Exfoliation syndrome

Comparison of Schlemm's Canal Morphology Parameters Between Propensity Score-Matched Primary Open-Angle Glaucoma and Exfoliation Glaucoma

Purpose

This study aimed to histologically compare the status of Schlemm's canal (SC) and Schlemm's canal endothelial (SCE) cells between trabeculectomy specimens from patients with primary open-angle glaucoma (POAG) and exfoliation glaucoma (EXG).

Methods

A total of 182 eyes from 152 patients with POAG and 138 eyes from 116 patients with EXG underwent immunohistochemical staining for thrombomodulin. Equal numbers of cases were selected from both groups using propensity score matching. The following parameters were evaluated: total SC length, staining positive and negative SC length (PSC and NSC, respectively), opened and closed SC length, staining positive and opened SC length, staining positive and closed SC length, staining negative and opened SC length (NOSC), and staining negative and closed SC length.

Results

After matching for age and gender, 87 cases were selected in each group. The EXG group had significantly higher preoperative IOP and medication scores. PSC was significantly longer in the POAG group, while NSC and NOSC were longer in the EXG group. Multiple regression analysis of these 174 cases revealed that PSC was significantly shorter in the EXG group. After matching for age, gender, preoperative IOP, and medication score, 64 cases were selected in each group, and NOSC was significantly longer in the EXG group.

Conclusions

These findings suggest that in EXG, SCE loss occurs independently of background factors such as aging and medication use. The loss of SCE may have a more critical impact on IOP elevation in EXG compared to POAG.

Platelet Proteome Reveals Novel Targets for Hypercoagulation in Pseudoexfoliation Syndrome

Pseudoexfoliation syndrome (PEX) is characterized by the accumulation of abnormal extracellular matrix material in ocular and non-ocular tissues, including blood vessel walls. Clot-forming dysfunction might be responsible for venous thrombosis in PEX. We investigated global coagulation, the proteome, and functions of platelets in PEX patients and aimed to determine prognostic biomarkers for thrombosis risk in PEX. Peripheral blood was collected from PEX and retinal vein occlusion (RVO) patients, and age-sex matched controls. Viscoelastic hemostasis was evaluated by rotational thromboelastometry (ROTEM). Platelet markers (CD41, CD42, CD61, and CD62p) and endothelial markers (P-selectin, E-selectin, and von Willebrand factor) were investigated by flow cytometry and ELISA, respectively. The platelet proteome was analyzed by 2D fluorescence difference gel electrophoresis followed by mass spectrometry. Clot formation time (CFT) is significantly reduced in PEX patients compared to the controls (p < 0.05). P-selectin levels were higher in PEX patients than in controls (p < 0.05); E-selectin and von Willebrand factor remained unchanged. The monitorization of CFT by ROTEM, and soluble P-selectin, may help assess thrombotic risk in PEX patients. Proteomic analysis revealed differential expression of Profilin-1 in platelets. Profilin-1 regulates the stability of actin-cytoskeleton and may contribute to impaired platelet hemostatic functions. Increased P-selectin levels together with impaired coagulation dynamics might be responsible for the thrombotic events in PEX disease.

Endoplasmic reticulum stress: molecular mechanism and therapeutic targets

The endoplasmic reticulum (ER) functions as a quality-control organelle for protein homeostasis, or "proteostasis". The protein quality control systems involve ER-associated degradation, protein chaperons, and autophagy. ER stress is activated when proteostasis is broken with an accumulation of misfolded and unfolded proteins in the ER. ER stress activates an adaptive unfolded protein response to restore proteostasis by initiating protein kinase R-like ER kinase, activating transcription factor 6, and inositol requiring enzyme 1. ER stress is multifaceted, and acts on aspects at the epigenetic level, including transcription and protein processing. Accumulated data indicates its key role in protein homeostasis and other diverse functions involved in various ocular diseases, such as glaucoma, diabetic retinopathy, age-related macular degeneration, retinitis pigmentosa, achromatopsia, cataracts, ocular tumors, ocular surface diseases, and myopia. This review summarizes the molecular mechanisms underlying the aforementioned ocular diseases from an ER stress perspective. Drugs (chemicals, neurotrophic factors, and nanoparticles), gene therapy, and stem cell therapy are used to treat ocular diseases by alleviating ER stress. We delineate the advancement of therapy targeting ER stress to provide new treatment strategies for ocular diseases.

Premium Intraocular Lenses in Glaucoma-A Systematic Review

The incidence of both cataract and glaucoma is increasing globally. With increasing patient expectation and improved technology, premium intraocular lenses (IOLs), including presbyopia-correcting and toric IOLs, are being increasingly implanted today. However, concerns remain regarding the use of premium IOLs, particularly presbyopia-correcting IOLs, in eyes with glaucoma. This systematic review evaluates the use of premium IOLs in glaucoma. A comprehensive search of the MEDLINE database was performed from inception until 1 June 2023. Initial search yielded 1404 records, of which 12 were included in the final review of post-operative outcomes. Studies demonstrated high spectacle independence for distance and good patient satisfaction in glaucomatous eyes, with positive outcomes also in post-operative visual acuity, residual astigmatism, and contrast sensitivity. Considerations in patient selection include anatomical and functional factors, such as the type and severity of glaucomatous visual field defects, glaucoma subtype, presence of ocular surface disease, ocular changes after glaucoma surgery, and the reliability of disease monitoring, all of which may be affected by, or influence, the outcomes of premium IOL implantation in glaucoma patients. Regular reviews on this topic are needed in order to keep up with the rapid advancements in IOL technology and glaucoma surgical treatments.

Pseudoexfoliation Glaucoma as a Predictor of Refractive Surprise After Uneventful Cataract Surgery

PRCIS

The pseudoexfoliation glaucoma group produced higher mean absolute error (MAE) and higher percentages of large-magnitude prediction error, in all investigated intraocular lens formulas. Postoperative anterior chamber angle and change in intraocular pressure (IOP) were associated with absolute error.

PURPOSE

The purpose of this study is to evaluate refractive outcomes of cataract surgery in patients with pseudoexfoliation glaucoma (PXG) and to determine the predictive factors for refractive errors.

MATERIALS AND METHODS

Fifty-four eyes with PXG, 33 eyes with primary open angle glaucoma (POAG) and 58 normal eyes undergoing phacoemulsification, in Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey, were included in this prospective study. The follow-up was 3 months. Preoperative and postoperative anterior segment parameters measured by Scheimpflug camera were compared after adjusting for age, sex, and axial length. The mean prediction error, MAE, and percentages of large-magnitude prediction error (>±1.0 D) in SRK/T, Barrett Universal II, and Hill-RBF formulas were compared.

