Prevalence of exfoliation syndrome in Finland

The Effect of Trabecular Aspiration on Intraocular Pressure, Medication and the Need for Further Glaucoma Surgery in Eyes with Pseudoexfoliation Glaucoma

PURPOSE

To investigate whether trabecular aspiration (TA) has an effective medium-term intraocular pressure (IOP)-lowering and medication-saving effect in patients with pseudoexfoliation glaucoma (PEG). In addition, a subgroup analysis of patients with or without a previous trabeculectomy was performed.

METHODS

Records of 290 consecutive eyes with PEG that underwent TA between 2006 and 2012 at the Department of Ophthalmology, Mainz, Germany, were retrospectively analyzed with a follow-up period of 3 years. The main outcomes were IOP and the need for further medical treatment.

RESULTS

Of the 290 eyes with PEG that received TA, 167 eyes from 127 patients met the inclusion criteria. Among these eyes, 128 received TA and cataract surgery (Phaco-TA) without having had a trabeculectomy (group I) before, 29 had Phaco-TA after a previous trabeculectomy (group II) and 10 underwent stand-alone TA after a previous trabeculectomy (group III). In the whole cohort, the median IOP decreased immediately after TA and remained significantly lower compared to the baseline throughout the period of 36 months. Likewise, the median number of antiglaucoma drugs was reduced over the whole period. At the same time, in group I, the median IOP and the number of antiglaucoma drugs were reduced over 36 months. In contrast, in the post-trabeculectomy groups (group II and III), the median IOP and the number of antiglaucoma drugs could not be reduced. While most of the patients that received Phaco-TA with or without a previous trabeculectomy (group I and II) did not require further surgical intervention during the follow-up period, almost all patients receiving stand-alone TA after a previous trabeculectomy (group III) needed surgical therapy, most of them between the second and the third year following TA.

CONCLUSIONS

Phaco-TA has an effective medium-term pressure-lowering and medication-saving effect, especially in patients without a previous trabeculectomy. In trabeculectomized eyes, the effect of TA is limited but still large enough to delay more invasive surgical interventions in some patients.

Exfoliation Syndrome in Egypt: Prevalence and Association with Cataract in a Large Cohort

INTRODUCTION

Exfoliation syndrome is an age-related disease leading to ocular and systemic complications. We aimed to evaluate the prevalence of exfoliation syndrome (XFS) in Egypt and its association with cataract as one of its comorbidities.

METHODS

In a retrospective, hospital-based study, 155,032 Egyptians aged over 40 years from all 27 Egyptian governorates were evaluated for the prevalence of XFS and cataract in the period between January 2015 and June 2020.

RESULTS

A total of 2448 (1.6%) of the studied subjects had XFS. Their mean age was 71.2 ± 9.62 years which was significantly higher than those of subjects with no XFS. Men comprised 1348 (55.1%) of those diagnosed with XFS and this association was statistically significant (OR 1.57, 95% CI 1.45-1.70). Considering the ratio between subjects in our cohort from each region and its real population, the overall corrected prevalence in Egypt was 4.49% (Territorial regions 6.89%, Upper Egypt 5.51%, Lower Egypt 4.38%, and Greater Cairo 3.29%). Among all subjects with XFS, cataract was found in 2150 subjects (87.8%) and XFS represented 6.4% of all subjects diagnosed with cataract in our cohort (n = 33,610). Among subjects with no cataract (n = 121,422), 298 subjects had XFS (OR 0.04, 95% CI 0.03-0.04).

CONCLUSION

Egypt has a moderate XFS prevalence compared to other countries. There is a strong association between XFS and cataract, and XFS was more common in elderly males. The results can be explained by differences in diet, ethnicity, climate, and maybe other factors.

