70 (1992)440-446
ACTA O P H T H A L M O L O G I C A
Exfoliation syndrome in patients scheduled for cataract surgery Jaana Hietanen, Tero Kivela, Eija Vesti and Ahti Tarkkanen Department of Ophthalmology, Helsinki University Central Hospital,Helsinki, Finland
Abstract. A series of 305 consecutive patients 30 years of age or older scheduled for cataract surgery was examined to find out the frequency of exfoliation syndrome, the predominant type of cataract, and the intraocular pressure status. The mean age of 222 (72.8%)females and 83 (27.2%)males was 71.7 (+ 11.1) years (range 32 to 91 years). Exfoliation was detected in 77 (25.2%)patients. It was unilateral in 37 (48.0%) patients, the affected eye being in 29 (78.4Yu) cases scheduled for cataract surgery, and bilateral in 40 (52.0%)patients. Exfoliation was increased steadily with age. It was most often seen on the anterior lens capsule (88.9%).Krukenberg's spindle was seen in 31 (20.4%)eyes of patients with and in 12 (2.6%) eyes of patients without exfoliation (p < 0.001). Nuclear sclerosis predominated in eyes with (83.8%)as compared to those dithout (61.9%)exfoliation (p < 0.01). Posterior subcapsular cataract was less common in eyes with exfoliation (1.5%) than in eyes (21.1%)without it (p < 0.001). A tendency to slightly higher preoperative intraocular pressure was measured in eyes with exfoliation as compared to those without it, and glaucoma occurred much more frequently (33.8% vs 10.8%)in the former group (p < 0.001). Exfoliation and capsular glaucoma, which must be promptly detected to avoid surgical complications, are frequent in patients scheduled for cataract surgery. Key words: exfoliation syndrome - cataract - extracapsular cataract extraction - intraocular pressure - capsular glaucoma.
The exfoliation syndrome, first described by the Finnish ophthalmologist Lindberg (1917), is of manifold clinical importance. Its association with 440
capsular glaucoma has been studied by many investigators (Vogt 1925; Tarkkanen 1962; Kozart & Yanoff 1982). Glaucoma is more prevalent and its prognosis worse in eyes with exfoliation syndrome than in those without it (Tarkkanen 1965; Aasved 1971a; Hiller et al. 1982). Special attention has also been paid to pigment dispersion from the ins pigment epithelium in this syndrome (Lindberg 1917; Bertelsen 1966; Krause et al. 1973; Prince et al. 1987). A noticeably high complication rate during extracapsular cataract extraction in patients with exfoliation has brought special interest into discussion of this syndrome. These problems include a poorly dilating pupil, zonular rupture and vitreous loss during expression of the nucleus, and high intraocular pressures and frequent fibrinoid reactions postoperatively (Dark 1979; Raitta & Setala 1986;Tarkkanen 1986; Ueno et al. 1986; Guzek et al. 198'7; Ruotsalainen & Tarkkanen 1987; Cambiaggi 1988; Goder 1988; Naumann et al. 1989; Olivius et al. 1989). Otherwise, relatively little has been written about the relationship between exfoliation syndrome and senile cataract (Tarkkanen 1962; Krause & Tarkkanen 1978;Seland 8c Chylack 1982). The present study addresses several clinical aspects of exfoliation syndrome in patients scheduled for cataract surgery, such as the fi-equency of exfoliation and capsular glaucoma'in this context, and the type of lens opacity they are associated with.
NUMBER OF PATIENTS
AGE (YEARS) Fig. 1. Age and sex distribution of the 305 patients scheduled for cataract surgery.
