Generalized transluminance of the iris and the frequency of the pseudoexfoliation syndrome in the eyes of transient ischemic attack patients

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.

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.

Laminar and Prelaminar Tissue Characteristics of Glaucomatous Eyes Using Enhanced Depth Imaging OCT

PURPOSE

To investigate characteristics of the lamina cribrosa (LC) and prelaminar tissue (PLT) in eyes of patients with primary open-angle glaucoma (POAG), primary angle-closure glaucoma (PACG), and pseudoexfoliation glaucoma (PXG) using enhanced depth imaging (EDI) OCT.

DESIGN

Observational case-control study.

PARTICIPANTS

A total of 116 eyes from 116 participants with POAG (n = 30 eyes), PACG (n = 29 eyes), or PXG (n = 29 eyes) and 28 healthy eyes.

METHODS

Participants underwent a complete ophthalmologic examination in addition to corneal pachymetry, standard achromatic perimetry, peripapillary retinal nerve fiber layer (RNFL) OCT, and EDI OCT, as well as measurement of LC, PLT thickness, and LC depth.

MAIN OUTCOME MEASURES

Lamina cribrosa measurement, PLT thickness, and LC thickness.

RESULTS

Average LC thickness was significantly different among the 4 groups with the thinnest values in the PXG group. Prelaminar tissue also was significantly thinner in PXG eyes. The POAG eyes demonstrated the largest LC depths (P < 0.05), whereas PACG and healthy eyes demonstrated the smallest LC depths (P < 0.05). Mean deviation on standard achromatic perimetry and average thickness on peripapillary RNFL OCT were associated significantly with LC and PLT thickness.

CONCLUSIONS

Pseudoexfoliation glaucoma eyes demonstrate reduced LC and PLT thickness compared with POAG, PACG, and healthy eyes. Lamina cribrosa depth was larger in POAG eyes as compared with PXG, PACG, and healthy eyes. These findings may account for the peculiar appearance of the optic nerve head in PXG eyes.

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.

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.

Choroidal Vessel Diameters in Pseudoexfoliation and Pseudoexfoliation Glaucoma Analyzed Using Spectral-Domain Optical Coherence Tomography

PURPOSE OF THE STUDY

The purpose of the study was to analyze choroidal vessel diameters in pseudoexfoliation (PXF) and pseudoexfoliation glaucoma (PXFG) using spectral-domain optical coherence tomography (SD-OCT).

MATERIALS AND METHODS

Fifty patients (100 eyes) with PXF and PXFG who underwent high-definition 1-line raster SD-OCT imaging at New England Eye Center, Boston, were retrospectively identified and divided into unilateral PXFG (26 patients, 52 eyes), unilateral PXF (4 patients, 8 eyes), bilateral PXFG (4 patients, 8 eyes), and bilateral PXF (16 patients, 32 eyes). Eyes with concomitant chorioretinal pathology, history of shunting/filtering for glaucoma, and significant anisometropia were excluded. SD-OCT scans were divided into subfoveal, central, and peripheral zones and choroidal vessel diameters were measured.

RESULTS

In patients with unilateral PXFG, mean choroidal vessel diameter was 12.9 μm smaller in the affected eyes when compared with their contralateral eyes (45.7 vs. 58.6 μm; P<0.0001) with the greatest reduction (16.6 μm) in the subfoveal zone (49.0 vs. 65.6 μm; P<0.0001). In patients with unilateral PXF, the mean choroidal vascular diameter was 13.3 μm smaller in the affected eyes when compared with their contralateral eyes (42.8 vs. 56.1 μm; P=0.02). As expected, no significant difference was observed between the 2 eyes of patients with bilateral PXFG (45.5 vs. 45.7 μm; P=0.95) and bilateral PXF (51.4 vs. 50.2 μm; P=0.52).

CONCLUSIONS

Choroidal vessel diameters are smaller in the affected eyes of patients with unilateral PXF and PXFG when compared with their contralateral unaffected eyes. These changes appear to be independent of the presence or absence of glaucoma. Future studies may identify the choroidal vascular changes and their relationship with the pathogenesis of these conditions.

Ocular Pseudoexfoliation Syndrome Linkage to Cardiovascular Disease

PURPOSE OF REVIEW

Pseudoexfoliation syndrome (PEX) is a common cause of open-angle glaucoma that is characterized by stress-induced elastic microfibrillopathy related to an accumulation of matrix metalloproteinases. The accumulation of matrix metalloproteinases increases deposition of protein substance within ocular structures and other organs including the heart. Many studies have associated the presence of cardiovascular disease with pseudoexfoliation syndrome, but much debate exists between studies in terms of significant relationships. The following meta-analysis aims to relate pseudoexfoliation syndrome with certain cardiovascular events and disorders. A thorough literature review was performed to acquire information concerning PEX patients with certain cardiovascular disorders. Diseases considered included myocardial infarction, ischemic heart disease, angina, congestive heart failure, cardiomyopathy, aortic aneurysm, hypertension, and homocystinuria. Patients without evidence of pseudoexfoliation disease were the controls of our study. Multiple forest plots were created to compile and analyze collected data for statistical comparison.

RECENT FINDINGS

From a literature review, 18 studies were selected for our analysis. Cardiovascular disorders that had a statistically significant association (within a 95 % confidence interval) with PEX included ischemic heart disease, aortic aneurysms, and homocystinuria. The association between ischemic heart disease and PEX was statistically significant (p = 0.045). Myocardial infarction, chronic ischemic heart disease, angina, and hypertension did not show a correlation of relationship with the presence of pseudoexfoliation. Patients with PEX are prone to present with ischemic heart disease in addition to abdominal aortic aneurysms and homocystinuria. Patients that present with PEX should be screened for these detrimental cardiovascular disorders.

Comparisons of retinal vessel diameter and glaucomatous parameters between both eyes of subjects with clinically unilateral pseudoexfoliation syndrome

Purpose

Pseudoexfoliation syndrome (PEX), the most common identifiable cause of open-angle glaucoma, might affect the retinal hemodynamics. To test this, we compared retinal vessel diameter and glaucoma-related parameters between eyes with pseudoexfoliation material (PE+) and fellow unaffected (PE-) eyes of patients with clinically unilateral PEX.

