Ocular pseudoexfoliation syndrome and vascular disease: a systematic review and meta-analysis

Exfoliation syndrome and exfoliation glaucoma: Current perspectives and clinical paradigms

Exfoliation syndrome and exfoliation glaucoma comprise a unique age-related ocular aggregopathy characterized by the accumulation of protein complex aggregates in different ocular structures. Recent literature and studies have expanded our knowledge of the clinical characteristic features, phenotypical variations, and molecular pathophysiology associated with disease onset or development of glaucoma. Despite years of studies on the various epidemiological, clinical, and molecular facets of the disease, the exact mechanism of disease onset, formation of aggregates, and the events that trigger the development of glaucoma marking irreversibility in the disease remains elusive. This review elaborates on the existing and new insights that we have gained over the years and highlights gaps in the knowledge about the disease that need future exploration.

Risk factors for exfoliation glaucoma - Current evidence and perspectives

Exfoliation syndrome (XFS) and exfoliation glaucoma (XFG) represent a complex matrix of ocular age-related neurodegenerative changes. Numerous decades of research on this disease entity have highlighted the unique clinical features of ocular protein-complex aggregates, which lead to tissue dysfunction of the ocular outflow channels, leading to irreversible optic nerve damage and glaucoma. While genetic studies have reported several genes associated with XFS and XFG, numerous studies have shown their association with common systemic diseases such as ischemic heart disease, cerebrovascular accidents, and hypertension. Environmental factors are also reported to play a role in the disease pathogenesis by epigenetic control of gene expression and partly explain the difference in the prevalence rates of the disease process. Despite the identification of possible triggers for the disease onset or for the development of glaucoma, the exact mechanisms or the role of several reported risk factors in disease pathogenesis remain a mystery. This review comprehensively evaluated the several risk factors in XFS and XFG while discussing the interactive interplay between the risk factors that determine the disease onset or phenotype in XFS and XFG.

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.

Optic Nerve Head, Peripapillary and Macular Microvascular Characteristics in Patients With Unilateral Pseudoexfoliation Glaucoma

PRCIS

In unilateral pseudoexfoliation glaucoma (PEXG), there may be decreased choroidal vascularity index (CVI), radial peripapillary capillary plexus' perfusion and flow. CVI may also be reduced in fellow eyes, suggesting that PEXG is bilateral disease.

PURPOSE

Evaluation of peripapillary and macular choroidal microvascularity and radial peripapillary capillary plexus in both eyes with unilateral PEXG and healthy eyes.

MATERIALS AND METHODS

Ninety-six eyes of 48 patients with unilateral PEXG [PEX (+): 48 eyes with PEXG; PEX (-): 48 eyes without PEX] and the right eyes of 45 age- and sex-matched healthy controls were included in the study. CVI was calculated on enhanced depth imaging optical coherence tomography scans. Radial peripapillary capillary vascular layer were evaluated by OCT-angiography.

RESULTS

Macular CVI (mCVI), temporal and nasal peripapillary CVI (pCVI) was significantly decreased in the PEX (+) compared with the PEX (-) and control group ( P <0.05 for all). Although there was a significant difference between PEX (-) and the control group in terms of mCVI and temporal pCVI, there was no significant difference between the 2 groups in terms of nasal pCVI ( P =0.008, P =0.036, and P =0.604, respectively). There was a significant difference in perfusion density (PD) and flux index (FI) between PEX (+) group, PEX (-) group and control group in all quadrants and average value ( P <0.05 for all). Although the PD and FI values in all quadrants and average values of the PEX (-) group were lower than the control group, this difference was not significant.

CONCLUSIONS

CVI in the macula and peripapillary region was significantly decreased in eyes with PEXG. Similarly, PD and FI were lower in eyes with PEXG. Low mCVI and temporal pCVI can also be seen in eyes without PEX.

