Intra-operative challenges and post-operative follow-up of phacoemulsification in eyes with pseudoexfoliatin.

INTRODUCTION

Pseudoexfoliation syndrome is a systemic disease with primarily ocular manifestations characterized by deposition of a whitish-gray protein on the lens, iris, ciliary epithelium, corneal endothelium and trabecular meshwork. studies have revealed that the lens epithelium, trabecular meshwork, iris, ciliary processes, conjunctiva and periocular tissue are its source. This material is insoluble and floats in the aqueous humor, from where it is filtered and deposited in the trabecular meshwork. Meanwhile local production of the proteinaceous material by the trabecular endothelial cells continues. All  these materials  accumulates in the trabecular spaces and focally collapses Schlemm’s canal. This decreases aqueous humor outflow and increases IOP.

The signs of pseudoexfoliation syndrome can be identified on slit-lamp examination. Clinical examination using biomicroscopy has 85 percent sensitivity and 100 percent specificity. An easily recognizable sign of pseudoexfoliation is white, flaky material on the pupillary border of the iris or on the anterior surface of the lens. The lens frequently demonstrates a “three-ring sign†on the anterior lens capsule, which consists of a central zone of visible exfoliation material measuring 1 to 3 millimeters in diameter, combined with a middle clear zone and a peripheral cloudy ring. . The peripheral cloudy ring of the lens is usually only visible upon dilation.  The central zone is usually well demarcated and can have curled edges. The middle clear zone is thought to be created by the posterior surface of the iris rubbing off the pseudoexfoliative material from the lens. This also results in a loss of iris pigment leading to transillumination defects.

More than 20 percent of patients with pseudoexfoliation syndrome have associated narrow angles; therefore, the anterior chamber depth of these patients should be assessed before dilation in order to avoid precipitating acute angle-closure glaucoma. The pigment granules can often be seen accumulating in the trabecular meshwork Gonioscopy reveals pigment deposition on the trabecular meshwork, usually more marked inferiorly, along with pigment around Schwalbe’s line. Pseudoexfoliation material has also been identified on the iris surface, corneal endothelium and zonules.

Poor pupillary  dilation is a subtle finding that is frequently observed in patients with pseudoexfoliation.It is believed to be due to iris dilator muscle atrophy and this can complicate cataract surgery. Such eyes also have phakodonesis,zonular dehiscence,capsule tear,vitreous loss and nucleous drop which poses intraoperative and postoperative challenges for cataract surgeons. Postoperatively  it manifests as increased acqueous flare and cell response,fibrin reaction,posterior synechias and increased capsular opacification.

AIM &OBJECTIVE

To study the intra operative complications and postoperative out come of phacoemulsification  in patients with pseudoexfoliation

MATERIALS AND METHODS

An observational study will be undertaken in all patients with evidence of pseudoexfoliation who underwent phacoemulsification during the period between January 2014 and December 2014  in Giridhar eye institute,kochi .These patients  will be followed up for next one year.All patients will be  provided informed consent.All eyes will be thoroughly  examined preoperatively . BCVA,IOP,anterior chamber depth,gonioscopy A-scan biometry will be done.Detailed slitlamp biomicroscopy under maximal mydriasis will be done to identify any pseudoexfoliation deposition on anterior lens capsule,type and grade of cataract,and the presence of zonular dialysis.Detailed dilated fundus examination will be done in all cases and all these data will be recorded in the protocol sheet.

A standardized phacoemulsification  technique and the same type of  IOL will be used for all cases .CCC will be measured by using a 30cm scale in the TV screen under a microscopic magnification of 10x.Intraoperative observations like difficulty in performing CCC,phakodonesis,zonular dehiscence, posterior capsule tear,vitreous loss, nucleous drop, phaco parameters, pupil stretching techniques ,use of endocapsular ring  all will be recorded .Postoperative examination will include IOP,anterior chamber flare and cell,presence of posterior synechias,capsular change ,visual acuity.A standard postoperative drug regime will be used for all patients and postoperative follow-up in 1month,6month and 1 year will be done by  the same observer.

INCLUSION CRITERION

All patients with evidence of pseudoexfoliation who underwent phacoemulsification during the period between January 2014 and December 2014  in our institution.

EXCLUSION CRITERION

Previous vitreo-retinal  surgey

Previous history of Trauma to eyes

All other causes of Zonular weakness except  pseudoexfoliation

RESULTS OF THE STUDY

The study was successfully completed and the findings were statistically analysed and the final thesis submitted to the National Board of Examinations