Clinical signs of the pseudoexfoliation syndrome

Accuracy of intra ocular lens calculation formulae in patients with pseudoexfoliation syndrome

BACKGROUND

The purpose of this study was to investigate the visual and refractive outcomes in patients with pseudoexfoliation (PXF) undergoing routine cataract surgery and to compare the accuracy of intraocular lens (IOL) power calculation formulae.

METHODS

Retrospective case-series study from Shamir medical center, a public hospital, Israel. Medical records of patients who underwent routine cataract surgery between January 2019 and August 2021 were investigated. Postoperative visual acuity and manifest refraction were examined. The error in predicted refraction and IOL power calculation accuracy within a range of ± 0.50 to ± 1.00 diopters were compared between different IOL calculating formulae.

RESULTS

151 eyes of 151 patients ages 73.9 ± 7.1 years were included in this study- 58 eyes in the PXF group and 93 eyes in the control group. The mean absolute error (MAE) for the BUII formula was 0.63D ± 0.87 for the PXF group and 0.36D ± 0.48 for the control group (p < 0.05). The MAE for the Hill-RBF 3.0 formula was 0.61D ± 0.84 for the PXF group and 0.42D ± 0.55 for the control group (p = 0.05). There were significant differences in MAE and MedAE between PXF group and control group measures (p < 0.05). In the PXF group there were no significant differences between the different formulae.

CONCLUSIONS

There were significant differences in accuracy of IOL power calculations in all formulae between PXF group and control group measures. PXF patients show hyperopic shift from predicted refraction. Barret universal II formula had the highest proportion of eyes with absolute error in prediction below or equal to 0.50 D in both PXF and control groups.

Characteristic Differences between Normotensive and Hypertensive Pseudoexfoliative Glaucoma

PURPOSE

To compare the differences between eyes with pseudoexfoliative glaucoma (PXG) when they are divided into two groups (hypertensive PXG and normotensive PXG) according to the intraocular pressure (IOP).

METHODS

This is a retrospective study. Data from 86 hypertensive PXG eyes and 80 normotensive PXG eyes were included. Hypertensive PXG was defined as PXG with IOP ≥ 22 mmHg, and normotensive PXG was defined as with IOP ≤ 21 mmHg). Central corneal thickness (CCT) was measured by ultrasound pachymetry. Lamina cribrosa thickness (LT) was evaluated using swept-source optical coherence tomography.

RESULTS

No significant differences were observed between hypertensive and normotensive PXG in terms of age, gender, axial length, hypertension, or diabetes. Normotensive PXG eyes had thinner CCT than hypertensive PXG eyes (p = 0.02). To compare LT, a sub-analysis was performed after matching age, VF MD and retinal nerve fiber layer thickness. The normotensive PXG group (n = 32) demonstrated significantly thinner LT compared with the hypertensive PXG group (n = 32) at similar ages and levels of glaucoma severity (p < 0.001).

CONCLUSIONS

Eyes with normotensive PXG demonstrated thinner CCT and LT compared with those with hypertensive PXG, suggesting structural vulnerability to glaucoma.

Secondary glaucoma: Toward interventions based on molecular underpinnings

Glaucoma is a heterogeneous group of progressive diseases that leads to irreversible blindness. Secondary glaucoma refers to glaucoma caused by a known underlying condition. Pseudoexfoliation and pigment dispersion syndromes are common causes of secondary glaucoma. Their respective deposits may obstruct the trabecular meshwork, leading to aqueous humor outflow resistance, ocular hypertension, and optic neuropathy. There are no disease-specific interventions available for either. Pseudoexfoliation syndrome is characterized by fibrillar deposits (pseudoexfoliative material) on anterior segment structures. Over a decade of multiomics analyses taken together with the current knowledge on pseudoexfoliative glaucoma warrant a re-think of mechanistic possibilities. We propose that the presence of nucleation centers (e.g., vitamin D binding protein), crosslinking enzymes (e.g., transglutaminase 2), aberrant extracellular matrix, flawed endocytosis, and abnormal aqueous-blood barrier contribute to the formation of proteolytically resistant pseudoexfoliative material. Pigment dispersion syndrome is characterized by abnormal iridolenticular contact that disrupts iris pigment epithelium and liberates melanin granules. Iris melanogenesis is aberrant in this condition. Cytotoxic melanogenesis intermediates leak out of melanosomes and cause iris melanocyte and pigment epithelium cell death. Targeting melanogenesis can likely decrease the risk of pigmentary glaucoma. Skin and melanoma research provides insights into potential therapeutics. We propose that specific prostanoid agonists and fenofibrates may reduce melanogenesis by inhibiting cholesterol internalization and de novo synthesis. Additionally, melatonin is a potent melanogenesis suppressor, antioxidant, and hypotensive agent, rendering it a valuable agent for pigmentary glaucoma. In pseudoexfoliative glaucoma, where environmental insults drive pseudoexfoliative material formation, melatonin's antioxidant and hypotensive properties may offer adjunct therapeutic benefits. This article is categorized under: Neurological Diseases > Molecular and Cellular Physiology.

Prevalence of pseudoexfoliation in diabetic patients with senile cataract: A hospital-based study in Kashmir, India

Purpose

: To study the prevalence of pseudoexfoliation syndrome (PEX) in diabetics with senile cataracts and compare it to the prevalence in nondiabetic control group.

Methods

: Two hundred and fifty diabetics and 250 nondiabetics (age and sex matched) were evaluated for PEX deposition.

