Association of pseudoexfoliation syndrome with increased vascular risk

[New pathogenetic insights into pseudoexfoliation syndrome/glaucoma. Therapeutically relevant?]

Pseudoexfoliation (PEX) syndrome is a genetically determined, generalized disease of the extracellular matrix leading to the progressive deposition of an abnormal fibrillar material in various intraocular and extraocular tissues including the trabecular meshwork. It thus represents the most common identifiable cause of open-angle glaucoma and a leading cause of blindness worldwide. The PEX-specific fibrotic matrix process, a stress-induced elastosis, is characterized by an excessive production and abnormal cross-linking of elastic microfibrils into fibrillar PEX aggregates. Co-modulating factors triggering this fibrotic process include elevated concentrations of fibrogenic growth factors, such as TGF-β1, reduced activity of proteolytic enzymes, subtle inflammatory processes and various external stress factors, such as oxidative stress. Genetic studies identified a highly significant association between several polymorphisms in the LOXL1 (lysyl oxidase-like 1) gene with both PEX syndrome and PEX glaucoma. As these LOXL1 risk variants were found to occur in almost 100% of PEX patients throughout all geographical populations worldwide, LOXL1 appears to represent a principal risk factor for manifestation of the PEX phenotype. LOXL1 is a pivotal cross-linking enzyme in extracellular matrix metabolism and seems to be specifically required for elastic fiber formation and stabilization. The available data suggest that LOXL1 enzyme function and expression are dysregulated in PEX tissues and thereby play a central role in glaucoma development. On the one hand, increased expression of LOXL1 and elastic fiber components contributes to the formation of abnormally cross-linked PEX aggregates in the outflow pathways leading to increased outflow resistance and intraocular pressure. On the other hand, reduced expression and inadequate tissue levels of LOXL1 may lead to degenerative tissue alterations, particularly in the lamina cribrosa adversely affecting the biomechanical properties of this critical tissue. This PEX-specific elastinopathy of the lamina cribrosa rendering PEX eyes more vulnerable to pressure-induced optic nerve damage may constitute an independent risk factor for glaucoma development. The findings may have direct consequences for the clinical management of PEX patients underlining the need for an exact diagnosis, a strict IOP-reducing therapy and a close and regular follow-up.

[PEX syndrome. Clinical diagnosis and systemic manifestations]

As a result of demographic changes pseudoexfoliation (PEX) syndrome, an age-related systemic disorder of the extracellular matrix, will become an increasingly important issue in clinical practice. Apart from its well-known association with cataract and glaucoma, PEX syndrome predisposes to a broad spectrum of spontaneous and surgical ocular complications due to characteristic alterations of all anterior segment tissues. In view of the high risk of glaucoma development and potential complications during cataract surgery, an accurate and early diagnosis of PEX syndrome is of considerable clinical relevance. Since the characteristic central PEX deposits are lacking in up to 50 % of patients, a reliable diagnosis requires pupillary dilation. Early stages of the disease may be recognized on the basis of subtle alterations of the lens surface in addition to poor pupillary dilation and pigment-related signs including pigment dispersion and peripupillary atrophy. Any asymmetric clinical signs, e.g., regarding pupil width, pigmentation, cataract and intraocular pressure, should alert the ophthalmologist to the potential presence of PEX syndrome. Although the description of PEX syndrome as a systemic disorder of the extracellular matrix associated with the deposition of PEX material in the skin, blood vessel walls and various organ systems dates back to the early 1990s, a causal relationship between the abnormal material deposits and systemic diseases has not yet been clearly established. A growing number of smaller studies have found suggestive evidence for associations between PEX syndrome and cardiovascular/cerebrovascular diseases. The current evidence, however, is ambiguous and requires further investigation through multicenter or population-based, prospective, randomized clinical studies.

What is the effect of pseudoexfoliation syndrome on renal function in patients without glaucoma?

PURPOSE

To evaluate renal function in patients with pseudoexfoliation syndrome.

MATERIALS AND METHODS

This prospective, cross-sectional, case-control study involved 49 patients with pseudoexfoliation syndrome (PEX) and 42 control subjects. Renal function was examined by biochemical parameters and Doppler ultrasonography. Serum creatinine, blood urea nitrogen, urea levels, urine microalbumin level and creatinine clearance were measured. Renal volume, resistive index and pulsatility index were calculated using Doppler ultrasonography.

RESULTS

The mean laboratory values for both groups were as follows: Creatinine, PEX: 0.81 ± 0.28 mg/dL - Control: 0.79 ± 0.22 mg/dL; urea, PEX: 31.6 ± 9.7 mg/dL - Control: 32.2 ± 8.4 mg/dL; blood urea nitrogen, PEX: 14.8 ± 4.6 mg/dL - Control: 15.1 ± 4.0 mg/dL; creatinine clearance, PEX: 89.1 ± 35.6 mL/min - Control: 99.0 ± 47.2 mL/min; microalbumin, PEX: 5.8 ± 22.7 mg/dL - Control: 2.7 ± 6.0 mg/dL. The differences between groups were not significant (p > 0.300). Renal volume, resistive index and pulsatility index values were similar in both groups (p > 0.200).

CONCLUSIONS

This study showed that pseudoexfoliation syndrome does not affect biochemical and ultrasonographic parameters associated with renal function.

Pseudoexfoliation Syndrome

Pseudoexfoliation (PXF) syndrome is a well-recognized clinical entity of considerable clinical significance. It is associated with poor mydriasis, cataracts with weak zonular support, secondary glaucoma and possibly with biochemical abnormalities, such as elevated homocysteine and systemic diseases involving the cardiovascular and central nervous system. There have also been some recent studies identifying mutations in genes which are associated with PXF.

How to cite this article: Ariga M, Nivean M, Utkarsha P. Pseudoexfoliation Syndrome. J Current Glau Prac 2013;7(3): 118-120.

Mean platelet volume in pseudoexfoliation syndrome and glaucoma

PURPOSE

Pseudoexfoliation (PEX) syndrome (PES) is characterized by the widespread deposition of abnormal extracellular fibrillary material on many ocular and extraocular tissues. The objective of this study was to evaluate the association among PES, PEX glaucoma (PEG), and mean platelet volume (MPV).

METHODS

Forty patients with PES (mean age 62.6 ± 7.8 years), 31 with PEG (mean age 65.9 ± 6.6 years), and 37 healthy individuals (control group) (mean age 64.0 ± 7.1 years) were included in the study. The MPV of the 3 groups were compared.

RESULTS

Age and sex distribution were similar among groups (p>0.05). Mean MPV in PES, PEG, and control groups were 9.59 ± 0.94 fl, 9.53 ± 0.80 fl, and 7.7 ± 0.67 fl, respectively. In the PEX group, MPV values were significantly higher than in the control group (p<0.05). However, there was no difference between the PES and PEG groups (p>0.05).

CONCLUSIONS

The MPV values in both groups with PEX were higher than those in the healthy group.

Serum YKL-40 levels as a novel marker of inflammation and endothelial dysfunction in patients with pseudoexfoliation syndrome

PURPOSE

To evaluate serum levels of YKL-40 in patients with pseudoexfoliation syndrome (PEX) in comparison with those of age- and sex-matched healthy subjects.