Methods

The medical records of 30 consecutive Japanese subjects were reviewed retrospectively. The retinal vessel diameters were measured and expressed as the central retinal arteriolar equivalent (CRAE) and central retinal venular equivalent (CRVE) using standardized software. During the chart review, we recorded glaucoma-related parameters including intraocular pressure (IOP), visual field mean deviation (MD) value, planimetrically measured vertical cup-to-disc (C/D) ratio, circumpapillary retinal nerve fiber layer thickness (cpRNFLT) and macular inner retinal thickness (mIRT) measured by spectral-domain optical coherence tomography, anterior chamber flare (ACF), corneal endothelial cell density (CECD), and number of antiglaucoma medications.

Results

Compared with PE- eyes, the CRAE, CRVE, MD, cpRNFLT and mIRT, and CECD were significantly lower in PE+ eyes; the IOP, vertical C/D ratio, number of antiglaucoma medications, and ACF were significantly higher in PE+ eyes (P<0.0001 for all comparisons). The CRAE, cpRNFLT, and MD were correlated positively with each other (ρ = 0.456–0.499, P<0.0001–0.0002) and negatively with the IOP (ρ = -0.562- —0.432, P<0.0001–0.0006). The vertical C/D ratio was correlated positively with the IOP (ρ = 0.483, P<0.0001) and negatively with the CRAE, cpRNFLT, and MD (ρ = -0.745–-0.479, P<0.0001–0.0001).

Conclusions

Deposition of PE can cause retinal vessel narrowing in arterioles and venules. The roles and mechanisms of retinal vessel narrowing in glaucoma pathogenesis need clarification.

Electroneuromyographic findings in pseudoexfoliation syndrome

PURPOSE

To examine peripheral electroneuromyographic findings in patients with ocular pseudoexfoliation syndrome (PEX) and to compare them controls without PEX.

METHODS

A case-control study design was used to examine 31 patients with PEX and compare the findings with those of 31 age- and sex-matched healthy controls. All patients underwent complete ophthalmologic examination that included peripheral electroneuromyography examination. Motor and sensorial nerve conduction of the median, ulnar, tibial, peroneal, and sural nerve and the sympathetic skin response were measured.

RESULTS

The average sensorial nerve latency of the ulnar and sural nerve was significantly longer in the PEX group compared to the control group (p < 0.05). The average sensorial nerve conduction amplitude and the velocity of the ulnar and sural nerve were significantly lower in the PEX group (p < 0.05).

DISCUSSION

Peripheral nerves, especially sensorial fibers, appear to be affected in PEX patients. These finding may indicate that PEX is a systemic disease.

Pseudoexfoliation syndrome and meibomian gland dysfunction

Pseudoexfoliation syndrome (PEX) is a relatively widespread generalized age-related disease of connective tissue. The condition of meibomians gland in patients with PEX not evaluated yet. Purpose. To evaluate the condition of meibomians glands in PEX. Methods. 132 eyes of 66 patients with PEX syndrome and 128 eyes of 64 patients without it were enrolled in the prospective study. Results. Signs of atonic changes of meibomians glands were similar in both groups. Meibomians gland dysfunction was significantly more expressed in patients with PEX (p < 0,05).

Pseudoexfoliation syndrome and ocular adnexa

Pseudoexfoliation syndrome (PEX) is a relatively widespread generalized age-related disease of connective tissue. It seems reasonable to evaluate the condition of ocular adnexa in patients with PEX. Purpose. To evaluate the condition of ocular adnexal tissue in PEX. Methods. 132 eyes of 66 patients with PEX syndrome and 128 eyes of 64 patients without it were enrolled in the prospective study. We evaluated function of upper eyelid levator muscle, lower eyelid retractors, horizontal lid laxity (HLL), canthal integrity, degree of retractors disinsertion and tone of orbicularis muscle. Results. HLL, degree of retractors disinsertion, laxity of medial canthal tendon were statistically significantly more expressed in patients with PEX (p < 0,05). The tone of orbicularis muscle and function of lower eyelid retractors were statistically lower in patients with PEX (p < 0,05). The function of eyelids levator muscle, tone of lateral canthal tendon and degree of ptosis were similar in both groups. Conclusion. Signs of atonic changes of ocular adnexa are relatively more common in patients with PEX (p < 0,05).

Prevalence of Pseudoexfoliation Syndrome in Turkish Patients with Senile Cataract

PURPOSE

To investigate the prevalence of pseudoexfoliation syndrome (PEX) among Turkish patients with senile cataract.

MATERIALS AND METHODS

Records of 352 eyes of 352 patients who underwent cataract surgery were analyzed in this retrospective study. The presence of PEX, type of cataract, intraocular pressure (IOP), glaucoma, age-related macular degeneration, and systemic diseases (coronary artery disease, hypertension, diabetes mellitus) were recorded.

RESULTS

The overall prevalence of PEX syndrome was detected to be 11%. The mean age of PEX patients was significantly higher than without PEX (74.4 ± 7.2 years and 69.3 ± 11.4 years, respectively, p = 0.004). The most common cataract type in the PEX patients was mixed-type cataract determined in 51.2% of patients. IOP was significantly higher in eyes with PEX than in eyes without it (16.1 ± 4.5 mmHg and 14.7 ± 3.8 mmHg, respectively; p = 0.03). Moreover, the prevalence of age-related macular degeneration was found to be significantly higher, and prevalence of glaucoma slightly higher in PEX patients than without PEX.

CONCLUSION

Pseudoexfoliation syndrome is a common condition in Turkish people. PEX is associated with mixed type of cataract, age-related macular degeneration, and elevated IOP. Therefore, PEX patients should be checked for concomitant diseases.

Systemic Associations of Exfoliation Syndrome

Exfoliation syndrome (XFS) is an age-related disease characterized by the production, deposition, and progressive accumulation of a white, fibrillar, extracellular material in many ocular tissues, most prominent on the anterior lens surface and pupillary border. Its prevalence increases steadily with age in all populations. It is the most common identifiable cause of open-angle glaucoma worldwide and is a potentially reversible or even curable disease. First described in Finland in 1917 by Lindberg, it has long been associated with open-angle glaucoma. However, in recent years, it is being increasingly reported in conjunction with a multiplicity of both ocular and systemic disorders, and the number of these is expected to grow, particularly with investigations based on attempts to associate other diseases with those genes known to be associated with XFS. Despite the focus on XFS as a cause of open-angle glaucoma for nearly a century, in reality it is still only an ocular manifestation of a protean systemic disease. It is a unique disorder with extensive and often serious ocular and systemic manifestations and not, as it has long been termed, a "form" or "type" of glaucoma. This misconception has delayed research into the molecular and cellular processes involved in its development, and the underestimation of its overall importance and its underlying causative mechanisms have largely been long ignored. The purpose of this article is to review the systemic disorders which are becoming increasingly associated with XFS. Reviews of epidemiology, genetics, biomarkers, molecular mechanisms of development, and ocular findings may be found elsewhere.

