Association of pseudoexfoliation syndrome with increased vascular risk

Subfoveal choroidal thickness changes in patients with pseudoexfoliation syndrome (PEX) compared to healthy controls: A systematic review and meta-analysis

PURPOSE

To investigate changes in choroidal thickness in patients diagnosed with pseudoexfoliation syndrome (PEX) compared to healthy controls, using optical coherence tomography (OCT).

METHODS

PubMed and Scopus databases were systematically searched for published articles comparing choroidal thickness between patients with PEX and healthy controls. Standardized Mean Difference (SMD) with 95 % confidence interval (CI) was computed to compare continuous variables. Revman 5.4 was used for the analysis. Subgroup analyses were performed according to OCT devices used.

RESULTS

12 studies were included in our analysis. Subfoveal choroidal thickness was decreased in patients with PEX compared to healthy controls. Subgroup analysis confirmed this finding in studies that used Heidelberg or Optovue OCT Devices.

CONCLUSION

Our meta-analysis showed that choroidal thickness was decreased in patients with PEX compared to controls. Increased heterogeneity and small case-control studies are the main limitations of the meta-analysis. Further studies are needed to evaluate the clinical significance of reduced subfoveal choroidal thickness in PEX.

The use of calprotectin and other inflammatory parameters in the investigation of pseudoexfoliation syndrome concomitant glaucoma and systemic diseases

PURPOSE

The present study aimed to investigate the value of calprotectin and other inflammatory parameters in patients with glaucoma and systemic diseases accompanying pseudoexfoliation syndrome (PEX-S).

METHODS

This prospective study included 45 PEX-S patients and 45 non-PEX control patients. Patients were investigated for the presence of glaucoma, cardiovascular disease (CVD), ischemic brain disease (IBD), Alzheimer's disease, and neurosensory hearing loss (NSHL). After excluding diseases that may affect inflammatory parameters, a detailed biomicroscopic examination, and blood tests were performed for the patients.

RESULTS

Glaucoma, CVD, NVK, Alzheimer's disease, and NSHL were high in the PEX-S group ( P = 0.01, P = 0.01, P = 0.04, P = 0.04, and P = 0.03, respectively). Calprotectin, ferritin, neutrophil-to-platelet ratio, and lymphocyte-to-platelet ratio were found to be high in the PEX-S group ( P < 0.01, P = 0.04, P < 0.01, and P < 0.01, respectively). On evaluating the relationship between PEX-S and glaucoma and systemic diseases, it was found that elevated calprotectin increased the risk of glaucoma by 4.36 times and elevated neutrophil-to-lymphocyte ratio (NLR) increased the risk of CVD by 3.23 times in PEX-S patients ( P = 0.02 and P = 0.03, respectively).

CONCLUSION

This study demonstrated the value of calprotectin elevation in detecting concomitant glaucoma in PEX-S patients and, in addition, the value of NLR elevation in detecting concomitant CVD.

Association between Diabetes and Exfoliation Syndrome

Topic

This systematic review and meta-analysis summarizes the existing evidence for the association of diabetes mellitus (DM) and exfoliation syndrome (XFS).

Clinical Relevance

Understanding and quantifying these associations may aid clinical guidelines or treatment strategies and shed light on disease pathogenesis. The role of DM in determining XFS risk may also be of interest from an individual or public health perspective.

Methods

The study protocol was preregistered on the International Prospective Register of Systematic Reviews with registration number CRD42023429771. We systematically searched PubMed and Embase from inception to June 15, 2023. Screening and full-text review were conducted by 2 independent reviewers. All observational studies reporting an age-adjusted odds ratio (OR) and 95% confidence interval (CI) for the association between DM and XFS among adults were included. Quantitative synthesis involved a random-effects meta-analysis using the DerSimonian-Laird method to generate a pooled OR. Risk of bias was evaluated using the Newcastle-Ottawa Scale.

Results

Fourteen studies (9 cross-sectional and 5 case-control) comprising 47 853 participants were included in the systematic review and meta-analysis. Random-effects meta-analysis indicated no overall association between DM and XFS (OR 0.94; 95% CI, 0.73–1.21; I 2  = 68.5%). However, subgroup analysis revealed a significant inverse association among individuals ≥ 65 years (OR 0.71; 95% CI, 0.54–0.93) versus individuals < 65 years (OR 1.22; 95% CI, 0.80–1.87; P effect modification  = 0.04). The relation between DM and XFS was also inverse in case-control studies (OR 0.75; 95% CI, 0.58–0.97) but was nonsignificant in cross-sectional studies (OR 1.17; 95% CI, 0.83–1.66; P effect modification  = 0.04). Overall risk of bias was low, with tests for publication bias showing P  ≥ 0.06.

Conclusion

This meta-analysis suggests no association between DM and XFS overall, with possible inverse associations of DM with XFS in older populations. However, given the substantial heterogeneity and borderline significance for publication bias, these findings should be interpreted with caution. Our results give insight into the unique etiology and clinical relevance of XFS while proposing the need for larger longitudinal and genetic biomarker studies.

Financial Disclosure(s)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Pseudoexfoliation Syndrome Presenting With Bilateral Visual Impairment and Intraocular Pressure Discrepancy: A Case Report

Pseudoexfoliation syndrome (PEX) presents a significant clinical challenge due to its diverse ocular manifestations, including glaucoma and zonular weakness of the lens, which can lead to irreversible visual impairment if left untreated. We report a case of a 78-year-old male presenting with bilateral visual impairment persisting for four years, with a more pronounced decline in the right eye over the past six months. Examination revealed aphakia with pseudoexfoliative material in the right eye, a cataract with pseudoexfoliative material in the left eye, and a notable intraocular pressure (IOP) discrepancy. Surgical intervention was required for both eyes, with cataract extraction and IOP-lowering procedures performed to preserve vision and prevent further deterioration. This case underscores the importance of timely recognition and comprehensive management of PEX-related ocular complications to optimize visual outcomes and quality of life for affected individuals. Close collaboration between ophthalmologists and other healthcare professionals is essential to address the multifaceted nature of PEX and tailoring treatment strategies to individual patient needs. Further research is needed to elucidate the underlying pathophysiology of PEX and refine therapeutic approaches to mitigate its detrimental effects on vision.

Clinical outcomes of Ahmed glaucoma valve implantation in primary open-angle glaucoma and pseudoexfoliative glaucoma

PURPOSE

To investigate the clinical outcomes of Ahmed glaucoma valve (AGV) implantation in primary open-angle glaucoma (POAG) and pseudoexfoliative glaucoma (PEXG).

METHODS

The patients who underwent AGV implantation for POAG and PEXG between January 2015 and December 2021 in a single tertiary center eye clinic were reviewed retrospectively. Thirty-one eyes with the diagnosis of POAG constituted Group 1 and 40 eyes with the diagnosis of PEXG constituted Group 2. The primary outcome measures were intraocular pressure (IOP) changes after AGV implantation and surgical success at the last visit. We evaluated complete and qualified surgical success using the following three criteria: (1) IOP ≤ 21mmH g, (2) IOP ≤ 18 mmHg, and (3) IOP ≤ 15 mmHg, as well as the absence of any serious complications, such as light perception loss and phthisis bulbi, and additional de novo glaucoma surgery.

RESULTS

The mean follow-up times were 25.2 (± 21.4) months and 27.6 (± 19.8) months for Groups 1 and 2, respectively (p > 0.05). In Groups 1 and 2, the mean preoperative IOPs were 31.9 ± 9.4 mmHg and 32.3 ± 8.4 mmHg, respectively, which significantly reduced to 14.5 ± 0.7 mmHg and 11.6 ± 0.6 mmHg, respectively at the last postoperative visit (p < 0.001 for both). The mean IOP value at the last visit was statistically significantly lower in Group 2 (p = 0.006). At the last visit, the number of eyes with qualified success according to criteria 1, 2, and 3 was 26 (83.9%), 25 (80.6%), and 18 (58.1%), respectively, in Group 1 and 39 (97.5%), 39 (97.5%), and 32 (80%), respectively, in Group 2. The comparison of the qualified success rates showed statistically significantly higher rates in Group 2 for criterion 2 (p = 0.038).

CONCLUSION

AGV implantation had high success rates in both POAG and PEXG, but at the final visit, lower IOP levels were reached in the latter.

Visual Field Progression After Glaucoma Surgery in Pseudoexfoliation versus Primary Glaucoma

Purpose

To compare visual field progression in severity-matched pseudoexfoliation glaucoma (XFG) and primary glaucoma after intraocular pressure (IOP) reduction by filtering surgery.