Results

: Chi-squared test was employed, and a P value < 0.05 was considered significant. In the PEX group, most patients belonged to the age group of 60-70 years (55.17%). Out of 18 patients with PEX, 11 (61.1%) showed bilaterality. There was a higher frequency of raised intraocular pressure (IOP; >20 mmHg) in PEX eyes (10.3%) than in the non-PEX eyes (5.9%). The PEX group had a higher number of eyes with cup-to-disc ratio (CDR) >0.6 (11.12%) than the non-PEX group (4.32%). Nuclear cataracts were more frequent in PEX eyes than non-PEX eyes, whereas PSC and mature cataracts were more prevalent in the non-PEX group. Most eyes had PEX deposition on the anterior lens capsule and pupillary margin. Of the 500 study eyes corresponding to the diabetic group, 418 had cataracts (rest pseudophakic), of which 28 had pseudoexfoliation, accounting for 6.7% of the total. In the nondiabetic control group comprising 500 eyes, 430 had senile cataracts (rest pseudophakic), of which 105 had PEX deposition, accounting for 24.4% of the total.

Conclusion

: According to our findings, diabetics have a lower prevalence of PEX than nondiabetics. Few such studies have been conducted so far, and none have been conducted in the Indian population.

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.

Normotensive Glaucoma in the Fellow Eye of Patient with Unilateral Pseudoexfoliation

PURPOSE

To investigate the characteristics of normotensive glaucoma (NTG) in the fellow eye of patients with unilateral pseudoexfoliation syndrome (PXS).

METHODS

This study is a retrospective chart review. We included 313 patients with NTG. Using the 1:1 matched propensity score, only 94 well-matched patients were selected. A total of 47 NTG patients who had PXS in their contralateral eye (PXS group) and 47 NTG patients who did not (control group) were compared. The propensity score was matched based on age, mean intraocular pressure (IOP), baseline retinal nerve fiber layer (RNFL) thickness and baseline mean deviation (MD) of visual field (VF) score. The diagnosis of NTG was based on the presence of glaucomatous optic nerve head injury with VF defect, intraocular pressure less than 22 mmHg, open angles and no pseudoexfoliation material.

RESULTS

The PXS group had a higher ratio of males (34.0%) than the control group (17.0%). No significant differences were observed between the two groups in terms of CCT, axial length, untreated baseline IOP, baseline PSD of VF, systemic blood pressure and follow-up duration. The rate of RNFL thinning was significantly faster in the PXS group (-1.88 ± 2.83 μm/year) compared with the control group (-0.27 ± 5.29 μm/year) (p = 0.02). The progression rate of VF MD was slightly faster in PXS than in the control group, but there was no statistically significant difference (PXS group, -0.33 ± 0.90 dB/year; control group, -0.11 ± 0.84 dB/year; p = 0.236).

CONCLUSIONS

NTG eyes with PXS showed faster RNFL thinning than did control NTG eyes.

Light and electron microscopic features of preclinical pseudoexfoliation syndrome

PURPOSE

This study sought to explore the features of the anterior lens capsule in patients with preclinical pseudoexfoliation syndrome (pPEX) via light microscopy (LM) and transmission electron microscopy (TEM).

DESIGN

Cross-sectional, prospective, and observational case series.

METHODS

We recruited consecutive patients with and without pPEX who underwent routine cataract surgery at Ramathibodi Hospital, between April 2018 and November 2020. pPEX can be characterized by pigmented spoke-wheel deposition (P) on the anterior lens capsule, midperiphery cleft/lacunae (C), faint central disc present within the photopic pupil (D), white-spoke pattern (W) noted at the midperiphery, and a combination of at least two signs (Co). LM and TEM were used to examine anterior lens capsule specimens for the presence of characteristic pseudoexfoliation material (PXM). The features of the anterior lens capsule in pPEX explored via LM and TEM were recorded.

RESULTS

This study included a total of 96 patients (101 excised anterior lens capsules); among them, 34 (35 excised anterior lens capsules) exhibited pPEX signs (pPEX group) but 62 (66 excised anterior lens capsules) did not (control group). The patients had a mean age of 74 ± 7 (range, 58-89) years. LM and TEM revealed no definite PXM in any patient. In the pPEX group, LM analysis identified two capsule specimens with suspected PXM; PXM precursors were observed in 1 of the 34 excised capsule specimens analyzed via TEM. Furthermore, 39 eyes (59.09%) exhibited signs of true exfoliation syndrome (TEX) in LM analysis (12.82%, 25.64%, 10.26%, 10.26%, and 41.03% for patients exhibiting P, D, C, W, and Co, respectively). However, no TEX signs were observed in the control group. We found that the anterior lens capsules exhibiting C and D were significantly associated with TEX (odds ratio = 5.4 and 7.9; P = 0.007 and 0.004, respectively).

CONCLUSIONS

LM analysis revealed no definite PXMs were detected in the excised anterior lens capsules, whereas TEM analysis showed PXM precursors in one specimen (2.94%). Notably, a significant association was observed between C and D signs and TEX.

Evaluation of Anterior Segment Parameters in Pseudoexfoliation Disease Using Anterior Segment Optical Coherence Tomography

PURPOSE

To compare anterior segment and angle parameters between pseudoexfoliation syndrome (PEX) and PEX glaucoma (PEXG) and normal control subjects using anterior segment optical coherence tomography (AS-OCT) imaging.

DESIGN

Cross-sectional study.

METHODS

One hundred and two subjects with PEXG, PEX, and normal eyes as the control group were recruited from an academic referral institution. All subjects underwent a complete ophthalmologic examination, axial length measurement, and AS-OCT imaging. Anterior segment and angle parameters were evaluated.

RESULTS

After excluding 4 eyes because of poor imaging of the scleral spur, data from 34 eyes with PEXG, 33 eyes with PEX, and 31 eyes of normal control subjects were analyzed. Anterior chamber depth was significantly shallower in eyes with PEXG compared with eyes of control subjects (P < .001). The differences in anterior chamber angle parameters (AOD500, AOD750, TISA500,and TISA750) were significant among study groups, with lower values in the PEXG group compared with the PEX and control subject groups. Lens vault (mean [mm]±SD) was higher in the PEXG (0.46 ±0.21) and PEX (0.427 +0.28) groups compared with the control group (0.305+ 0.20).