Ophthalmic artery blood flow parameters in pseudoexfoliation glaucoma

PURPOSE

To investigate orbital flow parameters of ophthalmic artery (OA) in patients with pseudoexfoliation glaucoma (XFG) by ultrasonography.

METHODS

This case-control study included 38 patients with XFG and 32 healthy control subjects. Color Doppler imaging was performed to evaluate orbital flow parameters of OA. Receiver operating characteristic analyses were performed to define the best cutoff value.

RESULTS

In the XFG group, decreased peak systolic velocity (p = 0.114), end diastolic velocity (p = 0.002), and increased resistivity index (RI) (p&lt;0.001) at OA compared to healthy controls were observed. A cutoff value 0.72 for OA RI was found to have a sensitivity of 66% and specificity of 94%.

CONCLUSIONS

The results support the findings of increased vascular resistance in OA XFG. High sensitivity and specificity obtained for OA RI may be useful in evaluation of future therapeutic vascular agents.

Evaluation of choroidal thickness using enhanced depth imaging by spectral-domain optical coherence tomography in patients with pseudoexfoliation syndrome

PURPOSE

To investigate the choroidal thickness using optical coherence tomography in the eyes of patients with unilateral and bilateral pseudoexfoliation syndrome and to compare them with healthy controls.

METHODS

We studied four groups: (1) affected eyes from 30 patients with unilateral PEX syndrome affecting the right eye of 17 patients and the left eye of 13 patients; (2) clinically unaffected eyes of 30 patients with unilateral PEX syndrome; (3) the eyes of 30 patients with bilateral PEX syndrome; and (4) the eyes of 30 normal healthy subjects. Choroidal thickness was evaluated using high-speed, high-resolution enhanced depth imaging by spectral-domain optical coherence tomography. Optical coherence tomography features were compared in all groups using the statistical package SPSS v 15.0.

RESULTS

The mean subfoveal choroidal thicknesses were 237.35±58.01 μm in group 1; 330.75±47.84 μm in group 2; 206.3±86.75 μm in group 3; and 311.8±51.42 μm in group 4. Significant differences in the mean subfoveal choroidal thickness were found between groups 1 and 2 (P<0.001), groups 1 and 4 (P=0.004), groups 2 and 3 (P<0.001), and groups 3 and 4 (P<0.001).

CONCLUSION

In this study, it was observed that clinically affected eyes of patients with PEX syndrome have significantly thinner choroids compared with the clinically unaffected eyes of patients with unilateral PEX syndrome and eyes of healthy controls.

Pseudoexfoliation syndrome in chronic kidney disease patients

This study was performed to determine whether chronic kidney disease (CKD) is associated with an increased risk of pseudoexfoliation (PEX) syndrome. This is an age-matched case control study evaluating frequency of PEX in patients over age 40 with the diagnosis of stage 1-4 CKD and those undergoing hemodialysis (HD). Subjects over age 40 with hypertension and/or diabetes mellitus (DM) and normal kidney functions were studied as a control group. CKD was diagnosed as decreased glomerular filtration rate (GFR) of less than 60 mL/min/1.73 m(2) for at least 3 months. Study groups were arranged as group 1 consisting of HD receiving CKD patients, group 2 consisting of CKD patients who do not need HD and group 3 as a control. Demographic properties and the prevalence of PEX were evaluated and compared between groups. Because of the effect of DM on PEX occurrence, it was also evaluated after exclusion of diabetic patients. A total of 101 cases in group 1, 106 cases in group 2 and 117 cases in group 3 were included in the study. Pseudoexfoliation was found in 7 (6.9%) patients in group 1, 5 (4.7%) patients in group 2 and 7 (5.9%) patients in group 3 (p > 0.05). After exclusion of diabetic patients the prevalence of PEX changed as 4 (5.6%) in group 1, 2 (4.4%) in group 2 and 1 (1.8%) in group 3 (p > 0.05). In conclusion, CKD was not associated with increased prevalence of PEX in this study.

Pseudoexfoliation syndrome and cardiovascular diseases

Pseudoexfoliation (PEX) syndrome is a well-recognized late-onset disease caused by a generalized fibrillopathy. It is linked to a broad spectrum of ocular complications including glaucoma and perioperative problems during cataract surgery. Apart from the long-known intraocular manifestations, PEX deposits have been found in a variety of extraocular locations and they appear to represent a systemic process associated with increased cardiovascular and cerebrovascular morbidity. However, as published results are inconsistent, the clinical significance of the extraocular PEX deposits remains controversial. Identification of PEX deposits in the heart and the vessel wall, epidemiologic studies, as well as, similarities in pathogenetic mechanisms have led to the hypothesis of a possible relation between fibrillar material and cardiovascular disease. Recent studies suggest that PEX syndrome is frequently linked to impaired heart and blood vessels function. Systemic and ocular blood flow changes, altered parasympathetic vascular control and baroreflex sensitivity, increased vascular resistance and decreased blood flow velocity, arterial endothelial dysfunction, high levels of plasma homocysteine and arterial hypertension have all been demonstrated in PEX subjects. Common features in the pathogenesis of both atherosclerosis and PEX, like oxidative stress and inflammation and a possible higher frequency of abdominal aorta aneurysm in PEX patients, could imply that these grey-white deposits and cardiovascular disorders are related or reflect different manifestations of the same process.

Systemic arterial stiffness in patients with pseudoexfoliation glaucoma

AIM

: To evaluate carotid-femoral pulse wave velocity (CF-PWV) values of patients with pseudoexfoliation (PEX) glaucoma in comparison with healthy subjects.

METHODS

Twenty-five consecutive patients with PEX glaucoma (PEXG group) and 25 controls (control group) were included in the study. CF-PWV was assessed by a noninvasive device by the measurements of pulse transmit time and the distance between 2 recording sites.

