The amount of lens exfoliation and chamber-angle pigmentation in exfoliation syndrome with or without glaucoma

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Frequency and risk factors of narrow angles in patients with pseudoexfoliation: a case-control study

PURPOSE

To determine the frequency and risk factors of narrow angles in pseudoexfoliation (PXF) patients.

METHODS

A prospective case-control study was conducted during the period from March 2017 to December 2020. Adult patients (above 40 years) presenting with PXF were consecutively enrolled (study group). Cases were matched with individuals above 40 years presenting to a comprehensive ophthalmology clinic without evidence of PXF (control group).

RESULTS

We enrolled 196 PXF patients and 98 controls. The occurrence of narrow angles was 25% in the PXF group and 5.1% in the control group (P = 0.0001). Compared to controls, PXF patients were older (72.6 ± 9.6 vs. 64.4 ± 8.5, P < 0.0001) and had a lower mean ACD (2.79 ± 0.4 vs. 3.05 ± 0.4, P < 0.0001). There was no difference in AL measurements between both groups (23.3 ± 1.4 vs. 23.7 ± 1.0, P = 0.0714). After stratification by age group and gender, the risk of narrow angles was higher in PXF patients above 70 years (OR, 4.15; 95% CI, 0.91-23.87; P, 0.044). There was no gender difference in the risk of developing narrow angles.

CONCLUSION

Narrow angles are more frequently encountered in PXF patients compared to controls. Advanced age (> 70 years) is significantly associated with an increased likelihood of developing narrow angles.

Update on pseudoexfoliation syndrome pathogenesis and associations with intraocular pressure, glaucoma and systemic diseases

PURPOSE OF REVIEW

Pseudoexfoliation (PEX) syndrome is a common age-related disorder affecting intraocular and extraocular tissues. This review focuses on recent publications related with the pathogenesis and associations of PEX syndrome with intraocular pressure (IOP), glaucoma and systemic diseases.

RECENT FINDINGS

In PEX tissues, expression of lysyl oxidase-like 1 (LOXL1) was found to be markedly dysregulated. This may adversely affect elastin metabolism and lead to elastotic alteration in tissues such as lamina cribrosa. There is increasing evidence that cellular stress conditions and low-grade chronic inflammatory processes are involved in the pathogenesis of PEX. Although there is an increased risk for glaucoma development in patients with PEX and ocular hypertension as compared with non-PEX patients with ocular hypertension, LOXL1 single nucleotide polymorphisms were not associated with intraocular pressure (IOP) differences. Lack of association of PEX with all-cause mortality or dementia has been reported recently. The association with vascular diseases is not consistent among different studies.

SUMMARY

Despite the high prevalence of the LOXL1 variants in the general population, a much lower proportion of the population develops PEX, suggesting that in addition to LOXL1, other genetic, epigenetic and environmental factors may contribute to the development of PEX. Also, LOXL1 cannot help to identify those with PEX at increased risk for glaucoma development. Increased risk for glaucoma development in PEX patients who present with increased IOP may be related to other factors beyond IOP, contributing to increased vulnerability of the optic nerve to glaucoma development in the presence of PEX.

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.

Novel grading system for pupillary ruff changes and associated features

BACKGROUND

  To evaluate the reproducibility of a new system for grading pupil ruff changes and associated findings.

DESIGN

  Observational comparative study.

PARTICIPANTS

  Forty-seven photograph sets including iris, pupil edge and ruff, and inferior anterior chamber drainage angle.

METHODS

  A novel system for recording pupillary ruff changes was developed, along with reference iris, pupil and gonioscopy images. A prospective masked agreement study was undertaken using two observers who graded the photograph sets using this new system. Parameters included pupillary ruff absence and abnormality, pupil edge pigment, trabecular meshwork pigment, Sampaolesi line pigment, iris root pigment, and pigment 'lumps' and 'piles'.

MAIN OUTCOME MEASURES

  Intraobserver and interobserver agreement for the parameters of the grading system, assessed with the intraclass correlation coefficient and Bland-Altman plots.

