Coincidence of normal tension glaucoma, progressive sensorineural hearing loss, and elevated antiphosphatidylserine antibodies

Glaucoma, Pseudoexfoliation and Hearing Loss: A Systematic Literature Review

Purpose: To investigate the relationship between glaucoma, pseudoexfoliation and hearing loss (HL). Methods: A systematic literature search following PRISMA guidelines was conducted using the PubMed, Embase, Scopus and Cochrane databases from 1995 up to 28 August 2023. Results: Thirty studies out of the 520 records screened met the inclusion criteria and were included. Most articles (n = 20) analysed the association between pseudoexfoliation syndrome (XFS) and HL, showing XFS patients to have higher prevalence of sensorineural hearing loss (SNHL) at both speech frequencies (0.25, 0.5, 1 and 2 kHz), and higher frequencies (4 and 8 kHz) compared to controls in most cases. No significant differences in prevalence or level of HL between XFS and pseudoexfoliative glaucoma (XFG) were detected in most studies. Eight articles analysed the relationship between primary open-angle glaucoma (POAG) and HL. Overall, a positive association between the two conditions was highlighted across all studies except for two cases. Similarly, articles focusing on NTG and HL (n = 4) showed a positive association in most cases. The role of autoimmunity and, in particular, the presence of antiphosphatidylserine antibodies (APSA) in patients with NTG and HL suggested an underlying autoimmune or vascular mechanism contributing to their pathogenesis. Only one study analysed the relationship between angle-closure glaucoma (ACG) and HL, showing higher incidence of ACG in patients with SNHL compared to normal hearing controls. Conclusions: Most studies detected an association between XFS and HL as well as POAG/NTG/ACG and HL, suggesting the presence of a similar pathophysiology of neurodegeneration. However, given the strength of the association of XFS with HL, it remains unclear whether the presence of XFG is further associated with SNHL. Further research specifically targeted to assess the correlation between glaucoma, XFS and HL is warranted to provide a more comprehensive understanding of this association.

Bidirectional Association Between Sudden Sensorineural Hearing Loss and Glaucoma: A Cohort Study

OBJECTIVES

To investigate the bidirectional association between sudden sensorineural hearing loss (SSNHL) and open-angle glaucoma (OAG) over a 12-year follow-up period using nationwide, population-based data.

METHODS

The study was conducted using the National Health Information Database of the National Health Insurance Service (NHIS-NHID), which covered 3.5 million individuals from 2008 to 2019. In Study 1, we evaluated the effect of OAG on SSNHL, and in Study 2, we evaluated the effect of SSNHL on OAG. Participants of the control group were enrolled through "greedy nearest-neighbor" 1:1 propensity score matching.

RESULTS

In Study 1, 26,777 people were included in each group. The hazard ratio (HR) for SSNHL of the OAG group was 1.27 (95% confidence interval [CI], 1.15-1.39). In subgroup analysis, there was significant HR value regarding (old age: 1.17, hyperlipidemia: 1.19). In Study 2, 15,433 people were included in each group. The HR for OAG of the SSNHL group was 1.18 (95% CI, 1.07-1.30). In subgroup analysis, the HRs were significant for old age (2.31), hypertension (1.17), diabetes (1.39), and hyperlipidemia (1.26).

CONCLUSION

Over the 12-year follow-up, we found a bidirectional association between SSNHL and OAG, suggesting a shared pathogenesis.

LEVEL OF EVIDENCE

N/A. Laryngoscope, 133:3169-3177, 2023.

Ocular Manifestations Related to Antibodies Positivity and Inflammatory Biomarkers in a Rheumatological Cohort

Purpose

Ocular involvement is frequent in autoimmune diseases and even can be the first manifestation. There are multiple descriptions in the literature around the world regarding this topic. However, we evidenced a lack of studies analyzing the relationship between the ocular manifestations and systemic biomarkers, especially in Latinamerica. Therefore, this study aimed to examine the relationship between the positivity of inflammatory biomarkers and the ocular manifestations in a Colombian cohort of rheumatological patients.