RESULTS

The mean age was 64.7±7.3 (range, 55 to 79) years the in PEXG group and 63.8±6.6 (range, 51 to 77) years in the control group. There were 8 men (32%) and 17 women (68%) in the PEXG group and 11 men (44%) and 14 women (56%) in the control group. The CF-PWV of the PEX group was significantly higher than that of the control group (P<0.001).

CONCLUSIONS

We have revealed an association between PEXG and increased CF-PWV. Also, increased CF-PWV may be considered as a risk factor for the development of PEXG.

Pseudoexfoliation syndrome and coronary artery ectasia

AIMS

To determine whether pseudoexfoliation syndrome is associated with coronary artery ectasia or not.

METHODS

This cross-sectional study was undertaken at Bulent Ecevit University's Ophthalmology Department with the participation of the Cardiology Department. Eighty consecutive patients who underwent coronary angiography and were classified into two groups-those diagnosed with a normal coronary artery (n=40) and those diagnosed with coronary artery ectasia (n=40)-were included in the study. Pseudoexfoliation was diagnosed if typical exfoliation material was found to be present on the anterior surface of the lens, the iris, or at the pupillary border on slit-lamp examination. Age, sex, presence of pseudoexfoliation material, hypertension, diabetes mellitus, hyperlipidemia rates, cigarette smoking history, and family history of coronary artery disease were compared between the two groups. The continuous variables were compared by using the independent sample t-test or the Mann-Whitney U-test, and the categorical variables were compared using Pearson's χ(2)-test or Fisher's Exact χ(2)-test for the two groups.

RESULTS

There was no difference in demographic data of both groups. The presence of pseudoexfoliation material was more common in patients with coronary ectasia compared with controls [(n=21 (52.5%) vs n=8 (20%), P=0.005)]. In all patients, there was a higher glaucoma rate in the patients with pseudoexfoliation syndrome [n=7 (24.1%), 6 CAE (+), 1 CAE (-)] than in the normal patients [n=2 (3.9%), 2 CAE (-)] (P=0.010).

CONCLUSIONS

In this study, we found a possible association of pseudoexfoliation and coronary artery ectasia. Coronary artery ectasia patients had higher prevalence of pseudoexfoliation.

Cardiovascular involvement in patients with pseudoexfoliation syndrome

AIM

Pseudoexfoliation (PEX) syndrome, diagnosed by ocular examination, is a common disorder of the extracellular matrix. Previous studies have demonstrated accumulation of PEX material in the walls of blood vessels and myocardium. We aimed to investigate whether PEX is associated with cardiovascular involvement using carotid ultrasound measurements and myocardial tissue Doppler imaging (TDI).

METHODS

Thirty-six PEX patients and 34 age-matched and sex-matched healthy controls who had no PEX material were included. Fasting blood samples were taken and the following data were obtained from all cases: myocardial TDI measurements, the mean carotid intima-media thickness (IMT), total carotid plaque area and number.

RESULTS

There were no significant differences between the groups regarding clinical and biochemical data. The peak systolic TDI velocities at the septal (septal S) and lateral annuli (lateral S), and the isovolumic contraction velocity at the lateral annulus [lateral isovolumic contraction velocity (IVC)] were significantly lower in patients with PEX, than in controls (P = 0.001, <0.001 and 0.016, respectively) whereas IMT, total carotid plaque area and number were significantly higher (P = 0.002, 0.035 and 0.033, respectively). In a logistic regression analysis including age, septal S, lateral S, lateral IVC, IMT, total carotid plaque area and number, septal S, lateral S and IMT were significantly associated with PEX, (P = 0.035, 0.011 and 0.035, respectively).

CONCLUSION

Peak systolic TDI velocities were significantly lower and IMT was significantly increased in patients with PEX. However, PEX was weakly associated with carotid plaque measurements.

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

PURPOSE

To evaluate renal function in patients with pseudoexfoliation syndrome.

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Mean platelet volume in pseudoexfoliation syndrome and glaucoma

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

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

DESIGN

Prospective, case-control study.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Assessment of myocardial ischaemia using tissue Doppler imaging in pseudoexfoliation syndrome

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Epidemiology of exfoliation syndrome in the Reykjavik Eye Study

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

The evaluation of vestibular functions in patients with pseudoexfoliation syndrome

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

Decreased cardiovagal regulation in exfoliation syndrome

PURPOSE

To investigate the parasympathetic cardiovascular regulation, baroreflex sensitivity (BRS), and pulse wave velocity (PWV) in exfoliation syndrome (XFS).

METHODS

Heart rate variability indices [standard deviation of all RR intervals (SDNN); the mean of absolute successive differences (RMSSD); the percentage of intervals differing by >50 ms from the preceding interval (pNN50); low frequency power, and high frequency power], as well as BRS and PWV, were determined on 27 consecutive white XFS patients and 20 white control subjects under standard circumstances, with controlled breath rate of 0.25 Hz. The paired t test, the Mann-Whitney U test, and the Fisher exact test were used for comparisons.

RESULTS

There was no significant difference between the XFS and control groups in sex distribution, age, heart rate, blood pressure, body mass index, systemic diseases, or medication. But in XFS patients, SDNN (mean+/-SD, 24+/-7.3 vs. 49+/-16.5 ms), RMSSD (17+/-7.3 vs. 45+/-29.1 ms), pNN50 (1.6%+/-2.5% vs. 17.7%+/-25.9%), high frequency (112+/-109 vs. 479+/-554 ms), and BRS (4.64+/-2.12 vs. 9.49+/-4.76 ms/mm Hg for BRS+ and 5.28+/-2.16 vs. 10.29+/-4.62 ms/mm Hg for BRS-) were all significantly lower than in the control group (P<0.01 for each parameter). Low frequency was also reduced in XFS (72+/-55 vs. 253+/-241 ms) (P=0.027). In XFS, PWV was significantly increased compared with the control group (11.6+/-4.1 vs. 9.3+/-2.2 m/s) (P=0.023).

DISCUSSION

Our results suggest a clinically and statistically significant impairment of cardiovagal regulation and impairment of conduit artery function in XFS patients.