RESULTS

There was a significantly greater anterior chamber angle (ACA) enlargement in PXG eyes compared with POAG ( P =0.006) and normals ( P =0.04). The PXG group showed significantly higher MAE in SRK/T, Barrett Universal II, and Hill-RBF (0.72, 0.79, and 0.79 D, respectively) than POAG (0.43, 0.25, and 0.31 D, respectively) and normals (0.34, 0.36, 0.31 D, respectively) ( P <0.0001). The large-magnitude error was significantly more frequent in the PXG group among the 3 groups with SRK/T (37%, 18%, and 12%, respectively) ( P =0.005), Barrett Universal II (32%, 9%, and 10%, respectively) ( P =0.005), and Hill-RBF (32%, 9%, and 9%, respectively) ( P =0.002). The MAE was correlated with postoperative ACA and IOP decrease in Barrett Universal II ( P =0.02 and 0.007, respectively) and Hill-RBF ( P =0.03 and 0.02, respectively).

CONCLUSIONS

PXG may be a predictor for refractive surprise after cataract surgery. Prediction errors may be due to IOP-lowering effect of surgery and larger postoperative ACA than expected, in the presence of zonular weakness.

Light and electron microscopic features of preclinical pseudoexfoliation syndrome

PURPOSE

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

DESIGN

Cross-sectional, prospective, and observational case series.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Head and Neck Region Dermatological Ultraviolet-Related Cancers are Associated with Exfoliation Syndrome in a Clinic-Based Population

OBJECTIVE

We assessed the relationship between ultraviolet (UV)-associated dermatological carcinomas (basal cell carcinoma [BCC] and squamous cell carcinoma [SCC]) and exfoliation syndrome (XFS) or exfoliation glaucoma (XFG).

DESIGN

Case-control study.

PARTICIPANTS

Between 2019 and 2021, 321 participants and control subjects (XFS or XFG = 98; primary open-angle glaucoma [POAG] = 117; controls = 106; ages 50-90 years) were recruited.

METHODS

A cross-sectional survey assessing medical history, maximum known intraocular pressure, cup-to-disc ratio, Humphrey visual field 24-2, the propensity to tan or burn in early life, history of BCC or SCC, and XFS or XFG diagnosis. The multivariable models adjusted for age, sex, medical history, eye color, hair color, and likeliness of tanning versus burning at a young age.

MAIN OUTCOME MEASURES

History of diagnosed XFS or XFG.

RESULTS

Any history of BCC or SCC in the head and neck region was associated with a 2-fold higher risk of having XFS or XFG versus having POAG or being a control subject (odds ratio [OR], 2.01; 95% confidence interval [CI], 1.04-3.89) in a multivariable-adjusted analysis. We observed a dose-response association in which the chance of having XFS or XFG increased by 67% per head and neck BCC or SCC occurrence (OR, 1.67; 95% CI, 1.09-2.56). When we excluded POAG participants, head and neck BCC or SCC was associated with a 2.8-fold higher risk of XFS or XFG (OR, 2.80; 95% CI, 1.12-7.02), and each additional occurrence had a 2-fold higher risk of XFS or XFG (OR, 1.97; 95% CI, 1.09-3.58). The association between head and neck region BCC or SCC and POAG compared with the control subjects was null (OR, 1.42; 95% CI, 0.58-3.48). With BCC or SCC located anywhere on the body, there was a nonsignificantly higher risk of having XFS or XFG compared with having POAG or being a control subject (OR, 1.65; 95% CI, 0.88-3.09).

CONCLUSIONS

Head and neck region BCCs or SCCs are associated with a higher risk of having XFS or XFG. These findings support prior evidence that head and neck UV exposure may be a risk factor for XFS.

Emerging roles of oxidative stress in the pathogenesis of pseudoexfoliation syndrome (Review)

Pseudoexfoliation syndrome (PEXS) is a systemic disease caused by defects in the extracellular matrix (ECM) remodelling process leading to the chronic deposition of extracellular, fibrillary, white flaky pseudoexfoliation material (PEXM) throughout the body. Specifically, PEXM deposits on the lens capsule cause open-angle glaucoma, cataracts and blindness in patients with PEXS. Several gene single nucleotide polymorphisms are linked to the development of PEXS in humans, including lysyl oxidase-like 1 gene, clusterin and fibulin-5. The exact reason for the PEXM generation and its resulting pathogenesis is not well understood. However, defective ECM remodelling and oxidative stress (OS) have been hypothesized as significant events leading to the PEXM. Specifically, the link between OS and PEXS has been well studied, although the investigation is still ongoing. The present review explored recent advances in various aspects of PEXS and the involvement of OS in the eye for PEXS development.

Intraocular Pressure in Eyes with Intraocular Lens Dislocation and Pseudoexfoliation Syndrome

PURPOSE

To investigate intraocular pressure in eyes with intraocular lens subluxation and pseudoexfoliation syndrome.

METHODS

In this retrospective study conducted at one eye centre (tazz) in Zurich, Switzerland, we reviewed 85 eyes with intraocular lens subluxation and pseudoexfoliation syndrome. Intraocular lens exchange was carried out by two surgeons between 03/2016 and 12/2019 (45 months). Information on baseline characteristics and diagnosis of glaucoma was recorded. Intraocular pressure and best-corrected visual acuity were analysed preoperatively and at five time points up to 12 months after lens exchange. Data on antiglaucomatous medication was collected before surgery and at two different time points after surgery. Postoperative pressure lowering procedures and complications were further analysed.

RESULTS

This study includes 85 pseudoexfoliation eyes with intraocular lens subluxation. The mean interval between cataract surgery and lens exchange was 8.9 ± 5.2 years. Intraocular pressure elevation in the event of intraocular lens subluxation was found in 54% (46/85) of eyes. Mean intraocular pressure decreased from 22.9 ± 9.4 mmHg preoperatively to 15.2 ± 3.4 mmHg at follow-up 12 months after lens exchange (p < 0.001). Postoperative topical antiglaucomatous drug requirements were comparable to preoperative levels (p = 0.520). Less systemic acetazolamide was required 12 months postoperatively (p = 0.018). A pressure lowering procedure was required in seven (8%) eyes in the postoperative period due to persistence of high intraocular pressure. Intermittent increase or persistence of high intraocular pressure occurred in 13 (15%) eyes.

