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DOI: 10.7860/IJARS/2016/19467:0000 Original Article

Study of Prognostic
Ophthalmology Section

Indicators in Patients with

Pseudoexfoliation Syndrome
Undergoing Cataract Surgery
Shruti Prabhat Hegde, Vijay Kautilya Dayanidhi, Ravi

ABSTRACT small incision cataract surgery (SICS) and were followed up

Introduction: Pseudoexfoliation syndrome is systemic for 6 weeks post surgery.
disorder characterized by deposits on the lens and iris in the Results: All our patients were aged more than 50 years.
eye. This syndrome has been reported to be associated with About 64% patients belonged to the age group of 70 – 80
increased intraoperative and post operative complications years. About 20 (40%) patients had a rigid pupil which
during cataract surgery. In this study we have documented dilated not more than 3.5 mm. Zonular dialysis was seen in
the complications occurring during small incision cataract 8 (16%) patients and of these patients five also had vitreous
surgery(SICS) in pseudoexfoliation syndrome and compared loss. Four patients had subluxated PCIOL when seen on
the same with prognostic indicators like pupillary dilatation. long term follow up after six weeks.
Aim: To document and compare the complications occurring Conclusion: Poorly dilating pupil is a common
during small incision cataract surgery in pseudoexfoliation accompaniment with this condition and is an important
syndrome with different grades pupillay dilatation as a prognostic indicator of intraoperative zonular dialysis &
prognostic indicator. vitreous loss, the rate of these complications being inversely
Materials and Methods: The study was conducted at Shri proportional to the maximum pupillary dilatation. Those
Sathya Sai Medical College & Research Institute Hospital by patients with poorly dilating pupil need to be given realistic
including 50 eyes of 50 patients with pseudoexfoliation over expectations regarding the complications and recovery
a period of two years, between July 2013 and June 2015 time. Sphincterotomy can be useful when modern pupil
after obtaining ethical clearance. All the patients underwent dilating devices are not available.

Keywords: Complications, Pupillary dilatation.

Introduction to two pathological manifestations of pseudoexfoliation

Pseudoexfoliation syndrome is a systemic disorder with syndrome namely zonular weakness and poor pupillary
important eye manifestations, including development of dilatation. Zonular weakness occurs because of proteolytic
open and closed angle glaucoma and cataract with zonular disintegration of the zonules. Poor pupillary dilatation occurs
instability [1]. Its prevalence increases dramatically with age due to both mechanical obstruction as well as mechanical
[2]. This condition involves both the genders [3]. Clinically the restriction. Pseudoexfoliative material infiltrating the iris stroma
diagnosis is made by detecting the whitish powdery deposits causes an obstruction in pupillary dilatation and adhesion of
along the pupillary margin or whitish grey flaky material on the exfoliative material to the iris pigment and lens epithelium
the anterior surface of the lens or both. Other parts of the cause mechanical restriction[5]. During cataract surgery
eye where the material may get deposited include zonules, these patients have more chances of developing sphincter
ciliary body, corneal endothelium, anterior vitreous and tear, difficult nucleus delivery due to rigid pupil and posterior
trabecular meshwork [4]. One of the significant concerns for synechiae and zonular dialysis with or without vitreous loss
patients with pseudoexfoliation syndrome is the increased due to weak zonules [6]. Other intra operative complications
incidence of intra and post operative complications when can be iridodialysis and retained lens matter. Post operatively
they undergo cataract surgery. This is attributed mainly there can be increased incidence of prolonged corneal

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 Shruti Prabhat Hegde et al., Cataract Surgery in Pseudo Exfoliation Syndrome http://ijars.jcdr.net