METHODS

Forty patients with PEX (PEX group) and 40 age- and sex-matched control subjects (control group) were enrolled in the study. An enzyme immunoassay method using the commercially available test MicroVue YKL-40 was used to measure serum YKL-40 concentration. Systolic and diastolic blood pressures, serum levels of high sensitivity C-reactive protein (hsCRP), total cholesterol, low-density lipoprotein cholesterol (LDL), high-density lipoprotein cholesterol (HDL), and triglycerides were also examined.

RESULTS

The mean age was 54.4±7.6 (ranging 41-65) years in each group. The mean serum YKL-40 level of the PEX group was significantly higher than that of the control group (P<0.001). In addition, the mean serum HsCRP, total cholesterol, LDL, and triglycerides levels were significantly higher, and mean serum HDL level was significantly lower in the PEX group than in the control group (all P<0.001, excluding both P=0.002 for triglycerides and HDL levels). Further, the mean systolic and diastolic blood pressures were significantly higher in the PEX group than in the control group (P₁=0.001 and P₂=0.01, respectively).

CONCLUSION

We have shown a relationship between PEX and elevated serum levels of YKL-40. We imply that a better understanding of the role of YKL-40 in the pathogenesis of endothelial dysfunction and atherosclerosis is necessary to develop new therapies for preventing or treating PEX. Further studies are warranted to clarify the clinical relevance of these findings.

Renal artery stenosis and abdominal aorta aneurysm in patients with pseudoexfoliation syndrome

PURPOSE

To evaluate the renal arteries and abdominal aorta in patients with pseudoexfoliation syndrome (PEX).

DESIGN

Prospective, case-control study.

METHODS

The study involved 49 patients with PEX and 42 control subjects. Abdominal aorta and renal arteries were examined by Doppler ultrasonography. In both renal arteries (proximal and distal portions) and abdominal aorta, the peak systolic velocity (PSV) was measured. Renal artery stenosis (RAS) was defined as the renal artery PSV >150 cm/s or renal-to-aortic ratio (RAR) >3.0. Patients who had an abdominal aortic diameter >3 cm were recorded. Computed tomographic angiography was performed to confirm these findings in patients with RAS and/or abdominal aorta aneurysm.

RESULTS

The mean PSV in the proximal renal artery was 88.3 cm/s in PEX group and 79.5 cm/s in control group (P=0.314); in distal renal artery was 91.7 cm/s in PEX group and 93.0 cm/s in control group (P=0.794); in abdominal aorta was 76.0 cm/s in PEX group and 65.2 cm/s in control group (P=0.046). RAS was observed in nine patients with PEX and in only one patient without PEX (P=0.017). Seven out of 10 patients with RAS (six patients in PEX group; one patient in control group) had hypertension. Abdominal aorta aneurysm was observed in four patients in PEX group but not in control group (P=0.061).

CONCLUSIONS

Our study has demonstrated that there is a significant association between PEX and RAS. The abdominal aorta aneurysm may be seen in patients with PEX.

Serum vitamin D deficiency and its association with systemic disease in exfoliation syndrome

PURPOSE

To determine the association of serum vitamin D levels with exfoliation syndrome (XFS) and evaluate its impact on co-associated systemic diseases.

METHODS

Forty patients with XFS and 40 control subjects without XFS were recruited for this study. Se-rum concentrations of 25-hydroxy vitamin D [25(OH) D] were measured by high-performance liquid chromatography. Vitamin D deficiency was defined as a serum 25(OH) D concentration of <20 ng/mL. A detailed medical history including hypertension, diabetes mellitus, ischemic heart disease, cerebrovascular stroke, autoimmune disease, and neurologic disorders such as Parkinson disease and Alzheimer disease was recorded. Student t test and chi-square test was used for statistical evaluations.

RESULTS

The mean age of patients with XFS and control subjects was 69.6 ± 8.1 years (range 58-90 years) and 67.1 ± 6.3 years (range 60-86 years), respectively (p>0.05). Mean 25(OH) D levels did not differ between XFS (19.8 ± 8.3 ng/mL) and control (19.9 ± 10.3 ng/mL) groups (p = 0.978). Patients with XFS had higher prevalence of cerebrovascular (p = 0.026) and cardiovascular disease (p = 0.001). There was no association between the systemic disease status and serum vitamin D levels of patients with XFS.

CONCLUSIONS

Although vitamin D levels were similar between XFS and control subjects, the levels were found to be decreased in both groups. Patients with XFS had a significantly higher prevalence of cerebrovascular and cardiovascular disease as compared to controls independent of their serum 25(OH) D levels. Low vitamin D level does not appear to be linked to XFS in the studied population.

Does an association exist between pseudoexfoliation syndrome and chronic kidney disease?

PURPOSE

To determine whether pseudoexfoliation (PEX) syndrome is associated with an increased risk of chronic kidney disease (CKD).

PATIENTS AND METHODS

In this cross-sectional study, 271 consecutive patients were recruited into 3 study groups---PEX syndrome (n=86), primary open-angle glaucoma (POAG) (n=91), and nonglaucoma controls (n=94)---and underwent serum creatinine testing to determine their glomerular filtration rates (eGFR). Repeat eGFR and testing for urine albumin:creatinine ratio were performed a minimum of 3 months later if the initial eGFR was less than 60 mL/min/1.73 m. CKD was diagnosed if both eGFR levels were less than 45 mL/min/1.73 m or both eGFR levels were less than 60 mL/min/1.73 m and the urine albumin:creatinine ratio was greater than 2.0. The main outcome measure was the rate of CKD for each group.

RESULTS

The CKD rate for the control group (11.7%, 11 of 94) was statistically higher than the PEX (3.5%, 3 of 86, P=0.050) and the POAG (3.3%, 3 of 91, P=0.049) groups. However, there was a significantly higher rate of diabetes mellitus, a known risk factor for CKD, in the control group than the PEX and POAG groups. After adjusting for the differences in the rate of diabetes mellitus and mean age (another risk factor for CKD) between groups, a multivariate logistic regression analysis showed that none of the study groups was a predictor of an increased rate of CKD. A post-hoc analysis performed with all patients with diabetes mellitus removed also showed no statistical difference between groups for CKD rates and mean eGFR levels.

CONCLUSIONS

Compared with age-matched patients with POAG and nonglaucoma controls, PEX syndrome was not found to be associated with an increased prevalence of CKD.

Ocular pseudoexfoliation and cardiovascular disease: a national cross-section comparison study

BACKGROUND

Pseudoexfoliation is a systemic disorder characterized by the deposition of extracellular matrix material. The microfibrillar material that gives rise to the condition is visible clinically in the anterior segment of the eye, and is also found in other tissues, including blood vessels, skin, gallbladder, kidneys, lungs, and heart.

AIMS

The present study aims to determine whether ocular pseudoexfoliation is associated with selected cardiovascular diseases.

MATERIALS AND METHODS

A cross-section comparison study was conducted with the help of the Veterans Health Administration databases, using the International Classification of Diseases, Ninth revision, Clinical Modification for pseudoexfoliation of lens capsule and pseudoexfoliation glaucoma. Selected cardiovascular diseases and risk factors for cardiovascular disease were identified using the appropriate medical codes. Patients with primary open-angle glaucoma, chronic sinusitis, and benign prostatic hyperplasia served as the comparison groups. A logistic regression model was used to control for age, gender, race, and major cardiovascular risk factors.