Patients and Methods

We conducted an observational, descriptive, non-comparative cross-sectional study in a rheumatology center, in Bogotá, Colombia, from 2013 to 2019. We calculated a sample size of 797 patients to assess the prevalence of ocular manifestations and inflammatory biomarkers. We performed univariate analyses for categorical and continuous variables and bivariate analyses using the Chi-square and Fisher’s exact test for categorical variables.

Results

Women represented 84% of the population, and the mean age was 54.61± 15.64 years. Of 797 patients, 21.45% reported one or more ophthalmological diagnoses, being keratoconjunctivitis sicca (KCS) the most common (15.93%), followed by uveitis, and cataract (1.38%, each one). Regarding ophthalmological symptoms, 35% presented at least one, being dry eye sensation (DE) the most common (30.86%), followed by ocular pain (2.76%), red eye, and decreased visual acuity (2.63%, each one). The antibodies or inflammatory biomarkers most frequently found were antinuclear antibodies (ANAs) (35.3%), C-reactive protein (28.7%), and rheumatoid factor (27.9%). We found statistical associations between consumption of complement 3, anti-CCP, anti-RO, and anti-LA antibodies with ocular manifestations such as photophobia, DE, conjunctivitis, KCS, uveitis, retinal vasculitis, and maculopathy.

Conclusion

Ocular manifestations are frequently found in patients with positive antibodies and inflammatory biomarkers. Our results suggest antibodies and inflammatory molecules could be biomarkers for ocular manifestations in patients with rheumatological diseases. This study provides the basis for future longitudinal studies.

Discrepancy between NTG and POAG with corneal nerves in CCM

BACKGROUND

To investigate the morphological features of corneal subbasal nerve plexus (CSNP) in normal-tension glaucoma (NTG) and primary open-angle glaucoma (POAG).

METHODS

Thirty-four eyes with NTG (16 untreated), 23 eyes with POAG (11 untreated) and 31 eyes of healthy subjects were recruited. CSNP were assessed by corneal confocal microscopy (CCM) and peripapillary retinal nerve fibre layer (RNFL) was measured with optical coherence tomography (OCT). CCM parameters including corneal subbasal nerve fibre length (FL), corneal subbasal nerve branch number (BN), corneal subbasal nerve width (NW), corneal subbasal nerve reflectivity (NR), total and local corneal subbasal nerve tortuosity (NT) was compared across all groups, as well as between the topical medication treated and the nontreated patients.

RESULTS

The newly diagnosed NTG patients had the longest FL (3619.15 ± 501.55), most BN (21.02 ± 5.90), thinnest corneal subbasal nerve width (3.04 ± 0.82), corneal subbasal nerve lowest reflectivity (140.43 ± 10.24) and the corneal subbasal nerves were most bending (1.09 ± 0.06) and tortuous (123.36 ± 7.82) compared with untreated POAG patients and controls. Untreated POAG had similar CSNP to controls. The treated glaucoma patients had longer FL and more BN than the nontreated but with no significant difference. FL and BN had correlations with RNFL thickness in untreated NTG patients, and NR and NW had correlations with RNFL thickness in untreated POAG patients. NT had no correlations with RNFL thickness.

CONCLUSIONS

The NTG group had different CSNP characteristics from the POAG group and controls, while the latter two shared more morphological features. The CCM parameters except NT had associations with the RNFL thickness in glaucoma patients.

Ophthalmologic manifestations in primary antiphospholipid syndrome patients: A cross-sectional analysis of a primary antiphospholipid syndrome cohort (APS-Rio) and systematic review of the literature

OBJECTIVE

There is a broad spectrum of eye involvement in antiphospholipid syndrome (APS). The majority of descriptions are presented as case reports that include mostly APS patients secondary to systemic lupus erythematosus (SLE), with no compelling evidence in primary APS (PAPS). This study aimed to describe ocular manifestations in our well-defined PAPS cohort (APS-Rio) and then perform a systematic literature review (SLR) of ocular manifestations in patients with APS or positivity to aPL without SLE.

