“CLINICAL STUDY OF MANAGEMENT OF CATARACT IN EXFOLIATION SYNDROME”
BRIEF RESUME OF THE INTENDED WORK
6.1 Need for the Study:
In India the prevalence of exfoliation syndrome in general population above 50 years is 2%.Exfoliation often occurs unilaterally, reports indicate that 48-76%cases appear to be unilateral at time of diagnosis. In addition studies indicated 13.43%patients with unilateral exfoliation will acquire it in the fellow eye after 5-10 years(1).
Making the diagnosis often requires a careful slit lamp examination after pupillary dilatation otherwise exfoliation syndrome frequently goes undiagnosed. Exfoliaiton poses both intraoperative and postoperative complications in cataract surgery.Pseudoexfoliation is associated with a number of ocular findings including open angle glaucoma (exfoliative glaucoma),closed angle glaucoma,association of cataract(nuclear), phacodonesis, lens subluxation,rigid pupil,breakdown of blood aqueous barrier, posterior synechiae, retinal vein occlusionand postoperatively decentration and dislocation of I.O.L,corneal oedema.2,3,4
This prospective study is undertaken to be aware of possibility of exfoliation associated with cataract in all elderly patients.Cataract surgery is undertaken judiciously with due care towards possible challenges and complications with goal of attaining better visual outcome.
6.2 Review Of Literatures:
In India the prevalence rates reported were 1.88% by Sood N.N.(1965),7.4% by Lamba and Giridhar (1984) and south India prevalence is 3.8% by Aravind H et al(2004)5,6,7.
Skuta G.L, Parrish R.K8(1987)showed increase incidence of zonular dialysis in patients with pseudoexfoliation syndrome during cataract surgery.They stated that pre-operative phacodonesis,anterior chamber depth asymmetry and excessive lens movement during anterior capsulotomy should alert to the presence of zonular dialysis
Naumann G.O,Kuchle M.Schon herr u 9 noted a seven fold increase in vitreous loss in 72 patients with pseudoexfoliaion syndrome undergoing cataract surgery
Moreno et al 10suggested irido-phacodonesis ,poor dilatation and presence of glaucoma as the clinical factors related to capsular rupture during cataract surgery
Freyler H.and Radax U 11.compared extracapsulr cataract surgey with phacoemulsification in 311 and 68 patients respectively.Miosis and phacodonesis were reported as the primary risk factors for cataract surgery associated with pseudoexfoliation syndrome.Compared with extra capsular cataract surgery .phacoemulsification had significantly fewer complications with regard to miosis but not phacodonesis.They advised applying a small iris retractors,hooks to stem the complications arising from miosis.
Kuchle et al 12suggested that a shallow anterior chamber depth of less than 2.5mm preoperatively was indicative of zonular instability and should alert the surgeon of intra operative complications.
Albert Galand MD,Micheal Kuchle MD,Etienne Hachet MD13,(2004)at asymposium during 21st congress of the ESCRS reviewed the pathophysiological alterations associated with exfoliation,consequences of cataract surgery,and considerations for surgical modifications and intraocular lens selection.They stressed its management by injection of high viscosity visco elastic agent,irirs hooks,either plastic or metallic as necessary,use of circular plastic dilator to push the pupil rim aside,advocated on use of capsular tension rings.
Vickie Lee and Anthony Maloof 14(2002) stated that a CTR allows for the expansion and stabilization of the capsular bag by redistributing forcres with the resulting tautness of bag providing counter traction to faciliatate cataract surgery and cortical aspiration.The CTR can be inserted after completion of capsulorrhexis but before hydrodissection.
6.3 Objectives Of the Study
To study the clinical features of exfoliation syndrome in association with cataract.
To study the management of cataract in exfoliation syndrome.
To determine the measures to minimize the complications of cataract surgery in eyes with exfoliation.
MATERIAL AND METHODS 7.1 Source of Data:
The materials for the present study will be drawn from 50 patients of pseudoexfoliation with cataract attending the outpatient department of ophthalmology at Chigateri General Hospital and Bapuji Hospital attached to J.J.M Medical College, Davangere during the period from November 2011 to September 2013.
