Oman Journal of Ophthalmology

: 2013  |  Volume : 6  |  Issue : 1  |  Page : 23--26

Visual outcome following extracapsular cataract extraction in mature cataracts with pseudoexfoliation syndrome: A retrospective study

Abdullah Al-Mujaini, Upender K Wali 
 Department of Ophthalmology, College of Medicine and Health Sciences, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman

Correspondence Address:
Abdullah Al-Mujaini
Department of Ophthalmology, Sultan Qaboos University Hospital, 123 Al-Khod, Muscat
Sultanate of Oman


Purpose/Objective: To report the best corrected visual acuity, at the end of one year, in 33 patients (35 eyes), who underwent extracapsular cataract extraction (ECCE) with posterior chamber intraocular lens implantation (PC-IOL) for mature and hypermature cataracts, with pseudoexfoliation (PEX). Design: Retrospective, non-comparative, single-institutional (Sultan Qaboos University Hospital) study. Participants: Thirty-three patients with mature and hypermature cataracts, with PEX operated upon between January 2007 and December 2008, by one surgeon (AM). Materials and Methods: Retrospective study of thirty-three patients (35 eyes) with mature and hypermature cataracts, with ocular PEX, evaluating the visual outcome at the end of 12 months following ECCE with PC-IOL. Results: Thirty eyes (85.71%) showed improvement in the best corrected visual acuity (BCVA) ranging from 0.2 to 1.0 Snellen lines. Four eyes (11.43%) had unchanged BCVA from the baseline. There were no intraoperative complications in any patient. One eye (2.86%) that did not improve developed retinal detachment at three months follow-up, and was referred to the Vireoretinal Unit and follow-up has been lost. Conclusion: Extracapsular cataract extraction is a safe and effective technique in eyes with mature and hypermature cataracts with PEX.

How to cite this article:
Al-Mujaini A, Wali UK. Visual outcome following extracapsular cataract extraction in mature cataracts with pseudoexfoliation syndrome: A retrospective study.Oman J Ophthalmol 2013;6:23-26

How to cite this URL:
Al-Mujaini A, Wali UK. Visual outcome following extracapsular cataract extraction in mature cataracts with pseudoexfoliation syndrome: A retrospective study. Oman J Ophthalmol [serial online] 2013 [cited 2020 Jul 11 ];6:23-26
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Cataract is the leading cause of preventable and reversible adulthood blindness in the world. A majority of such cases are from the developing and underdeveloped countries, which form the bulk of the volume with cataract on our planet. Cataract surgery is the most common ocular surgery performed worldwide. Phacoemulsification has been the standard method of cataract surgery since more than three decades now, with many more innovative machines and methods coming up; however, there are instances where new techniques may not be the best and old techniques may not be the worst. Even with the current phacoemulsification procedures, in hypermature cataracts, complications like zonular dehiscence, posterior capsular rent, vitreous loss, and a nuclear drop do occur. [1] Even as small incision cataract surgery is gaining tremendous popularity in developing countries; extracapsular cataract surgery remains the time-tested technique in unusual and challenging types of cataracts. [2]

Pseudoexfoliation is an age-related degeneration of the basement membrane characterized by deposition of granular or fibrillar dandruff-like elastin material on ocular structures like the corneal endothelium, iris, anterior capsule of the lens, zonules, anterior vitreous, conjunctiva, and blood vessels. It is a systemic disease involving other organs such as the myocardium, kidneys, gall bladder, and dura as well; however, ocular manifestations are most obvious and associated with many complications. The most common ocular complication due to PEX is glaucoma, intraoperative posterior capsule rupture, and vitreous loss during cataract surgery.

In this study we have attempted to find the visual outcome following ECCE in patients with mature and hypermature cataracts with pseudoexfoliation (PEX) among the Omani population.