Methods

Patients with XFG (n=32), primary open-angle glaucoma (POAG, n=33) or primary angle closure glaucoma (PACG, n=28) that underwent routine cataract and glaucoma filtering surgery by the same surgeon (APR) between May 2017 and September 2021, were included for this prospective study. Rate of progression (ROP) was determined using guided progression analysis and compared between XFG and primary glaucoma. Multivariate regression was done to analyse the factors responsible for progression in each group.

Results

Visual field progression after surgery was noted in 48 eyes (n=11 XFG, 18 POAG and 19 PACG eyes) at a mean follow-up of 10±5.6 months after surgery with RVI seen in 18 of 48 eyes. The final IOP (p=0.8) and mean ROP (p=0.09) were not significantly different between XFG and primary glaucoma. The XFG eyes had a greater number of eyes (36%) showing an ROP worse than -5dB/yr, with 45% of eyes showing an IOP spike >5mm Hg, and a higher mean IOP spike between visits. The ROP in eyes with RVO and >5mm Hg IOP spikes was greater in XFG than in POAG or PACG. In the multivariate analysis, higher IOP fluctuations >5mm Hg, and associated retinal vein occlusions (RVO) were significant factors for visual progression greater than -5dB/year (R2=53.5%) in POAG and XFG eyes. Age, gender, baseline MD, and number of medications before surgery or at final follow-up did not influence visual progression rates in either group.

Conclusion

A higher IOP fluctuation >5mm Hg and associated RVO were the significant factors predicting visual field progression after filtering surgery in XFG and POAG eyes. Control of both IOP-dependent and -independent mechanisms of VF progression is therefore essential in these eyes.

Retinal nerve fiber layer and ophthalmic artery blood flow parameters in pseudoexfoliation syndrome and pseudoexfoliative glaucoma

OBJECTIVES

To investigate the relationship between ophthalmic artery (OA) blood flow parameters and retinal nerve fiber layer (RNFL) thickness in eyes with pseudoexfoliation (PEX).

METHODS

We compared PEX eyes without glaucoma (group A, n=53) and those with glaucoma (group B, n=18) with control eyes (group C, n=44). Subsequently, eyes in groups A and B were compared. Finally, OA color Doppler imaging measurements were recorded, and peripapillary RNFL analysis was performed.

RESULTS

The total RNFL measurements differed significantly among the groups (P=0.012), being thicker in group C than in group A (P=0.010) and significantly different between group B and groups A and C (both P=0.001). The peak systolic velocity (PSV) and end diastolic velocity (EDV) measurements of groups A and B were lower than those of group C (PSV: P=0.001 and P=0.001, respectively; EDV: P=0.001 and P=0.001, respectively). No significant difference was noted in resistive index (RI) measurements (P=0.370). In group B, significant negative correlations were noted between total RNFL and PSV (r=-0.743; P=0.001) and between total RNFL and EDV (r=-0.691; P=0.001), but not between total RNFL and RI measurements (P=0.548).

CONCLUSIONS

Pseudoexfoliation syndrome (PXS) with or without glaucoma was associated with a decrease in the PSV and EDV values of the OA. An extensive study may be needed to further explore the role of PXS in OA blood flow parameters. Total RNFL thickness values were lower in eyes with PEX than in those without.

Clinical profile and demographic distribution of pseudoexfoliation syndrome: An electronic medical record-driven big data analytics from an eye care network in India

Purpose

To describe the demographics and clinical profile of pseudoexfoliation syndrome (PXF or PES) in patients presenting to a multi-tier ophthalmology hospital network in India.

Methods

This cross-sectional hospital-based study included 3,082,727 new patients presenting between August 2010 and December 2021. Patients with a clinical diagnosis of PXF in at least one eye were included as cases. The data were collected using an electronic medical record system.

Results

Overall, 23,223 (0.75%) patients were diagnosed with PXF. The majority of the patients were male (67.08%) and had unilateral (60.96%) affliction. The most common age group at presentation was during the seventh decade of life with 9,495 (40.89%) patients. The overall prevalence was higher in patients from a lower socio-economic status (1.48%) presenting from the urban geography (0.84%) and in retired individuals (3.61%). The most common location of the PXF material was the pupillary margin (81.01%) followed by the iris (19.15%). The majority of the eyes had mild or no visual impairment (<20/70) in 12,962 (40.14%) eyes. PXF glaucoma was documented in 7,954 (24.63%) eyes. Krukenberg's spindle was found in 64 (0.20%) eyes, phacodonesis in 328 (1.02%) eyes, and lens subluxation in 299 (0.93%) eyes. Among the surgical interventions, cataract surgery was performed in 8,363 (25.9%) eyes, trabeculectomy was performed in 966 (2.99%) eyes, and a combined procedure in 822 (2.55%) eyes.

Conclusion

PXF more commonly affects males presenting during the seventh decade of life from lower socio-economic status and is predominantly unilateral. A quarter of the affected eyes are associated with glaucoma and the majority of the eyes have mild or no visual impairment.

Pseudoexfoliation Syndrome-Clinical Characteristics of Most Common Cause of Secondary Glaucoma

Pseudoexfoliation syndrome (XFS) is a condition in which excess material builds up not only in the structures of the anterior chamber but also throughout the body. The frequency of the syndrome varies significantly (0.3-18%) depending on the region and the method of examination. Environmental risk factors for XFS include a large number of sunny days, proximity to the equator, dietary factors such as higher consumption of coffee and tea, long-term alcohol consumption, exposure to UV, and outdoor work. The pathognomonic sign of XFS is the presence of white material on the lens capsule and other anterior chamber components. In addition, a characteristic Sampaolesi line can be observed during gonioscopy. Systemic alterations indicative of XFS have been observed in the extracellular matrix of the eyelid skin, the heart, lungs, liver, kidneys, gallbladder, meninges, and endothelium of the blood vessels. XFS is the most common cause of secondary open-angle glaucoma, which is called pseudoexfoliative glaucoma and is more severe than primary open-angle glaucoma. It is plausible that a combination of environmental factors and genetic alterations promotes the onset of pseudoexfoliation syndrome, which requires additional research.

Long-Term Evaluation of Pseudoexfoliation Syndrome Post-Cataract Extraction

The study aimed to examine the effect of cataract extraction on ophthalmologists' ability to detect pseudoexfoliation (PXF) syndrome. A total of 31 patients admitted for elective cataract surgery were enrolled in this prospective comparative study. Prior to surgery, patients underwent slit-lamp examination and gonioscopy conducted by experienced glaucoma specialists. Subsequently, patients were re-examined by a different glaucoma specialist and comprehensive ophthalmologists. Pre-operatively, 12 patients were diagnosed with PXF on the basis of a Sampaolesi line (100%), anterior capsular deposits (83%), and pupillary ruff deposits (50%). The remaining 19 patients acted as controls. All patients were re-examined 10-46 months post-operatively. Of the 12 patients with PXF, 10 (83%) were correctly diagnosed post-operatively by glaucoma specialists and 8 (66%) by comprehensive ophthalmologists. There was no statistically significant difference in PXF diagnosis. However, detection of anterior capsular deposits (p = 0.02), Sampaolesi lines (p = 0.04), and pupillary ruff deposits (p = 0.01) were significantly lower post-operatively. Diagnosis of PXF is challenging in pseudophakic patients as the anterior capsule is removed during cataract extraction. Therefore, PXF diagnosis in pseudophakic patients relies mainly on the presence of deposits at other anatomical sites, and careful attention to these signs is required. Glaucoma specialists may be more likely than comprehensive ophthalmologists to detect PXF in pseudophakic patients.

Results of Nailfold Videocapillaroscopy in Patients with Pseudoexfoliative Glaucoma

The aim of this study was to evaluate the nailfold videocapillaroscopic examination results from patients with pseudoexfoliative glaucoma (XFG) and to assess the relationship between the results of this examination and the patient's clinical status in the XFG group.

MATERIAL AND METHODS

The studied group consisted of 39 Caucasian patients with XFG and 32 patients in a control group. The patients were classified into two subgroups: the hypertensive pseudoexfoliative glaucoma (hXFG) subgroup and the normotensive pseudoexfoliative glaucoma (nXFG) subgroup. The nailfold videocapillaroscopy (NVC) was performed on all participants. The results of each NVC were classified as having a normal or abnormal pattern.

RESULTS

There was no statistical difference between the results of an abnormal NVC pattern in the study group vs. the control group (p = 0.8773). Microhemorrhages were shown in 30.0% of patients with nXFG vs. the control group (6.25%) (p = 0.0520). Microhemorrhages tended to be more frequent in the XFG group (p = 0.1221). A prevalent number of tortuous capillaries was observed in hXFG patients with advanced glaucomatous neuropathy. Dilatation in the capillaries and microbleedings were observed in the group of patients with lower IOP values. Tortuosity in the capillaries was significantly more frequent in PEXG patients (XFG vs. control: p = 0.0386). No relationships between the results of NVC and age, c/d, BCVA, time of treatment, and visual field defect were found.

