likelihood of such complications.
| Materials and Methods|| |
This prospective, non-randomized, case series study was carried out in the eye department of a tertiary hospital from 1 st August 2009 to 30 th June 2011. Patients with cataract associated with PXE were included in this study. All patients with a history of miotic use, traumatic cataract, complicated cataract, high myopia and previous ocular surgery were excluded from the study. Institutional ethics committee clearance was obtained before the start of the study.
A written and informed consent was obtained from all patients after explaining the procedure and associated risk. Patients were admitted 1 day prior to surgery and detailed history was taken. Best corrected visual acuity was measured using Snellen's visual acuity chart. Intraocular pressure was measured by applanation tonometer. Gonioscopy was done and the angle was graded by Shaffer's system of grading. Detailed slit lamp examination was done and pseudoexfoliative deposits were looked for on the cornea, iris and pupillary margin and after dilatation, on the anterior capsule of the lens. Cataract was graded using "lens opacity classification system."
All patients were operated by the same surgeon with more than 5 years' experience using a small incision cataract surgery (SICS) or phacoemulsification. All patients were put on topical antibiotic drops 1 day prior to surgery. Patients were dilated with mydriatic - cycloplegic drops and non-steroidal anti-inflammatory drops were used to maintain the dilatation. Pupillary diameter after dilatation was measured and graded as poor (2-4 mm), [Figure 1] moderate (5-6 mm) [Figure 2] and good (7-9 mm or more) [Figure 3].
Peribulbar block with 5 ml of 2% xylocaine and 5 ml of 0.5% bupivacaine with 150 units/ml of hyaluronidase. Povidine-iodine 5% was instilled into the conjunctival sac. For SICS, fornix base conjunctival flap was made, scleral incision was made with bard parker knife with 15 no. blade superiorly and sclerocorneal tunnel was constructed with crescent. Side port entry was made by side port entry blade, trypan blue dye (0.1%) was injected intracamerally to stain the anterior capsule. Gentle continuous curvilinear capsulorhexis aimed at 6 mm to 6.5 mm was done using the needle cystitome and completed using Utrata's capsulorhexis forceps. Gentle, thorough hydrodissection was performed to separate cortex from nucleus. Nucleus was delivered by visco expression. Irrigation and aspiration was done with Simcoe's two way irrigation and aspiration cannula. Rigid, single piece, biconvex, polymethyl melta acrylate posterior chamber intraocular lens (IOLs) with optic diameter of 5.25 mm without dialing holes was used and was implantated in bag using Kelman McPherson forceps.
In patients who were operated by phacoemulsification, clear corneal incision was made and nucleus was emulsified by stop and chop technique.
Post-operatively, patients were put on topical antibiotics and steroids tapered over 4-6 weeks depending upon the post-operative inflammation. Patients were followed on the post-operative day 1, day 7 and day 14 and at weekly intervals for 3 months to evaluate intraocular pressure spikes, presence of intraocular inflammation, decentration/tilt of intra ocular lens and corneal decompensation.
Data was entered and analyzed using statistical package for social sciences version 15.0 (IBM). Analysis was done for quantitative and qualitative measures.
| Results|| |
Fifty-two eyes of 52 patients with PXE who underwent cataract surgery by SICS or phacoemulsification technique were included in this study to evaluate the perioperative and post-operative complication. All patients were operated by the same surgeon with more than 5 years' experience. Twenty patients with the pupillary size of at least 7 mm underwent clear corneal phaco while 27 patients with smaller pupils underwent SICS. Five patients originally posted for phacoemulsification had to convert to SICS due to operative difficulties.
The ages of the 52 patients in this study was between 60 and 80 years. Out of these 25 (48.1%) were in 60-70 years age group and 27 (51.9%) patients were in 71-80 years age group. 28 (53.8%) were male and 24 (46.2%) were female with a male:female ratio of 7:6. 7 (13.46%) eyes had nuclear sclerosis, 5 (9.6%) had cortical cataract and both nuclear sclerosis and cortical cataract was present in 40 (76.9%) eyes. Mean intraocular pressure (IOP) was 18.23 ± 2.10 mmHg.
Pre-operative features showed that a high percentage of eyes had a rigid pupil. Eight cases had poor pupillary dilatation while 15 had moderate dilatation. None of the pupils dilated beyond 7 mm. Almost all eyes showed some evidence of pigment dispersion mainly on the anterior surface of the lens and cornea. None of the eyes showed frank subluxation of lens.
All patients underwent cataract surgery using SICS technique or clear corneal phacoemulsification. Surgical complications are listed in [Table 1]. Thirteen cases (25%) required sphincterotomy to facilitate capsularhexis and nucleus delivery. Four eyes (7.69%) had vitreous loss due to difficulty in surgical maneuvers. All four patients with vitreous loss were given anterior chamber lenses after doing anterior vitrectomy. Patients were followed on the post-operative day 1, day 7, day 14 and at monthly intervals for 3 months to evaluate intraocular pressure spikes, increased in intraocular inflammation, decentration/tilt of intraocular lens and corneal decompensation.
Post-operative hazy cornea was seen in 12 (23%) cases. Six cases (11.5%) had significant intraocular inflammation.
The IOP was measured both pre-operatively and post-operatively. We did not find any pressure spikes in any patient.
Final visual acuity was recorded after 12 weeks of surgery [Table 2]. At the end of 12 weeks, 4 (7.69%) patients showed persistent corneal edema probably due to corneal decompensation. However, pre- or post-operative specular microscopy and pachymetry were not included in this study.
| Discussion|| |
PXE syndrome affects mainly elderly group of patients who are also likely to undergo cataract surgery. In the present study, 52 eyes of 52 patients with PXE were evaluated for perioperative and post-operative complications following SICS and phacoemulsification surgery in a tertiary care center.
