[Pseudoexfoliation syndrome and pseudoexfoliation glaucoma]

Normal-Tension Glaucoma and Potential Clinical Links to Alzheimer's Disease

Glaucoma is a group of optic neuropathies and the world's leading cause of irreversible blindness. Normal-tension glaucoma (NTG) is a subtype of glaucoma that is characterized by a typical pattern of peripheral retinal loss, in which the patient's intraocular pressure (IOP) is considered within the normal range (<21 mmHg). Currently, the only targetable risk factor for glaucoma is lowering IOP, and patients with NTG continue to experience visual field loss after IOP-lowering treatments. This demonstrates the need for a better understanding of the pathogenesis of NTG and underlying mechanisms leading to neurodegeneration. Recent studies have found significant connections between NTG and cerebral manifestations, suggesting NTG as a neurodegenerative disease beyond the eye. Gaining a better understanding of NTG can potentially provide new Alzheimer's Disease diagnostics capabilities. This review identifies the epidemiology, current biomarkers, altered fluid dynamics, and cerebral and ocular manifestations to examine connections and discrepancies between the mechanisms of NTG and Alzheimer's Disease.

Glaucoma, Pseudoexfoliation and Hearing Loss: A Systematic Literature Review

Purpose: To investigate the relationship between glaucoma, pseudoexfoliation and hearing loss (HL). Methods: A systematic literature search following PRISMA guidelines was conducted using the PubMed, Embase, Scopus and Cochrane databases from 1995 up to 28 August 2023. Results: Thirty studies out of the 520 records screened met the inclusion criteria and were included. Most articles (n = 20) analysed the association between pseudoexfoliation syndrome (XFS) and HL, showing XFS patients to have higher prevalence of sensorineural hearing loss (SNHL) at both speech frequencies (0.25, 0.5, 1 and 2 kHz), and higher frequencies (4 and 8 kHz) compared to controls in most cases. No significant differences in prevalence or level of HL between XFS and pseudoexfoliative glaucoma (XFG) were detected in most studies. Eight articles analysed the relationship between primary open-angle glaucoma (POAG) and HL. Overall, a positive association between the two conditions was highlighted across all studies except for two cases. Similarly, articles focusing on NTG and HL (n = 4) showed a positive association in most cases. The role of autoimmunity and, in particular, the presence of antiphosphatidylserine antibodies (APSA) in patients with NTG and HL suggested an underlying autoimmune or vascular mechanism contributing to their pathogenesis. Only one study analysed the relationship between angle-closure glaucoma (ACG) and HL, showing higher incidence of ACG in patients with SNHL compared to normal hearing controls. Conclusions: Most studies detected an association between XFS and HL as well as POAG/NTG/ACG and HL, suggesting the presence of a similar pathophysiology of neurodegeneration. However, given the strength of the association of XFS with HL, it remains unclear whether the presence of XFG is further associated with SNHL. Further research specifically targeted to assess the correlation between glaucoma, XFS and HL is warranted to provide a more comprehensive understanding of this association.

Investigating the Impact of Sun/UV Protection and Ease of Skin Tanning on the Risk of Pseudoexfoliation Glaucoma: A Mendelian Randomization Study

Purpose

To investigate the potential causal associations between the use of sun/ultraviolet (UV) protection and ease of skin tanning and the risk of pseudoexfoliation glaucoma (PXG) in European populations.

Methods

Single nucleotide polymorphisms (SNPs) associated with the use of sun/UV protection and ease of skin tanning were selected from the UK Biobank genome-wide association study database consisting of 498,751 European participants. SNPs of PXG were obtained from the FinnGen study including 3424 PXG cases and 326,434 controls. Two-sample Mendelian randomization (MR) analyses were performed to assess the association between the use of sun/UV protection and ease of skin tanning and risk of PXG.

Results

Inverse variance weighted regression of genetic susceptibility predicted that both use of sun/UV protection and ease of skin tanning were potentially positively associated with the decreased risk of PXG in the European ancestry (use of sun/UV protection: odds ratio [OR] = 0.47; 95% confidence interval [CI], 0.24-0.92; P = 0.028; ease of skin tanning: OR = 0.81; 95% CI, 0.67-0.97; P = 0.025).

Conclusions

We found genetic evidence supporting a potential causal association between UV protection and a decreased risk of PXG in European population. Further research will help elucidate the underlying mechanisms and promote UV protection for eyes, especially in people with a high risk of PXG.