RESULTS

There were 6,046 case patients with pseudoexfoliation; approximately half were diagnosed with pseudoexfoliation glaucoma. Various stages of ischemic heart disease, cardiomyopathy, and aortic aneurysm were significantly associated with ocular pseudoexfoliation, after controlling for age, gender, race, and major cardiovascular risk factors. Associations, in general, were less demonstrable relative to the primary open-angle glaucoma comparison group.

CONCLUSION

Associations of ocular pseudoexfoliation with cardiovascular diseases were generally fewer and less pronounced when compared to patients with primary open-angle glaucoma. These results add to the results of earlier studies, which suggest that open-angle glaucoma itself might be a risk factor for certain cardiovascular disorders.

Pseudoexfoliation syndrome, a systemic disorder with ocular manifestations

Pseudoexfoliation syndrome (PXS) is a systemic condition with eye manifestations. In the eye, pseudoexfoliation material deposits on various structures of the anterior segment. The nature of this material is mostly fibrillar with fibers made up of microfibrils and coated with amorphous material. The composition of these fibrils is diverse and includes basement membrane components as well as enzymes involved in extracellular matrix maintenance. Pseudoexfoliation is the most common cause of secondary open-angle glaucoma (pseudoexfoliation glaucoma, PXG) worldwide. The goal of this review is to summarize our knowledge on the genetics of this systemic disorder and its resultant ocular manifestations. PXS familial aggregation suggests genetic inheritance. PXS has been strongly associated with single nucleotide polymorphisms (SNPs) of the lysyl oxidase-like 1 (LOXL1) gene on chromosome 15q24.1. Two of these SNPs confer a higher than 99% population attributable risk for PXS and PXG in the Nordic population; however, they carry different risks in different populations. The high risk haplotypes also vary among different populations. LOXL1 is one of group of the enzymes involved in the cross-linking of collagen and elastin in the extracellular matrix. Its function in connective tissue maintenance has been confirmed in mice; however, its actual role in PXS remains unclear. Contactin-associated protein-like 2 also has a strong genetic association with PXS in a German cohort and is an attractive candidate molecule. It encodes for a protein involved in potassium channel trafficking. Other candidate genes linked to PXS include lysosomal trafficking regulator, clusterin, adenosine receptors, matrix metalloproteinase-1 (MMP1), and glutathione transferase. These genes may be modifying genes for development of PXS and PXG.

Is pseudoexfoliation syndrome associated with coronary artery disease?

Background:

Pseudoexfoliation syndrome (PEX) is recognised by chronic deposition of abnormal pseudoexfoliation material on anterior segment structures of the eye, especially the anterior lens capsule. In recent years, several studies have shown the presence of vascular, cardiac and other organ pseudoexfoliative material in patients with ocular pseudoexfoliation.

Aims:

The purpose of this study is to determine whether an association exists between ocular pseudoexfoliation and coronary artery disease, aortic aneurysms and peripheric vascular disease.

Patients and Methods:

490 patients who underwent coronary angiography (CAG) at Kosuyolu Cardiovascula Research and Training Hospital were included in the study. Patients were evaluated for conventional risk factors such as age, sex, family history, hypertension, diabetes, dislipidemia and smoking. Detailed eye examinations including evaluation of lens were done in all patients. The presence of PEX material in the anterior segment was best appreciated by slit lamp after pupillary dilation. The patients were divided into two groups according to the presence of PEX, and compared for the presence of CAD and other risk factors.

Results:

CAD was present in 387 patients. 103 patients had normal coronary angiography. 20 (5.2 %) of CAD patients and 4 (3.9%) of normal CAG patients were found to have PEX (p>0.05). There was no significant relationship between CAD and the presence of PEX (p>0.05). When patients were grouped according to the presence of PEX, only age was significantly different between the two groups (r: 0.25, p<0.001).

Conclusion:

There is no significant relationship between the presence of PEX and CAD. Further studies in larger scales with elderly population may be more valuable.

The Relationship between caffeine and coffee consumption and exfoliation glaucoma or glaucoma suspect: a prospective study in two cohorts

PURPOSE

We examined the association between caffeine and caffeinated beverage consumption in relation to the risk of exfoliation glaucoma or exfoliation glaucoma suspect (EG/EGS).

METHODS

We followed 78,977 women from the Nurses' Health Study (NHS) and 41,202 men from the Health Professionals Follow-up Study (HPFS) who were at least 40 years of age, did not have glaucoma, and reported undergoing eye examinations from 1980 (NHS) or 1986 (HPFS) to 2008. Information on consumption of caffeine-containing beverages and potential confounders were repeatedly ascertained in validated follow-up questionnaires. Confirmation with medical record review revealed 360 incident EG/EGS cases. Multivariate rate ratios (RRs) for EG/EGS were calculated in each cohort and then pooled using meta-analytic techniques.

RESULTS

Compared with participants whose cumulatively updated total caffeine consumption was <125 mg/day, participants who consumed ≥ 500 mg/day had a trend toward increased risk of EG/EGS that was not statistically significant (RR = 1.43; 95% confidence interval [CI], 0.98-2.08); P trend = 0.06). Compared to abstainers, those who drank ≥ 3 cups of caffeinated coffee daily were at increased risk of EG/EGS (RR = 1.66; 95% CI, 1.09-2.54; P trend = 0.02). These results were not materially altered after adjustment for total fluid intake. Associations were stronger among women with a family history of glaucoma (P interaction = 0.06 for coffee; P interaction = 0.03 for caffeine). We did not find associations with consumption of other caffeinated products (caffeinated soda, caffeinated tea, decaffeinated coffee or chocolate) and risk of EG/EGS (P trend ≥ 0.31).

CONCLUSIONS

We observed a positive association between heavier coffee consumption with risk of EG/EGS in this large prospective study.

Association of ocular pseudoexfoliation syndrome with ischaemic heart disease, arterial hypertension and diabetes mellitus

PURPOSE

To determine the prevalence of pseudoexfoliation syndrome (PEX) in Lithuanian urban population and its association with ischaemic heart disease (IHD), arterial hypertension (AH) and diabetes mellitus (DM).

METHODS

In this population-based study, 1065 participants aged 45-72 years were randomly drawn from the population register of Kaunas, Lithuania. They were classified as having PEX if any pseudoexfoliation material was determined by a slit-lamp examination in at least one eye. The data were acquired from questionnaire; register of myocardial infarction, electrocardiogram, biochemical blood analyses and blood pressure measurement were used to determine IHD, AH, DM and smoking habits. Poststratification weights based on Kaunas population sex and age distribution were applied.

RESULTS

Pseudoexfoliation syndrome was estimated in 9% of a population. The AH rate was higher in PEX subjects than in non-PEX subjects (p=0.017) and the rates of IHD, DM and cholesterol levels did not differ statistically significantly. Chi-square linear-by-linear association test found higher AH rate in unilateral PEX subjects and even higher AH rate in bilateral PEX subjects than in non-PEX subjects (p=0.014). Pseudoexfoliation syndrome increased odds for AH by 1.8 times (p=0.021). Median of systolic blood pressure was higher in the PEX group than in non-PEX group (p=0.04). But all associations could not be confirmed after adjusting for age. Smoking duration increased age-adjusted odds for PEX. Pseudoexfoliation syndrome did not increase risk for IHD, AH or DM.