edema, severe anterior chamber reaction, and raised intra operative findings like extent of pupillary dilatation, location of
ocular pressure. Late dislocation of the intraocular lens within pseudoexfoliation material.
the bag or dislocation of the entire bag has also been reported
[7]. All these complications make cataract surgery a challenge Inclusion criteria
in patients with psuedoexfoliation syndrome. In this study 1. Patients with pseudoexfoliation getting admitted for
we have attempted to study the outcome of small incision cataract surgery.
cataract surgery (SICS) in patients with pseudoexfoliation 2. Patients consenting for Small incision cataract surgery
syndrome and compare the complications encountered with (SICS)
prognostic indicators.
Exclusion criteria
Materials and methods 1. Patients with raised intra ocular pressure (IOP).
We conducted a longitudinal cohort study at the Department 2. Patients with glaucomatous disc damage.
of Ophthalmology, Shri Sathya Sai Medical College and
3. Patients with other causes of cataract.
Research Institute Hospital by including 50 eyes of 50 patients
with pseudoexfoliation over a period of one year between July 4. Patients with uncontrolled diabetes mellitus or other severe
2014 and June 2015. They visited our hospital for complaints systemic and cardiovascular diseases.
of diminution of vision and had significant cataract which 5. Patients not giving consent to Small incision cataract
required cataract surgery. Institutional Ethics Committee surgery.
Clearance was taken before the conducting the study and
6. Patients having iridodonesis, phacodonesis and subluxation
written informed consent was obtained from all the willing
of the lens preoperatively.
subjects.
A detailed history was taken followed by a thorough anterior Statistical analysis
and posterior segment examination. A Slit lamp examination The data thus collected was tabulated and analyzed for
was done for the anterior segment to note down deposition descriptive statistics using SPSS Statistical analysis Software
of pigments or pseudoexfoliative material over the corneal (Version 20). The data is presented in terms of rates, ratios
endothelium, lens. Atrophic patches in the iris and the type and frequencies of occurrences of different complications
of cataract was also noted. Central anterior chamber depth
was measured. Gonioscopy was done before pupillary Results
dilatation to look for deposition of pigments, pseudoexfoliative A total number of 50 patients participated in the study. Among
material and presence of perepheral anteror synechiae in the them 36 (72%) were males and 14 (28%) were females. The
angle. Intraocular pressure was measured using Goldman,s age group wise distribution is shown in [Table/Fig-1].
applanation tonometer. Maximum pupillary dilatation was noted
after instilling (0.8%/0.5%) tropicamide and phenylephrine eye Age group No. of patients Percentage (%)

drops and waiting for 1 hour. After dilation repeat slit lamp >80 years 07 14%
examination was done to look for maximum pupillary dilation, 71-79 years 25 50%
posterior synechiae, phacodonesis and subluxation of lens.
61-70 yrs 17 34%
Preoperatively flurbiprofen eye drops were used along with
mydriasis to maintain the intraoperative mydriasis 50-60 Years 01 0.02%

All the patients underwent small incision cataract surgery <50 years 0 0%
with rigid single piece posterior chamber intraocular lens [Table/Fig-1]: Distribution of the subjects based on their age into
implantation and all the surgeries were done by a single different groups.
experienced surgeon to maintain uniformity. Post operatively
all patients were treated with antibiotics steroid eye drops As pseudoexfoliation is common in older age groups all our
and those with severe anterior chamber reaction were treated patients were aged more than 50 years. About 64% patients
with homatropine eye drops. Patients who had postoperative belonged to the age group of 70 – 80 years.
increase in intra ocular pressure were given oral acetazolamide
for short term, sometimes along with Timolol eye drops. Those Morphology of Pseudoexfoliation
who had severe corneal edema were treated additionally with During the initial clinical examination of the 50 subjects in the
hypersol eye drops. Patients were followed up to 6 weeks & study it was noted that 28(56%) patients had pseudoexfoliation
in few cases further follow-up was done depending on the in both the eyes, 18 (36%) had unilateral pseudoexfoliation
necessity. The longest follow-up period was about 1 year. and in 4 (8%) patients had pseudophakia in one eye and thus
All the surgeries were done under peribulbar block. Detailed laterality couldn’t be commented upon.
slit lamp examination was done on first post operative day Depending on the site of deposition of pseudoexfoliation
and then every week up to 6 weeks. All the intra operative and patients were broadly divided into 3 groups as those with
post operative complications were noted, correlated with pre