The correlation between pseudoexfoliation syndrome and the Triglyceride-Glucose index

PURPOSE

Pseudoexfoliation (PEX) syndrome is an age-related disease characterized by the accumulation of extracellular material in many ocular structures, skin and internal organs. Recent studies have shown that the Triglyceride-Glucose (TyG) index has clinical importance for the evaluation of vascular damage. The purpose of this study was to determine the relationship between PEX syndrome and TyG index, and to detect the risk in terms of vascular diseases.

METHODS

In the present study, 50 patients with PEX syndrome who were admitted to the ophthalmology outpatient clinic were evaluated along with 50 others who made up the control group. The Triglyceride-Glucose index was calculated with fasting plasma glucose and triglyceride values.

RESULTS

The mean age was 68.2 ± 1.2 years and 61.0% of the patients were male. There was no statistically significant difference between the two groups in terms of blood sugar and lipid profile (except triglyceride) (p > 0.05). The TyG index value was 8.9 ± 0.5 in the PEX group and 8.6 ± 0.6 in the control group. This difference was statistically significant (p = 0.003). In univariate regression analysis, TyG index (OR = 2.81; CI: 1.37-5.75; p = 0.005) was found to be correlated with PEX. In multivariate logistic regression analysis, this correlation remained statistically significant when adjusted for age and sex (OR = 2.89; CI: 1.35-6.18; p = 0.006).

CONCLUSION

Results showed that the TyG index was high in patients diagnosed with PEX. The risk of vascular diseases can be determined by examining the TyG index in patients with PEX, and this predetermination would have significant consequences for public health.

INCIDENCE OF PSEUDOEXFOLIATION SYNDROME AND GLAUCOMA IN A SET OF MORE THAN 14,000 EYES OF PATIENTS OPERATED FOR A CATARACT

PURPOSE

Evaluation of the incidence of pseudoexfoliation (PEX) syndrome and glaucoma in cataract patients operated at our Clinic, with an analysis of possible complications.

METHODOLOGY

Retrospective evaluation of medical records of PEX syndrome patients who have undergone cataract surgery at the Gemini Eye Clinic Ostrava-Hrusov was undertaken. The study period was from November 2016 to April 2021. The evaluated parameters were the incidence of PEX syndrome, age and gender of patients, intraocular pressure (IOP) before the surgery, pre-existing therapy of previously diagnosed secondary glaucoma and the occurrence of perioperative complications.

RESULTS

In the study period of 4.5 years, out of the total number of 14 167 operated eyes with cataracts there were 852 eyes of 689 patients with PEX syndrome diagnosed at our Clinic, i.e. 6.0 %. The mean age was 76.9 years, the median 77 years, range 54-100 years. The observed pathology was more common in women at a ratio of 1.84: 1 (552: 300). Elevation of IOP above 21 mmHg was recorded in 118 eyes, in 14 of them IOP reached values over 30 mmHg. Diagnosed and long-term treated secondary glaucoma was confirmed by 153 patients (204 eyes), out of which 22 eyes have undergone antiglaucoma laser (19 eyes) and / or surgery (5 eyes) in the anamnesis. Perioperatively, we recorded the following pathological findings accompanying the occurrence of PEX syndrome in 231 eyes. Most often it was poor artificial mydriasis (189 eyes), then subluxation of the lens (31 eyes) or zonular fragility (17 eyes). To reduce the risk of perioperative and postoperative complications, implantation of a capsular tension ring was indicated in 20 eyes. Complications during the procedure occurred in 11 eyes, of which 8 eyes were diagnosed with advanced cataract.

CONCLUSION

PEX syndrome and glaucoma are relatively common diseases that can complicate the lives of patients and eye surgeons. The incidence of PEX syndrome in our cataract patients was 6 %. Proper diagnosis of this disease is important not only for the possible occurrence of numerous complications during and after cataract surgery, but also for the possible presence of secondary glaucoma. It also serves to detect possible involvement of the contralateral eye. In addition, due to the involvement of practically all tissues in the body, the patient is endangered by numerous, especially vascular comorbidities. For these reasons, we find it appropriate that these patients are observed by other healthcare specialists. In our experience, early indication of cataract surgery is important to achieve a lower degree of zonular fragility and a softer lens core. In addition, lower levels of proinflammatory pseudoexfoliation material occur in the anterior segment of the eye in the early stages, which may have a beneficial effect on the postoperative healing.