Orbital blood flow parameters in unilateral pseudoexfoliation syndrome

PURPOSE

The evaluation of orbital blood flow parameters in patients with unilateral pseudoexfoliation syndrome (XFS) and in age-sex-matched control subjects using color Doppler imaging.

METHODS

This prospective, comparative case series included 33 unilateral XFS patients and 33 age-sex-matched control subjects. Color Doppler imaging was used to evaluate the XFS-affected (Group 1) and -unaffected (Group 2) eyes that were matched with the corresponding side (Groups 3 and 4) of control subjects. All subjects were given a complete ophthalmological examination. A masked radiologist obtained the peak systolic velocity (PSV) and end diastolic velocity (EDV) of ophthalmic (OA), central retinal (CRA), nasal posterior ciliary (NPCA) and temporal posterior ciliary arteries (TPCA) as well as mean velocity of central retinal vein (CRV). Resistivity indices (RI) were calculated.

RESULTS

Analysis of peak systolic and end diastolic velocity (PSV, EDV) and RI between Groups 1-2 and 3-4 did not show any significant difference. Comparing Groups 1-3 (corresponding eyes of pseudoexfoliation-affected and control subjects) and Groups 2-4 (corresponding eyes of pseudoexfoliation-unaffected and control subjects) revealed significantly low values for OA, PSV and EDV in both eyes of the XFS patients. The OA RI value in Group 1 was found to be significantly higher than that in Group 3 with the cut-off value of 0.72.

CONCLUSION

These findings suggest that ophthalmic artery hemodynamic parameters change in both eyes of unilateral XFS patients, illustrating out the systemic nature of the disease. We conclude that XFS decreases OA blood flow velocities and increases vascular resistance through progressive build-up.

Incidence and prevalence of pseudoexfoliations and open-angle glaucoma in northern Sweden: II. Results after 21 years of follow-up

PURPOSE

To prospectively evaluate the prevalence and incidence of pseudoexfoliation (PEX) syndrome and open-angle glaucoma (OAG) with and without PEX and to evaluate PEX as a risk factor for glaucoma in a population born in 1915 and living in the municipality of Skellefteå in northern Sweden.

METHODS

A randomized population study comprising 339 individuals. The cohort was followed for 21 years at 7 year intervals. The examination included tonometry, dilated slit-lamp biomicroscopy, optic disc evaluation and, if glaucoma was suspected, a visual field analysis.

RESULTS

The prevalence of PEX increased from 23%[95% confidence interval (CI): 20-26] at 66 years of age to 61% (CI 50-71) at 87 years. The annual incidence of PEX was 1.8% (CI 1.3-2.4). In the group of subjects with unilateral PEX, 55% converted to bilateral PEX during follow-up. The prevalence of OAG was 2.1% (CI 0.8-4.3%) at 66 years of age and 25% (CI 16-35) at 87 years. Of the glaucoma cases, 59% had PEX. There was no difference in incidence between the sexes. The annual incidence of PEX and OAG did not increase with time. The overall annual incidence of OAG was 0.9% (CI 0.6-1.3%) [0.5% (CI 0.2-0.9) without PEX and 2.1% (CI 1.2-3.3) with PEX]. PEX increased the risk of glaucoma four fold in both sexes. There was no significant difference in mortality between individuals with or without PEX.

CONCLUSION

PEX syndrome and OAG are common in the north of Sweden. Prevalences increase with age. PEX increases the risk of glaucoma four fold. The consequences of this situation demand guidelines for handling patients with PEX, with or without other risk factors. In order to issue guidelines, more information is needed on the impact of the disease on the general health in the ageing population.

Pseudoexfoliation syndrome prevalence in Greek patients with cataract and its association to glaucoma and coronary artery disease

PURPOSE

To investigate the prevalence of glaucoma and coronary artery disease (CAD) in patients with cataract and pseudoexfoliation (PEX) syndrome.

METHODS

Cross-sectional study of 2140 consecutive patients with cataract admitted at the University Hospital of Patras, Greece, for cataract surgery. Only patients with senile cataract were included in this study. All patients underwent a complete ophthalmological examination that included slit-lamp evaluation with dilated pupil for PEX material in the anterior segment, intraocular pressure (IOP) measurements, and optic disc cup examination. They also underwent an evaluation for CAD by a cardiologist. CAD was considered present if a patient had a history of myocardial infarction, or ischaemia, or abnormal coronary angiography. The patients were classified into two groups: the PEX and the non-PEX group.

RESULTS

One thousand and eighty-eight (50.8%) patients were men and 1052 (49.2%) were women. The overall prevalence of PEX syndrome was found to be 27.9% and it was found to increase with progressing age. Bilateral PEX was more frequent than unilateral PEX, with the percentage of bilateral PEX raising with progressing age. A total of 132 patients (22.1%) in the PEX group exhibited glaucoma, while in the non-PEX group only 2.5% suffered glaucoma. PEX was also found to be positively associated with the risk for CAD among subjects 50 years or older. No association between CAD and glaucoma was found.

CONCLUSIONS

PEX syndrome constitutes a major glaucoma risk factor and a CAD risk factor. Patients with PEX should be informed and examined frequently as the risk is present throughout.

Analysis of Retinal Nerve Fiber Layer Thickness in Patients with Pseudoexfoliation Syndrome Using Optical Coherence Tomography

OBJECTIVE

To evaluate the retinal nerve fiber layer (RNFL) thickness in patients with unilateral pseudoexfoliation syndrome (PXS) without glaucoma by using optical coherence tomography (OCT).

METHODS

22 patients with unilateral PXS were evaluated. Group 1 included the eyes with the pseudoexfoliation, group 2 included the fellow eyes; 18 age-matched normal control eyes were assessed in group 3. The mean and segmental RNFL thickness in eyes with pseudoexfoliation and their fellow eyes in patients with unilateral PXS was compared to age-matched control subject eyes.

RESULTS

The RNFL in patients with PXS were significantly thinner than controls in all quadrants except the nasal quadrant with regard to segmental analysis (p < 0.05). This RNFL loss was apparent at 7, 10 and 11 o'clock of the PXS eyes with regard to clock hour position (p < 0.05). In the fellow eyes, no significant difference in RNFL measurement was found except the temporal quadrant when compared with the controls. In the analysis with regard to clock hour position, no significant reduction in RNFL thickness was found except in the 11-o'clock segment. In PXS eyes, RNFL thicknesses at the inferior quadrant and the 1-, 2- and 5-o'clock segments were significantly lower than in non-PXS eyes (p < 0.05).

