Color Doppler imaging of the ophthalmic artery blood flow spectra of patients who have had a transient ischemic attack. Correlations with generalized iris transluminance and pseudoexfoliation syndrome

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Correlation between retinal oxygen saturation and the haemodynamic parameters of the ophthalmic artery in healthy subjects

PURPOSE

The aim of the study was to obtain the values of oxygen saturation in retinal vessels and ophthalmic blood flow parameters in a healthy Caucasian population and assess whether the oximetry parameters are affected by the flow rate or the vascular resistance.

METHODS

The spectrophotometric retinal oximetry and colour Doppler imaging (CDI) of retinal vessels were successfully performed with 52 healthy subjects (average age 29.7 ± 5.6 years). The retinal oximeter simultaneously measures the wavelength difference of haemoglobin oxygen saturation in retinal arterioles and venules. The arteriolar and venular saturation in both eyes was measured. The peak systolic (PSV) end diastolic (EDV) velocities, resistive (RI) and pulsatility (PI) indices were obtained for both eyes using CDI in the ophthalmic artery. A paired t-test and two sample t-tests were used for statistical analyses. The correlation was assessed using the Pearson coefficient correlation.

RESULTS

The mean oxygen saturation level was 96.9 ± 3.0% for the retinal arterioles and 65.0 ± 5.1% for the retinal venules. The A-V difference was 31.8 ± 4.6%. The mean of the measured haemodynamic parameters was PSV 46.6 ± 9.4 cm/s, EDV 12.0 ± 3.5 cm/s, PI 1.68 ± 0.38 and RI 0.74 ± 0.05. No significant difference in oxygen saturation and haemodynamic parameters was found between the left and the right eyes or the dominant and non-dominant eye. The oximetry and ultrasound values were sex independent. The Pearson correlation coefficient demonstrated a significant yet weak negative correlation between A-V difference and RI (r = -0.321, p = 0.020).

CONCLUSIONS

A negative correlation between A-V difference and resistance index was observed, suggesting that reduced oxygen consumption may reflect the increased vascular tone of the ophthalmic vessels, which is likely determined by autoregulatory mechanisms.

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

OBJECTIVE

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

DATA SOURCES

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

REVIEW METHODS

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

RESULTS

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

CONCLUSIONS

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

Pseudoexfoliation syndrome: Are the eyes the mirror of the heart?

INTRODUCTION

Pseudoexfoliation syndrome (PEX) is a disease characterized by the accumulation of fibrillary material in the extracellular matrix in the eye and many tissues. Myocardial involvement occurs as in other storage diseases. Speckle tracking echocardiography is a quantitative echocardiography modality that enables the detection of subclinical changes that cannot be detected by standard echocardiographic evaluation. In this study, we aimed to evaluate potential subclinical myocardial dysfunction in PEX patients by speckle tracking echocardiography.

METHODS AND RESULTS

The study group consisting of 29 cardiac asymptomatic pseudoexfoliation syndromes and 30 healthy volunteers were included in this case-control cross-sectional study. Detailed echocardiographic evaluations and strain analyses of all participants were performed. Concerning standard echocardiographic parameters, there was only a marginally significant difference between the two groups in the e' mean wave, and it was lower in the PEX group than the control group (0.07 ± 0.03, 0.10 ± 0.08, respectively, P = .06). However, in strain echocardiography, the global longitudinal strain (GLS) value was observed to be significantly lower in the PEX group than the control group (-17.02 ± 2.02, -19.29 ± 2.26, respectively P < .001). GLS was observed to be an independent predictor in the multivariable logistic regression model made to determine independent predictors of PEX syndrome (OR = 0.59, CI = 0.418-0.832, P = .003).

CONCLUSION

Subclinical myocardial involvement in PEX syndrome, in which standard echocardiographic techniques are blinded, can be detected by the strain echocardiography. PEX causes deterioration in the deformation parameters of the left ventricle. Systemic involvement should not be forgotten in patients with PEX and cardiac functions should be monitored.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Comparison of the retinal nerve fiber layer and ganglion cell complex thickness in Korean patients with unilateral exfoliation syndrome and healthy subjects

Purpose

To compare retinal nerve fiber layer (RNFL) and ganglion cell complex (GCC) thickness in patients with unilateral exfoliation syndrome (XFS) and age-matched controls using spectral domain-optical coherence tomography (SD-OCT).

Materials and methods

This prospective case–control study included 54 eyes (the XFS-affected and the fellow eyes) of 27 unilateral XFS patients and 27 eyes of 27 age-matched control subjects. The RNFL and GCC thicknesses were measured using SD-OCT (RT-Vue 100, Optovue, Fremont, CA) after pupillary dilation. RNFL and GCC thicknesses were compared between case and control groups.