Selective laser trabeculoplasty as adjunctive treatment in pseudoexfoliative glaucoma patients

Introduction/Objective. Pseudoexfoliation syndrome is characterized by abnormal production and accumulation of fibrillar, white-gray, ?dandruff-like? material in almost all ocular structures. The aim of this study was to examine effect of selective laser trabeculoplast in pseudoexfoliation glaucoma patients. Methods. Thirty-two patients (47 eyes) were enrolled with medically uncontrolled pseudoexfoliation glaucoma. All patients could not reach target intraocular pressure with maximal tolerated medical therapy before treatment. Selective laser trabeculoplasty was performed with about 100 non-overlapping spots. Intraocular pressure was measured 1 hour, 7 days, 4 weeks, 3, 6, 12, 18 and 24 months after procedure. Results. The mean base intraocular pressure was 23.45 mmHg (SD = 3.07). Statistically significant reduction of mean intraocular pressure was observed at all follow-ups except 1 hour after treatment. Mean intraocular pressure after 24 months was 18.39mmHg (SD = 1.82). Success, defined as intraocular pressure reduction from base IOP of more than 20% after 24 months, was achieved in 27 eyes (57.45%). We did not find any influence of sex and age on selective laser trabeculoplasty effects in pseudoexfoliative glaucoma patients. Baseline intraocular pressure is proved to be reliable predictor of intraocular pressure lowering effect, as there were strong correlation between baseline intraocular pressure and percentage of reduction of intraocular pressure after 24 months (r = 0.71, p < 0.01). Conclusion. Selective laser trabeculoplasty is safe and effective method for reduction of intraocular pressure in pseudoexfoliation glaucoma patients and should be used more often in this challenging form of glaucoma. Baseline intraocular pressure seems to be reliable predictor of success.

Choroidal vascularity index in pseudoexfoliative glaucoma

PURPOSE

To evaluate choroidal vascular involvement in pseudoexfoliative glaucoma (PEXG) by applying the choroidal vascularity index (CVI) to optic coherence tomography (OCT) images.

METHODS

Seventy-eight eyes from 40 subjects were included the study. Group 1 included healthy eyes (n = 20), group 2 eyes with PEX (n = 16), and group 3 eyes with PEXG (n = 42). OCT imaging of macular and peripapillary regions and retinal nerve fiber layer (RNFL) analyses were performed. CVI was calculated using ImageJ software.

RESULTS

The mean age was 64.89 ± 5.8, 71.2 ± 7.8, and 68.24 ± 7.4 years in groups 1, 2, and 3, respectively (p = 0.046). There were no significant differences between the groups in terms of sex (p = 0.777). In macula, mean CVI rates were 66.97 ± 1.9%, 64.23 ± 1.2%, and 64.63 ± 1.6%, and in the peripapillary areas, mean CVI rates were 67.04 ± 1.5%, 65.20 ± 1.5%, and 64.14 ± 2.1% in groups 1, 2, and 3, respectively (group 1 vs. group 2 and 3, p = 0.000; group 2 vs. group 3, p > 0.05). The decrease in average RNFL thickness was statistically significant in group 3 compared to groups 1 and 2.

CONCLUSION

CVI could be used to assess choroidal vascular changes in ocular diseases. CVI was found to be reduced in PEX and PEXG, indicating an ocular vascular involvement in pseudoexfoliative process.

THE EFFECT OF PRIMARY ARGON LASER TRABECULOPLASTY ON INTRAOCULAR PRESSURE REDUCTION AND QUALITY OF LIFE IN PATIENTS WITH PSEUDOEXFOLIATION GLAUCOMA

The aim of the study was to assess the impact of primary argon laser trabeculoplasty (ALT) on intraocular pressure (IOP) lowering and quality of life improvement in patients with pseudoexfoliative glaucoma. Sixty patients with newly diagnosed pseudoexfoliative glaucoma who underwent primary ALT (group 2) or medication therapy (group 1) were followed-up. The effect of ALT on IOP reduction, dry eye development and number of antiglaucoma drugs used was examined. Patients were examined at the beginning of the study and then after 6, 12, and 18 months. A statistically significant difference between IOP values was observed throughout the 18-month follow-up, with the highest significance recorded 6 months after ALT (p=0.009). Twelve months after the start of the study, the TBUT value was 6.0±0.8 s in group 1 and 8.4±0.7 s in group 2. In group 2, the value of Schirmer test was constantly above 10 millimeters. The number of antiglaucoma medications used in group 1 was statistically significantly higher as compared to group 2 throughout the 18-month study period. ALT was found to be better choice for temporary regulation of IOP in patients with pseudoexfoliative glaucoma.