CONCLUSIONS

Specific features of NVC examination differentiate nXFG from hXFG patients. Some capillaroscopic features may correlate with the patient's clinical status of XFG.

Hearing Loss in Exfoliation Syndrome: Systematic Review and Meta-Analysis

OBJECTIVE

To determine if exfoliation syndrome (XFS) is associated with hearing loss (HL) or vestibular dysfunction.

DATA SOURCES

PubMed, Scopus, CINAHL, and Cochrane Library through April 1, 2022.

REVIEW METHODS

Two reviewers independently screened abstracts, selected articles for inclusion, and extracted data. Studies included for qualitative analysis conducted audiometric, tympanometric, or vestibular evaluations on all subjects.

RESULTS

Twenty-one publications (1148 patients with XFS and 1212 controls) were included in the systematic review, and 16 publications (968 patients with XFS and 1147 controls) in the meta-analysis. Greater severity of HL was seen for patients with XFS compared to controls across all frequencies (odds ratio [OR] 8.8 [7.3-10.2]). Patients with XFS were more likely to have moderate to profound sensorineural HL (OR 1.8 [1.3-2.5]), and less likely to have none to mild HL (OR 0.34 [0.17-0.67]) or no HL (OR 0.37 [0.28-0.50]). Three studies found patients with XFS had lower tympanometric peaks. Two studies found that abnormal vestibular testing results could be more common for patients with XFS.

CONCLUSIONS

HL is associated with XFS. A sensorineural component to HL is confirmed, and mixed HL is possible. Given the high prevalence and infrequent diagnosis of XFS, the authors hypothesize that the current understandings of presbycusis might be improved by further investigation in XFS. Laryngoscope, 2022.

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.

Comparison of Cardiovascular Risk and Events among Spanish Patients with and without Ocular Pseudoexfoliation

The purpose of this study was to calculate and compare individual cardiovascular risk (CVR) and the development of cardiovascular events and mortality in patients with and without ocular pseudoexfoliation (PEX). A cohort study was carried out to compare two groups of patients who underwent cataract surgery: patients with (n = 99) and without PEX (n = 239). The CVR factors were recorded for all the subjects, and CVR was calculated for each individual using ERICE risk assessment charts. After a six-year follow-up, the cardiovascular events and mortality rates were compared between the two groups. The mean CVR was 36.41% in the PEX group and 33.72% in the non-PEX group (p = 0.13). High blood pressure was detected in significantly more PEX patients (71.4%) than non-PEX patients (58.6%, p = 0.035), yet no differences were found in the other CVR factors. The prevalence of cardiovascular events in the PEX and non-PEX patients was 17.1% and 12.5%, respectively (p = 0.26), with 5% of patients in the PEX group and 5% in the non-PEX group suffering an acute coronary event (p = 0.9). Moreover, 12% of the PEX patients and 7.5% of the non-PEX patients experienced a stroke (p = 0.17), and the six-year mortality rate was 29.3% in the PEX group and 25.9% in the non-PEX group (p = 0.52). PEX was associated with high blood pressure in our cohort of patients, although cardiovascular risk was not shown to be higher in this group. In addition, patients with PEX did not experience more cardiovascular events or have a higher mortality rate than patients without PEX during the period studied.

[Secondary open-angle glaucoma: pseudoexfoliative glaucoma, pigmentary glaucoma and neovascular glaucoma]

Secondary open-angle glaucomas are a heterogeneous group of diseases in which a variety of pathophysiological mechanisms result in an elevation of intraocular pressure. This article is the first part of a review of the more common forms of secondary open-angle glaucomas. The pathogenesis, characteristic clinical findings and treatment of pseudoexfoliative glaucoma, pigmentary glaucoma and neovascular glaucoma are discussed. An emphasis is placed on the differences in treatment compared to primary open-angle glaucoma and prophylactic treatment approaches are explained where possible.

The Role of Vessel Density as Measured by Optical Coherence Tomography Angiography in the Evaluation of Pseudoexfoliative Glaucoma: A Review of the Literature

INTRODUCTION

To review the existing literature about the optical coherence tomography angiography (OCTA) findings regarding peripapillary and macular vessel density (VD) in patients with pseudoexfoliative glaucoma (PXG).

METHODS

A comprehensive search of the PubMed database was conducted to include articles up to November 1, 2021, using an appropriate search algorithm. The retrieved articles were assessed for eligibility and filtered manually to exclude duplicates, while articles and book chapters cited in the reference lists of the eligible articles obtained by this method were reviewed so as not to miss any relevant studies.

RESULTS

There is consistency among the studies published so far that a significant decrease in peripapillary VD exists in eyes with PXG compared to controls, and macular VD has also been reported to be significantly lower in PXG eyes than controls. However, the existing literature remains controversial regarding OCTA findings in eyes with PXG compared to those with primary open-angle glaucoma (POAG). Several studies have found that peripapillary VD and macular VD were significantly lower in PXG than POAG, while other studies reported no significant difference.

CONCLUSIONS

Eyes with PXG were found to present decreased peripapillary and macular VD compared to control eyes, suggesting that a vascular component, including optic nerve hypoperfusion, may be implicated in the pathogenesis of PXG.

Early Three-Dimensional Intrableb Structural Changes in Primary-Open Angle Glaucoma and Exfoliation Glaucoma After Ex-PRESS Surgery

Purpose

To compare early-stage intrableb structural changes after Ex-PRESS surgery using anterior-segment optical coherence tomography between primary open-angle glaucoma (POAG) and exfoliation glaucoma (XFG).

Methods

Twenty-five POAG eyes and 15 XFG eyes that underwent Ex-PRESS surgery were evaluated. Intrableb images were classified into four categories based on previously reported scattering intensity: high-, medium-, and low-scattering walls and fluid-filled spaces. Bleb measurements were evaluated in both groups throughout 6 postoperative months. The 3-year surgical success was defined by the criteria intraocular pressure (IOP) < 18 mmHg and IOP < 15 mmHg with or without medications.

Results

The fluid-filled space volume at 3 and 6 months (P = 0.005 and P = 0.022, respectively) and the volume ratio of the low-scattering wall to the bleb wall (P = 0.028) at 6 months were significantly smaller in XFG than POAG postoperatively. The volume ratio of the high-scattering wall to the bleb wall was correlated positively (P = 0.007) with the IOP, and that of the low-scattering wall to the bleb wall was correlated negatively (P = 0.002) with the IOP in XFG. The 3-year surgical success rates for both criteria were significantly lower in XFG than POAG.

Conclusions

Fluid-filled spaces were smaller in XFG than in POAG after Ex-PRESS surgery. The proportion of the high-scattering wall tended to increase and the low-scattering wall tended to decrease in XFG eyes with high IOP. Early-stage intrableb structural changes differed between POAG and XFG and may affect the prognosis.

Translational Relevance

Our cutting-edge observation of intrableb fibrosis can be an important predictor of the surgical outcome.

A comprehensive enhanced depth imaging spectral-domain optical coherence tomography analysis of pseudoexfoliation spectrum from non-glaucomatous to advanced stage glaucoma in the aspect of Bruch's membrane opening-minimum rim width

PURPOSE

To compare the correlations between lamina cribrosa (LC) and related structures with Bruch's membrane opening-minimum rim width (BMO-MRW) and retinal nerve fiber layer (RNFL) thickness in pseudoexfoliation syndrome (PXS) and different stages of pseudoexfoliation glaucoma (PXG).

METHODS

This prospective cross-sectional study included 32 PXS eyes of 24 patients and 94 PXG eyes (early-stage (n: 55) and advanced-stage glaucoma (n: 39) of 78 patients. Global and six sectors of RNFL thicknesses and BMO-MRW parameters were measured with enhanced depth imaging (EDI) mode of SD-OCT. Structural parameters; lamina cribrosa thickness (LCT), lamina cribrosa depth (LCD), prelaminar tissue thickness (PLTT), four quadrants of peripapillary choroidal thicknesses (PPCT), and subfoveal choroidal thickness (SFCT) were measured and statistical relationships between the structural parameters have been laid out. We apply the generalized estimating equations method to take into account dependency of right and left eyes.

RESULTS

From PXS to mild and advanced PXG groups LCT and PLTT decrease from 147.29 ± 33.10, 145.62 ± 30.64, 126.30 ± 29.14 and 260.93 ± 185.07, 247.27 ± 142.58, 159.89 ± 86.84, respectively, and LCD varies as 159.89 ± 86.84, 420.88 ± 117.80, and 505.64 ± 183.25. The correlations between LCD, LCT, and PLTT and the stage of the disease are significant. BMO-MRW shows slightly stronger correlations than the RNFL with LC related parameters. SFCT does not exhibit any significant relationship with the stage of the disease. However, PPCT in only the interior quadrant does. The significant correlations between LCD and all quadrants of PPCT is the sign of important anatomic relationship.