Results

The mean age of XFS patients was 73.3 years and that of age-matched controls was 74.3 years. Both groups demonstrated a male preponderance. Superior RNFL thickness of XFS-affected eyes were significantly thinner than those of the healthy age-matched controls (P = 0.002 by ANOVA). There were no statistically significant differences in the RNFL thickness between both eyes of unilateral XFS patients. Moreover, superior GCC thickness of both eyes in unilateral XFS patients were thinner than those in controls (P = 0.002 by ANOVA).

Conclusions

Thinner RNFL and GCC thicknesses were observed in unilateral XFS patients without visual field defects. These findings imply that XFS itself might be a risk factor for development of glaucomatous optic disc and RNFL damage.

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.

Retrobulbar hemodynamics and aqueous humor levels of endothelin-1 in exfoliation syndrome and exfoliation glaucoma

Background

Endothelin-1 (ET-1) is the most potent vasoconstrictor in the body. There are reports in the literature correlating plasma levels of ET-1 and its impact on retrobulbar hemodynamics. This study evaluates aqueous humor levels of ET-1 and retrobulbar hemodynamics in patients with exfoliation syndrome (XFS) and exfoliation glaucoma (XFG).

Patients and methods

Patients scheduled for cataract surgery were included. Patients were allocated to non-exfoliation non-glaucoma group (controls), XFG and XFS groups. Peak systolic velocity (PSV), end diastolic velocity, and resistivity index of the ophthalmic artery (OA), short posterior ciliary arteries, and central retinal artery (CRA) were determined preoperatively using color Doppler imaging. Aqueous humor samples obtained at the beginning of cataract surgery were analyzed with enzyme-linked immunosorbent assay.

Results

Sixty-nine participants of similar age were included (controls: n=24, XFG: n=22, XFS: n=23). Multiple regression analysis showed that ET-1, OA-PSV, OA-resistivity index, CRA-PSV, and CRA-end diastolic velocity were influenced by group but not by sex or age. ET-1 for the XFG group (15.93±2.8 pg/mL) was significantly higher than for the XFS (8.92±2.7 pg/mL) and control (8.44±2.6 pg/mL) groups. The difference in ET-1 titers between the control and XFS groups was not statistically significant. All four hemodynamic parameters affected by group status significantly correlated with ET-1 levels in eyes with XFS. In eyes with XFG, two of the four hemodynamic parameters significantly correlated with ET-1 levels. In control eyes, no correlation between ET-1 and hemodynamic parameters affected by group status was detected.

Conclusion

ET-1 aqueous levels in eyes with XFG were significantly higher than those of age-matched controls. Reduced blood flow and increased vascular resistivity were detected in the OA and the CRA in eyes with XFG/XFS. ET-1 levels in eyes with XFG/XFS exhibit a significant correlation with hemodynamic parameters that indicate reduced perfusion.

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.

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.

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.

Major review: Exfoliation syndrome; advances in disease genetics, molecular biology, and epidemiology

Exfoliation syndrome (XFS) is a common age-related disorder that leads to deposition of extracellular fibrillar material throughout the body. The most recognized disease manifestation is exfoliation glaucoma (XFG), which is a common cause of blindness worldwide. Recent developments in XFS genetics, cell biology and epidemiology have greatly improved our understanding of the etiology of this complex inherited disease. This review summarizes current knowledge of XFS pathogenesis, identifies gaps in knowledge, and discusses areas for future research.

Evaluation of the Macular Choroidal Thickness Using Spectral Optical Coherence Tomography in Pseudoexfoliation Glaucoma

PURPOSE

To evaluate the choroidal thickness (CT) in pseudoexfoliative (PEX) glaucoma and age-matched healthy subjects using spectral optical coherence tomography (SD-OCT).

PATIENTS AND METHODS

In this prospective study, 32 eyes of 32 PEX glaucoma patients and 30 eyes of 30 age-matched healthy subjects were enrolled. The CT is measured perpendicularly (from the outer edge of the hyperreflective retinal pigment epithelium to the inner sclera) at the fovea, and 1.5 mm temporal, 3.0 mm temporal, 1.5 mm nasal, and 3.0 mm nasal to the fovea using SD-OCT (RTVue-100).

RESULTS

The groups were similar regarding the mean age and axial length values (both, P>0.05). The CT measurements were 182.12 ± 39.88 and 201.56 ± 32.00 μm at 1.5 mm nasal to the fovea (P=0.039), and 126.47 ± 32.12 and 146.60 ± 31.37 μm at 3.0 mm nasal to the fovea (P=0.015) in the PEX glaucoma and control groups, respectively. There were no significant differences in the subfoveal and temporal CT measurements among the 2 groups (all, P>0.05).

CONCLUSIONS

The findings of this study indicate that PEX glaucoma causes significant thinning in the nasal choroid. Thus, measuring the CT with SD-OCT may be the way of better clarification of the relationship between PEX and glaucomatous optic neuropathy.