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 http://ijars.jcdr.net Shruti Prabhat Hegde et al., Cataract Surgery in Pseudo Exfoliation Syndrome

pseudoexfoliation deposits on the pupillary margin, those with and of these patients five also had vitreous loss. Stretch
deposits on the lens and those having deposits on both lens pupilloplasty (10%), synechiolysis (6%), sphincterotomy (12%)
and pupillary margin. The distribution of the patients based were performed in few patients whenever required.
on the location of pseudoexfoliative deposits is depicted in All the patients were examined on the first post operative
[Table/Fig-2]. day and then once every week for the next six weeks. Four
Morphology of Pseudoexfoliation No. of patients Percentage (%) patients had subluxated PCIOL when seen on long term follow
up after six weeks. Complications noted post-operatively are
White dandruff like deposits over 8 16%
pupillary margin listed in [Table/Fig-5]. Corneal oedema was the most common
complication seen post operatively followed by severe anterior
Deposits over the lens 4 8%
chamber reaction & raised IOP. Most cases responded to
Deposits both over the pupillary 38 76%
conventional management. Four patients had subluxated
margin and lens
PCIOL when seen on long term follow up after six weeks.
[Table/Fig-2]: Distribution of the patients base on the location of
pseudoexfoliative deposits in the eye. The complications thus, noted were compared with pre-
operative maximum pupillary dilation and the results of the
Pseudoexfoliation material over corneal endothelium was
same are presented in [Table/Fig-6]. There was not much
also seen in 4(8%) patients and in 2(4%) few glistening white
correlation seen between the location of pseudoexfoliation
deposits were seen over the zonules. These were visualised
and the operative complications.
intraoperatively.
Post operative Complications No. of patients Percentage (%)
Maximum Pupillary dilatation Raised IOP 12 24%
Maximum pupillary dilatation was noted after instilling
Corneal edema 15 30%
tropicamide and phenylephrine eye drops and waiting for
1 hour. The subjects were divided into 4 different groups Severe AC reaction 14 28%
based on the pupil size as those with pupils 3.5mm or less, Subluxation of PCIOL 4 8%
3.4-4.5mm, 4.5-6mm and > 6mm . About 20 (40%) people Pigment deposition over PCIOL 10 20%
had a rigid pupil which dilated not more than 3.5 mm. The on long term follow-up
distribution of subjects based on the pupil size is shown in [Table/Fig-5]: Distribution of subjects based on post-operative
[Table/Fig-3]. complications encountered after surgery.

Maximum Pupillary Dilatation No. of cases Percentage (%) Maximum Complication

Pupillary Dilatation
3.5 mm or less 20 40% Sphincter Tear Iridodialysis Zonular Dialysis Vitreous Loss

3.5 – 4.5 mm 18 36% 3.5 mm or less 0 2 (4%) 6 (75%) 4 (80%)

4.5 – 6 mm 5 10% 3.5 – 4.5 mm 3 (6%) 0 2 (25%) 1 (20%)
>6mm 7 14% 4.5 – 6 mm 1 (2%) 0 0 0
[Table/Fig-3]: Distribution of subjects based on the maximum pupil >6mm 0 0 0 0
size after instilling tropicamide and phenylephrine eye drops.
[Table/Fig-6]: Comparison of the complications noted with the pre-
operative maximum pupillary dilation.
Intra-operative and post-
operative complications
All the patients underwent Small incision cataract surgery with Discussion
posterior chamber intraocular lens implantation except those Pseudoexfoliation syndrome has been reported to be
associated with increasing age and it is typically more
patients who had intra-operative vitreous loss. [Table/Fig-4]
common after the age of 60 years as found by various other
shows the details of intra-operative complication encountered
studies [2,8-10]. One study reported that the incidence of
during the surgery. Zonular dialysis was seen in 8 (16%) patients
pseudoexfoliation doubled every decade after the age of
Intra op Complications No. of patients Percentage (%) 50 years [11]. All the patients in our study were aged more
than 50 years. About 50% belonged to the age group of 70
Sphincter tear 4 8%
to 80 years. This is in line with majority of published studies
Irido-dialysis 2 4%
[2,8‑11]
Zonular dialysis 8 16%
The relation between prevalence of pseudoexfoliation and
Vitreous loss 5 10% gender has not been well established. Few studies done
Retained cortical matter 6 12% in the past have shown a female predilection [3,8-10,12]
[Table/Fig-4]: Distribution of subjects based on intra-operative while few studies done in India and Pakistan shows a male
complications encountered during surgery. predilection [13-14], but majority of the reports do not show