Changes in peri-ocular anatomy and physiology in pseudoexfoliation syndrome (Review)

Pseudoexfoliation syndrome (PEX) is characterized by the deposition of proteinaceous material in the anterior ocular segment (resulting in ophthalmic pathologies such as glaucoma and increased risk of complications in cataract surgery), but also by several systemic manifestations. The involvement of peri-ocular tissues in PEX, including the eyelid skin, lacrimal gland, conjunctiva, orbital fat and vessels, as well as the optic nerve, has been reported by several previous studies. The peri-ocular effects of PEX include the development of eyelid laxity, conjunctival chalasis, tear film abnormalities, pronounced orbital fat atrophy in response to the administration of prostaglandin analogues in pseudoexfoliative glaucoma, deficient orbital vascular supply and biomechanical changes in both the eyeball and the optic nerve. These effects may have important clinical implications, including increased difficulty in cataract surgery, ocular surface disease and eyelid margin malpositions.

The association between ethnicity, environmental and lifestyle factors and chronic disease in the development of pseudoexfoliation syndrome

Objectives

To determine the association between ethnicity, environmental factors, lifestyle factors, chronic diseases and pseudoexfoliation syndrome (PEX).

Methods

A case control study conducted at four major hospitals in Pakistan from January to November 2019, with 241 cases and 294 controls, aged ≥ 40 years, who were administered a questionnaire assessing demographics, lifestyle factors, chronic diseases and ethnicity. Multivariate binary logistic regression was applied to calculate the odds ratio between cases and controls.

Results

PEX was found to be positively associated with ethnicity (p<0.001), time spent outdoors (p<0.001), educational status (p<0.001), asthma (p<0.001), mean age (p<0.001), daily tea intake (p=0.003), weighted maximum temperature (p<0.001) and weighted mean temperature (p=0.004). Poor association was found with weighted latitude (p=0.526) and weighted minimum temperature (p=0.079). Odds ratios for patients with asthma (OR=7.366, regression coefficient=1.993, p<0.001) Pathan ethnicity (OR=1.616, regression coefficient=0.48, p=0.016) and mean weighted temperature (OR=0.907, regression coefficient-0.097, p=0 .000) were significant in diagnosed cases of PEX.

Conclusion

Individuals with Pathan ethnicity and asthmatics should be made aware of the risk of developing PEX and the importance of periodic screening. Limiting exposure to sunlight and cold and reducing the intake of tea may help in reducing in the chances of developing PEX.

[The trabecular meshwork: Structure, function and clinical implications. A review of the littérature (French translation of the article)]

Glaucoma is a blinding optic neuropathy, the main risk factor for which is increased intraocular pressure (IOP). The trabecular meshwork, located within the iridocorneal angle, is the main pathway for drainage of aqueous humor (AH) out of the eye, and its dysfunction is responsible for the IOP elevation. The trabecular meshwork is a complex, fenestrated, three-dimensional structure composed of trabecular meshwork cells (TMC) interdigitated into a multilayered organization within the extracellular matrix (ECM). The purpose of this literature review is to provide an overview of current understanding of the trabecular meshwork and its pathophysiology in glaucoma. Thus, we will present the main anatomical and cellular bases for the regulation of aqueous humor outflow resistance, the pathophysiological mechanisms involved in trabecular dysfunction in the various types of glaucoma, as well as current and future therapeutic strategies targeting the trabecular meshwork.

XEN Gel Stent in Pseudoexfoliative Glaucoma: 2-Year Results of a Prospective Evaluation

PRéCIS:: This study confirms the safety and efficacy of XEN gel stents in the management of pseudoexfoliative glaucoma 2 years after implantation, with success rates similar to primary open-angle glaucoma regardless of the definition of success.

PURPOSE

To compare the long-term safety and efficacy of XEN gel implant surgery (Allergan Inc., Irvine, CA) in patients with pseudoexfoliative glaucoma (PEXG) and primary open-angle glaucoma (POAG).

SETTING

Prospective, interventional study in a tertiary glaucoma center.

METHODS

A total of 110 eyes of 85 patients with POAG (57 eyes) or PEXG (53 eyes) and uncontrolled intraocular pressure (IOP) despite medical treatment underwent combined XEN+cataract surgery or standalone XEN surgery. Mean IOP, mean number of medications, needling rates, and incidence of adverse effects were compared between the 2 groups. Complete surgical success was defined as an unmedicated IOP≤12, 15, 16, or 18 mm Hg at 2 years, both with and without a 20% reduction from baseline.