CONCLUSIONS

PEXG eyes have the narrowest anterior chamber angle parameters. There is a progressive decrease in angle parameters from control subjects to the PEX group to the PEXG group. Narrow anterior chamber angle and anterior chamber depth may have a role in the progression of PEX to PEXG. Detection of narrow angle in these patients may help clinicians manage the disease more properly.

Outcomes of the flanged intrascleral haptic fixation with double-needle technique in patients with Marfan syndrome

PURPOSE

To investigate the clinical outcomes and complications associated with the flanged intrascleral haptic fixation with double-needle technique (a.k.a. the Yamane technique/FIHFT) in patients with Marfan syndrome (MFS) with subluxated or dislocated lenses.

METHODS

Eighteen eyes of 11 patients with MFS with subluxated or dislocated lenses who had undergone intraocular lens implantation using the FIHFT from March 2019 to October 2020 were evaluated. All patient data were retrospectively collected from medical records, including a complete ophthalmologic examination at baseline and follow-up examinations of uncorrected visual acuity (UCVA, logMAR), best-corrected visual acuity (BCVA, logMAR), intraocular pressure (IOP), and slit-lamp examination.

RESULTS

The median follow-up period was 6 ± 3 (range, 3-12) months. The average patient age at the time of surgery was 13 ± 9 (range, 4-34) years. The mean preoperative BCVA was 0.49 ± 0.20 logMAR (Snellen equivalent visual acuity, 20/60), while the mean postoperative BCVA at the end of follow-up was 0.21 ± 0.14 logMAR (20/30), indicating an improvement of 0.28 ± 0.20 logMAR (20/40) postoperatively (p < 0.001). Postoperative iris capture occurred in six eyes (38.9%). No cases of hypotony, IOP elevation, or vitreous hemorrhage were noted, and no patients developed intraocular lens dislocation, retinal detachment, or endophthalmitis.

CONCLUSIONS

To our knowledge, the present study is the first to report outcomes of the FIHFT in patients with MFS. Our findings suggested that scleral lens fixation is safe and effective for improving visual acuity in patients with MFS who have subluxated or dislocated lenses.

The depigmentation degree of iris pigment epithelium in pseudoexfoliation syndrome

BACKGROUND

To compare the optical density of iris pigment epithelium (OD_IPE) and iris stromal thickness (IST) measurements in patients having pseudoexfoliation syndrome (PXS) and age-gender matched participants.

METHODS

This is a cross-sectional study. Patients with PXS were enrolled in the study group. Age and gender-matched healthy subjects with no evidence of PXS were recruited as controls. After a comprehensive ophthalmological evaluation, the anterior segment images were acquired using anterior segment spectral-domain optical coherence tomography (AS SD-OCT). The acquired pictures were further analyzed using the ImageJ program. Two investigators measured the OD_IPE and the IST of the subjects, and the repeatability and reproducibility were checked. SPSS program was used for statistical analysis.

RESULTS

The PXS group was comprised of twenty-two eyes (n = 22 patients), and the control group contained twenty-six eyes of 26 age and gender-matched healthy subjects. The mean temporal OD_IPE of the study group was found to be decreased significantly in comparison to the mean temporal OD_IPE of the control eye (p = 0.018). Both the mean nasal (N) and temporal (T) ISTs of the PEX eyes were thinner than the control eyes (p = 0.006 and p = 0.002, respectively). The mean baseline IOP was found to significantly negatively correlate with the OD_IPE in the PEX group at both N and T sides (r = -0.531, p = 0.011 and r = -0.685, p < 0.001, respectively).

CONCLUSION

The pupillary margin IPE was found more depigmented, and the mean N and T IST were significantly thinner in the PEX group by comparison with the age-gender matched healthy controls. The mean baseline IOP was negatively correlated with the pupillary margin's IPE pigmentation degree in patients with PXS.

Pigment dispersion syndrome and its implications for glaucoma

Pigment dispersion syndrome (PDS) represents a clinical spectrum of a relatively common and usually underdiagnosed phenomenon produced by spontaneous pigment dispersion from the iris into the anterior segment. PDS is often bilateral, has no gender predisposition, and presents at a young age, particularly in myopes. Although most patients experiencing an episode of pigment dispersion are asymptomatic, extreme photophobia, ocular pain, redness, and blurred vision may occur. Other characteristic signs are iridolenticular contact, concave iris configuration, 360° peripheral iris transillumination, and pigment deposition on the anterior chamber angle or the corneal endothelium (Krukenberg spindle). Early PDS diagnosis is crucial to detect patients with pigment-related ocular hypertension (POHT) that can eventually lead to pigmentary glaucoma (PG). The latter represents a sight-threatening condition in which mechanical, environmental, and genetic factors contribute to optic nerve damage. In this review, we update the pathogenic mechanisms involved in the clinical spectrum of the disease. We describe its clinical presentation, ophthalmologic manifestations, and complications, including the factors influencing the development of POHT and PG. Because PDS has variable clinical presentations that lead to misdiagnoses, we emphasize the differential diagnosis and the actual therapeutic strategies according to disease status.

Diagnosis of Pseudoexfoliation Syndrome in Pseudophakic Patients

OBJECTIVE

The aim of this study was to evaluate the sensitivity and specificity of pseudoexfoliation syndrome diagnosis in pseudophakic patients and potential means of improving it.