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 Shruti Prabhat Hegde et al., Cataract Surgery in Pseudo Exfoliation Syndrome http://ijars.jcdr.net

any correlation between sex and pseudoexfoliation [1]. In prognostic indicator for serious intra operative complications.
our study males were more commonly affected than females Sphincter tear was seen in four cases and none of these
(72%). Since, ours is a medical college hospital situated in the patients belonged to very poorly dilating pupil group. This could
peripheral part of Chennai and most patients are from a rural be due to the fact that procedures to increase the pupillary
background, this finding could be attributed to male patients diameter were more commonly performed in the groups with
getting more exposed to the tropical climate as they are more poor pupillary dilatation. These included Stretch pupilloplasty
commonly engaged in outdoor work. (5 cases), Sphincterotomy (6 cases). These simple procedures
need minimal instrumentation and are easy to perform and
As pseudoexfoliation syndrome is an age-related systemic
can be of great aid in patients with pseudoexfoliation with
microfibrillopathy of the eye, there is gradual deposition of
minimally dilating pupil during cataract surgery. Iridodialysis
fibrillary residue from the lens and iris pigment epithelium
was seen in two patients and both these patients had very
on lens capsule, ciliary body, zonules, corneal endothelium
poorly dilating pupil. About six patients had retained cortical
and iris. This is clinically diagnosed mainly by the presence of
matter and three of them were taken for cortical wash as the
white powdery / flaky material along the pupillary margin &/or
lens fibres were involving the visual axis.
over the anterior surface of the lens. In our study 76% of the
subjects had deposits both on the pupillary margin and on the Whole of the iris is said to be involved in production and
deposition of pseudoexfoliative material. The iris in pseudo­
anterior lens surface indicating an advanced stage.
exfoliation syndrome is rigid and has less dilating ability. Posterior
Pupillary dilatation after instilling mydriatics has been found synechiae are also reported to be common in pseudoexfoliation
to be poor in patients with pseudoexfoliation syndrome [10]. syndrome due to adherence of the posterior pigment epithelium
Poor pupillary dilation is a result of infiltration of the iris stroma to the lens capsule. This combination of the deposits in the
with excessive extracellular matrix, causing mechani¬cal stroma and iris muscle along with tissue degeneration and
obstruction during mydriasis [15]. In our study about 40% vascular damage leads to defective dilating ability of the iris [17].
patients had very poorly dilating pupil i.e. < 3.5 mm and This small size of the pupil limits the size of capsulorhexis which
another 46% had medium dilatation of 3.5 - 6mm. Only 14% in turn causes increased force on the zonules during surgery
patients had pupillary dilatation of > 6mm. Poor pupillary leading to capsular tear, difficulty in extracting lens matter and
dilatation has been suggested as an important cause for post operative capsule phimosis [17].
various intraoperative complications during cataract surgery Post operatively corneal edema (30%), severe AC reaction
in these patients [11,13,15-18]. This was true even in our (28%) and raised intra ocular pressure (24%) were seen more
study as most of the intra operative complications were seen commonly than usual in our study. The corneal endothelium
in the poorly dilating pupil group. in pseudoexfoliation syndrome shows focal degeneration.
The most common intra operative complication noted in our Phagocytosis of melanin granules and pseudoexfoliation
study was zonular dialysis. This was seen in 16% patients. Of fibres products has also been found in the endothelium. This
these eight cases with zonular dialysis five patients also had dysfunctional nature of the endothelium leads to increased
vitreous loss (10%) and PCIOL placement was deferred. About risk of decompensation of the cornea post surgery [17].
six patients had retained cortical matter and three of them On long term follow-up four (8%) of our patients had
were taken for cortical wash as the lens fibres were involving subluxation of PCIOL. This could again be due to zonular
the visual axis. The percentage of these complications are weakness. About 20% had deposition of pigments over the
comparable to those listed in similar studies by various other IOL surface. These findings are very consistent with most of
researchers [9,15-17, 19-21]. the other reported studies [15-21].
Zonular weakness found in pseudoexfoliation syndrome is In this study we have tried to divide patients depending on the
attributed to the deposits on zonular fibers and ciliary process extent of maximum pupillary dilatation and the results show
which result in proteolysis of the zonules. However, the degree that it’s the group of patients with pupillary dilatation <3.5 mm
of zonular weakness cannot be predicted by the extent of who have high chances of developing severe intra operative
deposits present [15]. complications. In our knowledge this is the first study where
extent of pupillary dilatation and the intra and post operative
Due to the nature of the disease and inherent zonular weakness
complications are compared.
in pseudoexfoliation, complications like zonular dialysis and
delayed spontaneous dislocation of the intraocular lens and
Limitations
capsule are more commonly noted.
As the study was done over a two years period in our
Among the eight cases of zonular dialysis noted in our study, tertiary care hospital in rural suburbs of Chennai we had a
six occurred in patients with pupillary dilatation of < 3.5mm small sample size. No long term follow-up of post operative
and remaining two in patients with pupillary dilatation < 4.5
cases was not conducted except in few cases hence, we
mm. Also four cases of vitreous loss occurred in the former
could not comment upon the long term complications like
group with maximum pupillary dilatation < 3.5mm and 1 in
posterior capsular opacification. Lens Opacities classification
the latter group with maximum pupillary dilatation < 4.5mm.
This shows that poor pupillary dilatation is the most important system(LOCS) and its correlation with complications could
have been done.