PXE is a relatively common finding in elderly patients undergoing cataract surgery, but pre-operative detection may be missed if the eyes are not seen under slit lamp.
Direct signs of zonule instability such as lens subluxation, zonular dialysis, iridodonosis or phacodonosis should be carefully looked for pre-operatively. Often the earliest sign is a subtle iridodonesis. It is best assessed prior to the pupillary dilatation while lens related changes are best seen after dilatation.  One study reported that an axial anterior chamber depth of less than 2.5 mm increased risk of surgical complications fivefold.  The amount of exfoliative material in the zonules does not seem to be predictive of intra operative zonule weakness. 
The ages of patients diagnosed with PXE in this study were in 60-80 years age group. Epidemiological studies of PXE have shown that it is more common in patients older than 60 years and prevalence further increases with age. ,
Of the 52 patients, 28 (53.8%) were male and 24 (46.2%) were female with a male:female ratio of 7:6. Reports regarding sex predilection in PXE are conflicting. Some previous studies showed male preponderance while Arvind et al. in 2003 showed no sex predilection  Avramides, Sakkias and Traindis reported a female preponderance.  External environmental factors have also been implicated for causing PXE.
Of the 52 patients studied, 7 (13.5%) had nuclear sclerosis, 5 (9.6%) had cortical cataract and both changes were seen in 40 (76.9%) cases. Most studies have found a strong association between PXE and nuclear cataract. ,, It has been hypothesized that high-levels of epithelial metabolic activity may be beneficial for ion pumps and electrolyte environment of cortical fibers. 
In the present study, most frequent problem encountered was a rigid pupil and none of the pupils dilated more than 7 mm in spite of use of standard mydriatic drops. Carpel  found a high 94.1% prevalence while, Alfaiate et al.  found prevalence of 48.4%. We resorted to sphincterotomy, but other alternatives include bimanual stretching and use of iris hooks or flexible iris retractors are also possible. Sphinterotomy and stretching have the disadvantage of causing post-operative distorted pupil, which may even lead to the pupillary capture.
A well centered and adequately sized capsulorhexis is critical in the presence of zonular weakness. Ideal size of a capsularhexis should be 5.0-5.5 mm in diameter. Surgeons performing capsularrhexis in PXE may encounter capsule splitting phenomenon in which multiple layers of split capsule may be raised. The false anterior layers are typically fragile and tear abnormally compared with the underlying true anterior capsule. It is important to identify this phenomenon to allow complete incision of true capsule. A small capsulorrhexis may lead to excessive pull on the zonules, difficulty in extracting nuclear material from capsular bag, increased risk of anterior capsular tear and higher incidence of post-operative capsular phimosis. Excessive intraoperative manipulations cause post-operative corneal edema and iritis. In presence of weak zonules, it may lead to severe complications of lens subluxation and vitreous loss.
Other complications, we encountered and also reported in previous studies include iridodialysis, intraocular bleeding, vitreous loss. These are also related to difficult maneuvers due to small rigid pupils and zonular instability. Zonular fragility increases the risk of lens dislocation, zonular dialysis or vitreous loss up to 10 times.  Rate of vitreous loss varied from 0% to 11% across different studies. ,
Post-operatively, 18 cases had significant intraocular inflammation with corneal decompensation seen in 12 cases. Frequency of retained lens matter especially subincisional cortex can invite severe post-operative inflammation and decentration of IOLs. Such complications can directly affect the visual recovery post-operatively. Hence surgical skill becomes an important factor for good visual outcome in such patients.
Strategies to reduce stress on the zonules include avoidance of excessive fluctuations in the anterior chamber pressure by controlled paracentesis and liberal use of viscoelastics and gentle maneuvers of lens especially gentle hydrodissection to allow unimpeded rotation of the nucleus. In cases with frank zonular weakness, use of a capsule tension ring that distributes forces circumferentially, also reduces post-operative IOLs decentration. Tangential stripping motion in the region of the defect may also reduce extension of the defect.
Other studies have reported an increase in posterior capsular opacification following cataract surgery in eyes with PXE , This may be due incomplete removal of cortical matter due to poor visibility secondary to a small pupil. In our study 18.8% of cases had posterior capsular opacification. IOL decentration has also been reported even when the lens is entirely in the capsular bag, primarily due to decentration of the entire bag. ,
This study demonstrated an increased incidence of intra-operative and post-operative complications. A thorough awareness of PXE syndrome and its effects on all ocular tissue is critical to understand the multifactorial causes of operative complication and thereby avoid or minimize them.
PXE presents challenges that must be adequately addressed with proper pre-operative preparation, surgical care and post-operative follow-up. However, cases may go undetected due to failure to dilate the pupil or to examine the lens with the slit lamp after dilatation. Adequate pre-operative assessment should aim to identify potential problems like the possibility of fragile zonules and difficult visualization due to small pupils. This can help with surgical planning, particularly predicting the possible need for ophthalmic viscosurgical devices, pupil expansion devices and capsule support devices all of which can increase the margin of safety in these potentially complex cases.
Appropriate post-operative follow-up is required to monitor and address IOP, capsular contracture and IOLs decentration issues. The main limitations of the study were the small sample size and duration of the study. Furthermore, we did not include pre- and post-operative specular microscopy and corneal pachymetry.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]