CONCLUSION

This study emphasises the connection between acute pressure elevation and intraocular lens subluxation in patients with pseudoexfoliation syndrome. Intraocular pressure decreases after lens exchange and decrease sustains for a postoperative period of 12 months. Postoperative pressure lowering procedures were not required in the majority of eyes. We therefore conclude that intraocular lens exchange is efficient in the management of lens subluxation and pressure elevation in patients with pseudoexfoliation syndrome.

TGFβ1, MMPs and cytokines profiles in ocular surface: Possible tear biomarkers for pseudoexfoliation

Purpose

Pseudoexfoliation (PXF) is a unique form of glaucoma characterized by accumulation of exfoliative material in the eyes. Changes in tear profile in disease stages may give us insights into molecular mechanisms involved in causing glaucoma in the eye.

Methods

All patients were categorized into three main categories; pseudoexfoliation (PXF), pseudoexfoliation glaucoma (PXG) and cataract, which served as control. Cytokines, transforming growth factor β1 (TGFβ1), matrix metalloproteases (MMPs) and fibronectin (FN1) were assessed with multiplex bead assay, enzyme-linked immunosorbent assay (ELISA), gelatin zymography, and immunohistochemistry (IHC) respectively in different ocular tissues such as tears, tenon’s capsule, aqueous humor (AH) and serum samples of patients with PXF stages.

Results

We found that TGFβ1, MMP-9 and FN1 protein expression were upregulated in tears, tenon’s capsule and AH samples in PXG compared to PXF, though the MMP-9 protein activity was downregulated in PXG compared with control or PXF. We have also found that in PXG tears sample the fold change of TGF-α (Transforming Growth Factor-α), MDC (Macrophage Derived Chemokine), IL-8 (Interleukin-8), VEGF (Vascular Endothelial Growth Factor) were significantly downregulated and the levels of GM-CSF (Granulocyte Macrophage Colony Stimulating Factor), IP-10 (Interferon- γ produced protein-10) were significant upregulated. While in AH; IL-6 (Interleukin-6), IL-8, VEGF, IFN-a2 (Interferon- α2), GRO (Growth regulated alpha protein) levels were found lower and IL1a (Interleukin-1α) level was higher in PXG compared to PXF. And in serum; IFN-a2, Eotaxin, GM-CSF, Fractalkine, IL-10 (Interleukin-10), IL1Ra (Interleukin-1 receptor antagonist), IL-7 (Interleukin-7), IL-8, MIP1β (Macrophage Inflammatory Protein-1β), MCP-1 (Monocyte Chemoattractant Protein-1) levels were significantly upregulated and PDGF-AA (Platelet Derived Growth Factor-AA) level was downregulated in the patients with PXG compared to PXF.

Conclusions

Altered expression of these molecules in tears may therefore be used as a signal for onset of glaucoma or for identifying eyes at risk of developing glaucoma in PXF.

Characteristics of Patients with Pseudoexfoliation Syndrome at a Tertiary Eye Care Center in Jordan: A Retrospective Chart Review

PURPOSE

To present the clinical profile of patients with pseudoexfoliation (PXF) and describe its association with pseudoexfoliation glaucoma and cataract surgery complications at a university hospital in Jordan.

METHODS

Electronic chart search was performed among patients aged ≥ 50 years who attended the Jordan University Hospital between January 2015 and March 2018, to identify patients with pseudoexfoliation. Data derived from history and ophthalmic examination regarding laterality of pseudoexfoliation, presence of glaucoma, glaucoma surgery, cataract, cataract surgery, lens instability, and complications of cataract surgery were collected and analyzed.

RESULTS

Of 19,753 patient records searched, 962 (477 male and 485 female) had PXF (4.9%). The mean (SD) age was 71.8 (8.1) years. Pseudoexfoliation was unilateral in 539 patients (56.0%). The mean age of patients with clinically bilateral PXF was significantly higher than those with clinically unilateral PXF (p = 0.001). Pseudoexfoliation glaucoma was present in 237 of 962 (25.4%) patients with PXF and was significantly associated with clinically bilateral PXF (p < 0.001) and male gender (p = 0.001). In 454 (48.9%) patients (638 eyes) who underwent cataract surgery, there was no statistically significant difference in the rate of intraoperative complications between PXF eyes and the fellow eyes of clinically unilateral PXF eyes (p = 0.37), or between patients with clinically unilateral and clinically bilateral PXF (p = 0.78).

CONCLUSION

In this large hospital-based study, the frequency of PXF was 4.9%. Glaucoma was present in one fourth of patients and was significantly associated with clinically bilateral PXF and male gender. Cataract surgery complication rates were not statistically different between PXF and the fellow eyes of clinically unilateral PXF eyes. Surgeons need to be aware of the potential increased risk of intraoperative complications in both groups.

Diagnosis of Pseudoexfoliation Syndrome in Pseudophakic Patients

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Epidemiology of Exfoliation Syndrome

BACKGROUND

From a historical standpoint the epidemiology of exfoliation syndrome (XFS) is one of the most controversial subjects in ophthalmic literature. Current literature abounds with studies on the prevalence of XFS in various ethnic populations and clearly XFS is a common condition, but its true prevalence is difficult to ascertain. Overall, XFS is considered to be the most common identifiable cause of glaucoma worldwide.

PURPOSE

This review critically examines the published literature documenting the epidemiological features of XFS and attempts to provide a unified concept concerning existing controversy.

METHODS

A critical review of selected literature pertaining to the epidemiology of XFS.

RESULTS

It is well established that XFS and the ensuing exfoliative glaucoma have a worldwide prevalence and a progressively increasing age-related incidence. The prevalence of the condition is significantly underestimated. Many past studies have proposed clear geographic variations within and between ethnic groups. In contrast, there has also been some epidemiological evidence suggesting that the prevalence of XFS is similar within various ethnic groups. Published literature fails to address the potential role and impact of suspected exfoliation cases in the reported prevalence figures of the condition. Incidence figures for the condition are limited and vary extensively. Cumulative data have indicated that several, as yet partly understood genetic, ethnic, and environmental factors contribute to the varied prevalence of this condition.

CONCLUSIONS

Further understanding on XFS epidemiology is needed. Only a future large prospective study conducted by the same investigators, using similar methodologies for different ethnic populations will prove beyond doubt the hypothesis that significant geographic variations exist. Since patients with exfoliative glaucoma are at significant risk of losing vision it is vital to elucidate the causes and the risk of developing XFS. To reach this goal, it is important to better delineate the early changes of XFS and to focus research efforts on modifiable factors for XFS development.

