Abstract
Objective:
The aim of this study was to evaluate the demographic characteristics and intraoperative complications of cataract surgery in patients with pseudoexfoliation syndrome (PEX).
Materials and Methods:
Cases of 225 eyes (80 eyes with pseudoexfoliation and 145 eyes without pseudoexfoliation as the control group) that underwent phacoemulsification cataract surgery and IOL implantation at the Silifke State Hospital Ophthalmology Clinic between April 2011 and April 2013 were analysed retrospectively. Patients with a history of previous ocular surgeries, ocular trauma, uveitis, glaucoma or corneal pathology were not included in the study. All cataract procedures were performed by the same surgeon. Patients’ age, gender, anterior segment and fundus findings in both eyes, presence of pseudoexfoliative material, pre- and postoperative day 1 intraocular pressure (IOP) and surgery notes were evaluated.
Results:
There were 51 (34.7%) males and 29 (38.6%) females among the PEX cataract patients, and 98 (65.3%) male and 47 (61.8%) female controls. The incidence of pseudoexfoliation was similar in women (38.2%) and men (34.7%) (p=0.660). The mean age was 74.64±6.8 in the PEX group and 68.95±7.5 in the control group. Mean age was significantly higher in the PEX group compared to controls (p<0.001). Poor pupil dilation occurred intra-operatively in 60 (75%) of the patients with pseudoexfoliation and in 17 (11.7%) of the control patients. Frequency of poor intraoperative pupil dilation was significantly higher in the PEX group (p<0.001). Intraoperative vitreous loss occurred in 7 (8.8%) PEX patients and 5 (3.4%) controls, but this difference was statistically insignificant (p=0.090).
Conclusion:
Surgeons should be aware of the potential complications of cataract procedures in patients with PEX. Caution should be taken at every stage of the surgery to prevent these complications, and surgeons should be knowledgeable and skilful in complication management should they arise.
Keywords: Pseudoexfoliation, cataract surgery, poor pupil dilation, intraoperative complications
ÖZ
Amaç:
Bu çalışmada Psödoeksfoliasyon sendromu (PES)’li katarakt olgularının demografik özelliklerinin ve katarakt ameliyatı sırasında gelişen komplikasyonların değerlendirilmesi amaçlanmıştır.
Gereç ve Yöntem:
Bu çalışmada Silifke Devlet Hastanesi göz kliniğinde Nisan 2011 ve Nisan 2013 tarihleri arasında fakoemülsifikasyon ile katarakt cerrahisi ve İOL implantasyonu uygulanmış 81 psödoeksfoliasyonlu göz ile kontrol grubu olarak 145 psödoeksfoliasyonsuz göz toplam 226 göz retrospektif olarak incelendi. Önceden geçirilmiş göz cerrahisi, geçirilmiş göz travması, üveit, glokom, kornea patolojisi olan hastalar çalışmaya alınmadı. Katarakt ameliyatları tek bir cerrah tarafından uygulandı. Hastaların yaşı, cinsiyeti, her iki gözünün ön segment ve fundus bulguları, psödoeksfoliatif materyal varlığı, preoperatif-postoperatif 1. gün GİB, ameliyat notları değerlendirildi.