LOXL1 folding in exfoliation glaucoma

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

Severe Abnormalities of Lens Epithelial Cells in Exfoliation Syndrome: A Transmission Electron Microscopy Study of Patients with Age-Related Cataract

Background and objectives: The aim of this study was to examine via electron microscopy the lens epithelial cells in age-related cataracts and compare the findings between patients with and without exfoliation syndrome, in the Greek population. Materials and Methods: Twenty-one patients with age-related cataracts, older than 60 years, were included in the study. Eleven of them also suffered from exfoliation syndrome. Anterior lens capsules, obtained during phacoemulsification, were examined with a transmission electron microscope. Results: In all cases, ultrastructural features of diffuse intracellular and extracellular oedema were noticed to a varying degree and transparent vacuoles were detected. Often, there was more than one layer of cells, giving the impression that healthier cells tried to cover neighboring cells presenting extensive damage. Commonly, cells lost their regular shape and appeared with expanded nuclei carrying dense granules. Apoptotic cells were also detected. The epithelial cells frequently were completely destroyed or absent, exhibiting loose connections amongst them or with the basement membrane. In exfoliation syndrome (XFS) patients the alterations were more severe. Additionally, the lens epithelial cells (LECs) apical cell membrane appeared with varying distances from the basement membrane, due to different cell "heights", creating an irregular margin of the epithelium (p<0.05). Conclusion: Transmission electron microscope (TEM) examination revealed ultrastructural abnormalities in all patients' lens epithelia, more extended and more frequently observed in XFS group. In all cases, the lesions were comparable to those described in severe pathologies, all of which were excluded from the study. Environmental factors such as increased ultraviolet B (UVB) radiation exposure in Mediterranean countries, genetic factors, epigenetic factors, or all of them, could contribute to these alterations. Further epidemiological and molecular biology research is needed, so as to justify these results.

Cataract surgery outcome in patients with non-glaucomatous pseudoexfoliation

Aim. To study the outcome of cataract surgery in eyes with pseudoexfoliation without signs of glaucoma. Methods. This prospective study was done over nine months on patients with pseudoexfoliation undergoing small incision cataract surgery. Only patients with normal intraocular pressure (Central Corneal Thickness Corrected), normal cup disc ratio and open angles were included. Patients on anti-glaucoma medication were excluded. Patients underwent surgery performed by a single senior surgeon. Intraoperative and postoperative day (POD) 1 findings were noted. Results. The mean age of the patients was 61.60 years +/ - 10.21 years. Males were 46% (n=16). Right eye was operated upon in 60% of the cases (n=21). The mean pupil dilation was 5.1 mm +/ - 1.47 mm. The postoperative day 1 visual acuity of the patients was logMar 1.02 +/- 0.64 and the mean POD 1 intraocular pressure was noted to be 26.23 mmHg +/ - 11.40 mmHg. Five cases had a zonular dialysis intraoperatively due to weak zonules. 11 cases had high anterior chamber reaction of 2+ or more. Four cases had unavoidable sphincter tears and two cases had iridodialysis superiorly during nucleus delivery. Conclusions. Intraoperative complications should be anticipated in patients with pseudoexfoliation even without glaucomatous changes due to poor pupillary dilation and zonular weakness. First postoperative day visual acuity in pseudoexfoliation patients undergoing cataract surgery was found to be low due to severe anterior chamber inflammation causing elevated intraocular pressure and corneal edema. Abbreviations. POD = Postoperative day, PEX = Pseudoexfoliation syndrome, LOXL 1 = Lysyl oxidase-like 1, IOP = Intraocular pressure, AC = Anterior chamber, IOL = Intraocular lens.

Transmission electron microscopy study of undescribed material at the anterior lens capsule in exfoliation syndrome

PURPOSE

In the present study, we aimed to examine the anterior lens capsule using transmission electron microscopy (TEM) and compare the findings in patients with and without exfoliation syndrome (XFS).

METHODS

Eighteen patients with senile cataract, including 10 with XFS, were included. Anterior capsule specimens were obtained from patients during phacoemulsification through continuous curvilinear capsulorrhexis, and were examined via TEM.

RESULTS

In the XFS group, in addition to the typical fibrillar material above the basement membrane of the lens capsule, another unknown, microgranular, electron-dense, unbound material was observed beneath the lens epithelium. Larger formations appeared to detach from the surface of the epithelial cells, and oval or crescent-shaped structures of an electron-denser material were less commonly observed on the apical side of the epithelium. Membranous structures were occasionally attached to epithelial cells that often exhibited thicker or ruptured cell membranes on their apical-free side, along with deposits of electron-dense material. Degenerative lesions of various severities were observed at the epithelium in both groups.