CONCLUSIONS

This study suggests that PXS without glaucoma may be associated with a thinner RNFL compared with those of age-matched control subjects and non-PXS fellow eyes. Further studies are needed to clarify the relationship between the decrease in RNFL thickness and the development of glaucomatous damage in eyes with pseudoexfoliation.

Cataract and glaucoma surgery in pseudoexfoliation syndrome: a review

Pseudoexfoliation syndrome is a risk factor in cataract surgery because of the increased weakness of zonular apparatus and reduced pupillary dilatation. The surgical outcome of using phacoemulsification in the central zone, inducing minimal stress on the zonules, inserting a capsular tension ring in selected cases, and stretching the pupil mechanically in eyes with miotic pupils, may turn out to be uneventful in most cases. Postoperative fibrosis with subsequent shrinkage of the capsule is increased in these eyes, and these centripetal forces will further loosen the zonular fibres. Late in-the-bag intraocular lens dislocation is therefore anticipated to become a growing problem in the future. Despite the dysfunctioning of the blood-aqueous barrier in eyes with pseudoexfoliation syndrome, the frequency of postoperative inflammatory reaction is low due to the improvements made in surgical technique and equipment in recent years. Glaucoma frequently occurs in eyes with pseudoexfoliation syndrome. Compared with primary open-angle glaucoma, optic damage is more pronounced in these eyes at the time of diagnosis and response to medical therapy is poorer. Although responses to argon laser therapy and filtering surgery are roughly similar between the two types of glaucoma, there are indications that primary laser trabeculoplasty has a higher success rate in pseudoexfoliation glaucoma than in primary open-angle glaucoma.

Ocular and systemic pseudoexfoliation syndrome

PURPOSE

To provide an update on most recent developments regarding ocular and systemic manifestations and complications, clinical diagnosis and management, and molecular pathophysiology of pseudoexfoliation (PEX) syndrome, and to discuss future tasks and challenges in this field.

DESIGN

Perspective.

METHODS

Review of recent literature and authors' own clinical and laboratory studies.

RESULTS

PEX syndrome is a common age-related generalized fibrotic matrix process of worldwide significance, which may not only cause severe chronic open-angle glaucoma and cataract, but also a spectrum of other serious spontaneous and surgical intraocular complications. Recent progress and advances have led to (1) improvements in clinical management by understanding the effects of the PEX process on ocular tissues, by refining diagnostic criteria, by applying new treatment regimes, and by developing preventive strategies to reduce surgical complications; (2) increasing evidence for systemic associations of PEX with cardiovascular and cerebrovascular morbidity; and (3) new insights into the molecular pathophysiology by analyzing the composition of PEX material, the differential gene expression of affected tissues, and key factors involved in pathogenesis. The current pathogenetic concept describes PEX syndrome as an elastic microfibrillopathy involving transforming growth factor-beta1, oxidative stress, and impaired cellular protection mechanisms as key pathogenetic factors.

CONCLUSIONS

Future tasks and challenges comprise epidemiologic prevalence and genetic studies of PEX syndrome, prospective randomized clinical and histopathological screening studies on its systemic manifestations and associations, and intensified basic research on differential protein and gene expression, animal and in vitro models, as well as potential biomarkers for PEX syndrome and its associated glaucoma.

Magnetic resonance imaging of the brain in patients with pseudoexfoliation syndrome and glaucoma

PURPOSE

To evaluate ischemic changes in brain magnetic resonance images in patients with pseudoexfoliation syndrome (PXS) and pseudoexfoliation glaucoma (PXG) and compare them with age- and sex-matched control subjects.

METHODS

This case-control study involved 16 consecutive patients with PXS, 21 patients with PXG and 18 healthy age- and sex-matched control subjects. Each subject underwent a comprehensive ophthalmological examination. In all participants, an axial T(1)-, T(2)- and proton-density-weighted and coronal cerebral 1.5-tesla magnetic resonance imaging (MRI) scan was made. White matter hyperintensities (WMH) were considered present if these were hyperintense on both proton-density- and T(2)-weighted images and not hypointense on T(1)-weighted images. White matter lesions were classified into two parts as the subcortical and periventricular regions. We used a validated rating scale of subcortical WMH: 0 = absent, 1 = punctuate foci, 2 = beginning confluence of foci and 3 = large confluent areas. Periventricular white matter lesions were classified on a scale of 0 (no white matter lesions), 1 (pencil-thin periventricular lining), 2 (thick lining) or 3 (large confluent white matter lesions).

RESULTS

The proportions of persons with WMH were 93.7% for patients with PXS, 95.2% for patients with PXG and 55.5% for control subjects. The numbers of white matter lesions in patients with PXS and PXG were significantly greater than in the control subjects (p < 0.05). White matter lesions at subcortical locations in patients with PXG were significantly more frequent than in the control subjects (80.9 vs. 33.3%; p < 0.05). The proportion of patients with subcortical WMH was 56.2% in PXS; no significant difference was found in subcortical WMH between PXS and controls. The proportions of patients with periventricular WMH were 93% in PXS, 90.4% in PXG and 44.4% in controls. White matter lesions at periventricular locations in patients with PXG and PXS were significantly more frequent than in the control subjects (p < 0.05). The difference between the pseudoexfoliation groups and controls with regard to the size of periventricular and subcortical white matter lesions was statically significant (p < 0.05). When patients with PXS were compared with PXG patients, there was no statistically significant difference in the number, size and scale of white matter lesions.

CONCLUSION

We found a significantly higher prevalence of MRI-defined WMH in patients with a clinical diagnosis of pseudoexfoliation with or without glaucoma versus control subjects. We think that the findings in this study may shed light on a possible link between ischemic brain lesions and pseudoexfoliation, which is not related with the presence of glaucomatous optic neuropathy. Further investigations are required to resolve the underlying associations.

Increase of carotid artery stiffness and decrease of baroreflex sensitivity in exfoliation syndrome and glaucoma

AIM

To investigate the distensibility of the common carotid artery (CCA), baroreflex sensitivity (BRS) and its relation to plasma homocysteine concentration in exfoliation syndrome or exfoliation glaucoma (XFS/XFG).