METHODS

This prospective, nonrandomized study comprised 41 consecutive patients (41 eyes) scheduled for cataract surgery at a tertiary medical center during 2016 and 2017. Preoperatively, all patients underwent a detailed slit-lamp examination, including gonioscopic assessment of the iridocorneal angle. The examination was performed by a glaucoma specialist who completed an assessment form documenting the presence/absence of clinical signs of pseudoexfoliation syndrome. It was repeated 1-2 weeks postoperatively by a second, masked, glaucoma specialist.

RESULTS

Sixteen patients (39.0%) were diagnosed with pseudoex-foliation syndrome preoperatively. The diagnosis was confirmed postoperatively in 11/16 patients (68.8% sensitivity) and in an additional patient not diagnosed preoperatively (96% specificity). The ability to diagnose pseudoexfoliation syndrome postoperatively was significantly worse than preoperatively (Z = 12.161, p < 0.0001). Pupillary border deposits (75% of cases) and the Sampaolesi line (83.3%) were the cornerstones of the postoperative diagnosis; anterior capsular deposits were evident in only 41.6% of cases diagnosed postoperatively (31.3% of the originally diagnosed cases).

CONCLUSIONS

Underdiagnosis of pseudoexfoliation syndrome is common in pseudophakic patients and may have significant implications for future management. Careful attention to pupillary border anatomy and meticulous gonioscopic assessment of the iridocorneal angle are essential for accurate diagnosis. Preoperative documentation of pseudoexfoliation syndrome could help prevent this diagnostic pitfall.

LOXL1 folding in exfoliation glaucoma

Exfoliation syndrome (XFS) is an age-related disease defined by the deposition of aggregated fibrous material (XFM) in the peri-cellular space. Principal morbidity occurs in the eye, where XFM accumulates on the anterior ocular tissues. GWAS have found that certain genetic variants of lysyl oxidase-like 1 (LOXL1), a matrix cross-linking enzyme that is required for elastic fiber formation confer risk for the development of XFS, but are not a single causative factor as many genetically affected individuals do not develop XFS or subsequent glaucoma (XFG). We have found that XFG cells display defects in lysosomes, microtubules, autophagy, and mitochondria resembling defects found in cells from age-related syndromes, such as the main neurodegenerative diseases. In the majority of these diseases, the determining cellular factor is a protein containing intrinsically disordered regions (IDRs) and displaying a high propensity for aggregation. We have found that in XFG patient-derived cells, LOXL1 protein is actively subjected to autophagic clearance, suggesting that LOXL1 is undergoing aggregation. In silico analysis demonstrates that LOXL1's first 369 aa constitute an IDR with the highest disorder probability peak centering around the known risk positions. Experimentally, we have found over-expression of either unmodified LOXL1 or fluorescent chimeras preserving the well-structured N-terminus cause copious intracellular aggregation and that aggregation wanes when the high IDR peaks are deleted. Overall, our work suggests that XFS/G results from the aggregation of the LOXL1 protein coupled with a reduction of cellular proteostasis capabilities in aging, resulting in a chronic build-up of LOXL1-containing protein aggregates.

Transient expression of Wnt5a elicits ocular features of pseudoexfoliation syndrome in mice

PURPOSE

Pseudoexfoliation (PEX) syndrome is an age-related systemic disease with ocular manifestations. The development of animal models is critical in order to elucidate the cause of the disease and to test potential treatment regimens. The purpose of this study is to report phenotypes found in mouse eyes injected with Adenovirus coding Wnt5a. Some of the phenotypes resemble those found in PEX patients while others are different.

METHODS

Recombinant Adenovirus coding Wnt5a or green fluorescent protein (GFP) were injected into mouse eyes. Two months after the injection, eyes were examined for PEX phenotypes using slit lamp, fluorescence stereomicroscope, histological staining, immunostaining and transmission electron microscope.

RESULT

Certain ocular features of PEX syndrome were found in mouse eyes injected with recombinant Adenovirus coding Wnt5a. These features include accumulation of exfoliation-like extracellular material on surfaces of anterior segment structures and its dispersion in the anterior chamber, saw-tooth appearance and disrupted basement membrane of the posterior iris pigment epithelium, iris stromal atrophy and disorganized ciliary zonules. Ultrastructure analysis of the exfoliation material revealed that the microfibril structure found in this model was different from those of PEX patients.

CONCLUSION

These features, resembling signs of ocular PEX syndrome in patients, suggest that new information obtained from this study will be helpful for developing better mouse models for PEX syndrome.

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.

Molecular Genetics of Pigment Dispersion Syndrome and Pigmentary Glaucoma: New Insights into Mechanisms

We explore the ideas and advances surrounding the genetic basis of pigment dispersion syndrome (PDS) and pigmentary glaucoma (PG). As PG is the leading cause of nontraumatic blindness in young adults and current tailored interventions have proven ineffective, a better understanding of the underlying causes of PDS, PG, and their relationship is essential. Despite PDS being a subclinical disease, a large proportion of patients progress to PG with associated vision loss. Decades of research have supported a genetic component both for PDS and conversion to PG. We review the body of evidence supporting a genetic basis in humans and animal models and reevaluate classical mechanisms of PDS/PG considering this new evidence.

Conjunctival changes in different clinical variants of early pseudoexfoliation

PURPOSE

To evaluate the conjunctival signs in different forms of pseudoexfoliation (PXF) syndrome to identify signs predicting early forms of the disease.

METHODS

This observational study included patients with newly diagnosed PXF screened in the outpatient department of glaucoma services. Slit lamp photographs were captured in low and high magnification after full dilatation, and details like melanotic pigmentation, vascularity and tortuosity of vessels, scarring if any, presence of pterygium and actinic changes along with basal Schirmer's test were analysed. Variables in each subtype of PXF previously described by us, namely radial pigmentary (group A), combined pigmentary and classical (group B) and classical PXF (group C), were analysed and compared to age-matched controls. The differences between manifest (group B + C) and unmanifest or early form (group A) were also compared.