Diurnal variation of central corneal thickness and intraocular pressure in eyes with pseudoexfoliation

Purpose:

Pseudoexfoliation syndrome (PXS) is an age related microfibrillopathy characterized by deposition of whitish flaky material over various ocular tissues. PXS eyes are known to have thinner corneas and thus can lead to an underestimation in intraocular pressure measurement. The purpose of this study was to find if there is any variation in central corneal thickness and intraocular pressure in PXS eyes and if there was any relationship between them.

Methods:

A prospective observational study was done on 141 eyes of 85 patients with PXS without glaucoma between November 2015 to April 2017 in the department of Ophthalmology in a tertiary hospital. CCT and IOP were measured by a handheld ultrasonic pachymeter (DGH Technology INC. Pachette 2, USA) and Goldmann applanation tonometer respectively at 4 different times during office hours.

Results:

A significant reduction of about 10 μm in mean CCT and 1.4 mmHg in mean IOP was noted over the 4 sessions which was statistically significant (P < 0.001). A significant correlation exists between IOP and CCT in PXS eyes at all times during the day (P < 0.001).

Conclusion:

The CCT measurements show significant thinning throughout the day, similar drop in IOP was also noted. Our study shows that there is a significant correlation between diurnal variation of CCT and IOP. Hence, it is prudent to measure CCT along with IOP at all times.

Growth Factors, Oxidative Damage, and Inflammation in Exfoliation Syndrome

Exfoliation syndrome (XFS) produces deleterious ocular aging and has protean systemic manifestations. Local ocular production of TGFβ1 is of central importance in XFS. TGFβ1 appears to induce the expression of LOXL1 and the production of other extracellular matrix components which are known to be present in exfoliation material. Furthermore, results from several studies find that the aqueous humor of exfoliation glaucoma patients exhibits a decreased antioxidant defense and increased oxidative stress systems. Finally, studies show that the levels of interleukin-6 and interleukin-8 in the aqueous humor of XFS patients were 3-fold higher than in controls. Overall TGFβ1, as well as a prooxidative and proinflammatory environment seems to play an important role in XFS.

Cognitive Function and Ophthalmological Diseases: The Beijing Eye Study

To examine associations between cognitive function and ophthalmological parameters, the population-based Beijing Eye Study examined ophthalmologically and physically 3127 individuals (mean age: 64.2 ± 9.8 years). Using the mini–mental state examination, cognitive function was assessed as cognitive function score (CFS). Mean CFS was 26.3 ± 3.7 (median: 27; range: 2–30). Prevalence of mild (CFS: 23–19), moderate (CFS: 18–10) and severe cognitive dysfunction was 9.6% (95% confidence interval (CI): 8.5, 10.6), 3.2% (95% CI: 2.6, 3.9) and 0.6% (95% CI: 0.4,0.9), respectively. In multivariate analysis, better cognition (i.e., higher CFS) was significantly associated with better best corrected visual acuity (r² = 0.38), smaller amount of undercorrected visual acuity, lower prevalence of primary angle-closure glaucoma, and thicker subfoveal choroidal thickness. Prevalence of age-related macular degeneration, open-angle glaucoma, diabetic retinopathy, any type of cataract, retinal vein occlusions or pseudoexfoliation was not significantly correlated with CFS. Though the causal relationship is unclear, the associations of lower cognitive function with undercorrected visual acuity suggest the need for earlier and more regular refraction testing in the elderly so that providing adequate glasses to the elderly can be provided and vision-associated cognitive decline can be reduced. Associations of cognitive function with primary angle-closure glaucoma and leptochoroid should be further explored.

Comparison of Rotational Thromboelastography Findings in Pseudoexfoliation Syndrome Patients and Healthy Controls

PURPOSE

Rotational thromboelastography (ROTEM) is a useful test for studying the characteristics of fibrin clot formation. As patients with pseudoexfoliation (PEX) have an increased risk for thrombotic events, clot-forming dysfunction may play a role. The aim of this study is to compare ROTEM findings in PEX syndrome patients with age-matched and sex-matched healthy controls.

PATIENTS AND METHODS

A total of 21 patients with PEX syndrome and 22 age-matched and sex-matched healthy controls were included. All study participants underwent detailed ophthalmologic and systemic medical examination, including blood pressure measurement, hemoglobin-hematocrit levels, platelet count, coagulation parameters including prothrombin time, activated partial thromboplastin time, fibrinogen levels, and D-dimer levels. Peripheral blood samples were collected and analyzed with ROTEM Coagulation Analyzer.

RESULTS

The mean age of patients with PEX and controls was 66.5±8.3 and 65.9±9.5 years, respectively (P=0.7). The 2 groups did not differ with respect to age, sex, hemoglobin, hematocrit, platelet numbers, prothrombin time, activated partial thromboplastin time, fibrinogen levels, D-dimer levels, and glucose levels. When extrinsic thromboelastometry results were analyzed, PEX patients showed a significantly decreased clotting time when compared with healthy controls (79.8 vs. 98.0 s; P=0.01), indicating faster clot formation. Other ROTEM parameters did now show any difference between the 2 groups.

CONCLUSIONS

PEX patients showed faster clotting time when compared with healthy controls. This fibrin clot formation dysfunction may lead to vascular thrombotic events in these patients. Further studies are needed to elucidate the exact underlying mechanism of thrombosis seen in PEX patients.

The Effect of Corneal Refractive Surgery on Glaucoma

Laser-assisted refractive procedures have become very popular in the last two decades. As a result, a "generation" of patients with altered corneal properties is emerging. These patients will require both cataract extraction and glaucoma follow-up in the future. Since the glaucoma examination largely depends on the corneal properties, the reshaped postrefractive surgery cornea poses a challenge in the diagnosis, follow-up, and management of the glaucomatous patient. In order to overcome this problem, every patient who is planned to undergo corneal refractive surgery must have a thorough glaucoma examination in order for the ophthalmologist to be able to monitor their patients for possible glaucoma development and/or progression. Some examinations such as tonometry are largely affected by the corneal properties, while others such as the evaluation of the structures of the posterior pole remain unaffected. However, the new imaging modalities of the anterior segment in combination with the most recent advances in tonometry can accurately assess the risk for glaucoma and the need for treatment.