CONCLUSION

The anterior lens capsule epithelium in patients with XFS exhibits a highly irregular and rough margin on its free side, with unbound material over its membrane, which probably contributes to loose contact with the underlying lens and leads to different clinical behaviors in XFS eyes during cataract surgery.

LOXL1 Polymorphisms: Genetic Biomarkers that Presage Environmental Determinants of Exfoliation Syndrome

An agnostic high throughput search of the genome revealed a robust association between LOXL1 genetic polymorphisms and exfoliation syndrome (XFS), a discovery that likely would not have been possible with candidate or family-based gene search strategies. While questions remain regarding how LOXL1 gene variants contribute to XFS pathogenesis, it is clear that the frequencies of disease-related alleles do not track with the varying disease burden throughout the world, prompting a search for environmental risk factors. A geo-medicine approach revealed that disease load seemed to increase as a function of the distance from the equator. The exact reason for this extraequatorial disease distribution pattern remains unclear, but a greater amount of time spent outdoors is a robust risk factor for XFS, suggesting climatic factors such as ocular solar exposure and colder ambient temperature may be involved in disease pathogenesis. Prospective studies have also implicated higher coffee consumption and lower dietary folate intake in association with incident XFS. The discovery of environmental risk factors for XFS suggests that preventive measures may help to reduce ocular morbidity from XFS.

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

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

Prospects for gene-environment interactions in exfoliation syndrome

Complex traits can be triggered by environmental factors in genetically predisposed individuals. The lysyl oxidase-like 1 gene (LOXL1) variants associated with exfoliation syndrome (XFS) are detected in >90% of cases that have been genotyped from sites around the world. Remarkably, roughly 80% of people without XFS also possess these same variants in all populations that have been tested. Nonetheless, the prevalence of XFS varies from ≤0.4% to >20%. These data suggest that other genetic variants, epigenetic modifications, or environmental factors also contribute to XFS. Furthermore, it is possible that environmental factors modify the association between LOXL1 and XFS. Interactions between LOXL1 variants and environmental factors could explain the varying prevalence of XFS seen throughout the world. At the very least, the discovery of the association between LOXL1 variants and XFS has opened the door to the discovery of environmental risk factors for this condition. Candidate gene-environment interactions in XFS will be discussed.

[Diagnosis and therapy of pseudoexfoliation glaucoma]

Pseudoexfoliation (PEX) glaucoma is the most frequent and most important type of secondary glaucoma, accounting for approximately 25% of open angle glaucoma worldwide and currently representing the most common identifiable cause of glaucoma overall. Due to high intraocular pressure levels, marked diurnal pressure fluctuations and spikes, and rapid optic nerve damage and visual field loss, PEX glaucoma represents a relatively severe and progressive type of glaucoma. Therefore, hard and fast lowering of intraocular pressure is necessary. Fixed combinations in medical therapy and early glaucoma surgery are recommended. When considering a surgical procedure (e.g. selective laser trabeculoplasty, bleb-dependent or bleb-independent surgery) the timing of cataract surgery plays a major role. Pathogenesis, clinical characteristics and therapeutic aspects of PEX glaucoma are described in the following article.

Pseudoexfoliation syndrome in Congolese patients

PURPOSE

To determine the frequency of pseudoexfoliation syndrome (PEX) in Congolese patients and its association with cataract and glaucoma.

METHODS

We performed a cross-sectional and descriptive analysis of the data from patients diagnosed with PEX. Data were collected between February 2005 and June 2008 in a general practice of ophthalmology in Kinshasa. Patients aged 50 or above who attended the general practice of ophthalmology were included in the study. Each patient underwent complete ophthalmic evaluation, including visual acuity testing, slit-lamp biomicroscopy, applanation tonometry, gonioscopy, and ophthalmoscopy. The diagnosis of PEX was based on presence of typical pseudoexfoliation material on the anterior lens surface and/or the pupillary margin in either or both eyes.