RESULTS

A total of 89 eyes from 55 patients (M/F = 38:17, 21 unilateral, 34 bilateral, 48 group A, 10 group B and 31 group C) were compared with 40 controls. The Schirmer's test was statically lower in patients with manifest PXF (10 ± 1.4 mm) and unmanifest PXF (14 ± 0.6 mm), p < 0.001. The most frequent conjunctival finding (n = 88) in this cohort was lightly pigmented melanotic pigmentation present close to limbus without evidence of any feeder vessels or actinic changes and associated with pupillary ruff atrophy in the same quadrant. Analysing different PXF forms, there was conjunctival melanosis in one or all quadrants in all forms of PXF which was more prominent in manifest PXF, present in a mean 2 ± 1.7 quadrants in unmanifest and manifest PXF, p = 0.01.

CONCLUSION

Conjunctival melanosis with associated pupillary ruff atrophy in the same quadrant may be the earliest signs of early pseudoexfoliation.

Update on pigment dispersion syndrome and pigmentary glaucoma

PURPOSE OF REVIEW

The present article reviews the clinical features and pathogenesis of pigment dispersion syndrome and pigmentary glaucoma and provides an update regarding their diagnosis and management.

RECENT FINDINGS

Newer imaging modalities including ultrasound biomicroscopy and anterior segment optical coherence tomography facilitate visualization of the iris concavity characteristic of eyes with pigment dispersion syndrome and pigmentary glaucoma. Patients with pigmentary glaucoma may be distinguished from those with other glaucoma types by the presence of typical symptoms, personality type, and patterns of diurnal intraocular pressure fluctuation. Although laser iridotomy has been shown to alter iris anatomy in pigmentary glaucoma, it is not proven to slow visual field progression. Multiple trials have validated the safety and efficacy of filtering surgery in treating pigmentary glaucoma, with fewer studies published on the role of micro-invasive glaucoma surgery.

SUMMARY

Literature from the review period has further defined the unique clinical characteristics of pigment dispersion syndrome and pigmentary glaucoma. Laser surgery has a limited role in the management of these entities, whereas trabeculectomy remains an acceptable first-line surgical treatment. Further studies are needed to define the potential application of the newer micro-invasive glaucoma procedures in pigmentary glaucoma.

Nailfold capillary morphology in exfoliation syndrome

PurposeThe purpose of the study was to investigate nailfold microvascular morphology in exfoliation syndrome with or without glaucoma (XFS/XFG) compared with primary open-angle glaucoma (POAG) and control subjects using nailfold capillary videomicroscopy.Patients and methodsWe used a JH-1004 capillaroscope to perform nailfold capillary videomicroscopy on the fourth and fifth digit of the non-dominant hand. We enrolled 56 XFS/XFG patients, 87 POAG patients, and 75 control subjects. Masked observers graded the videos for hemorrhages, avascular zones ≥200 microns (μm), and degree of microvascular tortuosity on a four-point subjective scale. Multivariable odds ratios, 95% confidence intervals and P-for trends for assessing the relation between morphological changes and POAG or XFS/XFG were obtained from logistic regression analyses. We also assessed this relation with XFS/XFG compared with POAG in multivariable models.ResultsAfter adjusting for multiple covariates, nailfold hemorrhages, avascular zones ≥200 μm, and higher degree of vascular tortuosity were more common in XFS/XFG vs controls (P-for trend ≤0.0001) and in POAG vs controls (P-for trend ≤0.01). For each 100 capillaries, the number of hemorrhages was similar (P-for trend=0.91) between XFS/XFG and POAG patients; however, there were more avascular zones per 100 capillaries with borderline significance (P-for trend=0.04) in the XFS/XFG group. XFS/XFG patients had more tortuosity than POAG patients; specifically, having a tortuosity score ≥1.5 was associated with a 4.4-fold increased odds of XFS/XFG (95% confidence interval: 1.5-13.3) relative to a tortuosity score <1.0 (P-for trend=0.005).ConclusionA high degree of nailfold capillary tortuosity is a distinct non-ocular feature associated with XFS/XFG compared with either POAG or controls.

Pseudoexfoliation syndrome: Effect of phacoemulsification on intraocular pressure and its diurnal variation

Purpose

To evaluate the effect of phacoemulsification on intraocular pressure (IOP) in pseudoexfoliation (PEX) syndrome and its diurnal variation.

Methods

In this prospective, non-comparative, interventional case series, phacoemulsification was done for patients with PEX and concomitant visually significant cataract. Follow-up examinations including IOP measurement were done at postoperative day 1, week 1, month 1, month 3, and month 6. All IOP measurements were performed twice daily: once in the morning between 8 and 10 AM and the other in the evening between 6 and 8 PM. The minimum and maximum IOP and the mean IOP were recorded. IOP variation was defined as the difference between maximum and minimum pressures.

Results

Sixty-eight eyes of 68 patients were analyzed. The mean IOP dropped from 17.45 ± 3.32 mm Hg to 12.57 ± 1.58 mm Hg at 6 months. The minimum and maximum IOP dropped from 14.97 ± 3.46 mm Hg and 20.03 ± 3.39 to 11.53 ± 1.79 mm Hg and 13.01 ± 1.81 after 6 months, respectively. Diurnal IOP variation dropped from 5.06 ± 1.85 mm Hg (range 2–10) at baseline to 1.49 ± 0.93 mm Hg (range 0–4) at postoperative month 6 (p < 0.001 for all). This drop was not correlated with age and CCT, but was strongly correlated with baseline IOP variation (r = 0.847, p < 0.001).

Conclusion

Phacoemulsification without any additional intervention can be an attractive choice in managing the IOP and its diurnal variations in pseudoexfoliation patients, even with elevated IOP, who do not have advanced optic nerve damage.