CONCLUSION

These findings show that the BMO-MRW parameter may be more sensitive than RNFL and can safely be used in the diagnosis and follow-up in PXS and PXG, but this result should be supported with longer and larger series.

Inhibitory and Agonistic Autoantibodies Directed Against the β2-Adrenergic Receptor in Pseudoexfoliation Syndrome and Glaucoma

Pseudoexfoliation syndrome (PEXS) and glaucoma (PEXG) are assumed to be caused by a generalized elastosis leading to the accumulation of PEX material in ocular as well as in extraocular tissues. The exact pathophysiology of PEXS is still elusive. PEXG, the most common type of secondary open-angle glaucoma (OAG), is characterized by large peaks of intraocular pressure (IOP) with a progressive loss of the visual field. Agonistic autoantibodies (agAAbs) against the β₂-adrenergic receptor (AR) have been shown to be present in sera of patients with primary and secondary OAG and ocular hypertension and are seemingly linked to IOP. In the present study, we investigated the autoantibodies directed against the β₂-AR in sera of patients with PEXS and PEXG. We recruited 15, 10, and 15 patients with PEXG, PEXS, and primary OAG, respectively. Ten healthy individuals served as controls. All patients underwent standard ophthalmological examination with Octopus G1 perimetry. agAAbs prepared from serum samples were analyzed in a rat cardiomyocyte-based bioassay for the presence of agAAbs. We identified the interacting loop of the β₂-AR and the immunoglobulin G (IgG) subclasses using synthetic peptides corresponding to the extracellular loops of the receptors and enzyme-linked immunosorbent assay, respectively. None of the controls were β₂-agAAb-positive (0.2 ± 0.5 U). No β₂-agAAbs (0.2 ± 0.4 U), but inhibitory β₂-AAbs were observed in 80% of the patients that partially blocked the drug-induced β₂-adrenergic stimulation; 5.8 ± 1.7 U vs. 11.1 ± 0.9 U for clenbuterol in the absence and the presence of sera from patients with PEXS, respectively. Epitope analyses identified the third extracellular loop of the β₂-AR as the target of the inhibitory β₂-AAbs, being of IgG3 subtype in PEXS patients. In contrast, patients with PEXG showed β₂-agAAbs (5.6 ± 0.9 U), but no inhibitory ones. The β₂-agAAbs levels of patients with PEXG and primary OAG patients (3.9 ± 2.8 U; p > 0.05) were at a similar level. In two cases of PEXG, the β₂-agAAbs exert synergistic effects with clenbuterol. The activity increased from 11.5 ± 0.3 (clenbuterol only) to 16.3 ± 0.9 U. As autoimmune mechanisms were reportedly involved in the pathogenesis of glaucoma, agonistic and inhibitory β₂-AAbs seem to be a part of this multifactorial interplay.

Exfoliation syndrome: association with systemic diseases-the Maccabi glaucoma study

PURPOSE

To investigate the relationship between exfoliation syndrome (XFS) and systemic diseases.

METHODS

A population-based, retrospective study with control group was conducted using the electronic medical database of Maccabi Health Services, the second largest Health Maintenance Organization (HMO) in Israel. Study population included Maccabi members from January 2003 to April 2016. Cases consisted of patients diagnosed with XFS regardless of glaucoma. The control group included Maccabi members without XFS, matched on age, sex, and ancestry, that were examined by an ophthalmologist within the last year.

MAIN OUTCOME MEASURES

Associations between XFS and systemic diseases.

RESULTS

We identified 16,388 patients with XFS, in whom 40.3% (n = 6613) had glaucoma. The control group included 14,015 patients. Mean age was 78.3 ± 8.9 years and 76.2 ± 8.5 years for the XFS and control group, respectively. In unconditional logistic regression analyses, after adjusting for age, sex, and ancestry, XFS was significantly associated with risk of cardiovascular diseases including hypertension (OR 1.07, 95% CI 1.01-1.13, p = 0.02), myocardial infarction (OR 1.21, 95% CI 1.17-1.31, p < 0.0001), and congestive heart failure (OR 1.70, 95% CI 1.55-1.88, p < 0.0001) as well as higher risk for high creatinine (OR 1.28, 95% CI 1.2-1.37, p < 0.0001). Diabetes mellitus and body mass index were inversely associated with XFS (OR 0.70, 95% CI 0.67-0.73, p < 0.0001 and OR 0.88, 95% CI 0.84-0.93, p < 0.0001, respectively). Overall cancer diagnoses were more common in the XFS group (OR 1.05, 95% CI 1.0-1.1, p = 0.05). XFS was associated with more hospitalizations (mean 5 ± 5.3 hospitalizations in the XFS group and 3.3 ± 4.0 in the controls, p < 0.0001).

CONCLUSION

XFS is significantly associated with cardiovascular systemic diseases (in a population living in Israel and predominantly born in Russia).

Correlation of the intronic LOXL1 polymorphism rs11638944 with pseudoexfoliation syndrome and glaucoma in a Greek population

BACKGROUND

The purpose of this study is the development and validation of a novel and robust genotyping method for a new lysyl oxidase-like 1 (LOXL1) intronic polymorphism (rs11638944, C > G) and the investigation of its potential association with pseudoexfoliation syndrome (PXS) and pseudoexfoliation glaucoma (PXG) in a Greek population.

MATERIAL AND METHODS

242 DNA samples from 49 PXS, 64 PXG, 50 primary open-angle glaucoma (POAG) patients and 79 healthy age-matched controls were analyzed. Novel methodologies were developed and optimized, in order to genotype the intronic LOXL1 polymorphism: a) a real-time qPCR and melting curve analysis in the Light Cycler platform for rapid and cost-effective analysis and, b) a conventional PCR-RFLP method for analysis of a small number of samples. In selected samples, validity was checked with the reference DNA Sequencing method.

RESULTS

The real-time qPCR methodology was reliable, demonstrating good efficiency, reproducibility, accuracy in genotyping (100% concordance with the PCR-RFLP method and DNA Sequencing), with good allele discrimination (Tm = 53.26°C for C allele, Tm = 61.83°C for G allele, ΔTm = 8.57°C). The results were characterized by Hardy-Weinberg equilibrium in all groups. An increase from 18% in healthy controls to 61% in PXS patients was detected for the G/G homozygote thus, the C allele is protective for PXS with OR = 0.22 (95%CI: 0.11-0.42, p < .0001). Moreover, an increase from 18% in healthy controls to 70% in PXG patients was detected for the G/G homozygote thus, the C allele is protective for PXG with OR = 0.13 (95%CI: 0.06-0.25, p < .0001).

CONCLUSIONS

A statistically significant association was verified for the intronic LOXL1 polymorphism rs11638944 and PXS/PXG in a Greek population.

Significant lifespan difference between primary open-angle glaucoma and pseudoexfoliation glaucoma

PURPOSE

Open-angle glaucoma (OAG) is a collective term for various subgroups of glaucoma of which primary open-angle glaucoma (POAG) and pseudoexfoliation glaucoma (PEG) are the most common. There is increasing evidence that both conditions have systemic ramifications. We wanted to examine to what extent lifespan and cause of death are influenced by POAG, pseudoexfoliation syndrome (PES), and PEG.

MATERIALS AND METHODS

Of 1864 people who underwent an eye examination in 1985-86, the presence of PES and/or glaucoma, along with date and cause of death were recorded. Based on information from the National Death Registry, the individuals were classified into the following groups of systemic diseases regarded as causing death: Cardiovascular disease (with two subgroups), cerebrovascular disease and neoplasms.

RESULTS

All 1864 persons were followed to death, up to 30 years after examination. No difference in lifespan was observed when comparing OAG (i.e. POAG and PEG together) with the rest of the population. When adjusting for gender and age at inclusion, patients with POAG showed a reduced lifespan in the cardiovascular death group (2.44 years, p = 0.043). When comparing lifespan in the neoplastic group in the glaucoma patients, POAG and PEG, directly against each other, a mean age difference of 6.87 years (p = 0.017) was found.

CONCLUSIONS

POAG patients showed reduced lifespan due to neoplasia and cardiovascular disease. Persons with PES and PEG did not show these lifespan reductions. Our main conclusion is that POAG and PEG, the two main OAG subgroups, are very different disease entities both from an ocular and a systemic point of view.