METHODS

We retrospectively analyzed PAPS patients followed at our outpatient clinics. All patients fulfilled Sydney APS classification criteria (2006). We evaluated them for ocular symptoms and previous ocular diagnoses. Antiphospholipid antibodies and clinical APS manifestations were compared between patients with and without ocular manifestations. For the SLR, electronic databases were searched up to November 2019.

RESULTS

We studied 105 PAPS patients; 90.5% were female and 56.2% were Caucasian. We found ocular manifestations in 37.1% of our cohort. Thrombosis was the main criteria manifestation (95.2%) and lupus anticoagulant was the most prevalent antibody. Ophthalmologic diagnoses were present in 7 patients, with 5 having retinal vessels thromboses. Amaurosis fugax was the leading complaint, present in 30 patients. In the univariate analysis, amaurosis fugax was related to livedo (p = 0.005), Raynaud's phenomenon (p = 0.048) and the presence of anticardiolipin antibody (≥40 GPL/MPL) (p = 0.041). Hemianopia was associated with arterial hypertension (p = 0.049). In the multivariate analysis, the only association found was between livedo and amaurosis fugax (OR 4.09, 95%CI 1.5-11.11, p = 0.006). Our SLR incorporated 96 articles of ocular manifestations in patients with PAPS or positivity to aPL without SLE. Ocular findings varied from 5 to 88%, including anterior and posterior segments, orbital and neuro-ophthalmologic changes.

CONCLUSION

There is little evidence on ocular manifestations in PAPS. We described an association between livedo and amaurosis fugax. Prospective studies are needed to promote the best treatment and avoid blindness in PAPS patients.

Open-angle Glaucoma and Sensorineural Hearing Impairment in the Korean Population

PURPOSE

This study identifies the prevalence and risk factors of sensorineural hearing loss and primary open-angle glaucoma (POAG).

MATERIALS AND METHODS

Patients aged 19 years or older who had undergone both ophthalmologic examination and audiometry as part of the Korea National Health and Nutrition Examination Survey V (2010-2012) were analyzed. Hearing loss was defined as the pure-tone average over 40 decibels based on the automatic hearing test to determine the threshold of airway hearing for each frequency. We investigated the prevalence of glaucoma and hearing loss when they occurred alone or simultaneously. The risk factors for concurrent glaucoma and hearing loss were examined.

RESULT

Among the participants, 6.6% had hearing loss alone, 2.3% had glaucoma alone, and 0.5% had both glaucoma and hearing loss. The weighted prevalence of glaucoma in patients with hearing loss was 7.5%; however, the weighted prevalence of glaucoma was 3.2% among patients without hearing loss, with a significant difference (P < .001). Multivariable logistic regression analysis revealed that the risk factors associated with concurrent glaucoma and hearing loss were age (3.786 times per 10 years, P < .001) and triglyceride level (1.002 times per 1 mg/dL, P = .028).

CONCLUSION

Sensorineural hearing loss and POAG are relevant. If hearing impairment and visual impairment occur together, the quality of life of the patient is worsened and the social burden is greater. Therefore, care should be taken when treating elderly patients with glaucoma.

Relationships between Hearing Loss and the Prevalences of Cataract, Glaucoma, Diabetic Retinopathy, and Age-Related Macular Degeneration in Korea

This study was conducted using the database of the Korea National Health and Nutrition Examination Survey to determine whether age-related eye diseases such as cataract, glaucoma, diabetic retinopathy (DR), and age-related macular degeneration (AMD), are related to hearing loss. 12,899 participants ≥ 40 years of age were included. The weighted prevalence of diabetic retinopathy was not significantly different between the normal hearing group and hearing-impaired group, but the weighted prevalences of cataract, glaucoma, early AMD, and late AMD were significantly different in the two groups. The odds ratio for cataract in the hearing-impaired group was 1.373 (1.118–1.687). The odds ratios of glaucoma, DR, early AMD, and late AMD were not significantly different in the hearing-impaired group. Age was significantly associated with the presence of concurrent cataract and hearing impairment by 6.574-fold per decade. Significant factors that increased the risk of concurrent glaucoma and hearing impairment were age, male gender, and triglyceride. Age, ex-smoker, systolic BP elevation, BMI decline, and fasting blood sugar significantly predicted the presence of concurrent DR and hearing loss. In early AMD, age and triglyceride, and in late AMD, age and systolic BP elevations increased the risk of concurrent AMD and hearing impairment.