CONCLUSIONS

Pseudoexfoliation syndrome prevalence is high in Lithuania. No clear PEX association with IHD, AH and DM was proven after controlling for effect of age.

Serum antiphospholipid antibody levels in pseudoexfoliation

PURPOSE

To evaluate the levels of serum antiphospholipid antibodies in patients with pseudoexfoliation syndrome (PXS), pseudoexfoliation glaucoma (PXG), primary open-angle glaucoma, and healthy controls.

MATERIALS AND METHODS

This prospective study included 17 patients with PXS, 19 patients with pseudoexfoliation glaucoma, 15 patients with primary open-angle glaucoma, and 19 normal individuals. Venous blood samples were obtained in the morning after an overnight 8-hour fasting. Anticardiolipin antibodies, isotypes IgG and IgM were measured by means of an enzyme-linked immunosorbent assay. Lupus anticoagulant antibodies were measured by dilute Russell viper venom time screen test.

RESULTS

Mean±standard mean of error of anticardiolipin antibody IgG levels in patients with PXS and PEG were significantly higher than those of the controls (P<0.05). The mean lupus anticoagulant antibody levels of the controls were not statistically different from the levels of patients with PXS, pseudoexfoliation glaucoma, and primary open-angle glaucoma (P>0.05). The anticardiolipin antibody IgG concentrations above the cutoff value of 15 GPL/mL were found in 8 patients (21.05%) with pseudoexfoliation. There was no individual in the control group having anticardiolipin antibody IgG level above the cutoff value (P<0.05).

CONCLUSIONS

Elevated serum antiphospholipid antibodies, a risk factor for cardiovascular and cerebrovascular disease, is more common in patients with PXS and pseudoexfoliation glaucoma than in the healthy controls and in patients with primary open-angle glaucoma.

Prevalence and early detection of abdominal aortic aneurysm in pseudoexfoliation syndrome and pseudoexfoliation glaucoma

PURPOSE

The goals of this study were to demonstrate the frequency of infrarenal abdominal aortic aneurysm (AAA) in patients with pseudoexfoliation (PEX) syndrome (PEXS) and PEX glaucoma (PEXG), and to determine whether limited screening for AAA in specific subgroups of patients with PEX is reasonable and justifiable.

MATERIALS AND METHODS

This prospective study comprised 60 patients with PEXS and 60 with PEXG (examined group), and 60 patients with primary open-angle glaucoma (POAG) and 60 with cataract (control group). Clinical ophthalmic examination included slit-lamp biomicroscopy of the anterior segment and direct slit-lamp gonioscopy (using a Goldmann three-mirror lens) of the anterior chamber angle. All patients underwent routine Color Doppler duplex ultrasonography of the infrarenal aorta and iliac arteries.

RESULTS

There was a statistically significant difference (p < 0.05) between the PEXG group and control group vis-a-vis presence of AAA, which occurred more frequently in patients with greater amounts of angle pigmentation (p < 0.05). Univariate logistic regression analysis indicated statistically significant associations between AAA and PEX (p < 0.01), angle pigmentation (p < 0.05), gender (p < 0.01), diabetes mellitus (DM) (p < 0.05), and arterial hypertension (AHT) (p < 0.01). Multivariate regression analysis, adjusted to gender and age, showed that the most important clinical parameters related to AAA in patients with PEXS and PEXG are gender, presence of PEX, DM, and AHT (p < 0.05).

CONCLUSION

The frequency of AAA is significantly higher in patients with PEXS and PEXG than in patients with POAG or cataract. Restricted screening for AAA in male PEXS patients, who also have elevated degrees of angle pigmentation, arterial hypertension, and DM, is clinically warranted.

Endothelial cell markers in patients with pseudoexfoliation syndrome

The aim of the study was the assessment of the von Willebrand antigen (vWF Ag), E-selectin, and P-selectin concentration in blood plasma of patients with pseudoexfoliation syndrome (PEX). The group studied comprised 30 patients with PEX, aged from 50 to 86 years (mean 73, SD ± 8 years). Patients with cardiovascular and cerebrovascular diseases, diabetes mellitus, infectious disease, cancer, renal or liver insufficiency, connective tissue disease, current smoking, and hormone, antiplatelet, hypolipidemic, antioxidant, or antihypertensive drug therapy were excluded from the study. Each subject underwent a complete ophthalmological examination. Venous blood samples from the cubital vein were taken into sodium citrate solution. VWF Ag, sP-selectin, and sE-selectin concentration were determined by a commercially available enzyme-linked immunosorbent assay (MedSystems, Diagnostica Stago/Roche, R&D). Concentrations of vWF Ag, soluble E-selectin, and soluble P-selectin in blood plasma in the study group were compared with the levels in blood plasma in the control group. No significant differences were found between the groups. Our results indicate that there might be no correlation between PEX and such endothelial cell markers as vWF Ag, sP-selectin, and sE-selectin concentrations. Since the study size is limited, further investigations to confirm that there is no association between endothelial dysfunction in PEX and risk of future cardiovascular disease are necessary.

Cholesterol-lowering drugs and incident open-angle glaucoma: a population-based cohort study

Background

Open-angle glaucoma (OAG) is a progressive neurodegenerative disease that may lead to blindness. An elevated intraocular pressure (IOP) is its major risk factor. OAG treatment is currently exclusively directed towards the lowering of the IOP. IOP lowering does not prevent disease progression in all patients and thus other treatment modalities are needed. Earlier studies reported cholesterol-lowering drugs to have neuroprotective properties. The aim of this study was to determine the associations between the use of cholesterol-lowering drugs and incident OAG.

Methodology/Principal Findings

Participants in a prospective population-based cohort study underwent ophthalmic examinations, including IOP measurements and perimetry, at baseline and follow-up. The use of statins and non-statin cholesterol-lowering drugs was monitored continuously during the study. Associations between the use of cholesterol-lowering drugs and incident OAG were analyzed with Cox regression; associations between cholesterol-lowering drugs and IOP at follow-up were analyzed with multiple linear regression. During a mean follow-up of 9.8 years, 108 of 3939 eligible participants (2.7%) developed OAG. The hazard ratio for statin use was 0.54 (95% confidence interval 0.31–0.96; P = 0.034) and for non-statin cholesterol-lowering drugs 2.07 (0.81–5.33; P = 0.13). The effect of statins was more pronounced with prolonged use (hazard ratio 0.89 [0.41–1.94; P = 0.77] for use two years or less; 0.46 [0.23–0.94; P = 0.033] for use more than two years; P-value for trend 0.10). The analyzes were adjusted for age and gender, baseline IOP and IOP-lowering treatment, the family history of glaucoma, and myopia. There was no effect of statins on the IOP.

Conclusions/Significance

Long-term use of statins appears to be associated with a reduced risk of OAG. The observed effect was independent of the IOP. These findings are in line with the idea that statins have neuroprotective properties and may open a way to a new OAG treatment modality.

High prevalence of pseudoexfoliation syndrome and its complications in Tarragona in northeast Spain

PURPOSE

To determine the prevalence of pseudoexfoliation syndrome (PEX) in our health area, in 4 counties of Tarragona, and its involvement in the health status of the population.

METHODS

This was a cross-sectional study of a sample of 2,342 inhabitants aged = 60 years, randomly selected from the population census. Subjects were classified in 3 groups according to age (group 1 = 60-69 years, group 2 = 70-79 years, group 3 = over 80 years). The diagnosis of PEX was made in all cases by the same ophthalmologist, using biomicroscopic and slit-lamp evaluation. Corneal endothelial study was made by specular microscope.