Outcome of phacoemulsification and intraocular lens implantion in eyes with pseudoexfoliation and weak zonules

PURPOSE

To evaluate the results of phacoemulsification and intraocular lens (IOL) implantation in eyes with pseudoexfoliation (PEX) and zonular weakness.

METHODS

Two hundred and ninety-five patients (295 eyes) were recruited. This study is a retrospective case review of 143 PEX eyes with preoperative (Group 1) and intraoperative (Group 2) signs of zonular weakness, 76 PEX eyes (Group 3) and 76 non-PEX eyes without zonular weakness (Group 4) undergoing phacoemulsification and IOL implantation performed by single surgeon from year 1988 to 2010. Outcome measures included frequency of postoperative pseudophakodonesis, anterior capsule contraction and IOL decentration/dislocation. Postoperative vision, intraocular pressure (IOP) and glaucoma medication requirements were also assessed. A subanalysis on identical postoperative outcomes of capsular tension ring (CTR) implantation was performed. Comparisons were made for 52 PEX eyes with zonular weakness receiving nonsutured CTR implantation (Group A), 91 PEX eyes with zonular weakness not receiving CTR implantation (Group B) and 142 PEX eyes without zonular weakness (Group C).

RESULTS

Mean follow-up was 4.08 ± 0.48 years and maximum was 8.3 years. Both Groups 1 and 2 showed higher incidence of complications than Groups 3 and 4 (p < 0.01). Vision, IOP and glaucoma medication requirements were similar postoperatively for all four groups. Groups A and B had a significantly higher proportion of postoperative complications than Group C (p < 0.01). There was no significant difference in risk of developing these complications between Groups A and B (p = 0.64).

CONCLUSION

Postoperative complication rates are higher in PEX eyes with preoperative and/or intraoperative signs of zonular weakness undergoing phacoemulsification. Nonsutured CTR implantation does not prevent IOL and capsular complications postoperatively.

Corneal Alterations Associated with Pseudoexfoliation Syndrome and Glaucoma: A Literature Review

A systematic literature review was performed evaluating articles examining the effects of pseudoexfoliation syndrome (PEX) and glaucoma (PEXG) on the cornea with a focus on the corneal endothelium. We searched for articles relevant to pseudoexfoliation syndrome, pseudoexfoliation glaucoma and corneal endothelial cell counts using Pubmed, Google Scholar Database, Web of Science and Cochrane Library databases published prior to September of 2016. We then screened the references of these retrieved papers and performed a Web of Science cited reference search. Corneal characteristics analyzed included central corneal thickness (CCT), corneal nerve density, endothelial cell density (ECD), polymegathism, and pleomorphism. These parameters were compared in the following populations: control, PEX, PEXG, and primary open angle glaucoma (POAG). Over 30 observational studies were reviewed. Most studies showed a statistically significant lower ECD in PEX and PEXG populations compared to controls. Overall, PEX eyes had a non-statistically significant trend of lower ECDs compared to PEXG eyes. No consistent trends were found when analyzing differences in CCT amongst control, PEX and PEXG groups. For the few studies that looked at corneal nerve characteristics, the control groups were found to have statistically significantly greater nerve densities than PEX eyes, which had significantly greater densities than PEXG eyes. ECD and corneal nerve densities may be potential metrics for risk-stratifying patients with PEX and PEXG. Our literature review provided further evidence of the significant negative influence PEX has on the cornea, worsening as patients convert to PEXG.

Modified 360-degree Suture Trabeculotomy for Pseudoexfoliation Glaucoma: 12-Month Results

PURPOSE

We aimed to evaluate the 12-month results of a modified 360-degree suture trabeculotomy (ST) technique in patients with pseudoexfoliation glaucoma (XFG).

PATIENTS AND METHODS

The modified 360-degree ST was performed on 20 eyes of 20 consecutive patients with XFG resistant to maximal topical treatment. In 8 patients, ST was combined with phacoemulsification. The main outcome measures were the surgical success rate, the mean postoperative intraocular pressure (IOP), the number of antiglaucoma medications, and the operative complications.

RESULTS

The baseline IOP (26.55 ± 8.91) and medications (3.15 ± 0.81) decreased significantly to 10.90 ± 2.73 mm Hg and 0.30 ± 0.80, respectively, at 12 months postoperatively (P<0.001). The magnitude of IOP reduction was 58.9%. Complete and qualified success rates were 68.4% and 94.7%, respectively. The entire circumference of Schlemm's canal was opened successfully in all cases. Hyphema, perforation of the trabeculodesmetic window, posterior synechia, peripheral anterior synechia, and a transient elevation of the IOP were noted. The results are comparable to our 6-month results and other previously published results for circumferential trabeculotomy.

CONCLUSIONS

The modified 360-degree ST provides a feasible choice in patients with XFG with a reasonable rate of complications. The 12-month success rates are promising. It can also be combined effectively with the current cataract surgery.

Autophagy and Mitochondrial Dysfunction in Tenon Fibroblasts from Exfoliation Glaucoma Patients

Purpose

To test the hypothesis that autophagy dysfunction is involved in exfoliation syndrome (XFS), a systemic disorder of extracellular elastic matrices that causes a distinct form of human glaucoma.

Methods

Fibroblasts derived from tenon tissue discards (TFs) from filtration surgery to relieve intraocular pressure in XFS patients were compared against age-matched TFs derived from surgery in primary open-angle glaucoma (POAG) patients or from strabismus surgery. Differential interference contrast light, and electron microscopy were used to examine structural cell features. Immunocytochemistry was used to visualize LOXL1 and Fibulin-5, lysosomes, endosomes, Golgi, and microtubules. Light scatter, Cyto-ID^TM and JC1 flow cytometry were used to measure relative cell size, autophagic flux rate and mitochondrial membrane potential (MMPT), respectively. Enhanced autophagy was induced by serum withdrawal.

Results

In culture, XFS-TFs were 1.38-fold larger (by light scatter ratio, p = 0.05), proliferated 42% slower (p = 0.026), and were morphologically distinct in 2D and 3D culture compared to their POAG counterparts. In extended 3D cultures, XFS-TFs accumulated 8–10 times more Fibulin-5 than the POAG-TFs, and upon serum withdrawal, there were marked deficiencies in relocation of endosomes and lysosomes to the perinuclear area. Correspondingly, the XFS-TFs displayed significant accumulation of the autophagasome marker LC3 II (3.9 fold increase compared to POAG levels, p = 0.0001) and autophagic flux rate as measured by Cyto-ID dye was 53% lower in XFS-TFs than in POAG-TFs (p = 0.01), indicating reduced clearance of autophagasomes. Finally the percent of cells with diminished MMPT was 3–8 times larger in the XFS-TFs than in POAG-TFs (p = 0.02).