Pseudoexfoliation Syndrome and Pseudoexfoliation Glaucoma: A Review of the Literature with Updates on Surgical Management

Pseudoexfoliation syndrome (PES) is a systemic disorder caused by progressive accumulation of extracellular material over various tissues. PES usually determines increased intraocular pressure, changes in the anatomical aspects of the optic nerve, and visual field alterations leading to the diagnosis of pseudoexfoliation glaucoma (PEG). Use of topical medical treatment usually leads to poor results in terms of long-term follow-up but many surgical techniques, such as Argon Laser or Selective Laser Trabeculoplasty, have been proposed for the management of PEG affected patients. The present paper is a review on the pseudoexfoliation syndrome and pseudoexfoliation glaucoma with an update on surgical management.

Total oxidative stress, paraoxonase and arylesterase levels at patients with pseudoexfoliation syndrome and pseudoexfoliative glaucoma

AIM

To investigate the oxidative stress status of the aqueous humor and serum of patients with pseudoexfoliation (PEX) syndrome and pseudoexfoliative glaucoma (PEG) and to measure paraoxonase (PON) and arylesterase (ARE) levels.

METHODS

A total of 78 patients were enrolled in the study, with 26 patients in each separate group. The patients were divided into three groups: the first group entailed PEX syndrome patients, while the second group consisted of patients with PEG and the third group involved patients with no additional systemic diseases, other than the diagnosis of cataract as control. Total oxidative stress (TOS), total antioxidant capacity (TAC), PON, and ARE levels in aqueous humor and serum were measured.

RESULTS

TAC, PON and arylesterase levels in aqueous humor and serum of the PEX syndrome and PEG patients were significantly decreased compared with control group (P<0.05). TOS values were higher in patients with PEX syndrome and PEG than controls (P<0.05). TAC, PON and ARE levels of aqueous humor did not differ significantly between the PEX syndrome and PEG groups.

CONCLUSION

These findings are potentially of significance and add to the growing body of evidence for oxidative stress in PEX syndrome and PEG. Decreased antioxidant defense and increased oxidative stress system may play an important role in the pathogenesis of PEX syndrome and PEG.

Evaluation of Optical Low Coherence Reflectometry Parameters in Patients with Exfoliation Syndrome

Purpose. To evaluate optical low coherence reflectometry (OLCR) parameters in patients with exfoliation syndrome (EXS) undergoing cataract surgery. Methods. Forty-seven eyes of 47 patients with EXS (Group 1), and 55 eyes of 55 healthy subjects (Group 2) were included in the study. Anterior chamber depth (ACD), lens thickness (LT), axial length (AL), central corneal thickness (CCT), horizontal corneal length (HCL), and pupil diameter (PD) parameters were measured by OLCR (Lenstar LS 900, Haag-Streit) and compared between groups. Shapiro-Wilk test and Mann Whitney U tests were used for statistical analyses. Results. The mean ACD, HCL, and PD values were significantly lower in EXS group than in healthy subjects (P = 0.01, P = 0.04, and P < 0.001, resp.). The mean LT was significantly higher in EXS group than in healthy subjects (P = 0.007). There was no significant difference between groups in means of AXL and CCT. Conclusions. According to OLCR measures, eyes with EXS have shallower ACD, smaller PD, thicker LT, shorter HCL, and no significantly different CCT levels.

Pattern of pseudoexfoliation deposits on the lens and their clinical correlation--clinical study and review of literature

PURPOSE

To study the clinical correlates of pattern of deposits over the lens in patients with pseudoexfoliation syndrome (PXF) or pseudoexfoliation glaucoma.

METHODS

This retrospective observational study screened 346 patients with PXF seen in glaucoma clinic of a tertiary hospital from 2011-2013. Details like pattern of deposits, location on the lens surface and pupillary abnormalities in slit lamp photographs and their correlation with clinical and demographic variables, were analysed.

RESULTS

A total of 84 eyes of 42 patients with bilateral PXF were included for the study. Glaucoma was seen in 30 eyes with baseline IOP of 24+3.8 mm Hg. Comparing the type of deposits, namely classical (n = 39 eyes), radial pigmentary (RP) form (n = 39 eyes) and combined classical and radial pigmentary (CR) forms (n = 6 eyes) of deposits, pupillary ruff atrophy was common in all forms while poor dilatation was rare in the RP type (n = 5 vs n = 25 in classical forms, p < 0.001). Mean deviation (MD) was worse in the classical and CR form as compared to RP type with the latter presenting much earlier, 43 ± 3.2 years vs 48 ± 4.1 years in CR and 56 ± 5.7 years in classical form, p < 0.001. The baseline IOP in the RP group (18 ± 2.3 mm Hg) was significantly lower than the other two forms (CR 20 ± 3.2 mm Hg, classical 28 ± 2.3 mm Hg), p < 0.001, with only 2 eyes on anti-glaucoma drugs at presentation.

CONCLUSION

Pattern of exfoliation deposits may indicate the stage and severity of the disease process in evolution with the RP representing an earlier/less severe form of pseudoexfoliation syndrome.

A novel method for quantifying the amount of trabecular meshwork pigment in glaucomatous and nonglaucomatous eyes

PURPOSE

To assess the use of a computerized program for evaluating the amount of trabecular meshwork (TM) pigmentation in normal (control), primary open-angle glaucoma (POAG), and pseudoexfoliation glaucoma/pigmentary dispersion glaucoma (PXFG/PDG) patients.

METHODS

All included patients were from the Goldschleger Eye Institute glaucoma clinic. After signing an informed consent, each patient's anterior chamber angle was photographed using a single photo-slit under the same conditions. Only one eye per patient was photographed. The superior TM and the inferior TM were documented. Then, the degree of "blackness" (representing melanin pigment) was assessed using the ImageJ program.