RESULTS

Combined XEN+cataract surgery was performed in 72% of POAG and 76% of PEXG eyes (P=0.67), the remainder underwent standalone XEN surgery. Patient characteristics were similar between the 2 groups except for older age for the patients with PEXG (78.5±8.5 vs. 71.3±8.7 y; P<0.005). Mean medicated IOP were 19.8±5.8 mm Hg (POAG) versus 19.8±8.2 mm Hg (PEXG) at baseline (P=0.98), and 14.5±3.6 mm Hg (-26.8%) versus 14.2±3.8 mm Hg (-28.3%), respectively, at 2 years (P=0.75). Mean medications concomitantly dropped from 1.9±1.6 (POAG) versus 2.0±1.3 (PEXG) to 0.6±0.9 versus 0.4±0.7, respectively (P=0.29). Using the 16 mm Hg threshold, 51.4% (POAG) versus 57.1% (PEXG) eyes achieved complete success (P=0.70) at 2 years. The difference in success rates between the 2 groups was not statistically significant under any of the definitions of success. By 24 months, needling was performed in 42.8% (POAG) and 43.2% (PEXG) (P=0.64), with an average time to needling of 162.8 and 134.9 days, respectively (P=0.46). The rates of adverse effects were 30.6% (POAG) and 36.4% (PEXG) (P=0.66), and additional glaucoma surgeries were carried out in 14.3% (POAG) versus 15.9% (PEXG) (P=0.89).

CONCLUSIONS

The XEN gel implant as a standalone or combined procedure demonstrated similar efficacy and safety results in PEXG and POAG eyes.

The trabecular meshwork: Structure, function and clinical implications. A review of the literature

Glaucoma is a blinding optic neuropathy, the main risk factor for which is increased intraocular pressure (IOP). The trabecular meshwork, located within the iridocorneal angle, is the main pathway for drainage of aqueous humor (AH) out of the eye, and its dysfunction is responsible for the IOP elevation. The trabecular meshwork is a complex, fenestrated, three-dimensional structure composed of trabecular meshwork cells (TMC) interdigitated into a multilayered organization within the extracellular matrix (ECM). The purpose of this literature review is to provide an overview of current understanding of the trabecular meshwork and its pathophysiology in glaucoma. Thus, we will present the main anatomical and cellular bases for the regulation of aqueous humor outflow resistance, the pathophysiological mechanisms involved in trabecular dysfunction in the various types of glaucoma, as well as current and future therapeutic strategies targeting the trabecular meshwork.

Surgical experience with a redesigned, fully preloaded, hydrophobic acrylic intraocular lens in challenging cases of pseudoexfoliation syndrome, phacodonesis, and small pupils

Purpose

The purpose of this study was to describe our surgical experience and evaluate safety and postoperative outcomes of a fully preloaded, monofocal, hydrophobic acrylic intraocular lens (IOL) (CT LUCIA 611P) with a newly designed optic-haptic junction in severe cases of pseudoexfoliation (PXF) syndrome, phacodonesis, and small pupils.

Setting

This study was conducted in Borkenstein & Borkenstein, private practice, Privatklinik der Kreuzschwestern Graz, Austria.

Patients and methods

This study presents outcomes of 15 eyes of 15 patients implanted with CT LUCIA 611P IOL with improved optical properties and more rigid and wider optic– haptic junction. All patients had advanced cataract and PXF syndrome, of which phacodonesis was detected in 12 cases and five cases had PXF glaucoma. All eyes had small pupils with no response to mydriatic drops, and the surgery was performed with the use of Malyugin ring. All eyes were targeted for a slight postoperative myopia (−0.25 to −0.50 D). Refractive outcomes were presented for 3 months follow-up, while adverse events were followed up for to 10 months.

Results

The mean age of the study group was 78.3 years (from 68 to 86 years). Three months postoperatively, the mean manifest spherical equivalent was −0.35 D (from 0.00 to −1.00 D) and all eyes were within ±0.50 D of their preoperative target. No significant refractive shift or refractive surprise occurred during the follow-up of 10 months. Corrected distance visual acuity (CDVA) improved from the mean value of 20/50 preoperatively to 20/20 postoperatively. No intraoperative adverse events were noted. Postoperatively, six eyes presented with a slight decentration or tilt, which did not significantly affect postoperative refraction, CDVA, or patients’ subjective visual symptoms.

Conclusion

The IOL provided good surgical performance, excellent refractive stability, and predictable outcomes in patients with PXF syndrome. Further studies are necessary to evaluate long-term stability.