METHODS

Homocysteine concentrations were measured in 30 XFS/XFG patients and 18 age matched controls. In 21 patients and 17 controls the end diastolic diameter of the CCA and pulsatile distension were measured and BRS was calculated.

RESULTS

There was no significant difference between the groups in sex distribution, age, heart rate, blood pressure, systemic diseases, or medication. In XFS/XFG patients homocysteine concentration was significantly elevated (unpaired t test, p = 0.023), and CCA stiffness was higher (p<0.05), while strain, cross sectional compliance coefficient, distensibility, and BRS were significantly reduced compared to the controls (Mann-Whitney U test, p< or =0.013 for each parameter). In XFS/XFG patients a positive correlation was found between age and plasma homocysteine level (Pearson's correlation, r = 0.490, p = 0.007), and a negative correlation between age and BRS (Kendall's correlation r = -0.374, p = 0.021), as well as between homocysteine concentration and BRS (Kendall's correlation r = -0.377, p = 0.024). No correlation was seen between these variables in the control group.

CONCLUSIONS

These results suggest a pathological large artery function as well as altered parasympathetic vascular control in XFS/XFG which increases with age and with higher homocysteine concentration.

Glaucomatous damage in normotensive fellow eyes of patients with unilateral hypertensive pseudoexfoliation glaucoma: normotensive pseudoexfoliation glaucoma?

BACKGROUND

The objective of the study was to investigate the prevalence of glaucomatous damage in normotensive fellow eyes of patients with unilateral high-tension pseudoexfoliation (PX) glaucoma.

METHODS

Initial examination records of 111 patients with unilateral PX glaucoma with intraocular pressure (IOP) > or = 22 mmHg in the hypertensive eye and IOP < or = 21 mmHg in the normotensive fellow eye without any prior antiglaucomatous treatment were retrospectively studied. Visual field and optic disc examination results were evaluated for glaucomatous damage in the normotensive eyes.

RESULTS

Glaucomatous changes were detected in 45 of the 111 fellow eyes (40%). The damage was mild in 25 eyes (22%), moderate in 18 eyes (16%), and severe in 2 (2%). The factors significantly associated with glaucomatous findings in the normotensive eyes were clinical detection of PX, higher age (> or =70 years), higher maximal IOP (> or =18 mmHg) and wider IOP fluctuation (> or =6 mmHg) in the univariate analyses. In the multivariate analysis, associated factors remained as higher maximal IOP (odds ratio = 7.92, confidence interval = 2.82-22.23, P < 0.001) and wider IOP fluctuation (odds ratio = 5.67, confidence interval = 2.05-15.74, P = 0.001).

CONCLUSION

Normotensive fellow eyes of patients with unilateral high-tension PX glaucoma are under significant risk of glaucomatous damage, related with the level and the fluctuation range of IOP.

Pseudoexfoliation syndrome and asymptomatic myocardial dysfunction

BACKGROUND

The purpose of this study was to investigate the frequency of asymptomatic left ventricular dysfunction in patients with pseudoexfoliation syndrome.

METHODS

Two-dimensional and pulsed Doppler echocardiography of transmitral flow was performed on 27 patients with pseudoexfoliation syndrome, aged 66.9+/-5.6 years, and 24 healthy volunteers aged 63.9+/-6.5 years. Left ventricular (LV) systolic contraction and ejection were assessed by LV ejection fraction (EF) and fractional shortening (FS). LV diastolic filling parameters tested were: early fast diastolic filling (E wave), late diastolic filling (A wave), ratio E/A, velocity time integral E wave (VTIE) and A wave (VTIA), their ratio (VTIE/VTIA), pressure at the end of filling (LVEDP) and a pulmonary capillary wedge pressure (PCWP).

RESULTS

Systolic parameters EF and FS, diastolic filling parameters such as A, LVEDP and PCWP were not significantly different between patients with pseudoexfoliation syndrome and controls (P>0.05). A significant difference (P<0.05) was found with regard to the diastolic filling parameters: E (61.6+/-15.1 vs 83.7+/-21.4), ratio E/A (0.8+/-0.1 vs 1.1+/-0.2), VTIE (8.6+/-1.8 vs 9.8+/-1.9), VTIA (10.3+/-2.4 vs 7.8+/-1.6) and ratio VTIA/VTIE (1.2+/-0.2 vs 0.8+/-0.2).

CONCLUSION

Our study suggests the possibility of an association between patients with pseudoexfoliation syndrome and a discrete asymptomatic myocardial diastolic dysfunction.

Glaucoma and mortality

PURPOSE

To compare mortality rates in glaucoma patients and matched controls from a large population screening as well as glaucoma patients diagnosed through routine clinical examination (self-selected patients).

METHODS

A population-based screening of 32,918 elderly citizens of Malmö was conducted between 1992 and 1997. Individuals with newly detected, previously untreated open-angle glaucoma were identified. Two controls of the same age and gender were chosen among the screening negative participants for each patient. From the same birth cohorts, glaucoma patients seen in routine clinical practice (self-selected patients) were identified through retrospective examination of patient records from the Eye Department at Malmö University Hospital. The number and time of deaths for each group were determined based on centrally administered registers.

RESULTS

Mean follow-up time was 7.75 years. Five-year mortality did not differ significantly between the groups, and was 9.2% among glaucoma patients from the screening (n=402), and 11.9% among the controls (n=804; p=0.7406). Self-selected glaucoma patients had a 5-year mortality of 8.5% (n=354), not significantly different from the screening-detected glaucoma patients (p=0.1361). Among glaucoma patients, neither IOP (p=0.1781) nor pseudoexfoliation (p=0.8882) was related to significantly increased mortality.

CONCLUSIONS

The results of this study strongly suggest that the life expectancy of glaucoma patients does not differ from the population at large.

Pseudoexfoliation syndrome in eyes with ischemic central retinal vein occlusion. A histopathologic and electron microscopic study

PURPOSE

To determine histopathologically the prevalence of pseudoexfoliation (PEX) material in eyes enucleated secondary to ischemic central retinal vein occlusion (CRVO) and to evaluate eyes with PEX material in the anterior segment and CRVO ultrastructurally for PEX deposits in the vicinity of central retinal vessels. These deposits could explain an association of CRVO and PEX.

