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ARTICLES
Year : 1971  |  Volume : 19  |  Issue : 4  |  Page : 155-159

Ocular changes following cataract extraction : Goniosynechias


Aligarh Muslim University Institute of Ophthalmology and Jawaharlal Nehru Medical College, Aligarh, India

Correspondence Address:
K Nath
Aligarh Muslim University Institute of Ophthalmology and Jawaharlal Nehru Medical College, Aligarh
India
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Source of Support: None, Conflict of Interest: None


PMID: 15745413

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How to cite this article:
Nath K, Vaid R L. Ocular changes following cataract extraction : Goniosynechias. Indian J Ophthalmol 1971;19:155-9

How to cite this URL:
Nath K, Vaid R L. Ocular changes following cataract extraction : Goniosynechias. Indian J Ophthalmol [serial online] 1971 [cited 2020 Aug 3];19:155-9. Available from: http://www.ijo.in/text.asp?1971/19/4/155/34973

Table 1

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Table 1

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Goniosynechia and secondary glaucoma are more frequent in cases, where the operative and post-operative complications like retained lens matter, flat anterior rhamber, vitreous loss, and irido­cyctitis occur after cataract ex­traction - Hughes and Owens [1] ; Kronfeld and Grossman [2] ; Lee and trotter [3] ; and Miller, Kesky and Becker [4] The purpose of the pre­sent study was to assess the effect of cataract extraction on the gonioscopic appearance of the angle of the anterior chamber in cases where the above mentioned complications did not occur.


  Materials and Methods Top


A group of 56 patients, with un­complicated senile cataracts in­cluded in this study, were sub­jected to pre- and post-operative gonioscopic examination.

Width of anterior chamber angle, type and extent of the pig­ment were charted in accordance with the method suggested by Schie [5] . For the purpose of record­ing, the angle of the anterior chamber was divided into 12 equal portions, like the hours of a clock, each division thus being 8.3% of the circumference. Type of gonio­synechia. whether band-shaped, cone-shaped or filamentary were noted. Cases with synechia and inflammatory conditions were not included in the present study.

All the cases were operated by the same surgeon and a similar surgical procedure was adopted in all cases, the variations being in the mode of extraction (intra­ or extra-capsular) and type of iri­dectomy.

Rupture of the capsule, vitreous loss, hyphaema, or other opera­tive complications were noted, and excluded from the present study. Cases were closely watched during the post-operative convalescence, the progress and compli­cations, if any were recorded.

6-24 weeks after the operations slit lamp and gonioscopy were performed. The location, extent, and type of peripheral anterior synechiae were charted. The width of the angle of anterior chamber and pigmentation were again recorded.


  Results Top


On gonioscopic examination after the cataract extractions, peripheral anterior synechiae of varying extent and types were seen in 35 cases (62.5%) out of a total of 56. These synechiae were either band shaped (28 cases), cone shaped (7 cases) or filamentary. The first type was very often as­sociated with other types while the filamentary type was invari­ably combined with the other two. Synechiae covered a variable extent of the circumference of the angle of the anterior chamber. [Table - 1] shows the results under the various categories. In the last two where more than half of the angle was included they had marked pigment dispersion over the angle recess. Although the in­traocular pressure in them was within normal limits (less than 20 mm of Hg.), the facility of out­flow was markedly impaired. On the basis of these observations, these cases were catagorised as suspicious cases of early secondary glaucoma.

Complete iridectomy was done in 19 cases. Gonioscopic examina­tion revealed that following com­plete iridectomy the iris stump left behind was invariably stuck or pulled towards the structures in the angle of the anterior chamber [Figure - 1].

Peripheral button hole iridec­tomy was done in 37 cases. The upper margin of the hole was free in 25 cases, while in the re­maining 12 it was gummed or pul­led towards the structures of the angle recess. In 4 cases (10.8%) the iris tissue along with the iri­dectomy pillar was either incarce­rated or adherent with the inci­sion scar. The facility of out­flow had increased in these cases, while it either decreased or remained unchanged in the rest [Figure - 2].


  Discussion Top


One is inclined to believe that after uneventful survey and con­valescence, in cases of cataract, the eye is not likely to show any subsequent complications. The studies of Kronfeld and Grossman [2], Miller. Kesku and Becker [4] and Trotter [3] in addition to our own, show that half to three-fourth of all the cases operated for cataract develop peripheral anterior syne­chiae to a variable extent. Kron­keld and Grossman [2] found them in the majority of his cases operated for cataract, while in the series of Miller et a1 [4] they were present in 74% cases. In our own series of 56 eyes, the goniosynechiae which were present in 62.5% cases, were absent prior to survery. Our ob­servations are in fair agreement with those of Kronfeld and Gross­man [2] and Miller et al [4].

Considering the effect of the mode of cataract extraction, it was observed that anterior peri­pheral synechiae are more fre­quent and extensive in cases of extra capsular extractions as com­pared to the intra-capsular method [Table - 1]. Goniosynechiac in 20 cases of intracapsular extraction, involved less than half of the cir­cumference, and after extracap­sular extraction in 2 cases they involved half to three fourth of the angle circumference, [Figure - 3] while in the remaining 13 cases they covered less than one-fourth.