Conclusions

Our results provide for the first time a link between XFS pathology to autophagy dysfunction, a major contributor to multiple age related diseases systemically throughout the body, in the brain and in the retina. A diminished capacity for degradation of denatured protein and aging cellular organelles may underpin the development of extracellular protein aggregates in XFS.

Analysis of Intraoperative and Postoperative Complications in Pseudoexfoliation Eyes Undergoing Cataract Surgery

INTRODUCTION

Pseudoexfoliation (PXE) is a genetically inherited condition affecting usually seen in those aged over 50 years. Surgical management of cataract in patients with PXE pose a challenge due to associated changes in ocular structures.

AIM

To study the challenges in the management of cataract in patients with PXE.

MATERIALS AND METHODS

This was an interventional study conducted in the Ophthalmology Department of MS Ramaiah Medical College and Memorial Hospital, Bangalore from June 2012 to September 2014. All patients admitted for cataract surgery during this period who were diagnosed as cataract associated with PXE above 50 years of age belonging to either sex were included in the study. All patients underwent cataract surgery with intraocular lens implantation. Depending on type of cataract both small incision and phacoemulsification operations were conducted. Intraoperative and postoperative complications were studied. The patients were reviewed up to 6 weeks postoperatively.

RESULTS

A total of 50 eyes of 50 patients diagnosed as cataract with PXE underwent cataract surgery. Of which 40 eyes (80%) underwent small incision cataract surgery whereas, 10 (20%) underwent phacoemusification. Corneal thinning (<535 microns) was noted in majority of the cases (41 cases). Preoperatively there were 3 cases of zonular weakness. Pseudo exfoliation with glaucoma was seen in 5 cases. Intraoperative complications encountered during surgery were; zonular dialysis in 3 cases, posterior capsular tear in 2 cases, out of these 5 cases vitreous loss was seen in 3 cases. Postoperative complications were corneal odema in 17 cases, of which endothelium de-compensated in one case, while early posterior capsular opacification was seen in 6 cases. Final best corrected visual acuity was between 6/6-6/12 in 39(78%) eyes, 6/18 -6/36 in 6(12%) cases; 6/60 to less in 5(10%) cases.

CONCLUSION

Cataract surgery in eyes with PXE has higher incidence of intraoperative and postoperative complications. A complete preoperative workup helps reduce intraoperative complications and maximises the postoperative results. As corneal thinning is more common a pre-operative pachymetry is desirable to prevent underdiagnoses of glaucoma.

Pseudoexfoliation syndrome at a Singapore eye clinic

Background

The purpose of this study was to investigate the demographics of pseudoexfoliation syndrome (PXF) and pseudoexfoliative glaucoma (PXG) in a Singapore hospital eye outpatient clinic.

Methods

A retrospective study of 93 consecutive patients (146 eyes) with PXF was undertaken by a single ophthalmologist over a period of 37 months (July 1, 2006, to July 31, 2009).

Results

Ninety-three (2.8%) of 3,297 patients seen during the study period were diagnosed with PXF. Forty-three (46.2%) of the 93 PXF patients were male. Indians were 5.04 times more likely to develop PXF than Chinese (P<0.001, 95% confidence interval 3.05–8.33), while Malays were 2.22 times more likely to develop PXF as compared with Chinese (P=0.029, 95% CI 1.08–4.55). Twenty-two (23.7%) of the 93 PXF patients had PXG at the time of diagnosis. There was no statistically significant difference in mean age between PXF and PXG patients. There was a larger proportion of males with PXG than females (P<0.001).

Conclusion

PXF is not infrequent in elderly Singapore eye clinic patients, and is more likely to occur in Indians than in Chinese. In the Singapore eye clinic setting, males may be more likely to develop PXG, although larger studies will be required to confirm this.

The Effect of Pseudoexfoliation and Pseudoexfoliation Induced Dry Eye on Central Corneal Thickness

PURPOSE/AIM OF THE STUDY

The aim of this study is to investigate the effect of pseudoexfoliation (PEX) and PEX-induced dry eye on central corneal thickness (CCT).

MATERIALS AND METHODS

This cross-sectional study consists of total 270 eyes of 135 patients (67 females, 68 males) in total. After excluding the PEX (-) 32 eyes with PEX in the other eye, totally 130 eyes in PEX (-) group and 108 eyes in the PEX (+) group were included in the study. The PEX (+) group was regrouped as PEX syndrome (80 eyes of 50 patients) and PEX glaucoma (28 eyes of 20 patients).

RESULTS

In the PEX (-) group, the mean Schirmer test result was 12 ± 4 mm (4-25 mm), in the PEX syndrome group 10 ± 4 mm (4-22 mm), in the PEX glaucoma group 9 ± 3 mm (4-15 mm). The difference among the PEX (-) group, the PEX syndrome and the PEX glaucoma groups was statistically significant (p < 0.001, p < 0.001, respectively). In the PEX (-) group, the mean tear break up time test result was 11 ± 2 s (5-16 s), in the PEX syndrome group 8 ± 3 (3-16 s), in the PEX glaucoma group 8 ± 3 s (5-15 s). Mean CCT result was 544 µm in the PEX (-), 521 µm in the PEX syndrome group and 533 µm in the PEX glaucoma group. The difference among the PEX (-) group, the PEX syndrome and the PEX glaucoma groups was significant (p < 0.001, p = 0.030, respectively). There was a significant (+) correlation between intraocular pressure and CCT in the eyes with PEX (r = 0.307, p = 0.001). However, there was no statistically significant correlation between CCT, Schirmer and tear break up time tests in the eyes with PEX.

CONCLUSIONS

PEX material can cause decrease in tear film secretion and disturb tear film stability. There is no effect of PEX-induced dry eye on CCT. Lower CCT values in the eyes with PEX material may be a result of decrease in corneal stromal cell density. Moreover, higher CCT values may be because of decreased endothelial cells in PEX glaucoma patients.

Clinical Signs and Characteristics of Exfoliation Syndrome and Exfoliative Glaucoma in Northern China

PURPOSE

To investigate the frequency and clinical features of exfoliation syndrome (XFS) and exfoliative glaucoma (XFG) in northern China.

DESIGN

A retrospective medical chart review.

