Pseudoexfoliation (PXF) syndrome is an important risk factor for capsular complications in cataract surgery. Studies have reported an increased rate of intraoperative posterior capsular complications during conventional extracapsular cataract surgery in eyes with PXF syndrome.1-3
My colleagues and I performed a retrospective study of 225 eyes (187 patients) that underwent manual small-incision cataract surgery with the sandwich technique. All eyes were operated on between 1997 and 2003 at Inˆnü University Turgut ÷zal Medical Center in Malatya, Turkey. We aimed to evaluate the rate of intraoperative posterior capsule complications including posterior capsule rupture and/or zonulolysis and vitreous loss in eyes with and without PXF syndrome. We also investigated whether the rate of intraoperative capsular complications increased in eyes with markedly decreased preoperative visual acuity due to the maturity level of the cataract. Eyes that met the inclusion criteria were seperated into two groups: Group 1 (99 eyes) had PXF syndrome and group 2 (126 eyes) did not. For statistical analysis, the chi-square and Student t tests were used.
Ninty-eight men and 89 women (mean age, 69.6 ±10.7 years; range, 22–103 years) were included. The mean age was 72.1 ±8.84 years (range, 5–103 years) in group 1 and 67.4 ±11.7 years (range, 22–95 years) in group 2, meaning that patients with PXF syndrome were significantly older than those without PXF syndrome (P=.002).
The types of cataracts in groups 1 and 2 are shown in Table 1. The most frequent type of the cataract in both groups was the nuclear cataract; however, mature and brunescent cataracts were almost twice as frequent in group 1 (49.5%) as in group 2 (26%). The number of eyes with a visual acuity worse than 20/200 (finger counting, hand motion, or light perception) was 70 (70%) and 63 (50%) in groups 1 and 2, respectively.
Intraoperative posterior capsular complications occurred in 18% of eyes with PXF syndrome and 5.5% without PXF syndrome (P=.003). The rate of the capsular complications was significantly higher in eyes with a preoperative visual acuity worse than 20/200 (21% in group 1 and 9% in group 2) than in eyes with 20/200 visual acuity or better (8.6% in group 1 and 1.7% in group 2). In both groups, the complication rate was also higher in eyes with mature or brunescent cataracts (22.5% in group 1 and 12.5% in group 2) compared with other cataract types.
We noticed that removing the entire capsular bag from the posterior chamber was easy. No vitreous loss occurred during surgery in four eyes with mature cataracts and PXF syndrome. No significant manipulation occurred. Of the eyes having capsular rupture, vitreous loss occurred in 12 of 18 eyes with PXF syndrome (12%) and in three of seven eyes (2.3%) without PXF syndrome (P=.004). Tables 2 and 3 show the incidence of capsular complications and vitreous loss and the statistical test results.
CONSIDERATIONS
Our results from a consecutive study of 225 eyes suggest that PXF syndrome has an increased rate of intraoperative posterior capsule complications such as zonular dialysis, posterior capsule rupture, and vitreous loss in manual small-incision cataract surgery. Additionally, we found a significant association between increased rates of intraoperative complications and greater cataract maturity.
The lower the preoperative visual acuity and the more advanced the maturity of cataract, the greater the risk is for intraoperative capsular complications. It appears that four variables that are not obviously independent of each other—namely increasing patient age, presence of PXF, poorer visual acuity, and denser nuclei—are positively correlated with more frequent capsular complications in manual small-incision cataract surgery. The root cause of this increased rate of capsular complications may be the hardness of the nuclei, which requires the application of more force during cataract removal. Another possibility is that the weak zonular apparatus resulting from PXF causes fragility in response to physical movement. Earlier surgical intervention in pseudoexfoliative eyes is recommended to reduce the risk of capsular complications from more advanced cataract.
Hüseyin Bayramlar, MD, is an Associate Professor of Ophthalmology, Ümraniye Egitim ve Arastrma Hastanesi, Ümraniye, Turkey. Dr. Bayramlar states that he has no financial interest in the products or companies mentioned. He may be reached at tel: +90 216 6321818 1992; fax: +90 216 6327121; hbayramlar@yahoo.com.
Cihan Ünlü, MD, practices at the Ümraniye Egitim ve Arastrma Hastanesi, Ümraniye, Turkey. Dr. Ünlü states that he has no financial interest in the products or companies mentioned. He may be reached at drcihanunlu@yahoo.com.