Evaluation of Retinal Nerve Fiber Layer and Ganglion Cell Complex Thickness in Unilateral Exfoliation Syndrome Using Optical Coherence Tomography

PURPOSE

To evaluate retinal nerve fiber layer (RNFL) and ganglion cell complex (GCC) thickness by using optical coherence tomography in unilateral exfoliation syndrome (XFS) and to assess whether exfoliation itself is an independent risk factor for glaucomatous optic nerve damage.

MATERIALS AND METHODS

Thirty exfoliative eyes of unilateral XFS cases, 30 fellow eyes of unilateral exfoliation, and 30 eyes of healthy subjects were enrolled the study. Peripapillary RNFL and macular GCC thickness measurements by Cirrus HD OCT (Carl Zeiss Meditec, Dublin, CA) were performed on all subjects.

RESULTS

RNFL thickness in superior quadrant was significantly different between groups (P=0.025) and it was thinner in XFS than healthy subjects (P=0.020). All GCC parameters except GCC thickness in inferior quadrant were significantly different between groups (P=0.110 for inferior quadrant, P<0.046 for other GCC parameters). GCC were thinner in XFS than healthy subjects except inferior and inferonasal quadrants (P=0.091, 0.051 for inferior and inferonasal quadrants, respectively, P<0.039 for other GCC parameters). Minimum GCC thickness, GCC thicknesses in superior, and inferonasal quadrants were significantly thinner in fellow eyes than healthy subjects (P=0.011, 0.013, 0.047, respectively).

CONCLUSIONS

XFS is related with thinner RNFL and GCC even in normal intraocular pressure values, similar optic disc parameters and visual field results. XFS may be an independent risk factor for glaucomatous optic nerve damage. So, further studies are needed to evaluate whether exfoliation itself is an independent risk factor for optic nerve damage.

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.

Ocular and systemic manifestations of exfoliation syndrome

Exfoliation syndrome is an age-related disease characterized by the production and progressive accumulation of a fibrillar extracellular material in many ocular tissues. It leads to the most common identifiable cause of open-angle glaucoma worldwide, comprising the majority of glaucoma in some countries. The material in the eye appears as white deposits on the anterior lens surface and/or pupillary border. During pupillary movement, the iris scrapes exfoliation material from the lens surface, while the material on the lens causes rupture of iris pigment epithelial cells, with concomitant pigment dispersion into the anterior chamber and its deposition on anterior chamber structures. Exfoliation material can be found in many different organs. It is an ischemic disease and is associated with elevated serum homocysteine. Systemic associations include transient ischemic attacks, hypertension, angina, myocardial infarction, cerebrovascular and cardiovascular disease, aortic aneurysm, Alzheimer disease, and hearing loss. The discovery in 2007 of nonsynonymous single nucleotide polymorphisms in the LOXL1 (lysyl oxidase-like 1) gene are expected to make a major impact not only in understanding exfoliation syndrome, but in leading to new avenues of therapy.

Is Pseudoexfoliation Syndrome a Risk Factor for Cerebro Vascular Disease?

PURPOSE

To determine the relationship between cerebro vascular disease and pseudoexfoliation syndrome.

MATERIALS AND METHODS

This cross-sectional case control study consisted of 50 patients with ischemic-type cerebro vascular disease and 50 control subjects. All subjects were investigated for diabetes mellitus and hypertension status and underwent a detailed ophthalmic examination. A diagnosis of pseudoexfoliation syndrome was made if characteristic greyish particulate matter was found on the anterior lens capsule after pupillary dilatation by slit-lamp examination. All subjects were compared in terms of pseudoexfoliation syndrome, diabetes mellitus, and hypertension. Pearson Chi Square and Student's t test were used for statistical analysis. Logistic regression analyses of the risk factors between groups were also made.

RESULTS

The presence of pseudoexfoliation syndrome was significantly higher in patients with cerebro vascular disease when compared to the control subjects (p = 0.02). The frequency of diabetes mellitus was similar between the two groups. Arterial hypertension was significantly more frequent in the patient group when compared to the control subjects (p < 0.01). The logistic regression analysis showed that both pseudoexfoliation syndrome and hypertension were significantly associated with cerebro vascular disease.

CONCLUSION

In the present study, we found that pseudoexfoliation syndrome frequency was found to be higher in patients with cerebro vascular disease than in control subjects. A slit-lamp examination of the eye could be an important marker that indicates the risk of cerebro vascular disease. We recommend an evaluation of all subjects with pseudoexfoliation syndrome for the presence of cerebro vascular disease. Longitudinal studies with larger populations are needed to confirm this relationship.

Measurement of Subfoveal Choroidal Thickness in Pseudoexfoliation Syndrome Using Enhanced Depth Imaging Optical Coherence Tomography

BACKGROUND/AIM

Pseudoexfoliation (PSX) syndrome is associated with blood flow disturbances; however, its exact effect on choroidal blood flow and thickness remains to be elucidated. This study compared subfoveal choroidal thickness in normal eyes and in eyes with PSX using enhanced depth imaging optical coherence tomography (EDI-OCT).