Serum Apelin and Asymmetric Dimethylarginine Levels in Patients With Exfoliation Syndrome or Exfoliative Glaucoma

PRéCIS:: Apelin and asymmetric dimethylarginine (ADMA) concentrations, affecting the nitric oxide pathway, were different in the patient group compared with the control subjects. These 2 molecules may have potential effects in vascular pathologies and their possible role in predisposition to vascular comorbidities in exfoliation syndrome (XFS) or exfoliative glaucoma (XFG).

PURPOSE

To evaluate apelin and ADMA levels in serum samples from patients with XFS or XFG compared with healthy control subjects.

METHODS

Serum ADMA and apelin concentrations were evaluated from 36 and 32 XFS patients; 27 and 24 XFG patients; and 34 and 30 healthy controls, respectively. Subjects without systemic disease (including diabetes mellitus, hypertension, coronary artery disease, obesity) were included in the study and body mass index was calculated in all participants. An enzyme-linked immunosorbent assay and high-performance liquid chromatography were used to determine serum apelin and ADMA concentrations. Independent sample t test, χ test, analysis of variance test, and Pearson test were used for statistical analysis.

RESULTS

Mean serum apelin levels of XFG, XFS, and control group were 1063.3±373.4, 1196.7±433.7, and 1343.3±405.1 ng/mL, respectively. Patients with XFG demonstrated significantly lower level of apelin versus controls (P=0.034). Mean serum ADMA concentration was significantly greater in XFS subjects (2.05±0.98 µmol/L) compared with normal controls (1.57±0.58 µmol/L) (P=0.042). No association was detected between ADMA and apelin concentrations and age, sex, and body mass index for both XFS and XFG groups.

CONCLUSIONS

Significant alterations in serum levels of apelin and ADMA may suggest potential effects in vascular pathologies and a possible role in predisposition to vascular comorbidities in XFS/XFG.

Comparison of Macular Choroidal Thickness and Volume between Pseudoexfoliative Glaucoma and Pseudoexfoliative Syndrome

Purpose

To evaluate the difference in macular choroidal thickness and volume between patients with pseudoexfoliative glaucoma (PXG), patients with pseudoexfoliative syndrome (PEX), and normal controls.

Methods

This case-control study included 49 PXG patients (group A), 33 PEX patients (group B), and 42 sex-, age-, and axial length-matched healthy volunteer eyes (group C). The macular choroidal thickness and volume of all subjects studied were measured by enhanced depth imaging optical coherence tomography.

Results

The average macular (AM) choroidal thickness was 170.79 ± 50.18 μm, 184.65 ± 57.54 μm, and 206.46 ± 48.90 μm, and the average volume was 0.52 ± 0.15 μm³, 0.56 ± 0.17 μm³, and 0.63 ± 0.15 μm³ in groups A, B, and C, respectively. The macular choroidal thickness, the volumes of various macular regions, and the average choroidal thickness and volume in group A were lower than those in group C (all P < 0.05). There were no significant differences in the macular choroidal thickness, volumes of various macular regions, or average choroidal thickness or volume between group A and B (all P > 0.05). The macular choroidal thickness and volume of the TIM and SOM in group B were lower than those in group C (P < 0.05). There was no association between the macular choroidal thickness of various macular regions and visual field mean defect (MD) in group A (all P > 0.05).

Conclusion

The macular choroidal thickness in patients with PXG or PEX (TIM and SOM) is thinner than that in normal subjects. The macular choroidal thickness in patients with PXG is not significantly different from that in patients with PEX. The role of macular choroidal thickness changes in the glaucomatous damage of patients with PXG is still unclear.

Association between Obstructive Sleep Apnea and Exfoliation Syndrome: The Utah Project on Exfoliation Syndrome

PURPOSE

Exfoliation syndrome (XFS), the most common recognizable cause of open-angle glaucoma worldwide, is a systemic disorder with genetic predisposition due to variations in lysyl oxidase-like 1 (LOXL1) function, leading to altered elastin matrices in ocular and systemic tissues. Obstructive sleep apnea (OSA) is a highly prevalent disorder also involving elastic tissue dysfunction and is associated with glaucoma. Because of the similarities between the disorders, we sought to uncover any relationship in the prevalence of these diagnoses.

DESIGN

Case-control, retrospective cohort study.

PARTICIPANTS

A cohort of 81 735 patients diagnosed with OSA at ages 50 to 90 years was identified from medical records from 1996 to 2017 in the Utah Population Database. Case subjects were matched to random controls on sex and birth year in a 4:1 ratio.

METHODS

International Classification of Diseases, Ninth Revision (ICD-9) codes or their Tenth Revision equivalent were used to define a diagnosis of OSA (ICD-9 327.23) and a diagnosis of XFS (ICD-9 365.52 and 366.11). Conditional logistic regression odds ratios (ORs) accounting for individual matching on sex and birth year were used to estimate the risk of XFS in patients with OSA. Models included adjustment for race, obesity, tobacco use, hypertension (HTN), atrial fibrillation (AF), and chronic obstructive pulmonary disease (COPD).

MAIN OUTCOME MEASURE

Whether patients with OSA have an increased risk of diagnosis of XFS compared with controls without OSA.

RESULTS

There was an increased risk of an XFS diagnosis in patients with OSA compared with non-OSA controls (OR, 1.27; 95% confidence interval [CI], 1.02-1.59; P = 0.03). In a stratification of patients by HTN diagnosis history, patients with OSA and HTN exhibited an increased risk of XFS compared with non-OSA controls with HTN (OR, 2.67; 95% CI, 2.06-3.46; P < 0.0001).

CONCLUSIONS

Patients with OSA may be at an increased risk of XFS compared with patients without OSA, particularly in patients with a history of HTN.

Analysis of Peripapillary and Macular Choroidal Thickness in Eyes with Pseudoexfoliative Glaucoma and Fellow Eyes

Purpose

To compare differences in peripapillary and macular choroidal thickness in pseudoexfoliative glaucoma (PXG) eyes, nonexfoliative fellow eyes, and normal eyes.

Methods

This case-control study included 37 PXG patients (group A: 37 PXG eyes; group B: 37 nonexfoliative fellow eyes) and 37 sex-, age-, and axial length-matched healthy volunteer eyes (group C). Peripapillary and macular choroidal thickness and volume were measured in all subjects via enhanced-depth imaging-optical coherence tomography.

Results

The average peripapillary (AP) choroidal thickness was (130.10 ± 46.14) μm, (131.43 ± 46.00) μm, and (147.89 ± 53.32) μm; average macular (AM) choroidal thickness was (191.72 ± 68.07) μm, (204.62 ± 69.54) μm, and (215.10 ± 45.40) μm; and average volume was (0.59 ± 0.21) μm³, (0.63 ± 0.21) μm³, and (0.65 ± 0.14) μm³ in groups A, B, and C, respectively. NIP choroidal thickness was significantly lower in groups A and B than in group C (P < 0.05). TIM and TOM choroidal thickness and volume were significantly lower in group A than in group C (P < 0.05). NIM, SIM, NOM, IOM, AM choroidal thickness and volume, and CSM choroidal thickness were significantly lower in group A than in group B (P < 0.05). CSM, TIM, and TOM in group A and TIM, TOM choroidal thickness, and volume in group B were significantly lower than in group C (P < 0.05).

Conclusions

NIP choroidal thickness in PXG eyes and nonexfoliative fellow eyes and temporal macular choroidal thickness in PXG eyes were significantly lower than in normal eyes. Macular choroidal thickness (except in temporal regions) was significantly lower in PXG eyes than in nonexfoliative fellow eyes. Changes in peripapillary and macula choroidal thickness further elucidate the choroid's role in PXG development and progression.

Clinical Features of Pseudoexfoliative Glaucoma in Treated Polish Patients

PURPOSE

The aim of this study was to describe clinical characteristics of glaucomatous optic neuropathy in treated Polish patients with pseudoexfoliative glaucoma.

METHODS

In the course of the study, 348 eyes of 231 patients with pseudoexfoliative glaucoma. The patients involved in the study were treated in the Department of Diagnostic and Microsurgery of Glaucoma in Lublin between 2012 and 2019. The following parameters were assessed in the examination: visual acuity, slit-lamp biomicroscopy with evaluation of anterior segment of the eye, gonioscopic examination, stereoscopic fundus examination of the eye, intraocular pressure, visual field, and pachymetry.

RESULTS

The mean age of all the patients was 73.16 years (SD±8.03). The mean age of women was 74.06 (SD±6.97), and the mean age of men was 71.8 (SD±8.51, p=0.006265). Women represented 37.93% (n=132) of the studied group, while men 62.07% (n=216). In the group of patients younger than 65 years of age, 27.9% were male and 15% female (p=0.0021). In the whole studied group, mean peak IOP was 29.25 mmHg with higher mean values in male patients (M vs F: 33.24 mmHg vs 26.86 mmHg; p=0.000). Peak values exceeding 30 mmHg were significantly more frequent in males (M vs F: 56.5% vs 31.9%; p=0.0000). Peak IOP never exceeding 21 mmHg was observed in 18.6% of the patients. The mean value of MD (Mean Deviation) was -12.85 dB in the whole group. The men were more likely to have more advanced glaucoma, according to MD (M vs F: -16.35 dB vs -11.13 dB; p=0.0000).