Glaucoma: recent advances in the involvement of autoimmunity

Glaucomatous optic neuropathy is the most commonly acquired optic neuropathy encountered in clinical practice. It is the second leading cause of blindness globally, after cataracts, but it presents a greater public health challenge than cataracts, because the blindness it causes is irreversible. It has pathogenesis still largely unknown and no established cure. Alterations in serum antibody profiles, upregulation, and downregulation have been described, but it still remains elusive if the autoantibodies seen in glaucoma are an epiphenomenon or causative. Hypertension, diabetes, and hearing disorders also are associated. This review is a glaucoma update with focus about the recent advances in the last 15 years.

Emerging Concepts in Glaucoma and Review of the Literature

Glaucoma is the most commonly acquired optic neuropathy. It represents a public health challenge because it causes an irreversible blindness. Emerging evidence indicates that the pathogenesis of glaucoma depends on several interacting pathogenetic mechanisms, which include mechanical effects by an increased intraocular pressure, decreased neutrophine-supply, hypoxia, excitotoxicity, oxidative stress, and the involvement of autoimmune processes. In particular, alterations in serum antibody profiles have been described. However, it is still unclear whether the autoantibodies seen in glaucoma are an epiphenomenon or causative. Oxidative stress appears to be a critical factor in the neurodestructive consequences of mitochondrial dysfunction, glial activation response, and uncontrolled activity of the immune system during glaucomatous neurodegeneration. In addition, hearing loss has been identified in association with glaucoma. A higher prevalence of antiphosphatidylserine antibodies of the immunoglobulin G class was seen in normal-tension glaucoma patients with hearing loss in comparison with normal-tension glaucoma patients with normacusis. This finding suggests a similar pathological pathway as a sign for generalized disease.

Hearing in older adults with exfoliation syndrome/exfoliation glaucoma or primary open-angle glaucoma

PURPOSE

To determine whether adults, aged 66-96 years, with exfoliation syndrome (XFS)/exfoliation glaucoma (XFG), or primary open-angle glaucoma (POAG) have poorer hearing than controls of similar age.

METHODS

Case (XFS/XFG and POAG) and control status was diagnosed in the Reykjavik Glaucoma Studies (RGS) using slit-lamp examination, visual field testing and optic disc photographs; the RGS data were merged with the Age, Gene/Environment Susceptibility-Reykjavik Study that collected hearing data using air-conduction, pure-tone thresholds obtained at 0.5, 1, 2, 3, 4, 6 and 8 kHz categorized by better ear and worse ear, based on pure-tone averages (PTAs) calculated separately for low and middle frequencies (PTA512 - mean of thresholds at 0.5, 1 and 2 kHz) and high frequencies (PTA3468 - mean of thresholds at 3, 4, 6 and 8 kHz). Multivariable linear regression was used to test for differences in PTAs between cases and controls.

RESULTS

The mean age for 158 XFS/XFG cases (30.4% male) was 77.4 years, 95 POAG cases (35.8% male) was 77.9 years, and 123 controls (46.3% male) was 76.8 years. Using multivariable linear regression analysis, there were no consistent, statistically significant differences in PTAs between the two case groups and controls in either the low- or high-frequency range, even when stratified by age group.

CONCLUSION

Among the older individuals examined in this study hearing loss is highly prevalent and strongly associated with male gender and increasing age. As we did not find consistent statistically significant difference in hearing between cases and controls the diagnosis of XFS/XFG or POAG does not as such routinely call for audiological evaluation.

Serum antiphospholipid antibody levels in pseudoexfoliation

PURPOSE

To evaluate the levels of serum antiphospholipid antibodies in patients with pseudoexfoliation syndrome (PXS), pseudoexfoliation glaucoma (PXG), primary open-angle glaucoma, and healthy controls.