RESULTS

The prevalence of PEX was 309/2,342 patients (13.19%), unilateral in 219/309 (70.87%). The prevalence of PEX in patients with open-angle glaucoma was 29.48%. Changes in corneal endothelium were higher in patients with PEX, with lower cell density and hexagonality percentage, with higher coefficient of variation, significant in age groups 2 and 3. The prevalence of cataract in patients with PEX was 80.58%, versus 54.64% in patients without PEX. Complications of cataract surgery were higher in patients with PEX and postoperative corneal edema was best correlated with a low hexagonality percentage. No systemic cardiovascular diseases were significant in patients with PEX.

CONCLUSIONS

In our health district area, a high prevalence of PEX exists. A more extensive study of the causes of these differences is needed, including analysis of the genetic makeup of the population.

Pseudoexfoliation syndrome in Congolese patients

PURPOSE

To determine the frequency of pseudoexfoliation syndrome (PEX) in Congolese patients and its association with cataract and glaucoma.

METHODS

We performed a cross-sectional and descriptive analysis of the data from patients diagnosed with PEX. Data were collected between February 2005 and June 2008 in a general practice of ophthalmology in Kinshasa. Patients aged 50 or above who attended the general practice of ophthalmology were included in the study. Each patient underwent complete ophthalmic evaluation, including visual acuity testing, slit-lamp biomicroscopy, applanation tonometry, gonioscopy, and ophthalmoscopy. The diagnosis of PEX was based on presence of typical pseudoexfoliation material on the anterior lens surface and/or the pupillary margin in either or both eyes.

RESULTS

Of 2142 patients seen during the study period, 37 (59 eyes) had PEX in either eye, for a frequency of 1.73%. The mean (±SD) age of the patients with PEX was 70.40 years±8 (range: 57-87 years). The frequency of PEX had a tendency to increase with age: 0.50% of patients aged 50-59 years had PEX, whereas 7.29% of those aged more or equal to 80 years were affected (P<0.0001), with a female predominance (2.18% of women versus 1.22% of men, P=0.035). PEX was bilateral in 22 (59.46%) of 37 patients (74.58% of eyes). Bilateral PEX was found more often in females (16 patients over 22, 72.72%) than in males (six patients over 15, 40%) (P=0.05). PEX was significantly associated with cataract (P=0.002) and glaucoma (P<0.001).

CONCLUSION

Despite the limitations inherent in a clinic-based study, this investigation provides an indication of the frequency of PEX in Central Africa. This shows that Congolese patients have a low frequency of PEX (1.73%), inferior to that of black people in South Africa (12.1-16%). This study confirms that PEX is an age-related condition and is associated with cataract and glaucoma, as in other races.

The association of ocular blood flow with haemorheological parameters in primary open-angle and exfoliative glaucoma

PURPOSE

To evaluate the ocular blood flow velocities and haemorheological parameters in patients with primary open-angle glaucoma (POAG), exfoliative glaucoma (XFG) and exfoliation syndrome (XFS) and to compare their results with those of healthy controls.

METHODS

Twenty-five patients with POAG (group 1), 25 patients with XFG (group 2), 25 patients with XFS (group 3) and 25 healthy controls (group 4) were included in the study. Ocular blood flow velocities of ophthalmic artery (OA), central retinal artery (CRA) and short posterior ciliary arteries (SPCAs) were measured using colour Doppler imaging (CDI). Haemorheological parameters (erythrocyte elongation and aggregation index, aggregation amplitude, aggregation half-life, plasma viscosity, haematocrit) were measured in venous blood samples of all patients.

RESULTS

The peak systolic velocity (PSV) and end-diastolic velocity (EDV) values were lower and resistive indices (RI) were higher for the OA, CRA and SPCA of glaucomatous (groups 1 and 2) patients compared with those of controls (group 4) (PSV: OA, 40.4 ± 11.3 versus 52.6 ± 12.8 cm/second, p < 0.001; CRA, 12.9 ± 2.9 versus 15.3 ± 4.2 cm/second, p = 0.02; SPCA, 21.7 ± 6.6 versus 26.6 ± 8.3 cm/second, p = 0.013) (EDV: OA, 10.3 ± 4.3 versus 14.2 ± 5.1 cm/second, p < 0.001; CRA, 3.7 ± 1.1 versus 4.5 ± 1.3 cm/second, p = 0.025; SPCA, 5.2 ± 1.8 versus 7.7 ± 3.2 cm/second, p = 0.001) (RI: OA, 0.75 ± 0.05 versus 0.66 ± 0.07, p < 0.001; CRA, 0.73 ± 0.08 versus 0.68 ± 0.10, p = 0.223; SPCA, 0.70 ± 0.10 versus 0.63 ± 0.11, p = 0.004). There were no statistically significant differences between the haemorheological parameters of glaucomatous and non-glaucomatous patients. The reduction in ocular blood flow velocities in groups 1, 2 and 3 were not associated with changes in haemorheological parameters.

CONCLUSION

Our results suggest that impairment of the retrobulbar blood flow in POAG and XFG is not associated with alterations in haemorheological parameters.

Assessment of myocardial ischaemia using tissue Doppler imaging in pseudoexfoliation syndrome

PURPOSE

Pseudoexfoliation (PEX) syndrome is characterized by the widespread deposition of abnormal extracellular fibrillary material on many ocular and extraocular tissues. We aimed to investigate the association between PEX syndrome and subclinical myocardial ischaemia, using tissue Doppler echocardiography.

METHODS

Thirty-two patients with pseudoexfoliation syndrome (mean age: 66±9 years, 22 men) and 25 healthy individuals (mean age: 67±8 years, 13 men) were included in the study. Patients with overt coronary artery disease, congestive heart failure, valvular heart disease, cardiomyopathy, and left ventricular hypertrophy were excluded from the study. Tissue Doppler imaging was performed at the septal, lateral, anterior, and inferior mitral annuluses. Differences between the groups were evaluated by the unpaired t-test and the Mann-Whitney U-test, with a P-value of <0.05 considered significant.

RESULTS

Baseline clinical characteristics, two-dimensional, and Doppler echocardiography parameters were similar in the PEX and control groups. Peak systolic velocities at the septal, lateral, anterior, and inferior annuluses were significantly lower in patients with PEX syndrome (P<0.001, 0.01, 0.02, and 0.02, respectively). The early diastolic velocity at the septal annulus, and the ratio of early/late diastolic velocity at the lateral annulus were significantly lower in the study group (P=0.03).

CONCLUSION

PEX syndrome is a common disorder of extracellular matrix. Our data suggest that there may also be an association between PEX syndrome and subclinical myocardial ischaemia in patients who have no signs and symptoms of ischaemia. Thus, we think that ophthalmologists should consider informing their PEX syndrome patients' general practitioners about a possible cardiac risk.