RESULTS

Of the 43 eyes photographed, 8 were excluded because of low-quality images. Of the remaining 35 patients, 14 were normal, 10 had POAG, and 11 had PXFG/PDG. The amount of pigment was the same in the control and the POAG patients whether the inferior TM (P=0.24), superior TM (P=0.58), or the sum inferior TM+superior TM (P=0.85) was measured. The pigment level was significantly higher in the PXFG/PDG group than in the control group (inferior TM, P<0.01; superior TM, P=0.047; sum, P<0.01). The difference between the inferior and the superior TM pigment levels was found to be statistically insignificant in all the groups (normal, P=0.86; POAG, P=0.10; PXFG/PDG, P=0.22).

CONCLUSIONS

The use of ImageJ software might play a role in the quantification of pigment evaluation of the TM.

Pseudoexfoliation Syndrome

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

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

Exfoliation syndrome in Nigeria

Purpose:

The purpose of this study was to estimate the prevalence of exfoliation syndrome (XFS) and its association with ocular disease in patients attending the eye clinic of the University College Hospital (UCH) in Ibadan, Nigeria.

Materials and Methods:

A total of 448 consecutive new patients, aged 30-90 years who presented to the eye clinic of UCH between December 2009 and November 2010 were evaluated. Each patient had a complete ophthalmic examination. Patients with exfoliative material on the anterior lens surface and/or pupillary margin in either or both eyes were considered to have XFS. Means, standard deviation, and 95% confidence intervals were calculated.

Results:

All the patients examined were from the southern part of Nigeria. Majority (94.2%) were of the Yoruba tribe from southwestern Nigeria, while 5.8% were from southeastern Nigeria. The mean age of the study cohort was 58.5 ± 13.8, 54.8% were males, 12 (2.7%) had XFS. All patients with XFS were of the Yoruba tribe, with a mean age 65.6 ± 5.6 years. There was a male predilection (66.7%). All eyes with XFS had lenticular opacities. XFS was bilateral in eight patients (66.7%) of whom seven patients (87.5%) had glaucoma and lenticular opacities bilaterally.

Conclusion:

This is the first report of the existence of XFS in Nigeria. Larger studies are necessary in this population to further investigate the disease.

Corneal endothelial cells 6-7 years following cataract surgery in patients with pseudoexfoliation syndrome

PURPOSE

To assess the condition of the corneal endothelium an extended period after cataract surgery in eyes with and without pseudoexfoliation syndrome (PES).

METHODS

Forty-six patients with PES who underwent cataract surgery in the Eye Department, Oslo University Hospital, in 2001 and 2002 were enrolled and compared to 101 matched controls without PES who had surgery in the same period. They were re-examined 6-7 years following surgery with measurements taken of corneal endothelial cell density (ECD), pleomorphism, polymegathism and corneal thickness.

RESULTS

Mean ECD was 2024 ± 371 cells/mm(2) in eyes with PES and 2144 ± 365 cells/mm(2) in eyes without PES. The difference was not statistically significant. No significant difference in polymegathism and pleomorphism was noted. Mean corneal thickness was 543 and 547 μm in eyes with and without PES, respectively (not statistically significant). The presence of glaucoma in pseudoexfoliative eyes was not associated with endothelial cell changes.

CONCLUSION

Six to 7 years following cataract surgery, no statistically significant differences were established in ECD, pleomorphism, polymegathism and corneal thickness in eyes with and without PES. No clinical signs of corneal decompensation were noted amongst the participants.

Delayed intraocular pressure elevation after pupillary dilation in exfoliation syndrome

PURPOSE

To determine the effect of pupillary dilation on intraocular pressure (IOP) in normotensive patients with exfoliation syndrome (XFS).

METHODS

Patients with XFS were enrolled in this prospective trial. All eyes were untreated, had no previous laser or operative surgery and were normotensive with full visual fields and open angles. IOP was measured before dilation and hourly for four consecutive hours after dilation with tropicamide 1% and phenylephrine 2.5% eyedrops.

RESULTS

Twenty-five eyes of 19 White patients (nine male, 10 female) with XFS were enrolled. Twelve eyes (48%) had a rise in IOP of ≥ 4 mmHg above the pre-dilation baseline IOP and four (16%) had a rise of ≥ 9 mmHg (9-28 mmHg). Post-dilation gonioscopy confirmed the presence of an open anterior chamber angle in all eyes. The maximum IOP was reached 3 hr post-dilation in three eyes and after 2 hr in the remaining eyes. The four eyes with marked IOP rise exhibited an elevation of between 1 and 7 mmHg at 1 hr. Extensive pigment release was noticed in all eyes that had a rise in IOP.

CONCLUSION

Patients with XFS are at risk of developing delayed post-dilation IOP rises. Awareness of this phenomenon is particularly important in patients with advanced cupping and/or severe visual field loss who may not be able to tolerate a marked elevation of IOP. An early, mild rise in IOP at 1 hr may serve as a warning sign for a more severe, delayed response. Eyes with XFS should be monitored carefully after dilation, especially those with marked pigment release.

Point prevalence of pseudoexfoliation syndrome in patients scheduled for cataract surgery in eye camps in yemen

Purpose:

To study the point prevalence of pseudoexfoliation syndrome (PXS) among Yemeni patients in different governorates with age-related cataract scheduled for surgery.

Settings:

Eye camps organized by the Nibras Health Society to perform cataract surgeries during the years 2002-2006. All patients aged 40 years and above were included in the study.

Materials and Methods:

A total of 2535 eyes of 2535 patients from 13 governorates, scheduled for cataract surgery in eye camps, were included. All eyes underwent complete eye examination before the surgery and were evaluated for the signs of pseudoexfoliation material in the pupil, iris and lens capsule on dilated slit lamp examination.

