Prevalence and Prognosis of Pseudoexfoliation Glaucoma in Western India

Transcription

1 ORIGINAL CLINICAL STUDY Prevalence and Prognosis of Pseudoexfoliation Glaucoma in Western India Vinita Rao, MS, Ophthalmology,* Mariam Doctor, MS, Ophthalmology,* and Girish Rao, MS, OphthalmologyÞ Purpose: To investigate the prevalence and reconnoiter treatment modalities for Pseudoexfoliation Glaucoma (PXG) in subjects with Pseudoexfoliation Syndrome (PXF) in a rural scenario of western India. Design: A prospective prevalence study. Methods: Occurrence of PXG in 250 subjects with PXF was studied in the Department of Glaucoma, Shri Ganapati Netralaya, Jalna, India, from 2009 to The subject pool presented with PXF, having intraocular pressure (IOP) Q 20 mm of Hg, and evidencing optic nerve damage and abnormal visual fields were judiciously selected as PXG cohorts. A decision table is formulated to assist the physician in rendering medical or surgical treatment options. Results: The prevalence of PXG increased with increasing age at 30% (95% CI: 28.56Y33.72) in the 60-year-old and older population. It was predominantly higher in cohorts involved in outdoor physical activities at 46% (95% CI: 41.24Y52.38). The eminence and prevalence of nuclear cataract in subjects with PXG was 72 % (95% CI: 65.72Y76.34). Visual impairment was highly prevalent in 75% (95% CI: 73.43Y78.29) and 10% (95% CI: 6.87Y13.21) cohorts with PXG and PXF respectively. In general, linear modelling IOP was 26.37T1.64 in subjects with PXG, which was managed to 16.50T1.32 after rendering our adapted treatment protocols. Conclusions: Increased IOP, occludable angles, and glaucomatous optic neuropathy occur more frequently in the population with PXF. It is inferred that that treatment protocol of combined cataract and glaucoma surgery gives maximum reduction in IOP. Key Words: pseudoexfoliation, glaucoma, intraocular pressure (Asia<Pac J Ophthalmol 2015;4: 121Y127) Pseudoexfoliation syndrome (PXF) is the most common identifiable cause of glaucoma, accounting for the majority of cases in many countries and causing both open-angle glaucoma and angle-closure glaucoma. 1Y10 Owing to pseudoexfoliation glaucoma s (PXG s) prevalence and severity, ophthalmologists should examine the eye for signs of PXF, as it is a major risk factor for glaucoma, and early treatment should be undertaken, to prevent damage to the optic nerve. 4Y20 Treatment approach to PXG is 2-fold, that is, medical and surgical. Medical management is similar to that for primary open-angle glaucoma and includes the use of aqueous suppressants, prostaglandin analogs, and miotic agents. 14Y25 However, PXG is frequently more resistant to From the Departments of *Glaucoma and Retina, Shri Ganapati Netralaya, Jalna, Maharashtra, India. Received for publication May 2, 2013; accepted June 14, The authors have no funding or conflicts of interest to declare. Reprints: Mariam Doctor, MS, Ophthalmology, Department of Glaucoma, Shri Ganapati Netralaya, Develgaonraja-Mantha Rd, Jalna, Maharashtra , India. mariamhd@gmail.com. Copyright * 2013 by Asia Pacific Academy of Ophthalmology ISSN: DOI: /APO.0b013e3182a0af43 medical management and has a higher failure rate, compared with primary open-angle glaucoma. 2Y6,12,13,22Y30 Surgical intervention includes cataract surgery alone or combined cataract surgery with trabeculectomy and intraocular lens (IOL) implantation. 12,14,18,31Y39 The results of trabeculectomy are favorable, with no significant difference in the postoperative complication rate, compared with filtration surgery for primary open-angle glaucoma. 5,8,9,11,13Y20,40Y44 Having established the importance of early and extensive diagnosis of PXF syndrome, we undertake this study on patients with PXG from Western India. This prospective study was performed in an effort to comprehensively analyze our clinical experience and determine the prevalence of PXG in India. We followed up 250 patients at Shri Ganapati Netralaya, Jalna, over a period of 2 years from 2009 to These clinical and epidemiological data were analyzed, and prognosis is deciphered from the results. MATERIALS AND METHODS The subject pool was selected from the presenting participants diagnosed with PXF, satisfying the inclusion criteria of intraocular pressure (IOP) of 20 mm Hg or greater, glaucomatous optic