Patients and Methods The material consists of 305 consecutive patients 30 years of age or older scheduled for cataract surgery in the Department of Ophthalmology,Helsinki University Central Hospital, Helsinki, Finland, during the time period from March 13 to May 24, 1989. A total of 289 (94.8%) patients was planned to undergo extracapsular cataract extraction with intraocular lens implantation and the remaining 16 (5.2%)patients were scheduled to have other kinds of cataract surgery. Both the eye scheduled for surgery and its fellow eye were included in the analysis. In three patients the fellow eye was excluded from the study because it was phthisical due to an old perforating injury or tuberculous chorioretinitis, or it had been enucleated. Each patient was examined according to a previously planned protocol on the day before surgery by one of three investigators trained to recognize exfoliation syndrome. The sex and age of the patient, the presence of prior glaucoma and in-
traocular surgery, the current glaucoma medication, the visual acuities with spectacle correction, and the intraocular pressures by applanation tonometry before instillation of mydriatics were recorded. The presence or absence of exfoliation was recorded on the basis of a careful slit-lamp biomicroscopy after pupillary dilatation. Exfoliation particles were looked for on the anterior lens capsule, at the pupillary border, and on the posterior corneal surface. In aphakic and pseudophakic eyes, exfoliation material was sought for in other locations except the lens. The cortical, nuclear and posterior suhcapsular cataractous changes, and the estimated predominant type of opacity in each patient were recorded. The presence of Krukenberg's spindle, a vertical pigment deposit on the endothelial surface of the cornea, was also registered. The data were entered into an IBM PC microcomputer using the SPSS/PC program (Version
+
441
EXFOLIATION DETECTED
AGE (YEARS) Fig 2. Frequency of exfoliation syndrome according to age and sex in the 305 patients scheduled for cataract surgery
2.0, SPSS Inc., Chicago, IL, USA). In addition, the BMDP program 4F (Version PC90, BMDP Statistical Software Inc., Los Angeles, CA, USA) was used to analyze differences between groups by Pearson’s and Yates’ corrected $-statistics. Bonferroni correction was used ifcell frequencies were combined prior to statistical analysis.
Results The mean age of the 305 patients in the series was 71.7 (+ 11.1) years (range 32 to 91 years). The distribution of the patients according to age and sex is given in Fig. 1. Females scheduled for cataract surgery were significantly older than males in the series (p < 0.05). Definite evidence of exfoliation syndrome was detected in 77 (25.2%)patients, of which 37 (48.0%)were unilaterally and 40 (52.0%) bilaterally affected. The age and sex distribution of patients with exfoliation syndrome is shown in 442
Fig. 2. Exfoliation was detected in 68 (30.6%)of the 222 females as compared to 9 (10.8%) of the 83 males. Although exfoliation syndrome seemed to occur earlier in females than in males and its frequency increased more steadily with age in females (Fig. 2), no statistically significant difference in its age distribution was detected between males and females in our series. Exfoliation material was noted on the anterior lens capsule in 104 (88.9%)of the 117 affected eyes, at the pupillary border in 92 (78.6%) of affected eyes, and on the posterior corneal surface in 27 (23.1%)of affected eyes. Krukenberg‘s spindle was found in 31 (20.4%)eyes of patients with exfoliation and in 12 (2.6%)eyes of patients without this syndrome. This difference was statistically significant (p < 0.001). An intraocular lens had already been implanted in 68 (22.4%)fellow eyes, and 15 (5.0%)of fellow eyes were aphakic. The visual acuities of the eyes with and without exfoliation syndrome that were scheduled for cata-
Table 1. The visual acuity and presence of exfoliation syndrome in the 305 eyes scheduled for cataract surgery. Visual acuity*
Exfoliation Negative
Positive
20/20 - 12/20 10/20 - 4/20 2/20 - CF HM-LP
1 57 103 75
( 0.4) ( 24.2) ( 43.6) ( 31.8)
1 18 31 19
(26.1) (44.9) (27.5)
Total
236
(100.0)
69
(99.9)
* CF
counting fingers, H M LP = light perception. =
Table2. The estimated predominant type of cataract and exfoliation syndrome in the 305 eyes scheduled for cataract surgery.