RESULTS

Of 2142 patients seen during the study period, 37 (59 eyes) had PEX in either eye, for a frequency of 1.73%. The mean (±SD) age of the patients with PEX was 70.40 years±8 (range: 57-87 years). The frequency of PEX had a tendency to increase with age: 0.50% of patients aged 50-59 years had PEX, whereas 7.29% of those aged more or equal to 80 years were affected (P<0.0001), with a female predominance (2.18% of women versus 1.22% of men, P=0.035). PEX was bilateral in 22 (59.46%) of 37 patients (74.58% of eyes). Bilateral PEX was found more often in females (16 patients over 22, 72.72%) than in males (six patients over 15, 40%) (P=0.05). PEX was significantly associated with cataract (P=0.002) and glaucoma (P<0.001).

CONCLUSION

Despite the limitations inherent in a clinic-based study, this investigation provides an indication of the frequency of PEX in Central Africa. This shows that Congolese patients have a low frequency of PEX (1.73%), inferior to that of black people in South Africa (12.1-16%). This study confirms that PEX is an age-related condition and is associated with cataract and glaucoma, as in other races.

Demographic and geographic features of exfoliation glaucoma in 2 United States-based prospective cohorts

PURPOSE

To examine prospectively the association between demographic and geographic factors in relation to exfoliation glaucoma (EG) or exfoliation glaucoma suspect (EGS).

DESIGN

Prospective cohort study.

PARTICIPANTS

Seventy-eight thousand nine hundred fifty-five women in the Nurses' Health Study and 41 191 men in the Health Professionals Follow-up Study.

METHODS

Female and male health professionals were followed prospectively from 1980 through 2008 and from 1986 through 2008, respectively. Eligible participants were 40 years of age or older, did not have EG or EGS at baseline, and reported undergoing eye examinations during follow-up. Information regarding demographic features, lifetime geographic residence, and potential confounders was collected. During follow-up, 348 EG or EGS cases were confirmed with medical record review. The relative risk of EG or EGS in each cohort was estimated separately and the results were pooled with meta-analysis.

MAIN OUTCOME MEASURES

Multivariate rate ratios (MVRRs) of EG or EGS and their 95% confidence intervals (CIs).

RESULTS

Exfoliation glaucoma or EGS was strongly age related with subjects 75 years of age or older at 46.22-fold (95% CI, 22.77-93.80) increased risk compared with those between 40 and 55 years of age. Although men were 68% less likely to develop EG or EGS than women (MVRR, 0.32; 95% CI, 0.23-0.46), no predisposition to EG or EGS by ancestry, particularly Scandinavian ancestry, emerged. Compared with a lifetime of living in the northern tier of the continental United States, lifetime residence in the middle geographic tier (MVRR, 0.53; 95% CI, 0.40-0.71) and in the southern geographic tier (MVRR, 0.25; 95% CI, 0.09-0.71) was associated with markedly reduced risks of EG or EGS.

CONCLUSIONS

In this mainly white cohort from the United States, increasing age and female gender were significant risk factors for EG or EGS; however, Scandinavian heritage was not. Living in the middle or southern regions of the United States relative to living in the northern region was associated with a reduced risk of EG or EGS.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Geographic and climatic factors associated with exfoliation syndrome

OBJECTIVE

To identify geographic and climatic risk factors associated with exfoliation syndrome (ES).

METHODS

A retrospective study of 626 901 eye care recipients, dating from 2001 to 2007 from 47 US states in a managed care network. Incident ES cases-patients (N = 3367) were identified by using billing codes. We assessed the risk of ES by geographic latitude tier in the continental United States and assigned state-level climatic data (eg, ambient temperature, elevation, and sun exposure) according to patients' residential location. The hazard of ES was calculated by using multivariable-adjusted Cox proportional hazards regression models.

RESULTS

Compared with middle-tier residence, northern-tier residence (above 42°N) was associated with an increased hazard of ES (adjusted hazard ratio [HR], 2.14; 95% confidence interval [CI], 1.94-2.35). Southern-tier (below 37°N) was associated with a reduced hazard of ES (HR, 0.83; 95% CI, 0.75-0.93). Excluding whites did not change these associations. After adjustment for joint environmental effects, for every 1° increase in July high temperature, the hazard of ES decreased by 9% (HR, 0.91; 95% CI, 0.89-0.93); for every 1° increase in January low temperature, the hazard decreased 3% (0.97; 0.96-0.98). For each additional sunny day annually, the hazard increased by 1.5% (HR, 1.02; 95% CI, 1.01-1.02) in locations with average levels of other climatic factors.