METHODS

The review was conducted in Beijing Tongren Hospital. Using diagnosis codes, all consecutive patients with XFS/XFG were included in the study. Exfoliation syndrome was diagnosed if the patient had exfoliationmaterial (XFM) on the pupillary margin or anterior lens capsule.

RESULTS

Of 73,976 inpatient records, 45 patients (75 eyes) with XFS/XFG were identified (27 men, 18 women). Exfoliation syndrome/XFG accounted for 0.55% (45/8205) of hospitalized patients with cataract aged 60 years or older. The mean (SD) age of the inpatients was 72.1 (8.1) years (range, 47-85 years). Thirty-six patients had XFG, comprising 4.3% (36/838) of hospitalized patients with open-angle glaucoma. The presence of XFM on the pupillary margin (66.7%) and anterior lens surface (65.3%) were the most common features. Loss of pupillary ruff (13.3%) was uncommon. Increased pigmentation (49.3%) and flecks of XFM (9.3%) were seen on the trabecular meshwork, and 25 eyes (33.3%) had narrow angles. For those with bilateral XFS/XFG (66.7%, 30/45), 7 patients had bilateral XFS, 15 patients had bilateral XFG, and 8 patients had XFS in 1 eye but XFG in another eye. Twenty-two patients (44.4%) had hypertension, and 7 (15.6%) had ischemic heart diseases.

CONCLUSIONS

Exfoliation syndrome/XFG is still uncommon in the northern Chinese population. Its major clinical characteristics are the deposit of XFM on the pupil rim or anterior lens surface and increased trabecular meshwork pigmentation.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Diurnal variation in central corneal thickness and intraocular pressure in eyes with pseudoexfoliation syndrome without glaucoma

Aim:

The aim was to ascertain if any differences exist in diurnal central corneal thickness (CCT) and intra-ocular pressure (IOP) between eyes with pseudoexfoliation (PXF) syndrome without glaucoma and eyes with no ocular pathology. A secondary aim was to determine whether there was a significant relationship between CCT and IOP.

Settings and Design:

This study was a prospective design conducted within a hospital setting.

Materials and Methods:

The experimental group consisted of seven participants with bilateral PXF (14 eyes) and the control group comprised of 15 participants (30 eyes). Testing included CCT and IOP measured at four different times on one given day (8.00 a.m.; 11 a.m.; 2 p.m. and 5 p.m.).

Statistical Analysis:

The data were analyzed with the generalized linear latent mixed model.

Results:

PXF eyes displayed a significantly thinner overall mean CCT (520 μm) compared to controls (530 μm). Furthermore, a significant reduction in CCT and IOP occurred in the PXF group from 8 a.m. to 5 p.m. The mean overall IOP in PXF eyes was significantly lower than the control group. A significant association between IOP and CCT was also found in PXF eyes.

Conclusions:

Displaying a significantly thinner mean CCT highlights the importance of measuring CCT in an ophthalmic clinical setting as to avoid falsely underestimated IOP measurements in such a high-risk glaucoma population. Furthermore, a statistically significant correlation between IOP and CCT in PXF eyes suggests that the reduction in CCT that occurred in PXF eyes between 8 a.m. and 5 p.m. may be partly responsible for the reduction in IOP measurements.

Rates of visual field progression in clinical glaucoma care

PURPOSE

To investigate rates of visual field progression and factors associated with progression rate in open-angle glaucoma in clinical glaucoma care.

METHODS

We performed a retrospective chart review of all patients with manifest primary open-angle glaucoma (POAG) and pseudoexfoliation glaucoma (PEXG) followed ≥ 5 years with ≥5 SITA Standard fields. Exclusion criteria were minimal. Demographics, intraocular pressure values (IOP), treatment and treatment changes, and visual field (VF) data were recorded. VF progression rates were calculated as slopes of mean deviation (MD) over time.

RESULTS

Five hundred and eighty-three patients were eligible. Three hundred and sixty-seven (62%) had POAG and 221 (38%) PEXG. Median MD at study start was -10.0 dB. Mean follow-up time was 7.8 years (SD ± 1.2); mean number of VF tests was 8.9 (SD ± 2.8). Progression rates varied very much among patients with a mean of -0.80 dB/year (SD ± 0.82; median rate, -0.62), and 5.6% of patients progressed at rates worse than -2.5 dB per year A negative slope of MD values was observed in 89% of patients. Mean IOP of all visits decreased over the study period from 20.15 to 18.10 mmHg. Higher age and mean IOP, and more intensive treatment were associated with more rapid progression, while PEXG and IOP variation were not, if treatment intensity was taken into account.

CONCLUSION

Rates of visual field progression in manifest glaucoma with field loss in ordinary clinical care were highly variable. Progression rates rapid enough to influence quality of life were common.

Ocular clinical profile of patients with pseudoexfoliation syndrome in a tertiary eye care center in South India

Purpose:

To study the clinical profile of pseudoexfoliation (PEX) syndrome in a hospital setting.

Materials and Methods:

A case series of patients with PEX, with and without glaucoma attending the general ophthalmology clinic of a tertiary care center in South India. All patients underwent a complete ophthalmologic evaluation including recording diurnal variation of tension (DVT), gonioscopy and visual field assessment.

Results:

The study cohort comprised 529 patients (752 eyes). There were 296 (56%) females. The highest number of patients (261 patients) was from the age group between 60 and 69 years. Of 752 eyes, 57.8% eyes had unilateral PEX and 72% had established PEX. Gonioscopy showed open angles in 98.1% of eyes. Intraocular pressure (IOP) greater than 21 mmHg in at least 1 of 4 measurements was recorded in 5.7% eyes. DVT was normal in 96.4% of unilateral PEX eyes, similar to fellow non-PEX eyes. Pseudoexfoliation glaucoma occurred in 1.9% of eyes and 4.7% of eyes were glaucoma suspects. There was no correlation between the stage of PEX and increased IOP. Mean central corneal thickness of PEX eyes was 522 ± 27μ. Pupillary dilatation in 90.5% eyes with early PEX was ≥ 7 mm.

Conclusions:

A small percentage of PEX eyes had raised IOP, and the number of eyes with glaucomatous optic neuropathy was even lower. PEX eyes did not demonstrate wide fluctuations in IOP. No correlation was found between raised IOP and stage of PEX. There was good pupillary dilatation in early stage PEX eyes suggesting that all PEX eyes may not have poor pupillary dilatation and related complications.

High prevalence of pseudoexfoliation syndrome and its complications in Tarragona in northeast Spain

PURPOSE

To determine the prevalence of pseudoexfoliation syndrome (PEX) in our health area, in 4 counties of Tarragona, and its involvement in the health status of the population.