=
( 1.4)
hand movements, and
ract surgery did not differ statistically from each other (Table 1).In 29 (78.4%)of the 37 patients with clinically unilateral exfoliation syndrome, the affected eye was scheduled for cataract surgery. The estimated predominant type of lens opacity in the 305 eyes scheduled for cataract surgery is shown in Table 2. Nuclear sclerosis predominated in eyes with exfoliation, as compared to eyes without it (p < 0.01). On the other hand, predominant posterior subcapsular cataract occurred primarily in eyes without exfoliation, as compared to eyes with exfoliation (p < 0.001). No difference was noted in the frequency of predominantly cortical lens opacities. History of glaucoma was recorded in 26 (33.8%) patients with exfoliation syndrome and in 23 (10.1%)patients without exfoliation, which was also a statisticallysignificant difference (p < 0.001). Furthermore, 24 (31.2%)patients with exfoliation syndrome and 17 (7.5%)patients without it had medical treatment €or high intraocular pressure preoperatively (p < 0.001). Irrespective of their treatment, a trend to higher preoperative intraocular pressures was seen in patients who had exfoliation syndrome, as compared to those without it (Table 3). This difference resulted from the fact that 24 (15.8%) of eyes in the former group had an intraocular pressure greater than 20 mmHg, as compared to 24 (5.3%)of eyes of patients who did not have exfoliation syndrome (p
ACTA O P H T H A L M O L O G I C A
Exfoliation syndrome in patients scheduled for cataract surgery Jaana Hietanen, Tero Kivela, Eija Vesti and Ahti Tarkkanen Department of Ophthalmology, Helsinki University Central Hospital,Helsinki, Finland
Abstract. A series of 305 consecutive patients 30 years of age or older scheduled for cataract surgery was examined to find out the frequency of exfoliation syndrome, the predominant type of cataract, and the intraocular pressure status. The mean age of 222 (72.8%)females and 83 (27.2%)males was 71.7 (+ 11.1) years (range 32 to 91 years). Exfoliation was detected in 77 (25.2%)patients. It was unilateral in 37 (48.0%) patients, the affected eye being in 29 (78.4Yu) cases scheduled for cataract surgery, and bilateral in 40 (52.0%)patients. Exfoliation was increased steadily with age. It was most often seen on the anterior lens capsule (88.9%).Krukenberg's spindle was seen in 31 (20.4%)eyes of patients with and in 12 (2.6%) eyes of patients without exfoliation (p < 0.001). Nuclear sclerosis predominated in eyes with (83.8%)as compared to those dithout (61.9%)exfoliation (p < 0.01). Posterior subcapsular cataract was less common in eyes with exfoliation (1.5%) than in eyes (21.1%)without it (p < 0.001). A tendency to slightly higher preoperative intraocular pressure was measured in eyes with exfoliation as compared to those without it, and glaucoma occurred much more frequently (33.8% vs 10.8%)in the former group (p < 0.001). Exfoliation and capsular glaucoma, which must be promptly detected to avoid surgical complications, are frequent in patients scheduled for cataract surgery. Key words: exfoliation syndrome - cataract - extracapsular cataract extraction - intraocular pressure - capsular glaucoma.
The exfoliation syndrome, first described by the Finnish ophthalmologist Lindberg (1917), is of manifold clinical importance. Its association with 440
capsular glaucoma has been studied by many investigators (Vogt 1925; Tarkkanen 1962; Kozart & Yanoff 1982). Glaucoma is more prevalent and its prognosis worse in eyes with exfoliation syndrome than in those without it (Tarkkanen 1965; Aasved 1971a; Hiller et al. 1982). Special attention has also been paid to pigment dispersion from the ins pigment epithelium in this syndrome (Lindberg 1917; Bertelsen 1966; Krause et al. 1973; Prince et al. 1987). A noticeably high complication rate during extracapsular cataract extraction in patients with exfoliation has brought special interest into discussion of this syndrome. These problems include a poorly dilating pupil, zonular rupture and vitreous loss during expression of the nucleus, and high intraocular pressures and frequent fibrinoid reactions postoperatively (Dark 1979; Raitta & Setala 1986;Tarkkanen 1986; Ueno et al. 1986; Guzek et al. 198'7; Ruotsalainen & Tarkkanen 1987; Cambiaggi 1988; Goder 1988; Naumann et al. 1989; Olivius et al. 1989). Otherwise, relatively little has been written about the relationship between exfoliation syndrome and senile cataract (Tarkkanen 1962; Krause & Tarkkanen 1978;Seland 8c Chylack 1982). The present study addresses several clinical aspects of exfoliation syndrome in patients scheduled for cataract surgery, such as the fi-equency of exfoliation and capsular glaucoma'in this context, and the type of lens opacity they are associated with.
NUMBER OF PATIENTS
AGE (YEARS) Fig. 1. Age and sex distribution of the 305 patients scheduled for cataract surgery.