MATERIALS AND METHODS

This prospective study included 17 patients with PXS, 19 patients with pseudoexfoliation glaucoma, 15 patients with primary open-angle glaucoma, and 19 normal individuals. Venous blood samples were obtained in the morning after an overnight 8-hour fasting. Anticardiolipin antibodies, isotypes IgG and IgM were measured by means of an enzyme-linked immunosorbent assay. Lupus anticoagulant antibodies were measured by dilute Russell viper venom time screen test.

RESULTS

Mean±standard mean of error of anticardiolipin antibody IgG levels in patients with PXS and PEG were significantly higher than those of the controls (P<0.05). The mean lupus anticoagulant antibody levels of the controls were not statistically different from the levels of patients with PXS, pseudoexfoliation glaucoma, and primary open-angle glaucoma (P>0.05). The anticardiolipin antibody IgG concentrations above the cutoff value of 15 GPL/mL were found in 8 patients (21.05%) with pseudoexfoliation. There was no individual in the control group having anticardiolipin antibody IgG level above the cutoff value (P<0.05).

CONCLUSIONS

Elevated serum antiphospholipid antibodies, a risk factor for cardiovascular and cerebrovascular disease, is more common in patients with PXS and pseudoexfoliation glaucoma than in the healthy controls and in patients with primary open-angle glaucoma.

Hearing Evaluation in Patients with Exfoliative and Primary Open-Angle Glaucoma

Objective. The aim of this prospective study was to audiologically evaluate consecutive glaucoma patients with or without exfoliation.

Study Design. Prospective study.

Setting. Glaucoma Unit and Audiology Department at a university hospital.

Subjects and Methods. Consecutive subjects with exfoliative glaucoma (XFG) or primary open-angle glaucoma (POAG) aged between 50 and 70 years were enrolled. Auditory thresholds at 0.5, 1.0, 2.0, 4.0, and 8.0 Hz were measured bilaterally. Cochlear activity was assessed by recording distortion product otoacoustic emissions (DPOEs). Functional changes in the retrocochlear auditory pathway were evaluated by auditory brainstem responses (ABRs).

Results. One hundred and ten patients with XFG and 85 patients with POAG who presented in a glaucoma clinic were investigated. The mean age of study patients was 66.2 ± 5.6 years; range, 50-70 years). The odds of pathologic ABR central transmission time (interpeak latencies I-III, III-V, and I-V and waves I, III, and V) were 4.34 times higher in patients with XFG than in patients with POAG (95% confidence interval [CI], 2.22-8.49; P < .001). This significant association remained after adjusting for sex and age (odds ratio [OR] 4.12; 95% CI, 2.07-8.22; P < .001). Furthermore, the odds of ABR remained significantly higher in patients with XFG than in patients with POAG (OR 4.36; 95% CI, 2.10-9.06; P < .001) after controlling for systemic diseases (arterial hypertension, coronary heart disease, high cholesterol, and stroke).

Conclusion. In the first study to compare XFG and POAG monitoring of the peripheral and central auditory pathway, it has been documented that XFG patients show a greater prevalence of retrocochlear pathology.

Sensorineural hearing loss in pseudoexfoliation syndrome

PURPOSE

To determine hearing thresholds at sound frequencies important for speech comprehension in subjects with ocular pseudoexfoliation and to compare them with that of age- and sex-matched controls without pseudoexfoliation.

DESIGN

Case-control study.

PARTICIPANTS

Eighty-three subjects with ocular pseudoexfoliation and 83 age- and gender-matched controls without pseudoexfoliation.

METHODS

Pure tone audiometry (air and bone conduction) was performed at 1, 2, and 3 kilohertzes in all subjects. Hearing thresholds were compared with an age- and gender-stratified standard (ISO7029) and between study groups.

MAIN OUTCOME MEASURES

Individual hearing thresholds at 1, 2, and 3 kilohertz and hearing loss, defined as the sum of tested thresholds lower than the ISO7029 standard median.