No association of LOXL1 gene polymorphisms with Alzheimer's disease

Aggregation of amyloid-beta is one of the major characteristics in brains of patients with Alzheimer's disease (AD). Although several mechanisms behind the formation of such aggregates have been suggested the regulatory factors are still unknown. The present study aimed at investigating the association of lysyl oxidase-like 1 (LOXL1) polymorphisms with AD diagnosis and cerebrospinal fluid biomarkers (CSF) for the disease. Proteins of the lysyl oxidase (LOX) family are involved in cross-linking extracellular matrix proteins to insoluble fibers and have been associated with neurodegenerative diseases including AD. Genetic polymorphisms in LOXL1 (rs1048661, rs3825942, and rs2165241) have been linked to exfoliation syndrome and exfoliation glaucoma, conditions that have shown association with AD. The polymorphisms were genotyped by Taqman allelic discrimination in a study sample including AD patients (n = 318) and controls (n = 575). In a subgroup of the population, the polymorphisms were analyzed in relation to APOE ε4 genotype and to CSF (T-tau, P-tau, and Aβ(1-42)). No evidence for associations of these polymorphisms with risk for AD or any of the studied CSF biomarkers measured was found. These results do not support LOXL1 as being a major risk gene for AD.

Pseudoexfoliation as a risk factor for peripheral vascular disease: a case-control study

AIM

To determine the association between pseudoexfoliation (PEX) and peripheral vascular disease (PVD) among age-related cataract.

SETTING

Iladevi Cataract and IOL Research Center, Ahmedabad, India.

MATERIAL AND METHODS

An observational age-matched case-control study of 160 patients over 60 years of age with age-related cataract. A total of 40 subjects with PEX (cases) were compared with 120 subjects with cataract but without PEX (controls). A detailed medical history, including hypertension, diabetes mellitus, cerebrovascular stroke and ischaemic heart disease, was recorded. Ankle brachial index (ABI) was used to determine the risk of PVD among age-related cataract patients. Color Doppler imaging was performed on the brachial and dorsalis pedis artery to measure ABI and detect PVD. Least mean ABI was the main outcome measure, as low ABI indicates higher risk for PVD. The lowest mean ABI was measured for each subject. An ABI ratio of <0.90 was considered abnormal. The Mann-Whitney U-test and logistic regression were used for analysis.

RESULTS

The lowest mean ABI in the controls was 0.98 ± 0.03 (SD; a range of 0.86-1.08) as compared with 0.88 ± 0.02 (SD) among the cases (a range of 0.79-0.92; P < 0.001). When compared with controls, cases had a lower ABI (P < 0.001) irrespective of the presence or absence of systemic illness. On multiple regression analysis adjusting for systemic illness, the presence of PEX increased the odds of a low ABI group 150 times (P < 0.001).

CONCLUSION

Subjects with cataract and PEX had a significantly lower ABI as compared with controls (cataracts without PEX). PEX is associated with and may be a risk factor for PVD.

Differences between Goldmann Applanation Tonometry and Dynamic Contour Tonometry in pseudoexfoliation syndrome

PURPOSE

To evaluate differences between Goldmann Applanation Tonometry (GAT) and Dynamic Controur Tonometry (DCT) in eyes with pseudoexfoliation syndrome (PEX).

METHODS

Thirty-eight patients (38 eyes) with PEX in both eyes (pseudoexfoliative group, PG) as well as 19 patients (19 eyes) without PEX in either eye (control group, CG), were included. All eyes were phakic. GAT, DCT, the central corneal thickness (CCT) and the axial length of the eyeball (AL) were measured and the difference between GAT and DCT (dIOP) was calculated. Differences in dIOP between CG and PG and correlations of dIOP with CCT and AL were examined.

RESULTS

dIOP was significantly (P = 0.02) higher in PG (mean value 3.69 mmHg), compared with CG (mean value 2.15 mmHg). In PG (but not in CG), dIOP was also significantly correlated with AL but not with CCT.

CONCLUSION

The fact that dIOP was significantly higher in PG than in CG implies that PEX may affect ocular biomechanical properties. The significant association of dIOP with AL but not with CCT is in agreement with previous reports and complies with the fact that pseudoexfoliative material is not deposited in corneal stroma.

Systemic high-sensitivity C-reactive protein level in pseudoexfoliation syndrome and pseudoexfoliation glaucoma

PURPOSE

To evaluate the systemic high sensitivity C-reactive protein (hsCRP) levels in patients with pseudoexfoliation syndrome (XFS) and pseudoexfoliation glaucoma (XFG).

MATERIALS AND METHODS

We prospectively examined 31 patients with XFS, 26 with XFG, and 25 controls. To the study patients with the exclusion of serious hypertension that do not have any cardiovascular and cerebrovascular disease and that diagnosed as XFS and XFG have been included. Each patient passed through a detailed blood sampling including hsCRP, biochemistry, and lipid profile. Plasma C-reactive protein (CRP) levels were measured with nephelometric method by using Beckman IMMAGE hsCRP reagent.

RESULTS

Each group had similar demographic parameters including age, sex, body mass index, heart rate, and blood pressure. When we compared with controls, there was no statistically significant difference in the hsCRP and biochemistry results between the 3 groups. When all patients with pseudoexfoliation (PEX) compared with controls there was no difference.

CONCLUSIONS

Our findings indicated no difference in the hsCRP level between XFS, XFG, and controls. This study suggests that CRP is not a predictive marker of inflammation and peripheral endothelial dysfunction in XFS, which is accepted as a systemic disorder.

Levels of plasma homocysteine in pseudoexfoliation glaucoma

BACKGROUND

To examine levels of serum homocysteine (Hcy), vitamin B12 and folic acid in patients with pseudoexfoliation glaucoma (PEXG), primary open-angle glaucoma (POAG), and healthy control subjects.

METHODS

This study included 36 patients with PEXG, 40 with POAG, and 40 age-matched healthy subjects. Fasting plasma Hcy concentrations and levels of serum vitamin B12 and folic acid were measured using competitive chemiluminescent enzyme immunoassay; values exceeding 14 μm/l were considered elevated.

RESULTS

Mean plasma Hcy was significantly higher in PEXG (16.55 ± 7.23 μm/l) compared with POAG (13.91 ± 3.61 μm/l) and controls (13.12 ± 5.13 μm/l) (p = 0.03 and p = 0.0007 respectively). There were no statistical differences in serum vitamin B12 and folic acid levels among PEXG, POAG and control subjects (p > 0.05). A moderate, although statistically significant, relationship between Hcy and folic acid levels was found in the PEXG group (R(2) = 0.23, p = 0.003). Hcy levels were found not to be related with folic acid or vitamin B12 in either POAG or control subjects.

CONCLUSIONS

In this study, plasma Hcy is significantly higher in PEXG group than the POAG and control groups. Hyper-Hcy might play a role in the pathogenesis of PEXG. Hyper-Hcy may be an independent factor stressing vasculopathy in addition to pseudoexfoliation, so might be a modifiable risk factor for PEXG.

Prevalence of pseudoexfoliation syndrome among adult Spanish in the Salnés eye Study

PURPOSE

To estimate the prevalence of Pseudoexfoliation syndrome (PXF) and to investigate its relationship with systemic and ocular diseases and lifestyle factors in a general adult population in north-western Spain.

METHODS

An age-stratified random sample of 1155 subjects was drawn from the population aged 40 years and over of O Salnés (Spain). From 937 eligible subjects, 619 (66.1%) participated (mean age (Standard Deviation [SD]): 63.4 (14.5) years, range: 40-96, 37.0% males). An interview to collect past history of ocular and systemic diseases and lifestyle details, and a comprehensive ophthalmic evaluation were performed. Study subjects with typical pseudoexfoliative material on the anterior capsule or in the pupil margin were labelled as having PXF. A design based analysis was performed and all calculations were weighted to give unbiased estimates.