4 International Journal of Anatomy, Radiology and Surgery, 2016

 http://ijars.jcdr.net Shruti Prabhat Hegde et al., Cataract Surgery in Pseudo Exfoliation Syndrome

Conclusion [9] Sulaiman A, Najwa M, Saad M, Nusrat M, Misbahul A,

Mohammad T, et al. Prevalence of ocular pseudoexfoliation
Poorly dilating pupil is a common accompaniment with
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this condition and is an important prognostic indicator of Arabia. Saudi Med J. 2015; 36 (1): 108-12.
intraoperative zonular dialysis and vitreous loss. The present [10] Setha SP, Sheeja SJ, Arathi RS, Smitha J, Andrew DB. Ocular
study shows that the rate of complication is highest in patients clinical profile of patients with pseudoexfoliation syndrome
having maximum pupillary dilation of 3.5 mm or less. The in a tertiary eye care center in South India. Middle East Afr J
Ophthalmol. 2012; 19(2): 231–36.
amount and site of deposition of pseudoexfoliative material
[11] Sushil K, Bhuyan L, Nanda AK. Pseudoexfoliation - a dreaded
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detailed slit lamp examination before and after dilatation and Research. 2015; 6(02): 159-62
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procedure which can be useful when modern pupil dilating [14] Hridya M, Rajini KC. A study of ascorbic acid concentration
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AUTHOR(S): NAME, ADDRESS, E-MAIL ID OF THE
1. Dr. Shruti Prabhat Hegde CORRESPONDING AUTHOR:
2. Dr. Vijay Kautilya Dayanidhi Dr. Vijay Kautilya Dayanidhi,
3. Dr. Ravi 61-2B, Cee Dee Yes Apartments,
Chennai Pattinam Township, Ammapettai,
PARTICULARS OF CONTRIBUTORS: Chennai-603108. India.
1. Assistant Professor, Department of Ophthalmology, E-mail: ksautilya.dactroo@gmail.com
Shri Sathya Sai Medical College & Research Institute,
Ammapettai, Chennai, India. Financial OR OTHER COMPETING INTERESTS:
2. Assistant Professor, Department of Forensic medicine None.
& Toxicology, Shri Sathya Sai Medical College &
Research Institute, Ammapettai, Chennai, India.
3. Professor & Head, Department of Ophthalmology,
Shri Sathya Sai Medical College & Research Institute,
Ammapettai, Chennai, India. Date of Publishing: ?????, 2016

International Journal of Anatomy, Radiology and Surgery, 2016 5