RESULTS

A total of 166 eligible subjects were evaluated. Equal numbers of male and female subjects were allocated into each of the study groups (60 male and 23 female subjects in either group). Mean ages of male and female participants did not significantly differ in cases versus controls (P = 0.88 and P = 0.83). Below average hearing thresholds were present in 88.4% of examined ears in the case group, versus 53.6% in the control group (P<0.001; odds ratio [OR], 6.69; 95% confidence interval [CI], 3.49-11.79). Overall, 78 subjects (94.0%) in the case group, versus 58 subjects (69.9%) in the control group, had below average hearing in one or both ears (P<0.001; OR, 6.72; 95% CI, 2.42-18.62). Hearing thresholds at each of the examined frequencies and the total threshold were also significantly higher in individuals with pseudoexfoliation. Although glaucoma was significantly more common in subjects with pseudoexfoliation, it was not associated with below average hearing in any of the study groups.

CONCLUSIONS

Hearing thresholds at frequencies that are important for speech comprehension are significantly worse in individuals with ocular pseudoexfoliation than in matched controls. This finding may support the multiorgan nature of pseudoexfoliation syndrome.

[Primary open-angle glaucoma and systemic diseases]

The exact pathomechanism of primary open-angle glaucoma (POAG) is still not completely understood. Besides elevated intraocular pressure, which has been identified as a major risk factor, there is mounting evidence for the involvement of systemic factors in the development of glaucomatous damage. Systemic peculiarities described in POAG include cardiovascular, endocrine, neurodegenerative, and sleep alterations. However, some of the studies available on systemic findings in glaucoma patients are contradictory, making further research necessary to identify the exact role of such disturbances in the pathogenesis of the damage. Another difficulty is that many studies are limited by their small sample size, their retrospective nature, and potential selection bias, thus making data interpretation more difficult. Moreover, it is not always clear whether we are dealing with coincidence or a true association between glaucoma and a particular systemic disease. Nevertheless, there is ample evidence for the involvement of vascular factors such as vascular dysregulation and blood pressure in the pathogenesis of POAG.

A Sick Eye in a Sick Body? Systemic Findings in Patients with Primary Open-angle Glaucoma

Despite intense research, the pathogenesis of primary open-angle glaucoma (POAG) is still not completely understood. There is ample evidence for a pathophysiological role of elevated intraocular pressure; however, several systemic factors may influence onset and progression of the disease. Systemic peculiarities found in POAG include alterations of the cardiovascular system, autonomic nervous system, immune system, as well as endocrinological, psychological, and sleep disturbances. An association between POAG and other neurodegenerative diseases, such as Alzheimer disease and Parkinson disease, has also been described. Furthermore, the diagnosis of glaucoma can affect the patient's quality of life. By highlighting the systemic alterations found in POAG, this review attempts to bring glaucoma into a broader medical context.

Antiphospholipid antibodies in patients with sensorineural hearing loss

Sensorineural hearing loss can be associated with autoimmune diseases and the presence of antiphospholipid antibodies. Sixty patients (mean age 47 years, range 18-76 years) with sudden sensorineural hearing loss were studied with audiograms, stapedial thresholds, otoacoustic emissions, positional and caloric testing. The serologic testing included antibodies against phosphatidylserine and beta(2)-glycoprotein. Additionally, a group of 34 patients (mean age 65 years, range 31-81 years) with normal tension glaucoma was examined because in a previous study these patients were reported to have elevated concentrations of antiphospholipid antibodies with a coincidence of progressive sensorineural hearing loss. The baseline for antiphospholipid antibody levels was established in a control group of 40 healthy blood donors. In 12 of the 60 patients with sudden sensorineural hearing loss, levels of antiphospholipid antibodies were elevated. Antiphosphatidylserine IgM antibodies were significantly lower compared to controls and patients with the combination of hearing loss and normal tension glaucoma (Fisher's exact two-sided test, P < 0.01). Our data suggest that antibodies against beta2-glycoprotein seem to coincidence with an acute event, such as sudden sensorineural hearing loss, whereas antibodies against phosphatidylserine IgG are detectable in the prolonged sequel, such as in patients with progressive sensorineural hearing loss and normal tension glaucoma.