RESULTS

The prevalence of PXF was 6.5% (95% confidence interval [CI]:4.9-8.1). PXF rates increased significantly with age (P = 0.000). No cases of PXF were detected in subjects between 40 and 60 years. Prevalence of PXF was 8.0% (95% C I5.4-11.6) in men and 5.4% (95% CI 3.8-7.6) in women (P = ns). The prevalence of glaucoma in subjects with PXF was 19.6% (95% CI 8.2-40.0). After controlling for age and sex, glaucoma, cataract surgery, rose bengal staining and diabetes were associated with PXF but only glaucoma and rose bengal staining associations remained significant in a multivariate model.

CONCLUSIONS

PXF is common among older individuals in north-western Spain. Subjects with pseudoexfoliation have a significantly higher prevalence of glaucoma than subjects without. An abnormal ocular surface detected by rose bengal staining is highly prevalent among subjects with pseudoexfoliation.

Association of exfoliation syndrome and central retinal vein occlusion: an ultrastructural analysis

PURPOSE

To evaluate prospectively the frequency with which exfoliation syndrome (XFS) occurs in patients with central retinal vein occlusion (CRVO) by clinical examination and ultrastructural examination of conjunctival biopsy specimens.

METHODS

Prospective observational case series. Thirty-six eyes of 36 consecutive patients with CRVO were investigated for XFS by slit-lamp examination and conjunctival biopsy when XFS was not clinically visible on examination.

RESULTS

A clinical diagnosis of XFS or a positive biopsy result for exfoliation material (XFM) was present in 22 of the 36 patients (61%; 95% confidence interval 45-75%). Twelve of these 22 patients (54%) had a clinical diagnosis of XFS. Aggregates of XFM were identified ultrastructurally in the biopsy specimens in 10 of 24 patients with no clinical signs of XFS (42%). Patients with and without XFS had similar distribution of age, gender, race and prevalence of systemic disorders. Twelve of the 22 (54%) XFS patients had neither glaucoma nor ocular hypertension prior to the CRVO.

CONCLUSION

In accordance with previous retrospective and histological studies, this prospective, in vivo study suggests that CRVO is commonly associated with XFS.

Epidemiology of exfoliation syndrome in the Reykjavik Eye Study

Exfoliation syndrome (XFS) is a major risk factor for glaucoma. It is characterized by a pathological accumulation of polymorphic fibrillar material in the anterior segment of the eye. It is likely that the increase in intraocular pressure (IOP) seen in XFS patients is at least in part because of flakes of material clogging up the trabecular meshwork, and thereby increasing the resistance to outflow and increasing IOP. XFS glaucoma progresses more rapidly, is more resistant to medical treatment and has worse prognosis than other glaucomas. The prevalence of XFS has been found to vary greatly between different studies, raising the possibility of racial and/or environmental modulators. XFS has also been linked to other changes in ophthalmological structures such as; changes in central corneal thickness (CCT), steeper corneal curvature (CC) and nuclear lens opacifications. Some studies have found XFS to be associated with systemic diseases, mostly cardiovascular and cerebrovascular. Exposure to ultra-violet (UV) light has also been investigated as a possible culprit, along with several other plausible factors. The aim of the present study was to determine the prevalence and 5-year incidence of XFS, to establish possible risk factors and/or concomitant symptoms and finally to investigate the relationship between XFS and glaucomatous changes. The Reykjavík Eye Study (RES) is a prospective study based on a random sample from the Icelandic national population sample. The baseline examination was performed in the autumn of 1996, when 1045 persons older than 50 years participated. Of these, 846 (88.2% of survivors) participated in a follow-up 5 years later. All participants went through a standard examination protocol, and answered a comprehensive questionnaire on health and life style. In the prevalence study, XFS was found in 10.7% of subjects, more frequently in women and older persons. Five years later, a further 5.2% of those that participated in the follow-up study and had no signs of XFS at baseline were diagnosed having XFS. We found a strong correlation between IOP and XFS. No difference was found in the anterior segment parameters measured, but there was a significant loss of neural tissue in the XFS as demonstrated by measurements of cup/disk ratio. In conclusion, we find XFS to be frequent among Icelanders, increasing with age and more in women. Our diagnostic criteria are reliable over time. We have also identified possible risk factors that point to a role of antioxidants in the development of XFS. We find changes in corneal curvature and thickness more related to age than XFS.

Sex- and gender-based differences in healthy and diseased eyes

PURPOSE

The aim of this study was to identify sex- and gender-based differences in ocular anatomy, physiology, and disease susceptibility or manifestation.

METHODS

Review of current indexed literature was conducted.

RESULTS

Sex and sex hormones influence the lacrimal system, eyelids and blinking, corneal anatomy and disease, aqueous humor dynamics and glaucoma, crystalline lens and cataract, uveitis and retinal disease, ocular circulation, and optic nerve anatomy and disease. Systemic conditions, particularly autoimmune disease, and conditions that are unique to women, such as pregnancy and menopause, further illustrate the effects of sex hormones on the eye. Gender-based differences in ocular conditions and disease should be considered within the context of the underlying physical and social environment.

CONCLUSIONS

Many sex- and gender-based differences exist in healthy and diseased eyes.

Directed therapy for exfoliation syndrome

Exfoliation syndrome (XFS) is an age-related disorder of the extracellular matrix that leads the production of abnormal fibrillar material that leads to elevated intraocular pressure and a relatively severe glaucoma. Exfoliation material is deposited in numerous ocular tissues and extraocular organs. XFS is associated with ocular ischemia, cerebrovascular disease, neurodegenerative disease and cardiovascular disease. Current modalities of treatment include intraocular pressure lowering with topical antihypertensives, laser trabeculoplasty and filtration surgery. The disease paradigm for XFS should be expanded to include directed therapy designed specifically to target the underlying disease process. Potential targets include preventing the formation or promoting the depolymerization of exfoliation material. Novel therapies targeting trabecular meshwork may prove particularly useful in the care of exfoliative glaucoma. The systemic and ocular associations of XFS underscore the need for a comprehensive search for neuroprotective agents in its treatment.

Directed therapy for exfoliation syndrome

Exfoliation syndrome (XFS) is an age-related disorder of the extracellular matrix that leads the production of abnormal fibrillar material that leads to elevated intraocular pressure and a relatively severe glaucoma. Exfoliation material is deposited in numerous ocular tissues and extraocular organs. XFS is associated with ocular ischemia, cerebrovascular disease, neurodegenerative disease and cardiovascular disease. Current modalities of treatment include intraocular pressure lowering with topical antihypertensives, laser trabeculoplasty and filtration surgery. The disease paradigm for XFS should be expanded to include directed therapy designed specifically to target the underlying disease process. Potential targets include preventing the formation or promoting the depolymerization of exfoliation material. Novel therapies targeting trabecular meshwork may prove particularly useful in the care of exfoliative glaucoma. The systemic and ocular associations of XFS underscore the need for a comprehensive search for neuroprotective agents in its treatment.

