|Year : 1971 | Volume
| Issue : 4 | Page : 155-159
Ocular changes following cataract extraction : Goniosynechias
K Nath, RL Vaid
Aligarh Muslim University Institute of Ophthalmology and Jawaharlal Nehru Medical College, Aligarh, India
Aligarh Muslim University Institute of Ophthalmology and Jawaharlal Nehru Medical College, Aligarh
Source of Support: None, Conflict of Interest: None
|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
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  ; Kronfeld and Grossman  ; Lee and trotter  ; and Miller, Kesky and Becker  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|| |
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  . 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|| |
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|| |
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 , Miller. Kesku and Becker  and Trotter  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  found them in the majority of his cases operated for cataract, while in the series of Miller et a1  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  and Miller et al .
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  reported that aphakic glaucoma is three times more comon after extra-capsular extraction than in intra-capsular, while Miller et al  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|| |
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|| |
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).
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).
LEE P. F. and TROTTER R. P. Tonography and gonioscopy before and after cataract extraction. A.M.A. Arch. Ophthal., (Chicago), 58, 407416 (1957).
MILLER J. E., KESKY G. R. and BECKER B. Cataract extraction and aqueous outflow. A.M.A. Arch. Ophthal., (Chicago), 58, 401-406 (1957).
SCHIE C. H. Width and pigmentation of angle of anterior chamber. A.M.A. Arch. Ophthal., (Chicago), 58, 510-512 (1957).
[Figure - 1], [Figure - 2], [Figure - 3]
[Table - 1]