7.2 Method of Collection of Data:
A minimum of 50 cases of eyes that had cataract with exfoliaton syndrome, attending the out patient department of ophthalmology will be selected for study. Each patient will be subjected to detailed history taking, followed by ocular and examination as per predesigned proforma.
Clinical examination will include the examination of
External occular examination with special reference to the assessement of adequate puppilary dilatation with mydriatics
Visual acuity testing for near and distance using snellens chart
Slit lamp biomicroscopy for evidence of exfoliation material in anterior segment before and after dilatation of pupil
Tonometry using applanation tonometry
Gonioscopy with goldmann three mirror lens
Lacrimal patency test,keratometry,A-scan and intraocular lens power calculation by SRK -2 formula
B-scan wherever necessary.
Elective surgery will be performed after careful pre-operative assessement by different faculty members from this institution.
Steps will be noted in the proforma.
Postoperative follow upwill be done making note towards complications and their management.
Patients undergoing cataract surgery with exfoliation syndrome and psedoexfoliative glaucoma
Patients with exfoliation syndrome as evidenced by exfoliative material on the corneal endothelium,ciliary body, pupillary margins,anterior chamber angle,anterior surface of lens capsule.
Patients with senile cataract –immature,mature,hypermature in exfoliation syndrome
Patients with exfoliation with glaucoma associated with cataract.
Following patients will be excluded from the study:-
Patient s with any type of catarct without exfoliation syndome
7.3 Does the Study require any investigations or interventions to be conducted on patients or other human beings or animals?If so please describe briefly.
Routine Blood Investigations
Urine Albumin, Sugar
HIV I & II, Hbs Ag
7.4 Has Ethical Clearance been obtained from your institution in case of 7.3 ?
LIST OF REFERENCES
Albert Jacobeic “The exfoliation syndrome a continous challenge”.chapter -205,principles and practice of ophthalmology,2nd edition,vol.4,edt. Douglous H. Johnson, London :W.B.Saunders company; 1994 .p.p 2718-2728
Shields Textbook of Glaucoma,6th Edition.“Exfoliation syndrome and exfoliative glaucoma”.c.Lippinctt Williams and Wilkins.2011:Philadelphia.p.p248-259.
Schlötzer-Schrehardt U, Naumann GOH .Ocular and systemic exfoliation syndrome. Am j. Ophthalmol. 2006;141(5):921–937
Tarkkanen A,pseudoexfoliation of the lens capsule.A clinical study of 418 patients with special refrence to glaucoma,cataract,and changes of the vitreous. Acta Ophthalmol (Copenh) 1962;suppl.71.
Sood N.N.”prevalence of pseudoexfoliation of lens capsule in india”-Acta ophthalmol. 1968;46:211-214
Lamba P.A. and Giridhar A.”pseudoexfoliation syndrome(prevalence based on random survey hospital data)” Indian Journal of Ophthal 1984;32:169-173
Aravind H.et al.”pseudoexfoliation in south India” British Journal of Ophthalmol 2003;87(11):1321-13231
Skuta G.L, Parrish R.K, Hodapp E, Forster RK, Rockwood EJ. Zonular dialysis during extracapsular cataract extraction in pseudoexfoliation syndrome. Arch Ophthalmol. 1987;105:632–634
Naumann G.O,Kuchle M.Schon herr u”pseudoexfoliation syndrome as a risk factor for vitreous loss in extra-capsular cataract extraction” Forts-chr Ophtal 1989;86:543-545.
Moreno M.J,Duch Sand Lajara”pseudoexfoliation syndrome:clinical factors related to capsular rupture in cataract surgery” Acta ophtahl (coepenh)1993;71:181-184.
Freyler H.and Radax U”pseudoexfoliation syndrome-A risk factor in modern cataract surgery” Klin Monatsbl Augeneikd 1994;205:275-279
Kuchle et al”Anterior chamber depth and complications during cataract surgery in eyes with pseudoexfoliation syndrome” American Journal of Ophthalmology 200;129:281-285.
Albert Galand MD,Micheal Kuchle MD,Etienne Hachet MD.”multiple surgical chaleges of pseudo exfoliaton ”symposium during 21st congress of ESCRS 2004.
Vickie LEE and Anthony Mallof.“clinical practice-cataract surgery in pseudoexfoliative syndrome” comprehensive ophthalmology update 2002,3(1).