nerve damage, and abnormal visual fields. Subjects excluded from investigation composed of those with a history of intraocular surgery, previous uveitis, pigment dispersion syndrome, and traumatic angle recession. Comprehensive ocular examinations were performed for all eligible subjects after an interview to collect demographic details and personal risk behavior, dietary history, and utilization of eye care services. Ocular examinations were conducted in a clinic specially set up for the study at our institute. First, we measured distance and near visual acuity, both presenting (with current refractive correction if any) and best corrected after refraction, with logarithm of minimum angle of resolution (logmar) charts. Furthermore, we performed an external eye examination, assessment of pupillary reaction, and anterior segment examination with a slit-lamp biomicroscope. Slit-lamp evaluation of the anterior segment was performed with Topcon slit-lamp SL-3F (Topcon Medical Systems, Oakland, NJ), with careful search for PXF deposits. Intraocular pressure was recorded by Goldmann applanation tonometry (Topcon Medical Systems, Oakland, NJ). Gonioscopy was performed on all subjects using a Sussmann type 4 mirror handheld gonioscope (Ocular Instrument, Bellevue, WA). Gonioscopy was first done using a short beam that does not cross the pupil, and indentation gonioscopy was performed whenever necessary. If pigmented, posterior trabecular meshwork was not visible in three fourths or more of the angle circumference, in the primary position, without manipulation in the presence of low illumination, the angle was considered occludable, otherwise open. Subjects with open angles had their pupils dilated with 5% phenylephrine and 1% tropicamide eye drops. If phenylephrine was contraindicated, 1% homatropine eye drops were used instead. If the angles were found to be occludable, the need for laser iridotomy was explained Asia-Pacific Journal of Ophthalmology & Volume 4, Number 2, March/April

2 Rao et al Asia-Pacific Journal of Ophthalmology & Volume 4, Number 2, March/April 2015 to the subject, and it was performed after obtaining the subject s consent. The rest of the examination was deferred to another convenient date following the laser iridotomy. Repeat slit-lamp evaluation was done after dilatation for biomicroscopic evaluation. The anterior lens capsule was examined again for PXF deposits under dilatation. The subject was classified as having PXF syndrome if PXF material was present in either or both eyes. Cataract grading was performed adhering to the LOCS II system. Stereoscopic evaluation of the fundus and the optic disc, with the indirect ophthalmoscope and the +90-diopter (D) lens, was performed. The vertical cup-to-disc ratio was assessed in units of The eyes were considered glaucomatous if the vertical cup-to-disc ratio was 0.60 or more in either eye, asymmetry in cup-to-disc ratio of greater than 0.2 between the 2 eyes, neuroretinal rim of less than 0.2 was seen in any quadrant in either eye, a notch was seen in the disc in either eye, or a disc hemorrhage or nerve fiber layer defect was observed. Fundus examination was also performed with the indirect ophthalmoscope with a 20-D lens. Automated visual fields were performed with the Humphrey visual field analyzer using the threshold central 24-2 strategy (stimulus size III) in those participants assessed to have suspected glaucoma. Visual fields were considered unreliable if fixation losses were greater than 20% and if false-positive and false-negative responses were greater than 33%. Amalgamated statistical correlations were performed using Fisher exact test, Wilcoxon signed rank test, analysis of variance (ANOVA), and t, z, and W 2 tests for identification of relevant trends for treatment protocol. The 95% confidence intervals (CIs) were calculated by assuming a Poisson distribution for prevalence of less than 1% and normal approximation of binomial distribution for prevalence of greater than 1%. Random-effects repeated model of generalized estimating equations modeling was used to test the association of PXF with blindness and PXG defined at eye level, considering subjects as random factors and adjusting the SEs after computing the within-subject correlation of the eyes. To compare the mean differences and trends