METHODS

This prospective, cross-sectional study included 35 eyes of 35 patients (20 males, 15 females) with unilateral or bilateral PSX and 26 eyes of 26 healthy volunteers (13 males, 13 females). Besides a comprehensive ocular and physical examination, all subjects underwent EDI-OCT examination using an Optovue RTVue OCT device (Optovue Inc., Fremont, Calif., USA).

RESULTS

The mean choroidal thickness (CT) and ocular perfusion pressure (OPP) were lower in the PSX group than in the healthy controls (249.4 ± 46.3 vs. 282.5 ± 55.8 µm, p = 0.014 and 40.7 ± 5.8 vs. 44.3 ± 4.3 mm Hg, p = 0.007, respectively). In addition, both systolic blood pressure and diastolic blood pressure measurements were lower among the PSX patients. However, no correlation was found between CT and OPP.

CONCLUSION

The findings of this study suggest that PSX is associated with an overall thinning of the subfoveal choroid and a significant decrease in OPP. Future studies are warranted to further examine these relations.

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.

[PEX syndrome. Clinical diagnosis and systemic manifestations]

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

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.

Use of colour Doppler imaging in ocular blood flow research

The main objective of this report is to encourage consistent quality of testing and reporting within and between centres that use colour Doppler imaging (CDI) for assessment of retrobulbar blood flow. The intention of this review is to standardize methods in CDI assessment that are used widely, but not to exclude other approaches or additional tests that individual laboratories may choose or continue to use.

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.

Directed therapy for exfoliation syndrome

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

Directed therapy for exfoliation syndrome

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

A comparison of the long-term effects of dorzolamide 2% and brinzolamide 1%, each added to timolol 0.5%, on retrobulbar hemodynamics and intraocular pressure in open-angle glaucoma patients

PURPOSE

To compare the effect on the retrobulbar hemodynamics and intraocular pressure (IOP) of dorzolamide 2% and brinzolamide 1%, each added to timolol 0.5% in patients with primary open-angle glaucoma (POAG).

METHODS

146 POAG patients were prospectively randomized to receive either dorzolamide 2% or brinzolamide 1% BID, each added to timolol 0.5%, during a 60-month evaluator-masked study. At baseline and every 6 months for 60 months, we measured the retrobulbar hemodynamic parameters in the ophthalmic artery (OA), central retinal artery (CRA), and short posterior ciliary arteries (SPCA) using color Doppler imaging (CDI), intraocular pressure (IOP), and blood pressure measurements.

RESULTS

Dorzolamide significantly increased the end-diastolic velocity (EDV) in the OA in 1.22 cm/s, 95% confidence interval (95% CI) 0.90-1.56 cm/s, P < 0.001 and reduced the resistivity index (RI) in the OA in 0.04 units, 95% CI 0.03-0.05, P < 0.001. None of the retrobulbar parameters changed significantly on therapy with brinzolamide when the results were analyzed at month 60. Both dorzolamide and brinzolamide significantly decreased IOP (-4.3, 95% CI -4.5 to -4.2 mmHg and -4.3, 95% CI -4.4 to -4.2 mmHg, respectively). Dorzolamide significantly reduced the RI in the OA from 0.74 (0.02) to 0.70 (0.02), CRA from 0.66 (0.02) to 0.62 (0.02), and SPCA from 0.66 (0.02) to 0.62 (0.02), P < 0.001, respectively.

CONCLUSIONS

Our results suggest augmented retrobulbar blood flow after 5 years of treatment with dorzolamide but not with brinzolamide, each added to timolol, in POAG patients.

Frequency of systemic vascular diseases in patients with primary open-angle glaucoma and exfoliation glaucoma

PURPOSE

Abnormal fibrils can be identified by electron microscopy in the heart, lung, liver, kidney, cerebral meninges and other tissues of patients with exfoliation syndrome (ES). However, a clinical association of ES with arterial hypertension (HT), ischaemic heart disease (IHD), cerebrovascular accidents and aneurysm of the abdominal aorta is debated. We conducted a national registry-based survey to further assess the first two of these associations.

METHODS

We reviewed the records of 519 consecutive patients to whom the Social Insurance Institution of Finland had granted free medication for glaucoma according to national common criteria. The glaucoma was classified either as primary open-angle glaucoma (POAG) or exfoliation glaucoma (EG), masked to any systemic diseases; 20 patients with other types of glaucoma were excluded from the survey. Masked to the type of glaucoma, the registry provided data on free medication similarly granted for HT, IHD and diabetes mellitus (DM), a known modifier of risk for cardiovascular disease. Data were analysed by logistic regression, modelling age, gender and DM as confounders.

