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      Outcome of Phacoemulsification in patients with and without Pseudoexfoliation syndrome in Kashmir

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          Abstract

          Background

          The aim of the study is to compare the outcome of phacoemulsification in patients with and without pseudoexfoliation syndrome in Kashmir.

          Methods

          200 patients were prospectively evaluated and divided into 2 groups. Group 1 comprised 100 cases with pseudoexfoliation and Group 2 (control) 100 cases without pseudoexfoliation. Phacoemulsification with posterior chamber intraocular lens implantation was performed by 3 surgeons. Intraoperative and postoperative observations were made in both the groups at regular intervals upto 6 months. A chi square test was used for statistical analysis.

          Results

          Patients with pseudoexfoliation were significantly older (P = 0.000), had harder cataract(P = 0.030) and smaller mean pupil diameter(P = 0.000) than the control group. Intraoperative complications were comparable between the 2 groups except the occurrence of zonular dehiscence which was seen in 7% patients of Group 1 compared to 0% in Group 2. Higher postoperative inflammatory response was seen in Group 1(P = 0.000). Decrease in intraocular pressure (IOP) at all postoperative measurements was more in Group 1(P = 0.000). The visual acuity was better in the control group in the early postoperative period (P = 0.029), however the final visual acuity at 6 months was comparable between the 2 groups.

          Conclusions

          Phacoemulsification in presence of pseudoexfoliation necessitates appropriate surgical technique to avoid intraoperative complications. Pseudoexfoliation is associated with higher inflammatory response, significant postoperative IOP drop and satisfactory visual outcome.

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          Most cited references19

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          Pseudoexfoliation syndrome for the comprehensive ophthalmologist. Intraocular and systemic manifestations.

          Renewed interest in pseudoexfoliation syndrome (PEX) may be attributed to an increased awareness of many clinical risks not only for open-angle glaucoma and its recent recognition as a generalized disorder. This review summarizes the range of intraocular and extraocular manifestations. Involvement of all tissues of the anterior segment of the eye results in a spectrum of intraocular complications that have management implication for all practicing ophthalmologists. The study design was a review. Clinical diagnosis depends on biomicroscopy, biocytology, and laser-tyndallometry. Laboratory research methods range from light and electron microscopy, to immunohistochemical and molecular biologic approaches. Clinical-histopathologic correlations focus on the involvement of lens (PEX-phacopathy), zonular apparatus (zonulopathy), ciliary body (cyclopathy), iris (iridopathy), trabecular meshwork (trabeculopathy), and cornea (corneal endotheliopathy) leading to the following complications: (1) open-angle glaucoma as well as angle-closure glaucoma due to pupillary and ciliary block; (2) phacodonesis, lens dislocation, and increased incidence of vitreous loss in extracapsular cataract surgery caused by alterations of the zonular apparatus and its insertion into the ciliary body and lens; (3) blood-aqueous barrier breakdown (pseudouveitis), anterior chamber hypoxia, iris stromal hemorrhage, pigment epithelial melanin dispersion, poor or asymmetric pupillary dilatation, and formation of posterior synechiae due to involvement of all cell populations of the iris; and (4) early diffuse corneal endothelial decompensation explained by a damaged and numerically reduced endothelium. In view of the multitude of clinical complications, PEX is of relevance to comprehensive ophthalmologists, including specialists in glaucoma, cataract, cornea, neuro-ophthalmology, and retina. Special attention to the risks associated with PEX is advised before, during, and after surgery.
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            Outcomes of phacoemulsification in patients with and without pseudoexfoliation syndrome.

            To characterize the differences in technique, complications, and outcomes in a large series of cataract extractions in patients with and without pseudoexfoliation (PEX) syndrome. Ophthalmic Consultants of Boston, Boston, Massachusetts, USA. A retrospective analysis was performed of 297 cases of cataract extraction in patients with PEX and 427 cases of cataract extraction in patients without PEX. This study examined and quantified the intraoperative and postoperative complications, performed a comparative outcomes analysis of intraocular pressure (IOP) change, and determined the prevalence of systemic vascular diseases in these patients. The overall rate of vitreous loss was 4% (7/297) in the PEX population and 0% (0/427) in the non-PEX group. There were no overall differences in the rate of postoperative complications. At 2 years, IOP had declined from a mean of 16.8 to 13.9 mm Hg in the PEX group and from 16.3 to 14.4 mm Hg in the non-PEX group. The decline was significantly greater in the PEX group. The prevalence of hypertension and diabetes was significantly greater in the non-PEX group (50% and 11%, respectively) than in the PEX group (38% and 5%, respectively). The increased frequency of intraoperative complications during cataract extraction in PEX patients stemmed from zonular weakness rather than capsule tears. Postoperative IOP declines were greater in the PEX group even 2 years after cataract extraction, suggesting the potential for long-term improvement in outflow facility in patients with coexisting cataract and glaucoma.
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              A histopathologic study of zonular instability in pseudoexfoliation syndrome.

              A weak zonular apparatus has been postulated to account for the high incidence of phacodonesis, lens dislocation, and vitreous complications during extracapsular cataract surgery in eyes with pseudoexfoliation syndrome. To clarify and localize the cause of zonular weakness, we examined 11 eyes with pseudoexfoliation syndrome by using scanning and transmission electron microscopy. The production of pseudoexfoliation material by both the nonpigmented ciliary epithelium and the pre-equatorial lens epithelium resulted in typical alterations of the zonules at three levels. (1) At their origin and anchorage in the ciliary body, the zonular bundles were separated from the disrupted basement membrane of the nonpigmented epithelium by intercalating pseudoexfoliation fibers. (2) In the pars plicata of the ciliary body, pseudoexfoliation material infiltrated the zonular bundles passing alongside the ciliary processes leading to zonular rupture. (3) At their attachment to the anterior lens capsule, the zonular lamella was focally lifted and subsequently ruptured by pseudoexfoliation masses erupting through the capsular surface. The immunohistochemical demonstration of lysosomal enzymes within pseudoexfoliation aggregates indicates that proteolytic mechanisms facilitate zonular disintegration. Ophthalmologists treating eyes with pseudoexfoliation syndrome should be aware of these alterations.
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                Author and article information

                Contributors
                Journal
                BMC Ophthalmol
                BMC Ophthalmol
                BMC Ophthalmology
                BioMed Central
                1471-2415
                2012
                6 June 2012
                : 12
                : 13
                Affiliations
                [1 ]Department of Ophthalmology, Government Medical College, Jammu & Kashmir, Srinagar, India
                [2 ]Directorate of Health Services, Kashmir, India
                [3 ]Department of Surgery, Government Medical College, Jammu & Kashmir, Srinagar, India
                Article
                1471-2415-12-13
                10.1186/1471-2415-12-13
                3482150
                22672195
                01cbd168-6504-4d87-9d50-f6dbc54ca01f
                Copyright ©2012 Sufi et al.; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 14 September 2011
                : 18 May 2012
                Categories
                Research Article

                Ophthalmology & Optometry
                Ophthalmology & Optometry

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