in IOP, we adapted general linear modeling and univariate and repeated-measures ANOVA. Differences at a 2-tailed level of P G 0.05 were accepted as statistically significant changes. RESULTS Of the 250 subjects evaluated in the study diagnosed with PXF, 50 (20%) presented PXG and fulfillment of our inclusion criteria over the span of 2 years. The prevalence statistics are summarized in Supplemental Digital Content 1 ( The occurrence of PXG was significant in the rural population at 10% (adjusted odds ratio [aor], 1.87; 95% CI, 0.1Y3.76), and the difference was statistically significant (P G ). Of the PXG study subjects, 38 (15%) were male, and 12 (5%) were female, with 43 (17%) engaging in outdoor activities and 40 (16%) belonging to the extreme or lower socioeconomic status. The occurrence of blindness was not significant with PXF (aor, 1; P G ); however, presence of cataract was statistically significant (aor, 18.67; 95% CI, 14.27Y87.64; P G ). From the subjects with PXG, 22 (44%) had unilateral disease, whereas 28 (56%) showed bilateral. Of those with unilateral disease, 15 (68.20%) were in the right eye, and 7 (31.80%) were in the left eye, thus totaling the number of eyes studied to be 78 in 50 subjects. The mean age of subjects with PXG was 65.5 (C = 6.40) years, whereas the mean age of subjects with PXF was (C = 10.49) years. Gonioscopic evaluation with a Sussmann type 4 mirror handheld gonioscope showed open angle in 32 subjects (aor, 17.46; 95% CI, 14.76Y40.87; P = ), the prevalence being statistically significant. Angles were considered occludable if the posterior trabecular meshwork is not seen for less than three fourths of the angle circumference. On the basis of the gonioscopic findings, patients either were dilated for further examination or underwent YaG laser iridectomy. Good mydriasis was obtained in 24 subjects (10%) (aor, 12.47; 95% CI, 16.82Y34.58; P G ). Pseudoexfoliation syndrome material deposition in the angle increased with higher trabecular meshwork pigmentation (4+ aor 8.71; 95% CI, 6.89Y28.54; P G ). We also found 48 eyes with pigmentation on endothelium, 54 with PXF on lens capsule, 5 each with iridodonesis and phacodonesis, and 3 with lens subluxation. The evaluation of C:D ratio indicates a slight progression with a higher F value of ANOVA as compared with the null The slight factor is confirmed by a low regression in the z value (j0.672) and almost equivalence of U and F and a higher P value at The K T C best corrected visual acuity (BCVA) for the 6/60 to 6/12 range was T and T for the initial and final follow-ups, respectively (aor, 98.17; 95 CI; 33.41Y145.27). In the cataract-operated eyes, a significant change in BCVA is shown by a high F value (42.48; null 3.77), and the improvement trend is validated by a negative z value (j4.76; U = 19.48; P = ). Root mean square error analysis of BCVA, as shown in Figures 1A and B for surgically managed subjects, shows a K T C root mean square error of T The lower root mean square error (G0.5) indicates a good improvement in BCVA after surgical procedures. Intraocular pressure, being an important indication of the treatment outcome, was calculated on quarterly follow-ups after the initial visits, for comparison, and was construed with a negated hypothesis of no change in IOP, for strong rejection. The K T C IOP for the 60- to 70-years age range was T 6.28 and T 3.28 for the initial and final visits, respectively (aor, ; 95% CI, 18.28Y189.32). F value of 1.73 (null = 1.61) suggests good improvement in IOP, and the positive z value of (U = 15.3) validates our negated hypothesis of no change in IOP. This is seen from the prevalence change of 52 subjects in the 20- to 30-mm Hg IOP range initially, to 67 in the 10- to 20-mm Hg IOP range in final, with their high F value (76.22: 10Y20 mm Hg; 82.18: 20Y30 mm Hg) and negative z values (j12.31: 10Y20 mm Hg; j10.28: 20Y30 mm Hg). Subject-wise IOP comparison is shown in the graph in Figure 2. During the initial visit, we note that the IOP is less than 30 mm Hg in all the subjects in the age group of younger than 60 years. However, the IOP is greater than 30 mm Hg in 11 eyes (15.73%) in the age group of those older than 70 years, which is further decreased by 53.07% after treatment. This indicates that IOP is higher in older PXG cohorts who were subjected