Bulgular:
Psödoeksfoliasyon sendromlu katarakt olgularının 51’si (%34,7) erkek, 29’i (%38,6) kadın, kontrol grubunun 98’i (%65,3) erkek, 47’i (%61,8) kadındı.Kadınlarda (%38,2) ve erkeklerde (%34,7) benzer oranlarda psödoexfoliasyon oluşumu gözlemlenmiştir (p=0,660). Çalışmadaki PES’li katarakt olgularının ortalama yaşı 74,64±6,8, kontrol grubunun ise ortalama yaşı 68,95±7,5 olarak tesbit edildi. PES’li grubun yaş ortalaması control grubundan istatistiksel olarak anlamlı şekilde yüksek bulundu (p<0,001). Psodoexfoliasyon bulunan grupta ameliyat sırasında pupilladilatasyon zayıflığı gelişen hasta sayısı 60 (%75), kontrol grubunda pupilla dilatasyon zayıflığı gelişen hasta sayısı 17 (%11,7) olarak bulunmuştur. PES’li grupta ameliyat sırasında pupilladilatasyonu zayıflığı görülme sıklığı kontrol grubundan istatistik olarak anlamlı olacak şekilde yüksek bulunmuştur (p<0,001). PES’li grupta ameliyat sırasında vitre kaybı gelişen hasta sayısı 7 (%8,8) iken kontrol grubunda ise 5 hastada vitre kaybı gelişmiştir (%3,4). PES’ li grupta ameliyat sırasında vitre kaybı daha fazla hastada gelişmiş olmasına rağmen bu fazlalık istatistik bir önem taşımamaktadır (p=0,090).
Sonuç:
Psödoeksfoliasyon sendromlu katarakt olgularına uygulanan katarakt cerrahisi sırasında oluşabilecek komplikasyonlar bilinmeli ve komplikasyonları önlemek açısından cerrahinin her aşamasında dikkatli olunmalıdır. Bu komplikasyonlarla karşılaşıldığında komplikasyon yönetiminde bilgi ve beceri sahibi olunmalıdır.
Introduction
Pseudoexfoliation syndrome (PEX) is a condition characterized by the secretion of a grey-white, fibrogranular substance in the anterior segment. The source of this substance is multifocal and is believed to appear secondary to abnormal basal membrane constituents produced by aging epithelial cells [1]. PEX is diagnosed clinically by anterior segment examination, and is defined as the presence of grey-white fibrogranular pseudoexfoliation material on the anterior capsule of the lens and edges of the pupil [2, 3]. The prevalence of PEX varies by population; however, PEX frequency increases with age and it is believed that an extremely significant relationship exists between age-related cataractous lens changes and PEX [4].
In eyes with PEX, it has been reported that degenerative changes in the iris stroma and muscle layer may interfere with sufficient pupil dilation [5]. In eyes with pseudoexfoliation, the lens zonules can become detached from the ciliary body and lens by mechanical forces or enzymatic zonulolysis. Clinically, this can lead to iridophacodonesis and spontaneous lens subluxation or dislocation [6]. These structural changes make cataract surgery more difficult and increase the incidence of intraoperative complications [7, 8].
The aim of this retrospective study was to evaluate the demographic characteristics and intraoperative complications of cataract surgery in PEX patients.
Materials and Methods
Cases of 225 eyes (80 eyes with pseudoexfoliation and 145 eyes without pseudoexfoliation as the control group) that underwent phacoemulsification cataract surgery and IOL implantation at the Silifke State Hospital Ophthalmology Clinic between April 2011 and April 2013 were analysed retrospectively. All patients were given detailed information about their diagnosis and surgical procedures to be applied, and written informed consent was obtained.
Patients with previous ocular surgery or trauma, uveitis, glaucoma, IOP≥21 mmhg or corneal pathology were excluded from the study. All cataract surgeries were performed using quick chop technique by the same surgeon. Patients’ age, gender, anterior segment and fundus findings in both eyes, presence of pseudoexfoliative material, preoperative and postoperative day 1 IOP, and surgical notes were evaluated. Intraocular pressure was measured by applanation tonometry (Haag-Streit, Switzerland) in all patients.
Statistical analysis
Statistical Package for the Social Sciences 15 for Windows, a statistical software application (SPSS Inc.; Chicago, IL, USA) was used for statistical analysis. Comparison of categorical variables was done with chi-square and Fisher exact tests. Independent t-test and paired t-test were used for mean comparisons. P values less than 0.05 were accepted as statistically significant.