METHODS

This was a cross-sectional study of a sample of 2,342 inhabitants aged = 60 years, randomly selected from the population census. Subjects were classified in 3 groups according to age (group 1 = 60-69 years, group 2 = 70-79 years, group 3 = over 80 years). The diagnosis of PEX was made in all cases by the same ophthalmologist, using biomicroscopic and slit-lamp evaluation. Corneal endothelial study was made by specular microscope.

RESULTS

The prevalence of PEX was 309/2,342 patients (13.19%), unilateral in 219/309 (70.87%). The prevalence of PEX in patients with open-angle glaucoma was 29.48%. Changes in corneal endothelium were higher in patients with PEX, with lower cell density and hexagonality percentage, with higher coefficient of variation, significant in age groups 2 and 3. The prevalence of cataract in patients with PEX was 80.58%, versus 54.64% in patients without PEX. Complications of cataract surgery were higher in patients with PEX and postoperative corneal edema was best correlated with a low hexagonality percentage. No systemic cardiovascular diseases were significant in patients with PEX.

CONCLUSIONS

In our health district area, a high prevalence of PEX exists. A more extensive study of the causes of these differences is needed, including analysis of the genetic makeup of the population.

Glutathione and Lipid Peroxide Changes in Pseudoexfoliation Syndrome

PURPOSE

To investigate the oxidative status of the aqueous humor of patients with pseudoexfoliation (PEX) syndrome.

METHODS

Aqueous humor samples obtained during cataract surgery of patients with PEX syndrome and normal age-matched control subjects were examined for changes in the levels of glutathione (GSH), glutathione disulfide (GSSG), and TBA reactive species (TBARS), products of lipid peroxidation. GSH, GSSG, and TBARS were determined by specific fluorescent assays.

RESULTS

Compared to normal controls, PEX syndrome aqueous humor samples showed a decrease of up to 28% of GSH concentration, and GSSG was increased up to 23%. The ratio of GSH/GSSG was 1.7-fold decreased in PEX syndrome samples. TBARS levels were increased by 100% in the PEX aqueous humor samples as compared to the controls.

CONCLUSIONS

High levels of GSSG and TBARS indicate high oxidative stress, as well as the decrease in the ratio of GSH/GSSG. Our findings suggest a role for oxidation stress in the pathogenesis and the progression of PEX syndrome.

Methylenetetrahydrofolate reductase 677 C-T and homocysteine levels in Turkish patients with pseudoexfoliation

PURPOSE

The 677 C-T polymorphism in the methylenetetrahydrofolate reductase (MTHFR) gene is associated with hyperhomocysteinaemia. This study aimed to investigate the frequency of MTHFR 677 C-T polymorphism and homocysteine (Hcy) levels in Turkish patients with pseudoexfoliation (PEX).

METHODS

This prospective study consisted of 60 patients with PEX glaucoma, 16 with PEX syndrome and 34 controls. All patients and control subjects were of Turkish origin. All participants underwent a complete ophthalmic examination. Plasma Hcy levels were measured using fluorescence polarization immunoassay (Abbott Diagnostics). Hyperhomocysteinaemia was defined as a plasma Hcy level above 14 micromol/L. MTHFR 677 C-T was genotyped by real-time polymerase chain reaction (Roche Diagnostics).

RESULTS

There was no statistically significant difference in patient and control groups for the age and sex (P > 0.05). The mean plasma Hcy levels were 15.76, 14.98 and 17.43 micromol/L in patients with PEX glaucoma, with PEX syndrome and controls, respectively. No significant differences between Hcy levels among the three groups (P > 0.05) were found. MTHFR 677 polymorphism did not show significant differences between the total patients with PEX (PEX glaucoma + PEX syndrome) and control subjects (CC: 51.3%n = 39, CT: 40.8%n = 31, TT: 7.9%n = 6 for patients with PEX; CC: 52.9%n = 18, CT: 35.3:%n = 12, TT: 11.8%n = 4 for controls) (P > 0.05). Frequency of T allele was 28.28% and 29.41% for the total patients with PEX and controls, respectively.

CONCLUSION

In Turkish patients with PEX, the authors could not find any association between Hcy levels, MTHFR 677 C-T polymorphism, and the disease.

Reducing intraocular pressure: is surgery better than drugs?

Reducing IOP is presently the evidence based, most accepted and most practised therapeutical approach for glaucoma patients. Currently topical ocular hypotensive medications, with its different classes, as well as filtering surgery (trabeculectomy and non-penetrating glaucoma surgery) are in the forefront of therapeutic modalities for IOP reduction. This article looks at the potential advantages and disadvantages of topical medications versus filtering surgery. It does not directly address the question of initial treatment of glaucoma, or what is the better treatment of glaucoma, as other review articles had, but rather looks in a more specific on the pros and the cons of each in relation to IOP reduction. In other words this article deals with the situation once the decision has been made to reduce IOP.

Microvascular blood flow of the optic nerve head and peripapillary retina in unilateral exfoliation syndrome

PURPOSE

To measure microvascular blood flow in patients with unilateral exfoliation syndrome (XFS) without glaucoma or ocular hypertension and to compare the values in the eyes with clinically detected exfoliation, their nonexfoliative fellow eyes of the same patients and control eyes.

METHODS

Twenty-two patients with clinically detected unilateral XFS and 30 age-matched healthy subjects were included in this study. Group 1 consisted of 22 eyes with clinical XFS, and the nonexfoliative fellow eyes of the same patients formed Group 2. The control group (Group 3) comprised te randomly selected eyes of 30 age-matched healthy subjects. Ocular blood flow values (volume, flow and velocity) were recorded from the opti nerve head (ONH) and peripapillary retina (PPR) using the Heidelberg retinal flowmeter (HRF). The difference between the three groups were compared statistically.

RESULTS

The mean values of blood flow obtained from the ONH and PPR in eyes with clinically detected exfoliation (Group 1) and their nonexfoliative fellow eyes (Group 2) were both significantly lower than the values for the control eyes (Group 3). The differences in ocular blood flow between the eyes with exfoliation and the nonexfoliative fellow eyes were not statistically significant [one-way analysis of variance (ANOVA), Dunnett's T3 test, p >/= 0.05].

CONCLUSION

These findings suggest that the eyes with clinically detected unilateral XFS were associated with reduced blood flow values in both the ONH and the PPR. The nonexfoliative fellow eyes also have lower blood flow values than the control eyes.