RESULTS

The control group of 344 patients with POAG was comparable as regards gender with the study group of 155 patients with EG, but patients with POAG were both younger (mean 69 versus 73 years; P < 0.0001) and had DM twice as often (10% versus 5%; P = 0.05) compared to those with EG. Adjusting for age, gender and presence of DM, no difference in frequency of HT [odds ratio (OR) 0.80 for presence of EG; 95% confidence interval (CI) 0.52-1.23, P = 0.31] or IHD (OR 0.86 for presence of EG; 95% CI 0.49-1.13, P = 0.66) was detected between the two groups.

CONCLUSION

In this population-based registry survey, no difference in frequency of HT or IHD was noted between patients with POAG and EG who had been granted free medication for these chronic diseases according to national common criteria. The frequency of DM was lower among patients with EG, in line with several previous reports.

Evaluation of the acoustic function in pseudoexfoliation syndrome and exfoliation glaucoma: audiometric and tympanometric findings

PURPOSE

Previous studies have reported increased audiometric thresholds in patients with pseudoexfoliation syndrome (XFS), compared with normative data. This study examines mean audiometric thresholds and tympanometric peak values in patients with XFS and in a control group.

METHODS

This is a prospective, nonrandomized control case study. Patients with XFS in one or both eyes constituted the study group (SG). Patients without XFS in either eye constituted the control group (CG). Patients with a history of conditions affecting hearing function were excluded. The SG and the CG included 54 and 48 patients, respectively. Pure tone hearing thresholds levels were measured at 0.25, 1, 2, 3, and 8 kHz. Tympanometric peak values were also recorded. Differences in audiometric mean threshold values and tympanometric peak values between SG and CG, as well as between glaucomatous and nonglaucomatous eyes, were examined.

RESULTS

Bone and air audiometric thresholds were significantly increased in SG for 3 kHz and 8 kHz but not for 0.25 kHz, 1 kHz, and 2 kHz. Tympanometric peak values were significantly lower in SG compared with CG. In SG, glaucomatous patients had significantly higher air-conduction thresholds for 3 kHz and 8 kHz. Differences in bone and air audiometric findings as well as tympanometric findings between glaucomatous and nonglaucomatous patients were statistically not significant in CG.

CONCLUSIONS

The results agree with previous reports on sensorineural hearing loss in XFS. The reduced tympanometric peak values in SG imply impairment in the elastic properties of the middle ear in XFS. The findings provide additional evidence for the systemic nature of XFS.

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.

The management of exfoliative glaucoma

Exfoliation syndrome (XFS) is an age-related, generalized disorder of the extracellular matrix characterized by the production and progressive accumulation of a fibrillar extracellular material in many ocular tissues and is the most common identifiable cause of open-angle glaucoma worldwide. XFS plays an etiologic role in open-angle glaucoma, angle-closure glaucoma, cataract, and retinal vein occlusion. It is accompanied by an increase in serious complications at the time of cataract extraction, such as zonular dialysis, capsular rupture, and vitreous loss. It is associated systemically with an increasing number of vascular disorders, hearing loss, and Alzheimer's disease. XFS appears to be a disease of elastic tissue microfibrils. The characteristic fibrils, composed of microfibrillar subunits surrounded by an amorphous matrix comprising various glycoconjugates, contain predominantly epitopes of elastic fibers, such as elastin, tropoelastin, amyloid P, vitronectin, and components of elastic microfibrils, such as fibrillin-1, fibulin-2, vitronectin, microfibril-associated glycoprotein (MAGP-1), and latent TGF-beta binding proteins (LTBP-1 and LTBP-2), the proteoglycans syndecan and versican, the extracellular chaperone clusterin, the cross-linking enzyme lysyl oxidase, and other proteins. A recent milestone study showed that two common single nucleotide polymorphisms in the coding region of the lysyl oxidase-like 1 (LOXL1) gene located on chromosome 15 were specifically associated with XFS and XFG. LOXL1 is a member of the lysyl oxidase family of enzymes, which are essential for the formation, stabilization, maintenance, and remodeling of elastic fibers and prevent age-related loss of elasticity of tissues. LOXL1 protein is a major component of exfoliation deposits and appears to play a role in its accumulation and in concomitant elastotic processes in intra- and extraocular tissues of XFS patients. This discovery should open the way to new approaches and directions of therapy for this protein disorder.

Ocular perfusion pressure and retrobulbar haemodynamics in pseudoexfoliative glaucoma

BACKGROUND

Previous investigations have shown that vascular factors are involved in pseudoexfoliative glaucoma (XFG). The present study aims at comparing ocular perfusion pressure (OPP), diastolic ocular perfusion pressure (dOPP), and retrobulbar haemodynamics in pseudoexfoliative glaucoma and primary open-angle glaucoma (POAG).