to surgical modalities. Humphrey visual field analysis was performed on all the 70 eyes, for all the visits. The K T C pattern standard deviation and mean deviation on the decibel scale was 6.00 T 2.26 and j18.45 T 9.97 initially and 8.46 T 1.24 and j19.55 T 4.98 at final follow-ups, respectively. These values indicate stability in most of the patients (71.8%), but some subjects, totaling 22 (28.2%) eyes, showed progression, and they were shifted to higher treatment modalities. The parametric findings are substantiated in Table 1, and the corresponding treatment decision matrix is documented in Table 2. Based on the evaluation, from the study population of n = 70 eyes in the initial visit, 36 eyes were designated for medical treatment, whereas 34 eyes were assigned surgical modality. Of * 2013 Asia Pacific Academy of Ophthalmology

3 Asia-Pacific Journal of Ophthalmology & Volume 4, Number 2, March/April 2015 Pseudoexfoliation Glaucoma in Western India FIGURE 1. A, Best corrected visual acuity tracking for the medical and surgical treatment protocol showing BCVA improvement due to removal of cataract. B, Root mean square error analysis on the surgical protocol values of BCVA on initial and final follow-up. the 36 eyes, 2 were assigned for 1 drug (timolol maleate [TM]), 4 for 1 drug (prostaglandin analog), 17 for 2 drugs, 7 for 3 drugs, and 6 for maximum medical therapy, respectively. In the surgical domain, subsets were assigned for patients who required only cataract surgery and those who required triple surgical modalities. For cataract only, 6 subjects were assigned for extracapsular cataract extraction (ECCE) + IOL, 1 for intracapsular cataract extraction (ICCE) + scleral fixated introacular lens implantation (SFIOL), and 8 for phacoemulsification + IOL. For triple surgical procedure, 2 subjects were assigned ECCE trabeculectomy, and 17 underwent phacoemulsification + trabeculectomy, respectively. At the 6 monthly follow-ups, the subjects were evaluated against their responsiveness to the treatment offered to them. Subjects who responded with the defined evaluation criterion were continued with the same treatment. However, 22 (28.2%) of the 78 eyes of study population were offered a change in their treatment protocol as documented in Table 3. We notice from the F values that majority of the changes prescribed were from medical to surgical protocols, further verified by the negative z trend in the U test. During surgical procedures conducted on the 34 eyes, intraoperative complications arose in 7 (20.6%), data quantification of which is shown in Table 4. Intraoperatively, zonular dehiscence was noticed in 3 eyes (8.8%), and posterior capsule rent was developed in 4 eyes (11.8%). However, precautions were taken to overcome these complications. For eyes in which zonular dehiscence was exhibited, they had preoperatively been diagnosed with phacodonesis and iridodonesis. However, because the zonular dehiscence was less than 4 clock hours, IOL implantation was possible. For eyes in which vitreous loss was observed, anterior vitrectomy was performed. In the eyes that developed posterior capsule rent, anterior vitrectomy was performed, and adequate posterior capsule support was ensured for secondary lens implantation. On the first day of postoperative examination, corneal edema was observed in 4 eyes (11.8%), and cellular reaction FIGURE 2. Comparison in improvement of IOP at each follow-up for each treatment protocol. * 2013 Asia Pacific Academy of Ophthalmology 123

4 Rao et al Asia-Pacific Journal of Ophthalmology & Volume 4, Number 2, March/April 2015 TABLE 1. Bivariate and Multivariate Logistic Regression Analyses for Control and Evaluation Parameters PXG Parameters Initial Final Adjusted* Odds Ratio F (Null) z (U) P Cup disc ratio (n = 78) 0.7Y (1.28Y19.47) (14.98) j0.358 (15) Y (1.49Y16.45) (14.67) j0.672 (14.52) e (2.34Y7.38) (14.63) 0 (0) 0 BCVA (n = 78) G6/ (7.82Y88.34) (4.35) j2.45 (18.32) /60Y6/ (33.41Y145.27) (3.77) j4.76 (19.48) /9Y6/ (54.29Y213.64) (4.24) j6.23 (21.35) IOP (n = 70) 10Y (24.54Y213.20) (1.23) j12.31 (34.82) Y (32.18Y224.76) (3.43) j10.28 (36.92) Y Y IOP (age) (n = K T C) 50Y T T (23.61Y231.14) 1.86 (1.59) (1.37) Y T T (18.28Y189.32) 1.73 (1.61) (1.53) Y T T (7.82Y121.58) 1.82 (1.64) (1.62) Humphrey visual field (n = 78) Optic nerve head (55.65Y98.32) 1.48 (1.49) 0 (0) (Glaucoma hemifield test) Mean deviation (db) (K T C) j18.45 T 9.97 j19.55 T 4.98 j18.76 (j15.65 to j1.32) 3.23 (3.12) (3.43) Pattern standard deviation (db) (K T C) 6.00 T T (1.27Y15.75) 4.59 (4.24) (4.57) *Adjusted for age, gender, and area. One-way ANOVA. Mann-Whitney U test. Average value from the paired t test. fibrin formation was observed in 5 eyes (14.7%). For patients with corneal edema, we used a step-up in the steroids therapy. Systemic steroid therapy was started in patients with cellular reaction fibrin formation. DISCUSSION Pseudoexfoliation syndrome is associated with cataract and glaucoma and is the most common identifiable form of TABLE 2. Treatment Decision Matrix secondary open-angle glaucoma worldwide. 10Y18,25Y31 The association of PXG and PXF is well established in several studies. 1Y44 Our study predominantly involved the older age group, with majority of the subjects being older than 55 years at the time of presentation, similar to that reported by previous studies. Although it showed a prevalence of male over female (3.2:1), we cannot rule out a gender referral bias because male patients presented to our Ophthalmic Outpatient Department more than did the female counterparts. However, it reflects the larger amount of outdoor activities and occupational hazards to which males are exposed. There was, however, no preponderance Treatment Protocol Decision Criterion Cup Disc Ratio Humphrey Visual Field 90.5 Visual field loss above or below the central fixation 90.8 Superior and inferior arcuate scotoma 90.9 Extensive visual damage in the central 10 degrees of fixation Target Pressure 16Y18 mm Hg 14Y15 mm Hg 12Y14 mm Hg Treatment Modality 1Drug 2 Drugs Cataract extraction 2 Drugs 3 Drugs Cataract extraction Maximum medical therapy Triple procedure TABLE 3. Intraoperative and Postoperative Complications and Remedies Intraoperative Complications Type No. Eyes (%) Precautions Adopted Intraoperative Zonular dehiscence 3 (8.8) G4 clock hours + IOL implantation possible Posterior capsular rent 4 (11.8) Anterior vitrectomy + posterior chamber IOL implantation Postoperative day 1 Corneal edema 4 (11.8) Step-up: topical steroid therapy Cellular reaction 5 (14.7) Step-up: topical steroid therapy Fibrin formation Systemic Steroid Therapy * 2013 Asia Pacific Academy of Ophthalmology

5 Asia-Pacific Journal of Ophthalmology & Volume 4, Number 2, March/April 2015 Pseudoexfoliation Glaucoma in Western India TABLE 4. Treatment Modulation Multivariate Logistic Regression Analyses Treatment Parameters Initial Final (+/j) Adjusted* Odds Ratio F (null) z (U) P Medical 1 Drug prostaglandin analogues 2 2 (2/2) 6.43 (1.34Y13.56) (13.45) j2.43 (16.34) Drug timolol maleate 4 3 (2/3) 5.21 (1.76Y9.23) (14.71) j3.15 (14.75) Drugs (1/4) 4.67 (1.89Y8.35) (15.32) j3.21 (12.28) Drugs 7 9 (5/3) 3.21 (1.94Y7.68) (17.35) j3.78 (10.27) MMT 6 7 (5/4) 2.89 (2.15Y5.65) (20.81) j3.92 (9.83) Surgery Cataract surgery ECCE 6 7 (3/2) 0.32 (0.01Y1.32) 2.34 (2.29) j0.049 (3.46) G0.001 ICCE + SFIOL 1 1 (1/1) 0.21 (0.01Y1.19) 2.75 (2.56) j0.024 (3.75) G0.001 Phacoemulsification + IOL 8 8 (1/1) 0.18 (0.01Y1.13) 2.86 (2.67) j0.072 (4.21) G0.001 CAT + trabeculectomy + IOL ECCE trabeculectomy 2 2 (1/1) 0.75 (0.01Y0.85) (12.11) 0 (11.73) G0.001 Phacoemulsification + trabeculectomy (1/1) 1 1 (1) 0 (1) 0 *Adjusted for age, gender, and area. One-way ANOVA. Mann-Whitney U test. Average value from the paired t test. found in the eye, which was affected. We also found that 10.25% of those with PXF were blind, similar to data reported from Southern India (25.7%) and Aravind Eye (20.5%). 7,9,21,26,33,40,41 Previous studies have shown a marked age-related increase in the prevalence of PXF; typically less than 1% in persons younger than 60 years and increasing to 6.28% among subjects 60 years or older. 1Y14,23Y28,33Y42 Although the reason for this age-related increase is unknown, it has been speculated that the changes in gene expression that occur with age may be responsible. 