The Differences in the Pattern of OCT and OCTA Examinations between Early Normal- and High-Tension Pseudoexfoliative Glaucoma

Purpose. The aim of this study was to compare the results of optical coherence tomography angiography (OCTA) and optical coherence tomography (OCT) examinations in patients with normal-tension glaucoma (NTG) in comparison to high-tension pseudoexfoliative glaucoma (HTG) patients at the early stage of glaucoma. Material and methods. The studied groups consisted of patients in the early stage of NTG (70 eyes) and the early stage of HTG (71 eyes). In NTG and HTG groups, a detailed ophthalmic examination was performed. Optic disc OCT with peripapillary RNFL measurements and OCTA examination with the evaluation of the macula and optic disc were performed for all participants using Zeiss Cirrus 5000. Results. NTG and HTG groups were statistically similar as far as the MD was concerned, and both groups had early glaucoma. When evaluating the RNFL thickness, the only statistical difference between early NTG and HTG was observed in the thicknesses in the temporal sector of peripapillary RNFL, with thinner values in the NTG group (53.94 vs. 59.94, p = 0.0071). When the OCTA results of the macula and optic disc were evaluated, there were no statistical differences between early NTG and HTG. Conclusions. The vascular density and flow parameters assessed in OCTA were equal between early NTG and HTG, and therefore the involvement of vascular factors in NTG pathogenesis could not be confirmed. Our results confirm the preponderance of more frequent temporal RNFL involvement in early NTG.

Results of Nailfold Videocapillaroscopy in Patients with Pseudoexfoliative Glaucoma

The aim of this study was to evaluate the nailfold videocapillaroscopic examination results from patients with pseudoexfoliative glaucoma (XFG) and to assess the relationship between the results of this examination and the patient's clinical status in the XFG group.

MATERIAL AND METHODS

The studied group consisted of 39 Caucasian patients with XFG and 32 patients in a control group. The patients were classified into two subgroups: the hypertensive pseudoexfoliative glaucoma (hXFG) subgroup and the normotensive pseudoexfoliative glaucoma (nXFG) subgroup. The nailfold videocapillaroscopy (NVC) was performed on all participants. The results of each NVC were classified as having a normal or abnormal pattern.

RESULTS

There was no statistical difference between the results of an abnormal NVC pattern in the study group vs. the control group (p = 0.8773). Microhemorrhages were shown in 30.0% of patients with nXFG vs. the control group (6.25%) (p = 0.0520). Microhemorrhages tended to be more frequent in the XFG group (p = 0.1221). A prevalent number of tortuous capillaries was observed in hXFG patients with advanced glaucomatous neuropathy. Dilatation in the capillaries and microbleedings were observed in the group of patients with lower IOP values. Tortuosity in the capillaries was significantly more frequent in PEXG patients (XFG vs. control: p = 0.0386). No relationships between the results of NVC and age, c/d, BCVA, time of treatment, and visual field defect were found.

CONCLUSIONS

Specific features of NVC examination differentiate nXFG from hXFG patients. Some capillaroscopic features may correlate with the patient's clinical status of XFG.

Optic nerve head vessel density in patients with pseudoexfoliation syndrome/glaucoma: a systematic review and meta-analysis

PURPOSE

Exfoliative material has been shown to accumulate in ocular and systemic tissues. We aimed to perform a systematic review and meta-analysis of the current literature evaluating optic nerve head vessel density (VD) using optical coherence tomography angiography (OCTA) in patients with XFS and XFG.

METHODS

Studies were retrieved from PubMed, Scopus, and Web of Science databases. Studies comparing patients with XFS and/or XFG patients to healthy controls, using the optic nerve head-centred 4.5 × 4.5 mm square OCTA scan protocol were included. Pooled results are presented as standardised mean differences with 95% confidence intervals (CI). Meta-regression analysis was performed between mean difference in circumpapillary VD between XFG and controls and mean pRNFL thickness in patients with XFG.

RESULTS

Fifteen studies with 1475 eyes were included in this review. Whole image VD and circumpapillary VD (cpVD) were significantly decreased in patients with XFS [-0.78(95% Cl: -1.08, -0.47); [-0.55(95% Cl: -0.80, -0.30); respectively] and XFG [-1.85(95% CI: -2.33, -1.36); -1.84 (95% CI: -2.30, -1.39); respectively] compared to healthy controls. Furthermore, pRNFL thickness decreased in patients with XFS [-0.55(95% Cl: -0.72, -0.35)] and XFG [-1.78(95% Cl: -2.21, -1.36)] compared to healthy controls. Meta-regression showed that pRNFL thickness decreased with increasing mean cpVD difference in XFG patients compared to healthy controls.