METHODS

Forty-seven XFGs, 41 POAGs, and 38 healthy controls were evaluated. OPP and dOPP were calculated. Peak systolic velocity (PSV), end-diastolic velocity (EDV), and resistivity index (RI) were recorded in ophthalmic artery (OA), central retinal artery (CRA), and short posterior ciliary arteries (SPCAs) by color Doppler imaging (CDI). Correlations between OPP and CDI parameters and between dOPP and CDI parameters were determined.

RESULTS

OPP and dOPP were significantly lower in XFGs than in POAGs and controls (p < 0.001). CDI investigation revealed decreased EDV of OA, SPCAs, and CRA (p < 0.001) and increased RI of all the three considered vessels in XFGs compared with POAGs and controls (p < 0.001). A negative correlation between OPP and RI of OA and between dOPP and RI of OA was found in XFGs (p = 0.022 and p = 0.015 respectively).

CONCLUSIONS

Ocular perfusion pressure is decreased and retrobulbar haemodynamics are worse in pseudoexfoliative glaucoma patients than in primary open-angle glaucoma patients and healthy controls. An impaired ocular vascular regulation is suggested in pseudoexfoliative glaucoma.

Ocular haemodynamics in pseudoexfoliative and primary open-angle glaucoma

OBJECTIVE

To compare the retrobulbar haemodynamic parameters in the ophthalmic artery (OA) and short posterior ciliary arteries (SPCA) in pseudoexfoliative and primary open-angle glaucoma patients.

SUBJECTS AND METHODS

Fourty-three eyes from 43 patients with pseudoexfoliative glaucoma (PXE) and 31 eyes from 31 patients with primary open-angle glaucoma (POAG) who met the inclusion/exclusion criteria were included in this prospective cross-sectional study. Colour Doppler imaging measurements, peak systolic velocity (PSV), and end-diastolic velocity (EDV) were assessed in the OA and posterior ciliary arteries (PCA). Pourcelot resistivity indices (RI) were calculated. Visual function was assessed using the 24-2 Swedish Interactive Threshold Algorithm (SITA). The main outcomes of the study were PSV, EDV, and RI in the OA and SPCA.

RESULTS

In POAG patients, PSV and EDV were significantly lower in the OA, P=0.003 and P<0.001 respectively, and in the PCA, P=0.003 and P<0.001 respectively, when compared with the PXE group. The RI was significantly higher, P<0.001, in both vessels, in the POAG group.

CONCLUSION

The results of this study have found reduced PSV and EDV and increased RI in the retrobulbar vessels of POAG patients when compared with PXE patients.

Hemodynamic evaluation of the posterior ciliary circulation in exfoliation syndrome and exfoliation glaucoma

BACKGROUND

Previous studies have reported impaired blood flow in the ophthalmic artery (OA) and central retinal artery (CRA) in exfoliation syndrome and exfoliation glaucoma. This study evaluates blood flow at the long and short posterior ciliary arteries (LPCA and SPCA, respectively) in these conditions.

METHODS

Consecutively examined candidates for cataract surgery were included. Only one eye (OD) was included in the analyses for consistency. Patients were classified into non-glaucoma and non-exfoliation (controls), primary open angle glaucoma (POAG), exfoliation syndrome and exfoliation glaucoma groups, based on the findings of the OD. Sixty-eight patients (41 males, 60.3%) were included. Color Doppler imaging (CDI) of the nasal and temporal branches of LPCA and SPCA was performed using a 7.5 Mhz probe. The peak systolic velocity (PSV), end diastolic velocity (EDV) and resistivity index (RI) were recorded for the examined vessels.

RESULTS

EDV at the LPCA was significantly lower in exfoliation syndrome and glaucoma, compared with controls and POAG respectively. EDV was significantly lower and RI was significantly higher at the SPCA in exfoliation glaucoma, compared with exfoliation, whereas respective differences were statistically not significant between controls and POAG.

CONCLUSIONS

The hemodynamic impairment at the LPCA in exfoliation syndrome and glaucoma supports an association between exfoliation and ischemic stress at the anterior ocular segment.

Depression and anxiety in patients with pseudoexfoliative glaucoma

OBJECTIVE

This study aimed to determine whether patients with pseudoexfoliative glaucoma (PXG), associated with vascular disorders, have more depressive and anxiety symptoms than patients with primary open-angle glaucoma (POAG) and controls without glaucoma. The vascular depression model was tested in this study.

METHOD

The sample consisted of 41 PXG patients, 32 POAG patients and 40 controls. Each subject was diagnosed as having PXG or POAG or chosen as a control patient by an ophthalmologist and then evaluated by a psychiatrist. The Structured Clinical Interview for DSM-IV, Turkish version; Hamilton Depression Rating Scale (HDRS); Hamilton Anxiety Rating Scale (HARS); Mini Mental State Examination; and Montgomery-Asberg Depression Rating Scale (MADRS) were administered to all subjects.