12,18,23 Our prevalence estimates for those 55 years or older are slightly higher than those in the recent report from Chennai 26 (3.08%; 95% CI, 3.50Y4.05) and those reported from Madurai 42 (6.0%; 95% CI, 5.3Y6.6), both in southern India. In our study of the 250 subjects presenting at our institute, diagnosed with PXF, 50 subjects (20.0%) presented PXG and fulfillment of our inclusion criteria over the span of 2 years. The age-specific standardized PXG rate (direct standardization using the population estimates for the United States for the year 2000 as the standard) in our study population, for those 55 years or older, was similar to the age-standardized rates of PXF in the Chennai 40Y44 study and Blue Mountains Eye Study 45 and higher than the rates in the Framingham Eye Study 46 and Visual Impairment Study. Specifically in our study, we had 68% of the subjects older than 60 years, which is in concurrence with the previous studies in India. 26,40Y43 However, the age-specific standardized PXF rates in other populationbased studiesvone from southern India 42 and another from central Iran, 47 were high in comparison to those in our study at 84%. Differences in prevalence of PXF across populations have to be interpreted with caution, considering the difficulties and lack of standardization in diagnosis and the potential for subclinical or early cases to be missed. 23,37,42Y44 There are conflicting reports of gender differences in the prevalence of PXF. 12,19,26,38,42,43,46,48 We found the prevalence of PXF among men to be higher than that among women. We also found a strong association between PXF and occupation. The fact that people exposed to outdoor activity as part of their occupation had a significantly higher prevalence of PXF, compared with those whose occupation was restricted to indoor activity, provides some support to the theory of an association between environmental factors (possibly solar radiation) and PXF. The majority of India s population (,58%) depends heavily on the agricultural sector for employment and income and would be exposed to outdoor activities in a routine way, which constitutes a significant risk factor for the occurrence of PXF in this population. Slit-lamp biomicroscopic examination (especially dilated) and gonioscopic evaluation of the angles are necessary to identify the presence of PXF, especially on the lens or TM. Many ophthalmologists still primarily rely on IOP measurements only for primary testing of glaucoma. 21Y29,33Y44 Routine slit-lamp and dilated examinations must become preferred practice if PXF is to be detected. Layden and Schaffer 49 reported a 23% prevalence of narrow angles in 100 patients with PXF. Wishart et al 44 reported 18% occludable angles in their 76 patients with PXF. A rigid and sticky iris, a greater tendency to form posterior synechiae, and anterior lens subluxation due to zonular weakness have been thought to predispose to these conditions, which are worsened by miotic therapy. Many studies did not include gonioscopy routinely on all subjects. In addition to differences in study design and target populations, variations between previous studies and our study may have been the result of differences in the definition of narrow angles, miotic use in the earlier days when these studies were reported, and true differences in the prevalence of angle closure between the populations. 1Y20,33Y46 In our study, we performed the gonioscopic evaluation and found that from the presenting subjects 11 (15.7%), 47 (67.1%), and 12 (17.2%) had closed, open, and occludable angles, respectively. We found 49 eyes with pigmentation on endothelium, 54 with PXF on lens capsule, 5 each with iridodonesis and phacodonesis, and 3 with lens subluxation, which is similar to the findings of Krishnadas et al 41 and Wishart et al. 44 In our study, theoretical cup-to-disc ratio was assessed in units of The C:D ratio was measured for patients at initial presentation, 6 months, and final follow-up. Our results are similar to those reported in the earlier studies with a mean C:D ratio of at the 6-month follow-up. Our progression in disease was similar to that in the study of Puska et al 11Y13 at 7.65% of the evaluated eyes. * 2013 Asia Pacific Academy of Ophthalmology 125