CONCLUSIONS

OCTA provides non-invasive, objective and reproducible assessment of peripapillary VD and is important for the detection of vasculopathy in patients with XFS or XFG. This study provides strong evidence for decreased cpVD in the eyes of patients with XFS and XFG.

Beyond vision:Cataract and health status in old age, a narrative review

Cataract is a leading cause of visual impairment in old age. Lens opacification is notoriously associated with several geriatric conditions, including frailty, fall risk, depression and cognitive impairment. The association is largely attributable to visual impairment, while other mechanisms, associated with extraocular comorbidity and lifestyle, might partly explain this correlation. Available literature suggests that cataract surgery may be effective in decreasing fall risk, improving depressive symptoms and limiting the risk of cognitive impairment and dementia incidence, although intervention studies on these outcomes are still limited. In this review we also emphasize the need to move from the concept of visual acuity to functional vision, especially in the context of the geriatric patient. Research is needed regarding the effect on the cited outcomes of different cataract treatment strategies, such as systematic bilateral versus monolateral surgery and use of different intraocular lenses.

Abdominal aortic aneurysm and exfoliation syndrome in Utah

PURPOSE

A pilot study of electronic medical records (EMR) in Utah was undertaken to investigate exfoliation syndrome and exfoliation glaucoma (XFS/XFG) in abdominal aortic aneurysm (AAA) patients. In a subsequent retrospective cohort study of Utah XFS/XFG patients and population controls, the risk of AAA was examined.

METHODS

EMR of a statewide healthcare population were obtained from the Utah Population Database (UPDB) which links decades of medical records with Utah demographic and vital records data. In a pilot study, 7167 patients ages ≥40 years identified with AAA diagnosed from 1996 to 2015, based on International Classification of Diseases (ICD) version 9/10 codes, were included. A univariable hazards model was used to determine the risk of XFS/XFG in AAA patients. An XFS/XFG outcome based on ICD 9/10 codes in AAA patients and in 5:1 sex- and age-matched non-AAA controls was determined. A retrospective cohort of 3412 XFS/XFG patients ages ≥50 years diagnosed from 1996 to 2020 and 10 227 3:1 sex- and age-matched controls who underwent ≥1 dilated eye examination(s) were recently identified and updated diagnoses of AAA were obtained. Multivariable logistic regression was used to estimate AAA risk in XFS/XFG patients compared with controls. In a subset of XFS/XFG patients, chart reviews were conducted to confirm clinically diagnosed AAA.

RESULTS

In the AAA pilot, 20 patients (0.3%) and 118 controls (0.3%) developed XFS/XFG, respectively. We observed no increased risk of XFS/XFG in AAA patients compared with non-AAA-matched controls (HR = 0.99, 95% CI 0.6-1.6). Among XFS/XFG study patients and controls, 122 patients (3.6%) and 376 controls (3.7%) had an AAA diagnosis. We likewise observed no increased risk of AAA in XFS/XFG patients (OR = 0.97, 95% CI 0.8-1.2). In 14 XFS/XFG patients with an ICD 9/10 diagnosis of AAA who underwent chart review, a clinical diagnosis of AAA was confirmed in 9 patients (64.3%).

CONCLUSION

Our findings do not support an association between AAA and XFS/XFG.

Paracentral Acute Middle Maculopathy Revealing a Giant Aortic Aneurysm

BACKGROUND

This report describes a case with paracentral acute middle maculopathy revealing a giant aortic aneurysm.

CASE DESCRIPTION

A 41-year-old man presented with unilaterally unexplained sudden vision loss in the left eye. Fundoscopy revealed a slightly pale r -26etinal reflex in the superior retinal hemifield. SDOCT revealed blurred boundaries between retinal segments and prominent edema in the middle retinal layers. OCTA revealed decreased vascular density in the deep capillary plexus. FA showed low arterial circulation mainly in the superior retinal hemifield. Humphrey VFT revealed an inferior altitudinal defect in the left eye, implying a related circulatory disturbance in the corresponding region.A thorough systemic work-up, including a cardiovascular etiological investigation, revealed giant aortic aneurysm in the ascending aorta, necessitating emergency surgery.

CONCLUSION

This report highlights the importance of a systemic etiological investigation in patients with PAMM to rule out any potential cardiovascular issues.