METHODS

All surgically enucleated eyes with secondary angle closure glaucoma due to rubeotic iris secondary to ischemic CRVO (1981-1998) available were re-analyzed light microscopically for the presence of PEX in the anterior segment (n=120; 76.9+/-8.5 years [range: 51-91]). Eyes with PEX in the anterior segment and available optic nerve cross sections were examined by electron microscopy for PEX material in the retrolaminar (n=7) and intralaminar central retinal vessels (n=3). All eyes surgically enucleated because of malignant melanoma of the choroid aged 70 years and older (1981-1998) with sections available served as age-matched controls (n=107; 76.4+/-5 years [range: 70-91]).

RESULTS

PEX material was present light microscopically in the anterior segment in 12 of 120 eyes with CRVO (10%) compared to 2 of 107 age-matched eyes with choroidal malignant melanoma (1.9%; p<0.05). Electron microscopically, neither structural alterations of the vessel wall nor PEX deposits were found in association with central retinal vessels both in the intra- and retrolaminar areas in any of the 7 eyes with PEX in the anterior segment and CRVO analyzed.

CONCLUSIONS

Histopathologically, PEX is significantly more common in eyes enucleated secondary to CRVO compared to eyes enucleated because of an intraocular tumor. This most likely is due to the secondary open angle glaucoma in eyes with PEX as a known risk factor for CRVO. According to the small number of optic nerves analyzed here, there seems to be no morphologically evident PEX vasculopathy in the central retinal vessels both within and immediately behind the lamina cribrosa in eyes with PEX in the anterior segment and CRVO potentially causing retinal venous thrombosis.

Ocular hemodynamics in pseudoexfoliation syndrome and pseudoexfoliation glaucoma

OBJECTIVE

To evaluate orbital blood flow velocities by using color Doppler imaging in patients with pseudoexfoliation syndrome and pseudoexfoliation glaucoma.

DESIGN

Prospective, comparative case series.

PARTICIPANTS

Twenty-eight patients with pseudoexfoliation syndrome (n = 14) or pseudoexfoliation glaucoma (n = 14) and 14 healthy control participants were included.

INTERVENTION

Color Doppler imaging was used with a 7.5-MHz probe. Evaluation of the ophthalmic, central retinal, short posterior nasal, and temporal ciliary arteries was performed, and peak systolic and end diastolic flow velocities were measured. Resistive indices were calculated.

RESULTS

When compared with the control participants, patients with pseudoexfoliation syndrome showed statistically significant decreases in the mean peak systolic velocity of the central retinal artery (11.21 +/- 2.19 cm/second; P < 0.05), and end diastolic velocities of the central retinal artery (3.00 +/- 1.03 cm/second; P < 0.005), and short posterior temporal ciliary arteries (3.50 +/- 1.74 cm/second; P < 0.005), whereas mean resistive indices of the ophthalmic artery (0.75 +/- 0.06 cm/second; P < 0.005) and central retinal artery were found to have increased (0.70 +/- 0.05 cm/second; P < 0.01). Patients with pseudoexfoliation glaucoma, when compared with the control participants, showed statistically significant decreases in the mean peak systolic and end diastolic velocities and increased mean resistive indices in all vessels measured (P < 0.05). Compared with the patients with pseudoexfoliation syndrome, patients with pseudoexfoliation glaucoma showed statistically significant decreases in the mean peak systolic velocities of the ophthalmic artery (30.07 +/- 4.00 cm/second; P < 0.05) and short posterior nasal ciliary arteries (2.35 +/- 0.09 cm/second; P < 0.05), and in the mean end diastolic velocities of the ophthalmic artery (6.28 +/- 2.12 cm/second; P < 0.05), and short posterior nasal ciliary arteries (2.35 +/- 0.09 cm/second; P < 0.05). The differences in the mean resistive indices were not statistically significant between the patients with pseudoexfoliation syndrome and the ones with pseudoexfoliation glaucoma.

CONCLUSIONS

The findings suggest that hemodynamic parameters in the retrobulbar vessels were altered in patients with pseudoexfoliation syndrome and pseudoexfoliation glaucoma; however, these alterations were more prominent in the latter group.

Exfoliation syndrome

Exfoliation syndrome (XFS) is an age-related disease in which abnormal fibrillar extracellular material is produced and accumulates in many ocular tissues. Its ocular manifestations involve all of the structures of the anterior segment, as well as conjunctiva and orbital structures. Glaucoma occurs more commonly in eyes with XFS than in those without it; in fact, XFS has recently been recognized as the most common identifiable cause of glaucoma. Patients with XFS are also predisposed to develop angle-closure glaucoma, and glaucoma in XFS has a more serious clinical course and worse prognosis than primary open-angle glaucoma. There is increasing evidence for an etiological association of XFS with cataract formation, and possibly with retinal vein occlusion. XFS is now suspected to be a systemic disorder and has been associated preliminarily with transient ischemic attacks, stroke, systemic hypertension, and myocardial infarction. Further ramifications await discovery. Deposits of white material on the anterior lens surface are the most consistent and important diagnostic feature of XFS. The classic pattern consists of three distinct zones that become visible when the pupil is fully dilated. Whereas the classic picture of manifest XFS has been often described, the early stages of beginning exfoliation have not been well defined. Next to the lens, exfoliation material is most prominent at the pupillary border. Pigment loss from the iris sphincter region and its deposition on anterior chamber structures is a hallmark of XFS. Despite extensive research, the exact chemical composition of exfoliation material (XFM) remains unknown. An overproduction and abnormal metabolism of glycosaminoglycans have been suggested as one of the key changes in XFS. The protein components of XFM include both noncollagenous basement membrane components and epitopes of the elastic fiber system such as fibrillium. Regardless of etiology, typical exfoliation fibers have been demonstrated electron microscopically in close association with the pre-equatorial lens epithelium, the nonpigmented ciliary epithelium, the iris pigment epithelium, the corneal endothelium, the trabecular endothelium, and with almost all cell types of the iris stroma, such as fibrocytes, melanocytes, vascular endothelial cells, pericytes, and smooth muscle cells. The presence of XFS should alert the physician to the increased risks of intraocular surgery, most commonly zonular dehiscence, capsular rupture, and vitreous loss during cataract extraction. Heightened awareness of this condition and its associated clinical signs are important in the detection and management of glaucoma, and preoperative determination of those patients at increased risk for surgical complications.