6 Rao et al Asia-Pacific Journal of Ophthalmology & Volume 4, Number 2, March/April 2015 According to the study by Arvind et al 42 and Ramakrishnan et al, 41Y43 the increasing prevalence of PXF and cataract with age and the association of PXF with the most common type of cataract (nuclear cataract) have public health implications for India. Improved health care results in a definite demographic shift toward aging in India that may result in a higher burden of both PXF and cataract. Eyes with PXF have a greater frequency of complications, such as zonular dialysis, posterior capsular rent, and vitreous loss at the time of cataract extraction. In our study, 36 (51.42%) of the eyes were designated for medical treatment, whereas 34 eyes were assigned surgical treatment. In the surgically treated cohorts, because of presence of inherent zonular weakness, observed preoperatively, 6 subjects were assigned for ECCE IOL and 2 subjects for ECCE trabeculectomy + IOL. One subject, who evidenced gross subluxation of lens, underwent ICCE + SFIOL. For triple surgical, 2 subjects were assigned ECCE trabeculectomy, and 17 underwent phacoemulsification + trabeculectomy, respectively. During surgical procedures conducted on the 34 eyes, intraoperative complications arose in 7 (20.6%), which is in agreement with the existing studies. The surgical procedure is more difficult because the pupil may not dilate well. It has also been shown that patients with PXG have a higher risk of acute increase in IOP after cataract surgery. Postoperative complications of posterior capsular opacification, capsule contraction syndrome, IOL decentration, and inflammation are also greater in eyes with PXG. A preoperative diagnosis of PXF and appropriate precautions during surgery may help to reduce the frequency of complications. If the risk of complications is increased in the earlier stages of PXF (brown and precapsular), the magnitude of the problem is likely to be even higher. Despite meticulous preoperative assessment to look for evidence of zonular weakness, intraoperatively 4 eyes (11.8%) had posterior capsular rent with vitreous loss, and zonular dehiscence was noticed in 3 eyes (8.8%), which is in agreement with the studies by Eagle et al 50 and Madden and Crowley. 51 Postoperative problems may include an increased risk of synechia formation and pupillary block, rapid development of capsular thickening requiring laser capsulotomy, cystoid macular edema in the presence of capsular trauma resulting in vitreous loss, transient IOP spikes, and progression of glaucomatous optic neuropathy. Schlotzer-Schrehardt et al 7 and Koliakos et al 8 reported corneal edema in 10.5% of the patients on the first day of postoperative examination may be attributed to higher IOP at presentation. Bartholomewl 52 reported fibrin formation in about 19% of the eyes. In our study on the first day of postoperative examination, corneal edema was observed in 4 eyes (11.8%), and cellular reaction was observed in 4 eyes (11.8%) with fibrin formation in 1. For patients with corneal edema, we used a step-up in the steroid therapy, and systemic steroid therapy was started in patients with cellular reaction fibrin formation, which is in agreement with the existing studies. However, in studies by Wilson, 53 only 4% of the patients developed cornea edema and 5% of the patients had fibrin formation in their eyes, which are comparatively much lower instances than that encountered by us. In a study by Brooks and Gillies, 54 they found that 25% of the subjects who were offered medical treatment initially had to be shifted to either stronger medical treatment or surgical procedures. This was also noticed in studies by Vannas et al, 55 Aasved et al, 56 and Lundvall and Zetterstrom 57 at 22%, 24%, and 33% of the PXG population, respectively. In consensus with these studies, we also found that at the 6-month follow-up, 22 (28.2%) of the 78 eyes of the study population were offered a change in their treatment protocol. After opting for higher treatment modalities, the target reduction of IOP in these eyes was achieved successfully, which is in agreement with the existing studies. In summary, we found a 20% prevalence of PXG in PXF eyes in this rural population of Western India aged 50 years or older. We found that increased IOP, occludable angles, and glaucomatous optic neuropathy occur more frequently in the population with PXG and PXF. Many major questions about PXF syndrome still remain obscure. The variation of its prevalence in different populations, its pathogenesis, and the composition of extraocular deposits are some of the topics that have to be clarified. 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