RESULTS

  Photographs of 47 eyes of 47 glaucoma suspects and glaucoma patients were evaluated. Agreement percentages of ≥95% (average 96%) and ≥60% (average 70%) were obtained for intraobserver and interobserver agreement, respectively. The average interobserver single-measure intraclass correlation coefficient and repeat-measures intraclass correlation coefficient were 0.75 (range 0.54-0.88) and 0.85 (range 0.70-0.94), respectively. There was a non-significant trend towards interobserver systematic bias on one of the nine parameters (iris stroma pigment at the pupil edge).

CONCLUSION

  This grading system provides a reliable and reproducible system for encoding of clinical signs of pupil ruff atrophy for clinical research.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Correlation of Capsular Pseudoexfoliation Material and Iridocorneal Angle Pigment With the Severity of Pseudoexfoliation Glaucoma

PURPOSE

To evaluate the correlation between the amount of pseudoexfoliation (PXF) material on the anterior lens capsule, pigment in the iridocorneal angle, presenting intraocular pressure (IOP) and severity of glaucoma in patients with PXF glaucoma/syndrome.

PATIENTS AND METHODS

Anterior lens capsule PXF material and iridocorneal pigment of 98 untreated patients with PXF syndrome/glaucoma were graded from photographs and correlated with untreated IOP and indices of glaucoma severity (cup to disc ratio, and visual field mean deviation, and pattern standard deviation).

RESULTS

There was a positive statistically significant correlation between the iridocorneal angle pigmentation and IOP (P=0.047, R2=0.2), but not the indices of glaucoma severity (P>0.13). There was no significant correlation between the anterior lens capsule PXF material and IOP or the indices of glaucoma severity (P>0.42). The grade of angle pigmentation, but not lens PXF, in eyes with IOP >21 mm Hg was significantly higher than in eyes with IOP < or =21 mm Hg (P=0.04).

CONCLUSIONS

In patients with PXF syndrome/glaucoma, gonioscopically identified iridocorneal angle pigmentation correlates more strongly with presenting IOP than the amount of PXF material on the anterior lens capsule.

Exfoliation syndrome in Estonian patients scheduled for cataract surgery

PURPOSE

To examine the frequency of exfoliation syndrome (XFS) in Estonian patients scheduled for cataract surgery.

METHODS

A series of 305 patients (mean age 71.5 +/- 8.6 years) scheduled for cataract surgery were examined for the presence of exfoliation syndrome, predominant type of lens opacification and intraocular pressure (IOP).

RESULTS

Exfoliation material was detected in 108 (35.4%) patients, of whom 51 (47.2%) were bilaterally and 57 (52.8%) were unilaterally affected. In the bilaterally phakic patients exfoliation material was detected in 92 (30.2%) patients, of whom 51 (55.4%) were bilaterally and 41 (44.6%) were unilaterally affected. Intraocular pressure was higher in eyes with exfoliation than in eyes without it (19.2 +/- 6.5 mmHg and 17.1 +/- 3.8 mmHg, respectively; p = 0.006). Nuclear sclerosis predominated in eyes with XFS compared to those without XFS (57.6% and 36.9%, respectively). Cortical (7.6%) and subcapsular (7.6%) cataracts were less common in eyes with XFS than in eyes without XFS (16.9% and 20.2%, respectively). Mature cataract was found in 41.3% of all mixed types of cataracts.

CONCLUSION

Exfoliation syndrome is common in Estonian patients. It was detected in 35.4% of the patients scheduled for cataract surgery.

Pseudoexfoliation syndrome and pseudoexfoliative glaucoma

BACKGROUND

Pseudoexfoliative glaucoma (PXG) is a common secondary glaucoma that occurs when pigment and abnormal basement membrane material from anterior segment anatomical structures deposit in the trabecular meshwork. This anomaly arises from the predisposing condition, pseudoexfoliation syndrome (PXE). Complications are common, making this one of the most difficult glaucomas to manage.

PURPOSE

The literature is reviewed in order to facilitate understanding of this condition.

Unilateral exfoliation syndrome: conversion to bilateral exfoliation and to glaucoma: a prospective 10-year follow-up study

PURPOSE

This prospective 10-year follow-up study was conducted to examine conversion of nonglaucomatous eyes with unilateral exfoliation syndrome (EXS) to bilateral EXS and to glaucoma. Risk factors for conversion to a bilateral condition and to glaucoma were studied.