Patients and Methods The material consists of 305 consecutive patients 30 years of age or older scheduled for cataract surgery in the Department of Ophthalmology,Helsinki University Central Hospital, Helsinki, Finland, during the time period from March 13 to May 24, 1989. A total of 289 (94.8%) patients was planned to undergo extracapsular cataract extraction with intraocular lens implantation and the remaining 16 (5.2%)patients were scheduled to have other kinds of cataract surgery. Both the eye scheduled for surgery and its fellow eye were included in the analysis. In three patients the fellow eye was excluded from the study because it was phthisical due to an old perforating injury or tuberculous chorioretinitis, or it had been enucleated. Each patient was examined according to a previously planned protocol on the day before surgery by one of three investigators trained to recognize exfoliation syndrome. The sex and age of the patient, the presence of prior glaucoma and in-
traocular surgery, the current glaucoma medication, the visual acuities with spectacle correction, and the intraocular pressures by applanation tonometry before instillation of mydriatics were recorded. The presence or absence of exfoliation was recorded on the basis of a careful slit-lamp biomicroscopy after pupillary dilatation. Exfoliation particles were looked for on the anterior lens capsule, at the pupillary border, and on the posterior corneal surface. In aphakic and pseudophakic eyes, exfoliation material was sought for in other locations except the lens. The cortical, nuclear and posterior suhcapsular cataractous changes, and the estimated predominant type of opacity in each patient were recorded. The presence of Krukenberg's spindle, a vertical pigment deposit on the endothelial surface of the cornea, was also registered. The data were entered into an IBM PC microcomputer using the SPSS/PC program (Version
+
441
EXFOLIATION DETECTED
AGE (YEARS) Fig 2. Frequency of exfoliation syndrome according to age and sex in the 305 patients scheduled for cataract surgery
2.0, SPSS Inc., Chicago, IL, USA). In addition, the BMDP program 4F (Version PC90, BMDP Statistical Software Inc., Los Angeles, CA, USA) was used to analyze differences between groups by Pearson’s and Yates’ corrected $-statistics. Bonferroni correction was used ifcell frequencies were combined prior to statistical analysis.
Results The mean age of the 305 patients in the series was 71.7 (+ 11.1) years (range 32 to 91 years). The distribution of the patients according to age and sex is given in Fig. 1. Females scheduled for cataract surgery were significantly older than males in the series (p < 0.05). Definite evidence of exfoliation syndrome was detected in 77 (25.2%)patients, of which 37 (48.0%)were unilaterally and 40 (52.0%) bilaterally affected. The age and sex distribution of patients with exfoliation syndrome is shown in 442
Fig. 2. Exfoliation was detected in 68 (30.6%)of the 222 females as compared to 9 (10.8%) of the 83 males. Although exfoliation syndrome seemed to occur earlier in females than in males and its frequency increased more steadily with age in females (Fig. 2), no statistically significant difference in its age distribution was detected between males and females in our series. Exfoliation material was noted on the anterior lens capsule in 104 (88.9%)of the 117 affected eyes, at the pupillary border in 92 (78.6%) of affected eyes, and on the posterior corneal surface in 27 (23.1%)of affected eyes. Krukenberg‘s spindle was found in 31 (20.4%)eyes of patients with exfoliation and in 12 (2.6%)eyes of patients without this syndrome. This difference was statistically significant (p < 0.001). An intraocular lens had already been implanted in 68 (22.4%)fellow eyes, and 15 (5.0%)of fellow eyes were aphakic. The visual acuities of the eyes with and without exfoliation syndrome that were scheduled for cata-
Table 1. The visual acuity and presence of exfoliation syndrome in the 305 eyes scheduled for cataract surgery. Visual acuity*
Exfoliation Negative
Positive
20/20 - 12/20 10/20 - 4/20 2/20 - CF HM-LP
1 57 103 75
( 0.4) ( 24.2) ( 43.6) ( 31.8)
1 18 31 19
(26.1) (44.9) (27.5)
Total
236
(100.0)
69
(99.9)
* CF
counting fingers, H M LP = light perception. =
Table2. The estimated predominant type of cataract and exfoliation syndrome in the 305 eyes scheduled for cataract surgery.
=
( 1.4)
hand movements, and
ract surgery did not differ statistically from each other (Table 1).In 29 (78.4%)of the 37 patients with clinically unilateral exfoliation syndrome, the affected eye was scheduled for cataract surgery. The estimated predominant type of lens opacity in the 305 eyes scheduled for cataract surgery is shown in Table 2. Nuclear sclerosis predominated in eyes with exfoliation, as compared to eyes without it (p < 0.01). On the other hand, predominant posterior subcapsular cataract occurred primarily in eyes without exfoliation, as compared to eyes with exfoliation (p < 0.001). No difference was noted in the frequency of predominantly cortical lens opacities. History of glaucoma was recorded in 26 (33.8%) patients with exfoliation syndrome and in 23 (10.1%)patients without exfoliation, which was also a statisticallysignificant difference (p < 0.001). Furthermore, 24 (31.2%)patients with exfoliation syndrome and 17 (7.5%)patients without it had medical treatment €or high intraocular pressure preoperatively (p < 0.001). Irrespective of their treatment, a trend to higher preoperative intraocular pressures was seen in patients who had exfoliation syndrome, as compared to those without it (Table 3). This difference resulted from the fact that 24 (15.8%) of eyes in the former group had an intraocular pressure greater than 20 mmHg, as compared to 24 (5.3%)of eyes of patients who did not have exfoliation syndrome (p