Results:

The study found 495 of the 2535 eyes (19.53%) with PXS with males more commonly affected than females (55.2 and 44.8%, respectively). The mean age of patients with PXS was 66.2 years while it was 64.6 years in non-PXS patients. The prevalence of pseudoexfoliation syndrome increased with age (10.1% in the age group of 41-50 years that increased to 28.8% in the age group of more than 81 years old). The rate of PXS detection in camps in 13 governorates ranged from 13.33 to 24.22% with an overall rate of 19.53%. The lowest rate was noticed in Sana'a and the highest in Al-Dhale governorate.

Conclusion:

This pilot study confirms that PXS was common in patients undergoing cataract surgery in Yemen with an increased detection rate with age. This study also highlights the prevalence of an ocular disease that is associated with systemic and ocular complications; however, further studies based on population studies are needed.

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

AIM

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

SETTING

Iladevi Cataract and IOL Research Center, Ahmedabad, India.

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Exfoliation syndrome prevalence in the glaucoma population of South Louisiana

A prospective study was performed to determine the prevalence of exfoliation syndrome in a glaucoma population of South Louisiana. Five hundred consecutive open angle glaucoma patients over 50 years of age (median age 70.6 years) from both indigent clinic and private referral sources were examined for the presence of exfoliation material on the lens capsule. The prevalence in caucasian patients was 2.7%, blacks 0.4%, combined 1.4%. This compares with a reported prevalence of exfoliation syndrome among patients with open angle glaucoma in the United States of 3% to 28%, Denmark of 26%, Ireland of 66%, and Sweden of 75%. This low prevalence may be a reflection of the ethnic origin of the population, but other explanations are considered.

Pseudoexfoliation syndrome at Jordan University Hospital

PURPOSE

This study aimed to estimate the prevalence of pseudoexfoliation syndrome (PXS) and analyse its association with particular ocular diseases in patients attending the Department of Ophthalmology at Jordan University Hospital.

METHODS

A total of 1195 consecutive patients, aged 40-90 years, who attended the Department of Ophthalmology at Jordan University Hospital between December 2005 and March 2007 were included in the study. Each patient underwent complete ophthalmic evaluation, including: relevant history; visual acuity testing; slit-lamp examination, applanation tonometry, gonioscopy and dilated fundus examination. Patients with typical pseudoexfoliative material on the anterior lens surface and/or the pupillary margin in either or both eyes were labelled as having PXS.

RESULTS

Of the 1195 patients, 9.1% had pseudoexfoliation (PXF). Their mean age was 68.3 years (standard deviation [SD] 9.57). The prevalence of PXS had a tendency to increase with age but had no sex predilection. Pseudoexfoliation was bilateral in 65.7% of cases. It was significantly associated with cataract, glaucoma and phacodenesis. Of the eyes with PXF, 92.1% had cataract, 33.1% had glaucoma and 7.9% had phacodenesis.

CONCLUSIONS

Although this study was not population-based, its findings increase our knowledge of PXS in a Middle Eastern country. Few data on PXS are available from this part of the world.

Matrix metalloproteinases and their tissue inhibitors after selective laser trabeculoplasty in pseudoexfoliative secondary glaucoma

BACKGROUND

The aim of this study was to assess changes in metalloproteinases (MMP-2) and tissue inhibitor of metalloproteinases (TIMP-2) following selective laser trabeculoplasty (SLT) in patients with pseudoexfoliative glaucoma (PEXG).

METHODS

We enrolled 15 patients with PEXG and cataracts (PEXG-C group) and good intraocular pressure (IOP) controlled with beta-blockers and dorzolamide eye drops who were treated by cataract phacoemulsification and 15 patients with pseudoexfoliative glaucoma (PEXG-SLT group). The PEXG-SLT patients underwent a trabeculectomy for uncontrolled IOP in the eye that showed increased IOP despite the maximum drug treatment with beta-blockers and dorzolamide eye drops and after ineffective selective laser trabeculoplasty (SLT). The control group consisted of 15 subjects with cataracts. Aqueous humor was aspirated during surgery from patients with PEXG-C, PEXG-SLT and from matched control patients with cataracts during cataract surgery or trabeculectomy. The concentrations of MMP-2 and TIMP-2 in the aqueous humor were assessed with commercially available ELISA kits.

RESULTS

In PEXG-SLT group in the first 10 days after SLT treatment a significant reduction in IOP was observed: 25.8 +/- 1.9 vs 18.1.0 +/- 1.4 mm/Hg (p < 0.001), but after a mean time of 31.5 +/- 7.6 days IOP increased and returned to pretreatment levels: 25.4 +/- 1.6 mm/Hg (p < 0.591). Therefore a trabeculectomy was considered necessary.The MMP-2 in PEXG-C was 57.77 +/- 9.25 microg/ml and in PEXG-SLT was 58.52 +/- 9.66 microg/ml (p < 0.066). TIMP-2 was 105.19 +/- 28.53 microg/ml in PEXG-C and 105.96 +/- 27.65 microg/ml in PEXG-SLT (p < 0.202). The MMP-2/TIMP-2 ratio in the normal subjects was 1.11 +/- 0.44. This ratio increase to 1.88 +/- 0.65 in PEXG-C (p < 0.001) and to 1.87 +/- 0.64 in PEXG-SLT (p < 0.001). There was no statistically significant difference between the PEXG-C and PEXG-SLT ratios (p < 0.671).

CONCLUSION

This case series suggest that IOP elevation after SLT can be a serious adverse event in some PEXG patients. The IOP increase in these cases would be correlated to the failure to decrease the TIMP-2/MMP-2 ratio.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN79745214.