PATIENTS

Sixty-three nonglaucomatous subjects (mean age, 68.6 +/- 6.2 years) with unilateral EXS were enrolled. Of these patients, 56 were followed-up (89%). The effects of age, initial intraocular pressure (IOP), IOP difference between the fellow eyes, angle pigmentation, amount of exfoliation material, pupillary dilatation, optic disc topography, and phenylephrine-induced pigmentary dispersion on occasional conversion to the bilateral form and to glaucoma were studied by multivariate survival analysis.

RESULTS

In 10 years, 38% had converted to bilateral EXS. Conversion to exfoliation glaucoma (EG) was 32% in the initially exfoliative eyes and 38% in the initially nonexfoliative (non-EXS) fellow eyes. Primary open-angle glaucoma developed in 3.5% of the non-EXS eyes. In the initially EXS eyes, a significant association was found between the initial IOP and conversion to EG (relative risk = 1.471, = 0.0001). When initial IOP was removed from the model, the pupillary dilatation values (relative risk = 0.488, = 0.035) and the differences in IOP between the fellow eyes (relative risk = 1.224, = 0.0181) were associated with conversion to EG. None of the factors studied was associated with conversion to the bilateral form.

CONCLUSION

In unilateral EXS, factors associated with conversion to EG were initial IOP, pupillary dilatation value, and difference in IOP between the fellow eyes. No risk factors for conversion to bilateral EXS were found.

Exfoliation syndrome

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

Exfoliation syndrome and exfoliation glaucoma

Exfoliation syndrome abnormal deposition in the anterior segment of the eye of an unknown substance thought to be related to elastic fibres and basement membrane components is associated with accelerated cataract progression. increased frequency of intraoperative and postoperative complications and increased risk for glaucoma and. therefore, is a clinically important finding. A clear association has been shown with age. The syndrome occurs worldwide but its prevalence seems to vary from country to country. The best-known sign of exfoliation syndrome is deposits of greyish-white material on the anterior lens surface. Sometimes exfoliation material can also be seen at the pupillary border, on the anterior iris surface, corneal endothelium, and on the anterior vitreous face. When clinically detected, exfoliation syndrome is somewhat more often unilateral than bilateral. According to recent investigations clinically unilateral exfoliation syndrome is probably never truly unilateral but rather asymmetric, because exfoliation material has been detected ultrastructurally and immunohistochemically around iris blood vessels of the nonexfoliative fellow eyes. Indeed, electron microscopy identifies in various organs of patients with exfoliation syndrome fibrils similar to those seen in intraocular exfoliation deposits. Other clinical signs associated with exfoliation syndrome are pigment dispersion, transillumination defects of the iris and reduced response to mydriatics. In unilateral exfoliation syndrome, intraocular pressure (IOP) of the exfoliative eye is approximately 2 mmHg higher than IOP of the nonexfoliative fellow eye. Whether elevated IOP, vascular changes or exfoliation syndrome itself is the main factor causing optic nerve head damage and conversion of an exfoliative eye to glaucomatous, is not known. Glaucoma in the exfoliation syndrome has been shown to have a more serious clinical course than in primary open-angle glaucoma (POAG). At the time of diagnosis, IOP and its diurnal variation are generally higher and visual field defects tend to be greater in exfoliation glaucoma than in POAG. Because the decrease in lOP variation and lowering of the mean IOP level has been shown to improve visual field prognosis more in exfoliation glaucoma than in POAG, the glaucomatous process is considered to be more pressure-related in exfoliation glaucoma. Furthermore, progression of optic disc damage has been shown to be similar in exfoliation glaucoma and POAG when lOPs are lowered to a comparable level by the treatment. However, vascular disturbances in the posterior segment of the eye might after all be of equal importance in these two types of glaucoma; optic disc haemorrhages and venous occlusions have been reported to be as frequent in exfoliation glaucoma as in POAG. Perhaps in exfoliation glaucoma circullatory disturbances combined with high IOP lead to a particularly relentlessly progressing form of the disease.