Exploring association between pseudoexfoliation syndrome and ocular aging

PURPOSE

Within a population-based follow-up study, to examine the 10-year incidence of pseudoexfoliation syndrome (PEX), possible risk factors for PEX and its association with ocular aging of the cornea, lens and retina.

METHODS

The baseline examination was conducted in 2006 on a random sample of 1,033 adult participants from Kaunas city (Lithuania) population of whom 631 had ophthalmic examination data at attendance of the 10-year follow-up in 2016. Detailed examination of the anterior and posterior segment of the eye was carried out. After diagnostic mydriasis PEX was diagnosed by the presence of typical grayish-white exfoliation material on the anterior capsule surface of the lens. The participants were divided to PEX and non-PEX groups.

RESULTS

PEX prevalence increased from 9.8 to 34.2% from baseline to 10-year follow-up. Nuclear cataract was common both in the PEX group (66.7%) and in those without PEX (72.2%), but this difference did not reach statistically significantly increased risk of developing cataract in those with PEX (OR 1.2; p = 0.61). Central corneal thickness (CCT) was thinner in the PEX group (529 ± 34 μm) and in the oldest group (525 ± 36 μm) (p < 0.001). Compared to baseline, corneal curvature (CC) became flatter in both groups (7.6 ± 0.27 vs 7.7 ± 0.26 mm; p < 0.001) during the follow-up, but the difference did not reach significance between groups. Corneal astigmatism was most commonly with-the-rule in both groups (37 (50.0%) vs 148 (68.5%); p > 0.05). Age, sex and PEX had no influence on age-related macular degeneration distribution.

CONCLUSION

The prevalence of PEX increased significantly with age in our population, with those with PEX having thinner and flatter corneae, but no difference in cataract and age-related macular degeneration characteristics.

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

OBJECTIVE

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

DATA SOURCES

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

REVIEW METHODS

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

RESULTS

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

CONCLUSIONS

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

Red cell distribution width levels in patients with pseudoexfoliation syndrome and pseudoexfoliation glaucoma

Purpose

The purpose of this study was to assess the levels of red cell distribution width (RDW) in patients with pseudoexfoliation syndrome (PEX) and pseudoexfoliation glaucoma (PEXG), and to compare their RDW values with healthy controls.

Methods

40 patients with PEX, 40 with PEXG, and 80 control subjects were enrolled in this study. Complete ophthalmologic examination and complete blood count measurements were performed of all subjects. Complete blood counts were performed within one hour of blood collection.

Results

RDW levels were significantly higher in patients with PEX and PEXG than in controls (P = 0.027 and P < 0.001, respectively). Furthermore, a significant difference was found in RDW values between PEXG and PEX groups (P = 0.016). RDW levels were gradually increased from control group to PEXG group (P < 0.001). Multivariate logistic regression analysis revealed that RDW was independently associated with the presence of PEX/PEXG (odds ratio 1.765, 95% confidence interval (CI) 1.095-2.867, P = 0.013).

Conclusion

We conclude that RDW may be a useful marker for predicting the presence of PEX and progression to PEXG.

Impact of cardiovascular comorbidity on increased neutrophil-lymphocyte ratio in pseudoexfoliation syndrome

BACKGROUND

The purpose of this study was to compare neutrophil-to-lymphocyte ratios (NLRs) of patients with pseudoexfoliation syndrome (PEX) according to the presence of cardiovascular disease (CVD) with those without CVD as controls.

METHODS

A total of 197 participants (97 patients with PEX and 100 participants without PEX regarded as the control group) were included in this retrospective study. The PEX group was divided into 2 subgroups, PEX with CVD (group 1) and PEX without CVD (group 2). NLRs were then compared to those of the control group.

RESULTS

The incidence of CVD was significantly (P = .015) higher in the PEX group than in the control group. NLR was significantly higher in the group 1 and group 2 compared with that of the control group (P = .048 and P = .002, respectively). In the PEX group, group 1 showed higher NLR than group 2 (P = .023).

CONCLUSION

Although the PEX group showed a higher incidence of CVD, the NLR was higher in the PEX group regardless of cardiovascular comorbidity than that in the control group.