CONCLUSION

Ambient temperature and sun exposure may be important environmental triggers of ES.

Exfoliation syndrome: prevalence and inheritance in a subisolate of the Finnish population

PURPOSE

To estimate the prevalence of pseudoexfoliation syndrome or exfoliation syndrome (ES) in a cross-sectional study and during a long-term follow-up, and to analyse how ES has been inherited in a large pedigree on an isolated population of Kökar island in southern Finland.

METHODS

In a population-based study conducted between 1960 and 1962, a comprehensive ophthalmological examination was performed on 595 subjects (85% of the population). From then until 2002, 965 subjects were examined at least once. A pedigree was constructed for all ES-affected subjects according to genealogical studies. The genetic contribution to ES was investigated in this pedigree by segregation analysis and the heritability of the intraocular pressure (IOP) quantitative trait estimated using SOLAR and SAGE software.

RESULTS

In the cross-sectional study, the prevalence of ES was 8.1% for 247 subjects over 50 years of age (males 7%, females 9%) and increased to 18.4% for 70 subjects over 70 years of age (males 13%, females 25%). In addition, two females less than 50 years of age were ES-affected. Between 1960 and 2002, 76 (14.3%) of 530 subjects over 50 years of age had ES [23 males (10%) and 53 females (18%)]. Exfoliation glaucoma (EG) was found more often in males (11 patients, 48%) than in females (13 patients, 25%) whereas primary open-angle glaucoma (POAG) was almost as frequent in males (seven patients, 3%) as in females (five patients, 2%). The relative risk (RR) of glaucoma (ES versus no ES) was 11.9 [95% confidence interval (CI) 6.2-22.9] for all the subjects - 14.6 for males (95% CI 6.3-34.0) and 11.8 for females (95% CI 4.4-31.6). Seventy-five pedigrees of 78 ES-affected patients were linked together into one large pedigree with 110 nuclear families. The segregation ratio of ES was 18% (8% for males, 24% for females) when both parents were unaffected, and 16% (9% for males, 27% for females) when at least one parent was affected. The heritability of IOP was estimated to be 30%.

CONCLUSION

In this population-based family study, ES is consistent with an autosomal dominant trait with incomplete penetrance, where the penetrance is more reduced in males than in females. However, the presence of ES was a greater risk factor for developing glaucoma in males than in females.

Cataract and glaucoma surgery in pseudoexfoliation syndrome: a review

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

Matrix metalloproteinases and their inhibitors in the chamber angle of normal eyes and patients with primary open-angle glaucoma and exfoliation glaucoma

BACKGROUND

In glaucoma, extensive pathological changes occur in the trabecular meshwork (TM) and juxtacanalicular tissue of the chamber angle. Aqueous humor drainage is disturbed due to the accumulation of extracellular matrix (ECM) material in the outflow system. Matrix metalloproteinases (MMPs) remodel ECM material and, thus, they may have a role in regulating outflow facility and intraocular pressure (IOP). This study examined the expression of MMPs and tissue inhibitors of MMPs (TIMPs) in the chamber angle of normal eyes and in primary open-angle glaucoma (POAG) and in exfoliation glaucoma (ExG).

METHODS

TM tissues were isolated from healthy donor eyes for corneal transplantation. Specimens of the inner wall of Schlemm's canal and the juxtacanalicular tissue were collected from patients with POAG or ExG during deep sclerectomy operation. Monoclonal antibodies against MMPs (MMP-1, -2, -3, and -9) and antibodies against TIMPs (TIMP-1, -2, and -3) were used for immunohistochemical staining.