CONCLUSION

Pseudoexfoliative glaucoma was more frequently observed in men with younger age, higher IOP, and more advanced glaucoma. Normotensive glaucoma was observed in 18.6% of the patients with pseudoexfoliative glaucoma.

Quantitative analysis of radial peripapillary capillary plexuses in patients with clinically unilateral pseudoexfoliation syndrome

PURPOSE

The aim of this study was to image the radial peripapillary capillary vessel densities (RPCvds) of the affected eyes and fellow unaffected eyes of individuals with unilateral pseudoexfoliation syndrome (PES) using optical coherence tomography angiography (OCTA) and to compare the RPCvds with those of normal age-matched individuals.

METHODS

The eyes were divided into three groups: the pseudoexfoliative material (PXM)-positive eyes of patients with clinically unilateral PES (study eyes), the fellow eyes of the PXM-positive patients (fellow eyes), and the eyes of healthy patients (control eyes). Those patients with glaucomatous findings, including peripapillary hemorrhaging, cupping, notching, focal thinning of the neuroretinal rim, or intraocular pressure readings greater than 21 mmHg, were excluded from the study. The RPCvd (%), peripapillary retinal nerve fiber layer (RNFL) thickness (μm), cup/disc area ratio, rim area (mm²), disc area (mm²), and cup volume (mm³) were automatically calculated via OCTA.

RESULTS

This cross-sectional comparative prospective study included 128 eyes of 88 patients: 40 PXM-positive eyes, 40 fellow eyes, and 48 control eyes. The RPCvds and RNFL thicknesses in the peripapillary region were significantly lower in the study eyes than in the fellow eyes and the control eyes (p = 0.011 and p = 0.011, p = 0.009 and p = 0.004, respectively). There were no significant differences between the fellow eyes and the control eyes with regard to the RPCvd and RNFL values in any region (p > 0.05 for all).

CONCLUSION

Lower RPCvds could provoke capillary deficiency and deterioration of the perfusion of the optic nerve head in patients with PES.

Prevalence and Associated Factors of Pseudoexfoliation in a Russian Population: The Ural Eye and Medical Study

PURPOSE

To assess the prevalence of pseudoexfoliation (PEX) and its associations in a Russian population.

DESIGN

Population-based cross-sectional study.

METHODS

Setting: Ufa capital of Bashkortostan, Russia and a rural region in Bashkortostan.

PARTICIPANTS

the Ural Eye and Medical Study included 5,899 (80.5%) of 7,328 eligible individuals (mean age, 59.0 ± 10.7 years old; range, 40-94 years).

OBSERVATION PROCEDURES

as part of an ophthalmological and general examination, presence and degree of PEX was assessed using slit-lamp biomicroscopy after medical pupillary dilation.

MAIN OUTCOME MEASUREMENTS

PEX prevalence.

RESULTS

After excluding pseudophakic and aphakic individuals, the study included 5,451 (92.4%) participants. PEX prevalence (3.6%; 95% confidence interval [CI]:3.1-4.1), increased from 0.5% (95% CI, 0.1-0.9) in individuals 40 to <50 years old to 10.4% (95% CI, 5.0-15.8) in individuals aged 80+ years. Higher PEX prevalence was associated (multivariate analysis) with older age (odds ratio [OR], 1.09; 95% CI, 1.07-1.11; P < 0.001), Russian ethnicity (OR, 1.50; 95% CI, 2.09-1.11;P = 0.02), higher prevalence of open-angle glaucoma (OR, 2.40; 95% CI, 1.36-4.23;P = 0.003), and higher intraocular pressure (OR, 1.06; 95% CI, 1.02-1.09;P = 0.001). PEX prevalence was not significantly associated with gender (P = 0.49), region of habitation (P = 0.11), body mass index (P = 0.68), level of education (P = 0.26), smoking (P = 0.11), alcohol consumption (P = 0.52), history of cardiovascular or cerebrovascular disease (P = 0.94) and dementia (P = 0.77), prevalence of diabetes mellitus (P = 0.16), arterial hypertension (P = 0.45), chronic obstructive pulmonary disease (P = 0.73), chronic kidney disease (P = 0.09), and hearing loss (P = 0.31).

CONCLUSIONS

In this typical, ethnically mixed, population from Russia with an age of 40+ years, PEX prevalence (3.6%; 95% CI, 3.1-4.1) was associated with older age, Russian ethnicity, higher intraocular pressure and open-angle glaucoma. It was independent of any systemic parameter including diabetes, arterial hypertension, previous cardiovascular and cerebrovascular diseases and dementia.

Link of ocular pseudoexfoliation syndrome and vascular system changes: results from 10-year follow-up study

PURPOSE

To examine the 10-year incidence of the pseudoexfoliation syndrome (PEX) in adults in a population-based follow-up study, to determine its link with vascular diseases, and to identify possible risk factors of the PEX.

METHODS

The baseline examination was performed in 2006 on a random sample of 1033 participants from Kaunas city (Lithuania) population. In 2016, a follow-up study of 686 participants who returned for the examination was conducted. The respondents filled out a questionnaire, an ophthalmological examination was performed, and the presence of vascular diseases was determined by the anamnesis and electrocardiogram evaluation data. Binary univariate and multivariate logistic regression analyses were conducted with the PEX and vascular diseases as predictors, controlling for age. Odds ratios (OR) and 95% confidence intervals of OR were calculated for the risk of new PEX cases.

RESULTS

During 10 years, the prevalence of the PEX in the study population increased from 10.3 to 34.2%. The rates of ischemic heart disease (IHD) and IHD combined with stroke were significantly higher in the PEX subjects than in the non-PEX subjects. The risk of the PEX among persons with IHD was, on the average, by 1.5-fold higher, and among those with IHD and stroke, on the average, by 1.6-fold higher as compared to persons without the aforementioned pathologies (accordingly, p = 0.014 and p = 0.010).

CONCLUSION

The prevalence of the PEX increased significantly with age. The risk of the PEX was significantly higher among persons with IHD and even higher among persons with IHD and stroke. In the future, a greater understanding of the cardiovascular, metabolic, and environmental components associated with the PEX may lead to more specific lifestyle-related preventive strategies to decrease the disease burden.

Retinal and Choroidal Vascular Changes in Eyes with Pseudoexfoliation Syndrome: A Comparative Study Using Optical Coherence Tomography Angiography

Background:

Optical coherence tomography angiography allows a detailed evaluation of retinal and choroidal microvascular structures without the need for a contrast agent. Pseudoexfoliation syndrome is a condition that leads to anatomical and functional losses due to accumulation of degraded abnormal fibrillar material in the intraocular and extraocular tissues. Histopathological studies have shown that the accumulation of Pseudoexfoliation syndrome material in the vascular structures may play a role in different ocular pathologies such as retinal vein occlusion, iris hypoperfusion, anterior segment hypoxia, retinal arterial occlusion, and neovascular glaucoma.

Aims:

To evaluate and compare flow and vascular density in the retina and choroid in eyes with Pseudoexfoliation syndrome, fellow eyes without Pseudoexfoliation syndrome, and healthy eyes using optical coherence tomography angiography.

Study Design:

Case control study.

Methods:

The study included 35 eyes with Pseudoexfoliation syndrome of 35 Pseudoexfoliation syndrome patients, 32 fellow eyes without Pseudoexfoliation syndrome of 32 unilateral Pseudoexfoliation syndrome patients, and 35 eyes of healthy control subjects. Flow area and vascular density in the superficial capillary plexus and deep capillary plexus were measured by optical coherence tomography angiography as three separate parameters: total, parafoveal, and foveal. Choroidal thickness and foveal avascular zone area were measured for each patient.

Results:

There were significant differences between the Pseudoexfoliation syndrome eyes and control eyes in total, parafoveal, and foveal flow and vascular density in the superficial capillary plexus (p<0.05 for all), while there were no significant differences between these groups in any of the flow or vascular density values in the deep capillary plexus (p>0.05). None of the superficial capillary plexus and deep capillary plexus flow and vascular density values showed significant differences between Pseudoexfoliation syndrome eyes and non-Pseudoexfoliation syndrome fellow eyes or between the non-Pseudoexfoliation syndrome fellow eyes and control eyes (p>0.05). Choroidal thickness was significantly lower in Pseudoexfoliation syndrome eyes compared to control eyes. Foveal avascular zone area was significantly enlarged in Pseudoexfoliation syndrome eyes compared to control eyes in both the superficial and deep layers (p<0.05).