 Materials and Methods

In this retrospective, interventional, single-institutional study, 33 patients (35 eyes) having mature and hypermature cataracts with ocular PEX were selected, to determine the best corrected visual acuity one year after undergoing cataract surgery. Being a retrospective study, no approval was required from the Medical Research Ethics Committee of the institution, however, the study adhered to the tenets of the Declaration of Helsinki. Two patients had both eyes operated at different periods. All patients had undergone ECCE with PC-IOL. All the patients were admitted through the eye clinic at the University Hospital, over two years, from January 2007 to December 2008. The patients were identified from the electronic patient record (EPR). Preoperative evaluation included uncorrected visual acuity, best corrected visual acuity (using Snellen 6 meter charts), slit-lamp (Haag-Streit, Switzerland) biomicroscopy, applanation tonometry, Atlas topography (Nidek-Japan), A and B-scan (Alcon-USA) measurements for intraocular lens power calculation, and a detailed fundus examination, wherever applicable. To identify PEX, all the patients were subjected to slit-lamp examination before and after pupillary dilatation. The main areas of examination were pupillary margins and lens capsule. The exclusion criteria included any patient who had a past history of uveitis, complicated or secondary cataracts, major trauma or intraocular surgery. Only patients with nebular or macular corneal opacities, where examination of the pupillary margin and anterior capsule of the lens was not hindered, were included in the study.

Retinal examination was not possible in a majority of the cases due to dense cataract.

Systemic evaluation included plasma sugar, complete blood count, blood urea and electrolytes, EKG, and X-ray chest.

Surgical technique

All patients (35 eyes) were operated under subtenon anesthesia with lignocaine 2%. After preparing a superior fornix-based conjunctival flap, a 6-8 mm elliptical incision was fashioned 1-2 mm behind the limbus, followed by shaping of a partial-thickness scleral tunnel. Using a 1.2 mm super sharp, a paracentesis was made at 2 o'clock. The anterior chamber was entered centrally using 2.8 mm keratome. Trypan blue (0.1-0.3 ml) was used and left for 2-3 seconds, to make the anterior capsule visible. The anterior chamber was filled with Viscoat. A large 6-8 mm capsulorrhexis was fashioned using cystitome. The nucleus was delivered after extension of the wound and gentle hydrodissection. The cortical material was cleared using the automated irrigation-aspiration system. A single piece polymethyl methacrylate (PMMA) intraocular lens (Alcon MZ60BD) was implanted in all patients under a cushion of Viscoat in the capsular bag. Removal of the Viscoat and reformation of the anterior chamber was done with balanced salt solution. The wound was closed with a running 10.0 nylon suture. A subconjunctival injection of gentamicin 20 mg and dexamethasone 2 mg was given at the end. None of our patients had any intraoperative complications like vitreous loss or posterior capsular rent.


Thirty-five eyes from 33 patients having mature and hypermature cataracts with ocular pseudoexfoliation, underwent cataract surgery by the ECCE technique under subtenon anesthesia. The patients included 17 females (age range 50 to 76 years) and 16 males (age range 44 to 84 years). The unusual feature of this study was the presence of PEX in a relatively younger age group in both genders. The preoperative and postoperative visual acuities were compared at the end of the 12-month follow-up [Table 1].{Table 1}

The preoperative visual acuity (VA) ranged from light perception (LP) to 0.1. Majority of the eyes (37.14%) had a preoperative VA of CF ranging from close to face to one meter [Table 2].{Table 2}

Thirty eyes (85.71%) showed improvement in BCVA ranging from 0.2 to 1.0 Snellen lines. Four eyes (11.43%) had unchanged BCVA from the baseline [Table 3].{Table 3}

One eye (2.86%) that did not improve developed retinal detachment at the three-month follow-up and was referred to the Vireoretinal Unit and follow-up has been lost.

Four patients whose BCVA remained unchanged from the baseline were found postoperatively to have ocular comorbidites like myopic posterior staphyloma, glaucomatous optic atrophy, and age-related macular degeneration.