Results
There were 51 (34.7%) males and 29 (38.6%) females among the PEX cataract patients, and 98 (65.3%) male and 47 (61.8%) female controls. The incidence of pseudoexfoliation was similar in women (38.2%) and men (34.7%) (p=0.660). There was no statistically significant effect of gender on pseudoexfoliation frequency (Table 1).The mean age was 74.64±6.8 in the PEX group and 68.95±7.5 in the control group. Mean age was significantly higher in the PEX group compared to controls (p<0.001, Table 2).
Table 1.
Relationship between gender and PEX
| Pseudoexfoliation | Total | p | ||||
|---|---|---|---|---|---|---|
|
| ||||||
| (−) | (+) | |||||
| Gender | Female | Number | 47 | 29 | 76 | 0.660 |
| % | 61.8% | 38.2% | 100.0% | |||
| Male | Number | 98 | 51 | 149 | ||
| % | 65.3% | 34.7% | 100.0% | |||
PEX: pseudoexfoliation syndrome
Table 2.
Relationship between age and PEX
| Pseudoexfoliation | n | Mean age (years) | SD | p |
|---|---|---|---|---|
| (−) | 145 | 68.95 | 7.591 | p<0.001 |
| (+) | 80 | 74.64 | 6.880 |
PEX: pseudoexfoliation syndrome; SD: standard deviation
Poor pupil dilation was observed intraoperatively in 60 (75%) of the patients with pseudoexfoliation and 17 (11.7%) of the control patients. Frequency of poor intraoperative pupillary dilation was significantly higher in the PEX group compared to controls (p<0.001, Table 3). Intraoperative posterior capsule rupture occurred in 10 (12.5%) PEX patients and 5 (3.4%) controls. The incidence of intraoperative posterior capsule rupture was statistically significantly higher in the PEX group compared to the control group (p=0.012, Table 4). Intraoperative vitreous loss occurred in 7 (8.8%) PEX patients and 5 (3.4%) controls. Despite the fact that more PEX patients developing vitreous loss than controls, the difference was statistically insignificant (p=0.090, Table 5). The difference between “posterior capsular rupture” and “vitreous loss” should be identified.
Table 3.
A comparison of PEX and poor pupillary dilation
| Poor pupillary dilation | Total | p | ||||
|---|---|---|---|---|---|---|
|
| ||||||
| (−) | (+) | |||||
| Pseudoexfoliation | (−) | Number | 128 | 17 | 145 | |
| % | 88.3% | 11.7% | 100.0% | p<0.001 | ||
| (+) | Number | 20 | 60 | 80 | ||
| % | 25.0% | 75.0% | 100.0% | |||
PEX: pseudoexfoliation syndrome
Table 4.
Relationship between PEX and posterior capsule rupture
| Posterior capsule rupture | Total | p | ||||
|---|---|---|---|---|---|---|
|
| ||||||
| (−) | (+) | |||||
| Pseudoexfoliation | (−) | Number | 140 | 5 | 145 | |
| % | 96.6% | 3.4% | 100.0% | 0.012 | ||
| (+) | Number | 70 | 10 | 80 | ||
| % | 87.5% | 12.5% | 100.0% | |||
PEX: pseudoexfoliation syndrome
Table 5.
Comparison of PEX and vitreous loss
| Vitreous loss | Total | p | ||||
|---|---|---|---|---|---|---|
|
| ||||||
| (−) | (+) | |||||
| Pseudoexfoliation | (−) | Number | 140 | 5 | 145 | |
| % | 96.6% | 3.4% | 100.0% | 0.090 | ||
| (+) | Number | 73 | 7 | 80 | ||
| % | 91.2% | 8.8% | 100.0% | |||
PEX: pseudoexfoliation syndrome
Discussion
The incidence of PEX varies by population, ethnic group and age. However, studies consistently show that the frequency of PEX increases with age [9–12]. In a study conducted in the Çukurova Region of Turkey, Yalaz et al. reported a PEX frequency of 11.2% in individuals over 60 years old [12]. In their epidemiological study, Elibol et al. (13) found a PEX incidence of 13.7%. Consistent with these findings, an increase in the frequency of PEX with age was observed in the current study. The mean age of the PEX patient group was significantly higher than that of the control group (p<0.001).