Conclusion:

Pseudoexfoliation syndrome eyes exhibit significant damage to the retinal and choroidal vascular structures.

Twelve-Year Incidence and Baseline Risk Factors for Pseudoexfoliation: The Thessaloniki Eye Study (An American Ophthalmological Society Thesis)

PURPOSE

To determine the 12-year incidence of pseudoexfoliation (PEX), baseline risk factors for incident PEX and risk factors for incident pseudoexfoliative glaucoma (PEXG) among those with PEX in an elderly white population.

METHODS

Longitudinal, population-based study in Thessaloniki, the major urban center in Northern Greece. The baseline cohort included 2554 participants ≥60 years old. The surviving cohort was re-examined 12 years later using the same methodology. PEX was defined as typical fibrillar material at the pupil margin and/or on the lens capsule. Glaucoma was defined as both structural and functional damage, irrespective of intraocular pressure (IOP).

RESULTS

Of 1468 eligible subjects in the surviving cohort, 1092 (74%) participated in the follow-up study. The mean age ± standard deviation (SD) at baseline was 68.9 ± 4.6 years. The mean follow-up time was 11.6 ± 1.6 years. The 12-year incidence of PEX was 19.6% (95% confidence interval (CI), 17.1-22.2), with women more likely to be affected than men (Fisher's exact test, P = .0197). Higher axial length was associated with lower odds of incident PEX (odds ratio [OR], 0.72 per mm; 95% CI, 0.57-0.92). PEX at baseline was not associated with an increased likelihood of major vascular disease (P = .9038). Higher baseline IOP (OR, 1.26 per mm Hg; 95% CI, 1.07-1.48) and history of heart attack at baseline (OR, 13.49; 95% CI, 2.85-63.87) were associated with a greater likelihood of developing PEXG among those with PEX. A history of alcohol consumption at baseline was protective of individuals developing PEXG if they had PEX at baseline.

CONCLUSION

This is one of the very few longitudinal population-based studies that has specifically assessed the incidence of PEX. The association with axial length was previously found only in a cross-sectional study. The associations with heart attack and alcohol consumption are new findings. In individuals with baseline PEX, higher IOP at baseline, history of heart attack at baseline, and no alcohol consumption were associated with a greater likelihood of developing glaucomatous damage approximately 12 years later. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Pseudoexfoliation syndrome: analysis of systemic comorbidities of 325 PEX-positive patients compared with 911 PEX-negative patients

PURPOSE

Pseudoexfoliation syndrome (PEX) is an age-related systemic elastic fibrillopathy disorder featuring an excessive production and accumulation of elastic fibre components in the extracellular matrix and is associated with impaired protective mechanisms against oxidative and cellular stress. PEX is diagnosed solely by ophthalmologists; however, PEX deposits have been detected in the connective tissues of many extraocular organ systems. This large, retrospective case-control study investigates whether patients with PEX have an increased risk of extraocular comorbidities.

METHODS

Cases and controls were drawn from consecutive patients over 50 years of age undergoing in-house ophthalmological operations under general anaesthesia or in standby preparedness for general anaesthesia. The participants were grouped based solely on PEX-positive (n = 325) or PEX-negative (n = 911) status. The same teams of ophthalmologists and anaesthesiologists uniformly documented every known systemic comorbidity of each patient through two independent rounds of standard anamnestic procedure and protocols in preparation for general anaesthesia. For the purpose of this study, every systemic comorbidity was registered from these forms and subsequently categorized into 17 disease groups based on the International Classification of Diseases (ICD-10) of the World Health Organization (WHO). Odds ratios (ORs) comparing comorbidities in cases and controls were adjusted for age and gender using logistic regression.

RESULTS

After adjustment for multiple testing, patients with PEX had an increased odds ratio for respiratory OR 2.1 [1.4; 3.0], cardiac OR 2.5 [1.6; 4.2], vascular OR 2.0 [1.4; 2.8], and urogenital conditions OR 2.3 [1.4; 3.7]. Renal and psychiatric comorbidities were nominally significant. While no substantially higher frequency was found for hernias, aneurysms, aortic dissection, or varicose veins among PEX-positive patients, higher rates of cardiac valve disorders and benign prostate hyperplasia were found among the PEX-positive individuals.

CONCLUSION

In addition to confirming an increased risk of respiratory, cardiovascular, and urogenital comorbidities, our data found an increased risk of cardiac valve disorders and benign prostate hyperplasia among PEX-positive patients, which may be manifestations of the underlying systemic elastotic fibrillopathy and warrants further exploration, including future histological study.

Pseudoexfoliation Syndrome and Antidepressant Drug Use

Objectives:

To investigate the relationship between pseudoexfoliation syndrome (PES) and the use of antidepressant medications.

Materials and Methods:

This population-based, cross-sectional study included 2,017 of 2,356 invited subjects who were randomly selected from the Turkish Statistical Institute database (www.turksat.gov.tr/) as part of an epidemiologic study which specifically aimed to detect the prevalence of PES in the province of Eskişehir. During the examination, a detailed questionnaire was administered to determine physician-diagnosed systemic disease and drug use.

Results:

Eight of the 2,017 participants in the study were excluded for various reasons (2 with posterior synechiae, 2 with corneal opacity, 1 uncooperative patient, 1 eviscerated patient, 1 with active adenoviral keratoconjunctivitis, and 1 with a history of angle closure). PES was detected in 100 (5%) of the 2,009 patients whose data were analyzed. The percentage of subjects with concurrent antidepressant drug use in the PES and non-PES non-glaucoma groups were 4.1% (n=3) and 1.1% (n=21), respectively. The difference between the two groups was statistically significant (p=0.024). In addition, the use of medications for hypertension (p<0.001) and coronary artery disease (p=0.009) was also higher in the PES group.

Conclusion:

The higher prevalence of antidepressant drug use in patients with PES may be related to the processes of vascular damage and inflammation common to the pathogenesis of both PES and depression, as well as the high rate of chronic systemic comorbidities in these patients.

Atherogenic indices in pseudoexfoliation syndrome

OBJECTIVES

Evaluation of atherogenic indices in patients with pseudoexfoliation syndrome (PEXS) by traditional serum lipid profiles [total cholesterol (TC), triglyceride (TG), low-density lipoprotein cholesterol (LDL-c), high-density lipoprotein cholesterol (HDL-c) and non-HDL-c] and non-traditional serum lipid ratios [TC/HDL-c, TG/HDL-c, LDL-c/HDL-c and non-HDL-c/HDL-c].

METHODS

A total of 100 patients were included in the study. Fifty patients diagnosed with PEXS were regarded as group 1 and 50 patients without PEXS were regarded as group 2, respectively.

RESULTS

The median TC, TG, LDL-c, HDL-c and non-HDL-c values were significantly higher in group 1 compared to group 2 (p = 0.007, p = 0.025, p = 0.016, p = 0.015 and p = 0.042, respectively). But there were no significant differences in the TC/HDL-c, TG/HDL-c, LDL-c/HDL-c and non-HDL-c/HDL-c ratios among the two groups (p = 0.581, p = 0.617, p = 0.292 and p = 0.583, respectively).

CONCLUSIONS

Non-traditional serum lipid ratios are superior to traditional serum lipid profiles for identifying the risk of vascular disease and this study did not demonstrate a complete relationship between PEXS and increased risk of vascular disease.

Association of pseudoexfoliation syndrome with cardiovascular and cerebrovascular disease: a systematic review and meta-analysis

OBJECTIVE

Pseudoexfoliation syndrome (PEX) is a systemic disease, but evidence of its association with cardiovascular disease (CVD) and cerebrovascular disease (CVA) is controversial. A quantitative systematic review will provide an accurate summary of the current body of the literature.

DESIGN

Meta-analysis.

PARTICIPANTS

Not applicable.

METHODS

A comprehensive literature search of published and unpublished English-language studies was performed. Summary statistics were calculated using inverse variance weighting and are presented in forest plots. Sources of variance were evaluated statistically.

RESULTS

After screening 4547 studies, 47 articles were reviewed, and 25 eligible studies were selected that reported patients from around the world. Twenty studies enrolling 9583 individuals with PEX evaluated CVD, providing a summary odds ratio (OR) of 1.61 (95% CI 1.37-1.90). Eleven studies, enrolling 1308 PEX patients, evaluated CVA and generated a summary OR of 1.76 (1.40-2.22). For any vascular event (AVE) using all 25 studies, there were 9716 PEX patients and 363,312 control patients, yielding a summary OR of 1.64 (95% CI 1.39-1.92). Analysis for publication bias with the Egger's test was not significant for studies reporting CVD and AVE (p = 0.92 and 0.64, respectively) but was significant for CVA (p = 0.03). Asymmetry of Begg's funnel plot was noted for the CVA and AVE analyses. Multiple sensitivity analyses were performed, including assessment of study quality; the OR for all 3 outcomes varied minimally and remained significant in all analyses.