RESULTS

The HDRS and MADRS scores of the PXG patients were significantly higher than those of the POAG and the control group (chi(2)=9.858, p=.007 and chi(2)=11.618, p=.003, respectively). The HARS scores did not show a significant difference between the patients with PXG or POAG and the control subjects (chi(2)=1.615, p=.446). In each of the three groups, there was no correlation between the HDRS, HARS or MADRS scores and any of the following parameters: duration of glaucoma, medical treatment, visual acuity, intraocular pressure, perimetric stage, cup-disc ratio and number of glaucoma operations (p>.05).

CONCLUSION

A relationship between PXG and severity of depressive symptoms was shown by our data. However, no significant difference could be found between the anxiety levels of the three groups.

Cerebral haemodynamics in patients with pseudoexfoliation glaucoma

PURPOSE

To evaluate the cerebral haemodynamics in patients with pseudoexfoliation glaucoma.

METHODS

A total of 19 consecutive patients with pseudoexfoliation glaucoma and 19 age- and sex-matched healthy volunteers were recruited in a prospective comparative study. The affected eye in patients with unilateral glaucoma and the eye with more advanced lesions in patients with bilateral glaucoma were included in the study, and the ipsilateral middle cerebral arteries (MCA) were evaluated. While in the controls, the study eye and the ipsilateral MCA were chosen randomly. Measurements included systemic arterial pressure, heart rate, intraocular pressure (IOP), and transcranial colour Doppler parameters, including peak systolic velocity (PSV), end-diastolic velocity (EDV), time-averaged maximum velocity (TAMAX), resistivity index (RI), and pulsatility index (PI).

RESULTS

The mean PSV, EDV, and TAMAX were significantly lower in the patients with pseudoexfoliation glaucoma than in healthy controls (P<0.001, <0.001 and <0.001, respectively). Additionally, patients with pseudoexfoliation glaucoma had significantly higher PI and RI than healthy controls (P=0.001 and 0.04, respectively). Systolic and diastolic blood pressures (P=0.19 and 0.91, respectively) and heart rate (P=0.06) were not different between the groups. The mean IOP were significantly higher in the glaucoma patients compared with the controls (P<0.001).

CONCLUSION

This study suggests that pseudoexfoliation glaucoma is associated with a reduction in the blood flow velocity and elevation in the resistance of the MCA.

A possible link between the pseudoexfoliation syndrome and coronary artery disease

PURPOSE

This is a collaborative case-control study from Ophthalmology and Cardiology departments of a tertiary care hospital, designed to explore the relationship between coronary artery disease (CAD) and pseudoexfoliation syndrome (PEX).

METHOD

In all, 50 patients with CAD proven by coronary angiography, and 50 controls with normal coronary angiographic findings were compared in terms of PEX, other vascular diseases, and retinal vascular findings. chi2-test and Student's t-test were used for statistical analysis.

RESULTS

The number of patients with PEX among CAD (+) patients was substantially larger than controls. In all, 28 of 50 CAD (+) patients and only 12 of 50 CAD (-) patients had PEX. PEX was significantly associated with CAD (P=0.001). When all patients were regrouped according to the presence of PEX, patients with PEX did not differ from patients without PEX in terms of age (P=0.360) and sex (P=0.507), but the prevalence of CAD was higher (P=0.001) and fundoscopic findings of vascular diseases were significantly more prominent (P=0.0001) in PEX (+) patients.

DISCUSSION

We demonstrated statistically significant difference in the prevalence of PEX in CAD patients, and also in the prevalence of CAD in PEX (+) individuals. These were striking differences. We should consider the possibility of the presence of PEX in CAD patients; and the predisposition of PEX (+) persons for CAD, which necessitates a fundus examination for findings of systemic vascular diseases.

Serum homocysteine, vitamin B 12 and folic acid levels in different types of glaucoma

Background

This study was performed to compare levels of serum homocysteine (Hcy), vitamin B12 and folic acid in patients with primary open-angle glaucoma (POAG), pseudoexfoliative glaucoma (PEXG), normotensive glaucoma (NTG) and healthy controls.

Methods

Twentyfive patients with POAG, 24 with PEXG, and 18 with NTG, along with 19 control healthy subjects were included this prospective study. Levels of serum Hcy were measured using immunoassay, and those of serum vitamin B12 and folic acid were measured using competitive chemiluminescent enzyme immunoassay.

Results

The mean Hcy concentration in the PEXG group was significantly higher (P < 0.001) as compared to the other groups. There were no significant differences with respect to the mean Hcy concentrations among other groups (P > 0.05). There were no statistical differences in serum vitamin B12 levels among POAG, PEXG, NTG and control subjects (P > 0.05).

The mean serum folic acid level was significantly lower in the subjects with PEXG (P < 0.009). However, the mean folic acid concentrations among the other groups did not differ significantly (P > 0.05).