The reason why ECCE is still popular in developing countries is its low cost and non-availability of phacoemulsification surgeons for a huge volume of patients with mature and hypermature cataracts. Besides, this technique has provided almost similar BCVA as small incision cataract surgery or phacoemulsification. [3],[4] However, it cannot be denied that ECCE can or must overtake phacoemulsification in developing countries, but at the same time, the vision for all by 2020 goal must be kept in mind. ECCE must be given as good a ranking as phacoemulsification in mature/hypermature cataracts, in the developing and third world countries. At our center, mature and hypermature cataracts with PEX have been selected for ECCE, as we feel that it will be safer in the presence of PEX. Performing phacoemulsification in these eyes would have involved high ultrasound power, which, in the presence of PEX would have put immense stress on the already fragile zonules and PEX-related corneal endothelium. Studies have confirmed higher rates of intraoperative posterior capsule tears and vitreous loss in phacoemulsification for advanced cataracts when compared to ECCE. [5],[6] This rate is likely to be higher (4-13%) in patients with PEX-related zonulopathy. [7],[8] Posterior capsule rupture rates of more than 10% have been reported, which is much higher than the rate reported in the National Cataract Surgery Survey of the United Kingdom. [9] One of the major risk factors for unplanned intraoperative conversion of phacoemulsification to ECCE is the prolonged phacoemulsification required for dense nuclei, especially in the presence of PEX. [10] Keeping all these high figures of complications associated with phacoemulsification in hypermature cataracts, we opted for the simple and safe technique of ECCE, as all our patients had PEX as well, and had no regrets with the visual outcome achieved, with no intraoperative complications.

Keeping in mind the poor educational status and semirural background of our patients, all the patients had continuous 10.0 nylon suturing, as we felt it would ensure better wound sealing. We used automated irrigation and aspiration, assuming it would ensure better chamber stability in PEX eyes, compared to the manual technique.

This study reveals the time-tested efficacy of ECCE in difficult cases, especially where the status of the zonules, in the presence of PEX, is highly uncertain.

The World Health Organization still recommends simple methods to evaluate the outcome of cataract surgery in terms of visual acuity. [11] Previous studies have shown that ECCE can restore functional vision, in developing countries. [12] The operative reasons for unchanged visual outcome in four patients could be explained on the basis of their macular and/or optic disc pathology, which could not be ascertained preoperatively due to the dense cataract. One patient developed retinal detachment, and this could not have been anticipated before surgery. The vision outcome (1.0 to 0.2) in our study (85.71%) was comparable to the one done by Gogate et al., (86.7%). [4] However, unlike our patients, Gogate's study did not have PEX in all patients and their vision outcome ranged from 6/6 (1.0) to 6/18 (0.3). Tobin et al., have reported BCVA of 6/24 (0.25) in 74% patients at the end of one year, operated by the ECCE technique, with IOL implantation, with no major sight threatening complications. [13] Our results appear much better quantitatively, knowing that all our patients had PEX.

Extracapsular cataract surgery remains the option of choice at centers where the preoperative status of the zonules cannot be assessed due to the nonavailability of imaging techniques like Pentacam or the Optical coherence tomogram.

The limitation of our study is its non-comparative nature to BCVA after ECCE in mature and hypermature cataracts without PEX. Pseudoexfoliation is commonly a disorder of old age, with the majority of the patients in the age group of sixties and above. Our patients had PEX even in their forties and fifties. This may be attributed to environmental, geographic or genetic predisposition in the Arabian Peninsula. Large, prospective, and controlled studies are required to confirm such an association.

In conclusion, this study confirms that the ECCE technique is still a needed procedure in certain situations where a good visual outcome can be achieved at minimal risk and cost. The technique still goes a long way in visual rehabilitation in the developing and underdeveloped countries, where modern equipment or manpower may not be available. To cure the backlog of the curable blind, ECCE can go a long way in achieving the target. [14]


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