CONCLUSION

There is strong evidence that PEX is significantly associated with both CVD and CVA.

Monitoring and management of the patient with pseudoexfoliation syndrome: current perspectives

Pseudoexfoliation syndrome (PES) is a complex and age-related systemic disorder characterized by the progressive accumulation and granular deposition of pseudoexfoliative material in various intraocular and extraocular tissues. The diagnosis of PES is so important because it is a major risk factor for complications during cataract surgery and the most frequent cause of secondary glaucoma. In addition to ocular complications, PES is related with numerous systemic abnormalities, for which the list is growing steadily. Therefore, management and monitoring of patients with PES are crucial. The aim of this paper was to review current perspectives on monitoring patients with PES and addressing management of ocular and systemic associations of this clinically important and biologically fascinating disease.

Pseudoexfoliation and aortic aneurysm: a long-term follow-up study

PURPOSE

To study the relationship between pseudoexfoliation (PEX) and aortic aneurysm in a population with a high prevalence of PEX.

METHODS

Survival analyses were performed in a cohort of 735 residents aged 65-74 years, examined in a population survey in the municipality of Tierp, Sweden, 1984-1986. To expand the sample size, 1040 people were recruited by means of glaucoma case records established at the Eye Department in Tierp in 1978-2007. In this way, the cohort comprised 1775 subjects, representing more than 25 400 person-years at risk. Medical records and autopsy reports were reviewed to identify subjects diagnosed with aneurysm. Those with a follow-up time shorter than 1 year were excluded.

RESULTS

By the end of the study in September 2017, 60 new cases of aortic aneurysm had been found. Of these cases, 23% (14 subjects) were affected by PEX at baseline, compared with 28% among subjects without aneurysm. No association between PEX and aortic aneurysm was found (hazard ratio 0.97; 95% confidence interval 0.53-1.77).

CONCLUSION

In this population-based study, we were unable to verify a relationship between PEX and the development of aortic aneurysm.

YKL-40 is a local marker for inflammation in patients with pseudoexfoliation syndrome

PURPOSE

To investigate the YKL-40, as a marker of inflammation, in aqueous humor and serum of cataract patients with and without pseudoexfoliation syndrome (PEX).

METHODS

Aqueous humor and serum samples were obtained from 44 patients who underwent phacoemulsification surgery. All patients were divided into two groups: PEX (n = 24) and control (n = 20). YKL-40 levels were measured with enzyme-linked immunosorbent assay (ELISA). The differences between the groups were assessed by using Chi-square and independent sample t-tests. The Pearson correlation coefficient was used to evaluate the correlation between variables.

RESULTS

There was a significant difference between the mean YKL-40 levels in the aqueous humor of PEX group (112.0 ± 35.8 ng/mL) and control subjects (88.2 ± 30.6 ng/mL) (P = 0.025). However, the difference between the mean YKL-40 levels in the serum of PEX group (53.5 ± 29.1 ng/mL) and control subjects (44.6 ± 30.2 ng/mL) was non-significant (P = 0.326). The correlation between aqueous humor and serum YKL-40 concentrations was significant in both the groups (r = 0.833, P < 0.001; r = 0.840, P < 0.001, respectively).

CONCLUSIONS

Increased aqueous humor levels of YKL-40 demonstrate that it is local, but not a systemic marker for inflammation in patients with PEX.

Lifespan reduction due to neoplasia is nullified by pseudoexfoliation syndrome

BACKGROUND

Pseudoexfoliation syndrome (PES) is a common eye condition, indicating a risk of various eye diseases. Whether or not PES has extra-ocular physiological or even pathophysiological implications has been a matter of controversy for years.

METHODS

In total 1888 persons were examined for PES in 1985-86. Of these, 1864 (98·7%) had died and were therefore available for analysis by 01.01.2016. Age and cause(s) of death were recorded. 9 diagnostic groups (cardiovascular disease, cerebrovascular disease, neoplasms, systemic hypertension, diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD), Parkinson's disease, aortic aneurysm (AA), and amyloidosis) based on ICD-coding were analyzed for both a possible association between PES and lifespan, as well as PES and specific systemic diseases.

FINDINGS

In the cardiovascular group, PES was not associated with an alteration in longevity. The subgroups acute myocardial infarction and other cardiovascular diseases revealed significantly reduced and increased lifespan, respectively, compared to the rest of the population. These deviations were independent of PES. The impact of PES on the neoplasm group showed that PES-positive persons lived 1·81 years (p < 0·001) longer than PES-negative persons. No significant differences in the PES prevalence were found in any of the cause of death diagnostic groups.

INTERPRETATIONS

The present study suggests that lifespan reduction due to neoplasia is nullified by PES, and that this phenomenon is not restricted to one specific neoplasm type. Thus, the paradoxical conclusion emerges that PES provides a lifespan benefit to the patient with a neoplasm. For the remaining diagnostic groups, PES was neither associated with an altered lifespan, nor with any cause of death diagnoses.

Homocysteine Levels in Plasma and Sensorineural Hearing Loss in Patients with Pseudoexfoliation Syndrome

PURPOSE

To determine the incidence and severity of hearing loss in different frequencies in patients with pseudoexfoliation. Furthermore, possible links between homocysteine and pseudoexfoliation were evaluated.

METHODS

Seventy-five consecutive patients with pseudoexfoliation and 75 sex- and age-matched subjects without pseudoexfoliation as control group were included in this prospective case-control study. Pure-tone audiometry was obtained in all subjects in both groups. Blood samples were obtained from 70 patients with pseudoexfoliation after overnight fasting for levels of homocysteine and analyzed by routine laboratory measurements.

RESULTS

Fifty-two (69%) patients with pseudoexfoliation and 39 (52%) controls had sensorineural hearing loss in speech frequencies. The difference between pseudoexfoliation and control group with regard to the frequency of sensorineural hearing loss in speech frequencies was statistically significant (p=0.03). No relationship was found between the degree of glaucomatous damage and hearing threshold variables in the patients with pseudoexfoliation glaucoma. Plasma homocysteine levels showed no significant difference when patients with pseudoexfoliation and hearing loss were compared with patients with pseudoexfoliation and normal hearing threshold (p=0.5). Hyperhomocysteinemia was found in 58% (29/50) of pseudoexfoliation patients with hearing loss, and 55 % (11/20) of pseudoexfoliation patients with normal hearing threshold (p=0.8). No statistically significant correlation was found between plasma homocysteine and hearing loss in patients with pseudoexfoliation.

CONCLUSIONS

These findings suggest an association between sensorineural hearing loss and pseudoexfoliation in patients with pseudoexfoliation and glaucoma. The severity of hearing loss was not correlated with the degree of glaucomatous damage. There is no association between increased homocysteine levels and hearing loss in patients with pseudoexfoliation.

[Pseudoexfoliation syndrome and pseudoexfoliation glaucoma]

Pseudoexfoliation syndrome is an age-related systemic disease that mainly affects the anterior structures of the eye. Despite a worldwide distribution, reported incidence and prevalence of this syndrome vary widely between ethnicities and geographical areas. The exfoliative material is composed mainly of abnormal cross-linked fibrils that accumulate progressively in some organs such as the heart, blood vessels, lungs or meninges, and particularly in the anterior structures of the eye. The exact pathophysiological process still remains unclear but the association of genetic and environmental factors are thought to play a role in the development and progressive extracellular accumulation of exfoliative material. Hence, LOXL1 gene polymorphisms, responsible for metabolism of some components of elastic fibers and extracellular matrix, and increased natural exposure to ambient ultraviolet or caffeine consumption have been associated with pseudoexfoliation syndrome. Ophthalmological manifestations are commonly bilateral with an asymmetric presentation and can lead to severe visual impairment and blindness more frequently than in the general population, mainly related to glaucoma and cataract. Pseudoexfoliation glaucoma is a major complication of pseudoexfoliation syndrome and represents the main cause of identifiable glaucoma worldwide. Visual field progression is more rapid than that observed in primary open angle glaucoma, and filtering surgery is more frequently required. Nuclear cataract is more frequent and occurs earlier than in the general population. Owing to poorer pupil dilation and increased zonular instability, cataract surgery with pseudoexfoliation is associated with a 5- to 10-fold increase in surgical complications compared to cataract surgery without pseudoexfoliation. Some specific treatments targeting production, formation or accumulation of exfoliative material could improve the prognosis of this syndrome.