RESULTS

Immunoreactivity for MMP-2, TIMP-2, or TIMP-3 was observed in human normal TM and in the inner wall of Schlemm's canal. In general, immunoreactions for all of the tested MMPs were more intense in POAG samples than in ExG samples or in the control group. The only exception was the MMP-2 level, which was the highest in the control group. The staining intensity of MMP-1 or MMP-3 was significantly higher in POAG when compared to ExG. TIMP-1 was significantly increased in POAG compared with ExG and there were no marked differences in the levels of TIMP-2 or TIMP-3 between POAG and ExG. The ratios of MMP-1/TIMP-1 and MMP(1+2+3+9) and TIMP(1+2+3) were significantly higher in samples from POAG compared to those of ExG.

CONCLUSIONS

Our results reveal an expression imbalance between MMPs and their endogenous tissue inhibitors in tissue samples from patients with POAG and ExG. Differences in immunohistochemical reactions reflect discrete local pathogenic mechanisms involved in POAG and ExG. With respect to the proposed role of MMPs in the remodeling of ECM material, this may point to a weaker reactivity to the accumulation of ECM material in TM in ExG than POAG eyes.

Exfoliation syndrome in Nordic countries: a comparative histopathological study of Danish and Finnish eyes with absolute glaucoma and uveal melanoma

PURPOSE

To compare the frequency of exfoliation syndrome (EXS) in Denmark and Finland in eyes enucleated for absolute glaucoma and uveal melanoma and to correlate these results to reported clinical prevalence rates.

METHODS

The material consisted of 304 and 39 eyes consecutively removed because of absolute glaucoma and of 240 and 149 eyes enucleated because of uveal melanoma in Denmark and Finland, respectively. Histological sections of all eyes were stained with haematoxylin-eosin and periodic acid-Schiff and examined under a light microscope for EXS. Diagnosis of EXS was made by the consensus of the investigators.

RESULTS

In absolute glaucoma eyes, EXS was observed in 12 out of 304 eyes (3.9%, 95% CI 2.1-6.8) in Denmark, and in 16 out of 39 eyes (41%, 95% CI 26-58) in Finland (p < 0.0001). In the melanoma eyes, EXS was noted in two out of 240 eyes (0.8%, 95% CI 0.1-3.0) in Denmark and in nine out of 149 eyes (6.0%, 95% CI 2.8-11) (p < 0.0037) in Finland.

CONCLUSIONS

The frequency of EXS was significantly higher in eyes removed for absolute glaucoma and malignant melanoma in Finland than in Denmark. This supports the clinical impression that EXS is rare in Denmark compared to other Nordic countries.

Results of combined phacoemulsification and trabeculectomy with mitomycin C in pseudoexfoliation versus non-pseudoexfoliation glaucoma

BACKGROUND

This study was conducted to evaluate the rate of intraoperative and postoperative complications and the outcome of combined phacoemulsification (phaco) with posterior chamber (PC) intraocular lens (IOL) and trabeculectomy in patients with pseudoexfoliation (PXF) versus non-pseudoexfoliation (non-PXF) glaucoma.

METHODS

One hundred and four eyes of 88 patients with combined phaco, PC IOL and trabeculectomy with mitomycin C (MMC) were included in the study. MMC 0.02% was applied for 1 min in all cases. Main outcome measures were rate of intraoperative and postoperative complications, intraocular pressure (IOP) and visual acuity (VA). Success rates were determined via Kaplan-Meier survival analysis. Surgical success for both groups was defined as IOP being less than 21 mmHg with no treatment or less than 16 with one topical pressure-reducing agent allowed.

RESULTS

The PXF group included 55 (52.9%) eyes and the non-PXF group 49 (47.1%) eyes. Transition to extracapsular cataract extraction (ECCE) occurred in 12.7% of the PXF group, and in 6.1% of the non-PXF group (P=0.16). The occurrence of vitreous loss did not differ significantly between the groups. Patients of both groups had a significant IOP reduction after surgery (P=0.0001). At the end of postoperative follow-up, the success rate approached 83.6% in the PXF group and 83.7% in the non-PXF group. The most common postoperative complications were hyphema (14.5%) in the PXF group and fibrin (14.3%) in the non-PXF group.

CONCLUSIONS

Although transition to ECCE was more frequent in the PXF than in the non-PXF group, there was no significant difference in the rate of complications between PXF and non-PXF eyes.

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.