There are reports in the literature of a significant relationship between PEX and cataract development; furthermore, certain challenges of cataract surgery in the presence of PEX and increased risk of complications have been reported [8, 14]. Complications during cataract surgery occur at a higher rate in eyes with pseudoexfoliation than in standard cataract cases due to increased frequency of glaucoma and poor pupillary dilation. There is also a higher risk of zonular dialysis, capsule rupture, vitreous loss and postoperative IOL decentralization [14]. It is considerably more difficult to achieve sufficient pupillary dilation for cataract surgery in eyes with PEX than normal eyes [8, 15, 16]. Iris haemorrhage, corneal endothelial damage, lens dislocation, vitreous loss, posterior capsule rupture and sphincter rupture occur more frequently in eyes with insufficient intraoperative pupillary dilation during cataract extraction [15–18].
Drolsum et al. [19] also reported a higher rate of posterior capsule rupture without vitreous loss in PEX eyes compared to controls, although there was no difference in the incidence of vitreous loss. There are many studies in the literature about intraoperative complications of cataract surgery in PEX patients. In a study of phacoemulsification in PEX eyes conducted by Drolsum et al. [20], intraoperative complications occurred in 9.6% of the eyes with pseudoexfoliation, compared to 3.7% of the eyes without pseudoexfoliation. Lumme et al. [7] found significantly higher rates of intraoperative complications including zonular rupture, posterior capsule rupture, and vitreous loss (14.8%, 10.2%, and 7.4%, respectively) during cataract surgery on eyes with PEX, and suggested that zonular and posterior capsule rupture are important risk factors for vitreous loss. Scrolli et al. [16] also found higher intraoperative incidences of zonular dialysis, posterior capsule rupture and vitreous loss in PEX patients undergoing phacoemulsification than in patients without pseudoexfoliation. Avramides et al. (21) found that 61.9% of the patients with PEX had a pupil diameter of less than 5 mm, and the incidence of intraoperative complications in these patients was as follows: zonulolysis, 13.09%; posterior capsule tear, 10.71%; and vitreous loss, 7.14% [21]. In the current study, poor pupillary dilation occurred in 75% of the patients in PEX group, compared to 11.7% in the non-PEX group. Intraoperative posterior capsule rupture occurred in 12.5% of PEX patients and 3.4% of the patients without pseudoexfoliation. Vitreous loss was observed in 8.8% of the patients in PEX group and 3.4% of non-PEX group; despite the fact that more patients in the PEX group had vitreous loss, the intergroup difference was not statistically significant. However, the rates of poor pupillary dilation and posterior capsule rupture were significantly higher in the PEX group when compared to the non-PEX controls. Our results support the observation that pseudoexfoliation increases the incidence of poor pupillary dilation and is a factor that increases the risk of complications such as posterior capsule rupture during cataract surgery.
Cataract patients considering surgery should be evaluated preoperatively for pseudoexfoliation. Surgeons should be aware of the possibility of poor pupillary dilation and the complications that can arise in patients with PEX during cataract surgery. Caution should be taken during every stage of surgery to avoid these complications, and surgeons should be knowledgeable and skilled in complication management should they occur.
Footnotes
Ethics Committee Approval: Ethics committee approval was not received due to the retrospective nature of this study.
Informed Consent: Informed consent was obtained from patients who participated in this study.
Peer-review: Externally peer-reviewed.
Author contributions: Concept - G.E., S.D.; Design - G.E., S.D.; Supervision - G.E., S.D.; Funding - G.E.; Materials -G.E.; Data Collection and/or Processing - G.E.; Analysis and/or Interpretation - G.E., S.D.; Literature Review - G.E., S.D.; Writing - G.E.; Critical Review - G.E.
Conflict of Interest: No conflict of interest was declared by the authors.
Financial Disclosure: The authors declared that this study has received no financial support.
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