The evaluation of vestibular functions in patients with pseudoexfoliation syndrome

The main objective of the study is to evaluate vestibular system of the inner ear with postural tests in the patients with pseudoexfoliation syndrome (PEX). It is clinical case-control study. The study group included 34 patients with PEX and 40 controls without PEX. The patients and controls underwent complete ophthalmic and otorhinolaryngologic examinations. Vestibular functions were done by Fitzgerald and Dix-Hallpike, caloric tests, Romberg test, tandem Gait test, Quiks test in both control and study groups. Pur-tone and high-frequency audiography were also performed in all cases. The mean patient age was 63 years (+/-11.80) (range 47-74 years) in the PEX group and 65 years (+/-8.70) (range 61-68 years) in the control group with no differences among the two groups (P > 0.05). Although none of the 34 patients with PEX had clinical history of balance disturbance, 21 (61.76%) had significant pathologic sign in vestibular function tests (P < or = 0.05), while only 3 (7.5%) of 40 cases in the control group had pathologic sign in vestibular function tests. The scales from pure tone and high-frequency audiogram in the PEX group were similar to those of the control group. In conclusion, the patients with PEX, there may be a vestibular involvement in the pathological level in the inner ear. Larger clinical studies, experimental animal studies, and post mortem studies in humans are needed to disclose the pathology in the vestibulocochlear system in the patients with PEX.

From epidemiology to lysyl oxidase like one (LOXL1) polymorphisms discovery: phenotyping and genotyping exfoliation syndrome and exfoliation glaucoma in Iceland

The first Icelandic articles on exfoliation syndrome (XFS) and exfoliation glaucoma (XFG) appeared some 35 years ago in 1974. Articles since then have included epidemiology, pedigree-based and twin-studies as well as investigations into XFG response to medical therapy and XFS/XFG genetics. All studies found XFS/XFG to be common in Iceland and to be age-related. The Reykjavik Eye Study (RES), a population-based epidemiological study, was first conducted in 1996. The RES found that XFS and XFG prevalence in patients aged 50 years and older was 11% and that XFS/XFG was more common in women than in men. These results were confirmed in 5- and 12-year incidence studies that also suggested that detailed characterization of the phenotype is important, including pupil dilation. In the RES, eyes with XFS were found to be clinically unilateral in about half of cases and to have higher mean intraocular pressure (IOP) than non-XFS eyes. However, XFS was not found to be associated with central corneal thickness, corneal curvature, anterior chamber depth, lens thickness, lens opacification or optic disc morphology. About 15% of persons with XFS had XFG, and XFG eyes had higher risk of developing visual impairment and blindness than eyes with primary open-angle glaucoma. The first genetic studies on Icelanders, conducted about 12 years ago, were linkage studies and were unsuccessful in discovering the genetics behind XFS/XFG. However, in 2007 a genome-wide association study in Iceland using more than 300 000 markers [single nucleotide polymorphisms (SNPs)] on a relatively small number of patients did discover that lysyl oxidase like 1 (LOXL1) on chromosome 15q24 is a major gene for XFS/XFG. These results have now largely been replicated world-wide.

A 12-week Study Evaluating the Efficacy of Bimatoprost 0.03% in Patients with Pseudoexfoliative and Open-Angle Glaucoma

Purpose

To evaluate the control of diurnal intraocular pressure (IOP) and the safety profile of bimatoprost in pseudoexfoliative glaucoma (PXG) compared to primary open angle glaucoma (POAG).

Methods

A prospective, observer-masked, nonrandomized study was performed. Seventy consecutive patients with either POAG (35 eyes) or PXG (35 eyes) drug-naive for glaucoma were assigned to receive bimatoprost 0.03% once daily for 12 weeks. Diurnal IOP was measured at baseline and after 12 weeks at three time points (8 AM, noon, and 4 PM). Main outcomes were diurnal IOP control and achievement of target IOP (CIGTS criteria). Mean diurnal IOP, hour-by-hour IOP measurements, and safety, including serious adverse events, were also evaluated.

Results

A significant IOP reduction from baseline was found in both groups (p<0.001). Mean and hour-by-hour IOP differences between groups were not statistically significant (NS). The observed IOP values and percentages of IOP reduction were 17.0 mmHg (31.5%) and 16.4 mmHg (31.9%) in PXG and POAG eyes, respectively; the differences were not statistically significant. Six eyes (1 POAG and 5 PXG, respectively) responded with a <20% IOP reduction (NS). Twenty-seven POAG (77.1%) and 23 PXG (65.7%) eyes achieved target IOP. Consequently, 20 eyes (8 POAG and 12 PXG, respectively) were classified as unable to achieve the IOP target values (NS).

Conclusions

Bimatoprost was effective and safe in lowering IOP both in open angle and pseudoexfoliative glaucoma, achieving target pressure in most patients. However, long-term efficacy in PXG must be evaluated.

Central retinal artery occlusion and non-arteritic anterior ischemic optic neuropathy associated with an overlap syndrome: a case report

Introduction

An "overlap syndrome" is defined as the sequential appearance over time of two or more risk factors for glaucomatous damage. The appearance of a new risk factor can alter the course and prognosis of previously stable disease. Exfoliation syndrome is a leading cause of glaucoma and is associated with vascular disease. We report a case of central retinal artery occlusion and non-arteritic anterior ischemic optic neuropathy in a patient with overlap syndrome.

Case presentation

An 87-year-old woman with longstanding stable primary open-angle glaucoma developed bilateral exfoliation syndrome, after which her intraocular pressure became uncontrolled and her glaucomatous damage progressed rapidly. She also developed ischemic arterial events in both eyes.

Conclusion

The case presented here shows that overlap syndromes can lead to rapid, irreversible vision impairment. To the best of our knowledge, this is the first reported case of central retinal artery occlusion and non-arteritic anterior ischemic optic neuropathy in a patient with overlap syndrome.

Is exfoliation syndrome a sign of systemic vascular disease?

Exfoliation syndrome (ES) is an age-related disorder in which greyish-white flakes accumulate in different tissues in the anterior eye. Its pathogenesis is not completely known, but it results in electron-dense microfibrils. The finding that these can be seen outside the eye in many visceral organs inspired the theory that ES might be a part of a generalized disorder. It was postulated that ES might contribute to increased morbidity, mainly of systemic vascular diseases. This review is a summary of the existing knowledge. The prevalence of arterial hypertension (AHT) in elderly populations is > 30%. No differences have been found in the frequency of AHT among patients with ES or exfoliative glaucoma (EG) compared with those with primary open-angle glaucoma (POAG) or no ES. There are conflicting reports of frequencies of ischaemic heart disease (IHD). A recent registry-based study that used uniform criteria for IHD found no difference in the rate of IHD between patients with EG and those with POAG. However, findings of elevated homocysteine levels in the plasma and aqueous humour of patients with ES or EG suggest an increased vascular risk. No studies have yet been conducted to assess possible links between ES and systemic vascular diseases. In a single-blind study, ES was associated with abdominal aortic aneurysm, but this was not found in a large, cross-sectional investigation. The frequency of ES in patients with diabetes mellitus (DM) is only about half of that when compared in patients with no ES or with POAG. This finding warrants further studies. Molecular genetics research has found no common denominator for ES and the vascular diseases. There is no evidence that ES or EG are related to increased mortality for cardiovascular diseases. Further large-scale, randomized clinical studies are required. At present there are no known medical indications that infer an increased systemic vascular risk or imply a need for the complete internal medical examination of a symptom-free patient with newly diagnosed ES in the eye.