Conclusion

Elevated levels of Hcy in PEXG may explain the role of endothelial dysfunction among patients with PEXG.

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.

Graves' ophthalmopathy: comparison of the Doppler sonography parameters with the clinical activity score

PURPOSE

Our aim was to compare the Doppler ultrasonography (US) parameters with clinical activity score (CAS) in patients with Graves' ophthalmopathy.

METHODS

Blood flow parameters in the ophthalmic artery (OA), superior ophthalmic vein (SOV), central retinal artery (CRA) and central retinal vein (CRV) were measured by Doppler US in 118 patients with Graves' disease in 3 groups (A, B, and C) and 20 control subjects. Group A included 25 patients with CAS value "0"; group B 55 patients with CAS value "1 or 2"; group C 38 patients with CAS value "3 or above."

RESULTS

Peak systolic velocities (PSV) and end-diastolic velocities (EDV) in the OA, PSV, and in the CRA calculated for group C were significantly higher than for group A, group B, and the control group. Resistance index in the OA and maximal velocity (MV) in the SOV calculated for group C were significantly lower than those calculated for group A, group B, and the control group.

CONCLUSION

Doppler parameters of MV in SOV, PSV and EDV in OA, and PSV in CRA seem to be helpful in the differentiation of active and inactive phases of Graves' ophthalmopathy.

Central Corneal Mechanical Sensitivity in Pseudoexfoliation Syndrome

PURPOSE

Corneal involvement and disturbances of the tear film have been reported in pseudoexfoliation syndrome (PEX). Tear film deficiencies are correlated with changes in corneal sensitivity. The present study aims at evaluating central corneal mechanical sensitivity (CCMS) in PEX.

METHODS

Patients with unilateral or bilateral PEX findings constituted the study group (SG). Age- and gender-matched patients without PEX in either eye constituted the control group (CG). Patients with conditions affecting corneal sensitivity were excluded. CCMS and central corneal thickness (CCT) were measured (using a Cochet-Bonnet esthesiometer and an ultrasonic pachymeter, respectively). Schirmer (ST) and break-up time (BUT) tests were also performed.

RESULTS

The SG included 40 patients (24 male, 60%). The CG included 38 patients (25 male, 65.78%). ST scores were significantly lower in the SG compared with the CG (11.45 +/- 2.52 mm and 14.27 +/- 1.18 mm, respectively, P = 0.04). BUT scores were also significantly lower in the SG compared with the CG (7.64 +/- 2.37 mm and 12.43 +/- 3.14 mm, respectively, P = 0.03). CCMS was significantly (P = 0.02) reduced in the SG compared with CG (4.54 +/- 0.23 cm and 5.73 +/- 0.44 cm, respectively). Differences in CCT between the SG and the CG were not statistically significant.

CONCLUSIONS

The decrease in CCMS in PEX eyes may be related to decreased BUT and ST scores in PEX, as previously described. However, a direct involvement of sensory nerves may also participate. The reduction in CCMS may have implications for the clinical management of PEX patients.

Plasma and aqueous humour levels of homocysteine in exfoliation syndrome

BACKGROUND

Recent studies have suggested that the relationship between elevated plasma homocysteine (Hcy) and increased risk of vascular disease holds also for certain diseases of the eye with vascular aetiology. Elevated plasma Hcy levels have been noted among patients with exfoliation syndrome (XFS). The purpose of this study was to establish whether subjects with XFS have higher plasma and aqueous humour Hcy levels values than non-XFS subjects, particularly in relation to vitamin B status.

METHODS

Using a cross-sectional study design, 36 subjects with XFS and 36 non-XFS subjects with intraocular pressure (IOP) lower than 23 mmHg, matched by age and gender, were first selected. The participant exclusion criteria included parameters known to alter Hcy metabolism. In the XFS group, 11 subjects had a concurrent diagnosis of exfoliative glaucoma (XFG). Fasting plasma and aqueous humour Hcy samples were collected, along with erythrocyte folate (E-Fol) and serum vitamin B6 and B12 samples. The Hcy samples were analysed using a fluorescence polarization immunoassay method.

RESULTS

Plasma Hcy level was significantly higher (P=0.020, after Bonferroni correction for multiple testing) in the XFS group than in the controls. The Hcy concentrations in the aqueous humour did not differ statistically between the two groups. Plasma and aqueous humour Hcy concentrations were not statistically significantly correlated within the groups of exfoliation-positive and -negative subjects. E-Fol, and serum vitamin B6 and B 12 levels did not differ statistically between the XFS group and the control group.

CONCLUSIONS

The finding that subjects with XFS are more prone to elevated plasma Hcy emphasizes exfoliation as a clinical sign and a marker of thromboembolic vasculopathies induced by hyperhomocysteinaemia.

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.