The facility of outflow was not significantly affected by the gonio­synechiae, when they covered less than half of "he circumference but in those cases where they were very extensive (three-fourth of circumference) facility of outflow was markedly decreased and out­flow value was above 120 for warning the subsequent develop­ment of aphakic glaucoma. Hug­hes and owens [1] reported that ap­hakic glaucoma is three times more comon after extra-capsular extraction than in intra-capsular, while Miller et al [4] gave the inci­dence of aphakic glaucoma as 30 per cent of all the extra-capsular cases. In the present, study, apha­kic glaucoma developed in 2 cases, i.e. 10.5% of all the extra-capsular extractions. The incidence of ap­hakic glaucoma could be reduced further if the cortical matter is completely washed out at the time of operation.

Going into the aetiology of these post-operative peripheral gonio­synechiae, it appears that they are more likely to form in cases where the angle is narrower and the full depth of anterior cham­ber is not attained either on the table or during the first few days after surgery. More frequently they occur in cases with opera­tive and post-operative compli­cations like a leaking section, per­sistant shallow anterior chamber, delayed healing of the section, prolapse of vitreous in the ante­rior chamber, post-operative iri­docyclitis and in cases with left over cortical matter.

As half to three-fourth of all the nicely operated uncomplicated cases of cataract. manifest gonio­synechia following surgery, and most of them do well subsequently as well, all These eyes can not be labelled as Pathological. At the same time the post-operative goniosynechiae formation cannot be regarded as a normal or physio­logical phenomenon, as a certain number of cases with extensive goniosynechiae do go into the glaucomatous stage due to de­crease in the facility of outflow.

Our studies show that amongst the 30 cases out of 35, who deve­loped goniosynechiae, the extent of synechia formation was less than one-fourth of the circumference and the facility of outflow was not significantly effected. Similarly in 3 cases having gonio­synechiae, covering quarter to half of the angle circumference, the facility of outflow was within nor­rnal limits while in the remaining 2 where the synechiae involved about three-fourth of the circum­ference, the facility of outflow was above 100 and they subsequently did develop secondary glaucoma between six months to a year.

It is also commonly believed that a large iridectomy is safer as com­pared to the peripheral one. Amongst the 19 cases of our series where a large iridectomy was done, the left over of the iris, got adherent or pulled in 12 cases (73.7%) and led to band shaped goniosynechiae. Thus on gonioscopic evidence, it is felt that a large iridectomy; may itself be­come occasionally responsible for the decrease in the facility of outflow and the blockage of the angle. When these cases were compared with those where a peripheral iridectomy was done it was observed that in one-third cases with peripheral iridectomies the outer mai gin of the peripheral button hole was either adherent or pulled away but none of these cases landed into glaucoma sub­sequently while on the other hand two cases where a complete iri­dectomy was done developed it (vide supra).

Four cases of peripheral iridec­tomies in which the outer margin or the pillar of the iris had either become adherent or incarcerated in the section, showed an increase in the facility of outflow which could have been due to an addi­tional filtration through the section.


  Summary Top


Gonioscopic studies were made in 56 cases before and after un­complicated cataract extractions.

Coniosynechiae of varying ex­tent were seen in 35 cases (62.5%) - even after an uneventful cata­ract surgery. They were more fre­quent and extensive after the ex­tra-capsi dar cataract extraction (79%) than after intracapsular cataract extraction (54.5%). Their incidence and extent in extra- and intra-capsular operations, with full iridectomy or a button hole one are recorded and commented upon. Facility of outflow was not significantly effected by the goni­osynechiae if they covered less than half of the angle circum­ference while it was markedly de­creased in 2 cases where more than half the circumference was involved, resulting in subsequent development of aphakic glaucoma. They were cases in which an extracapsular operation was per­formed.

Incarceration of iris tissue in the incisions which seemed to in­crease the facility of out flow was seen in 4 cases.

 
  References Top

1.
HUGHES M. W. and OWENS W. C. The extraction of senile cataract: A statistical comparison of various techniques and importance of pre­operative study. Amer. J. Ophthal., 28, 40-49 (1949).  Back to cited text no. 1
    
2.
KRONFELD P. C. and GROSS MAN E. E. The relation of gonioscopic findings to the incidence of secon­dary glaucoma in operative apha­kia. Tr. Amer. Ophthal., Soc. 45, 184 (1941).  Back to cited text no. 2
    
3.
LEE P. F. and TROTTER R. P. Tonography and gonioscopy before and after cataract extraction. A.M.A. Arch. Ophthal., (Chicago), 58, 407­416 (1957).  Back to cited text no. 3
    
4.
MILLER J. E., KESKY G. R. and BECKER B. Cataract extraction and aqueous outflow. A.M.A. Arch. Oph­thal., (Chicago), 58, 401-406 (1957).  Back to cited text no. 4
    
5.
SCHIE C. H. Width and pigmenta­tion of angle of anterior chamber. A.M.A. Arch. Ophthal., (Chicago), 58, 510-512 (1957).  Back to cited text no. 5
    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3]
 
 
    Tables

  [Table - 1]



 

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