The correlation between pseudoexfoliation syndrome and the Triglyceride-Glucose index

PURPOSE

Pseudoexfoliation (PEX) syndrome is an age-related disease characterized by the accumulation of extracellular material in many ocular structures, skin and internal organs. Recent studies have shown that the Triglyceride-Glucose (TyG) index has clinical importance for the evaluation of vascular damage. The purpose of this study was to determine the relationship between PEX syndrome and TyG index, and to detect the risk in terms of vascular diseases.

METHODS

In the present study, 50 patients with PEX syndrome who were admitted to the ophthalmology outpatient clinic were evaluated along with 50 others who made up the control group. The Triglyceride-Glucose index was calculated with fasting plasma glucose and triglyceride values.

RESULTS

The mean age was 68.2 ± 1.2 years and 61.0% of the patients were male. There was no statistically significant difference between the two groups in terms of blood sugar and lipid profile (except triglyceride) (p > 0.05). The TyG index value was 8.9 ± 0.5 in the PEX group and 8.6 ± 0.6 in the control group. This difference was statistically significant (p = 0.003). In univariate regression analysis, TyG index (OR = 2.81; CI: 1.37-5.75; p = 0.005) was found to be correlated with PEX. In multivariate logistic regression analysis, this correlation remained statistically significant when adjusted for age and sex (OR = 2.89; CI: 1.35-6.18; p = 0.006).

CONCLUSION

Results showed that the TyG index was high in patients diagnosed with PEX. The risk of vascular diseases can be determined by examining the TyG index in patients with PEX, and this predetermination would have significant consequences for public health.

Risk of atrial fibrillation is increased in patients with exfoliation syndrome: the Utah project on exfoliation syndrome (UPEXS)

PURPOSE

Exfoliation syndrome, a systemic disorder with ocular manifestations, is associated with lysyl oxidase-like gene variants. Along with transforming growth factor beta-1, lysyl oxidase-like 1 is a key enzyme in stabilizing extracellular matrix and remodelling collagen/elastin. Given the role that transforming growth factor beta-1, lysyl oxidase-like gene variants and fibrosis play in atrial fibrillation, an association with exfoliation syndrome was investigated.

METHODS

An exfoliation syndrome cohort of 2803 patients and an atrial fibrillation cohort of 43 694 patients aged 60-90 years at disease onset were identified using the Utah Population Database (1996-2015). Conditional logistic regression was used to estimate risk of atrial fibrillation in exfoliation syndrome patients and risk of exfoliation syndrome in atrial fibrillation patients compared with respective 5:1 sex- and age-matched control cohorts. Kaplan-Meier curves were examined to assess survival in atrial fibrillation patients by exfoliation syndrome status.

RESULTS

Exfoliation syndrome patients had a 21% greater risk (95% CI 1.06-1.37; p < 0.0001) of atrial fibrillation. This was more pronounced in exfoliation syndrome patients with no hypertension history, who exhibited a 52% increased atrial fibrillation risk (95% CI 1.27-1.82; p < 0.0001). Atrial fibrillation patients exhibited a 20% increased risk of exfoliation syndrome (95% CI 1.07-1.35; p = 0.003), while atrial fibrillation patients with no hypertension had a 72% higher exfoliation risk (95% CI 1.45-2.03; p < 0.0001). Atrial fibrillation patients with exfoliation syndrome had a higher estimated probability of survival (alive at study end or at last follow-up) compared with patients with no exfoliation history (p < 0.0001, log-rank test).

CONCLUSIONS

Exfoliation syndrome patients were at a statistically significant increased risk of atrial fibrillation. Similarly, atrial fibrillation patients were at a statistically significant higher risk of exfoliation, particularly when hypertension history was absent.

Electrodiagnostic signs of carpal tunnel syndrome in ocular pseudoexfoliation syndrome

PURPOSE

To assess the occurrence and severity of electrodiagnostic signs of carpal tunnel syndrome (ED-CTS) in patients with ocular pseudoexfoliation (PEX) and compare them with normal subjects.

METHOD

A cross-sectional study with comparison group was designed and 60 patients with PEX were recruited from May 2019 to February 2021, and the findings were compared with 59 healthy subjects. All patients underwent complete ophthalmologic examination and nerve conduction velocity test at the median nerve was used to assess the occurrence and severity of ED-CTS in both hands.

RESULTS

The mean age of participants was 59.8 ± 4.5 years. Occurrence of ED-CTS was 38.3% in PEX patients and 20.3% in control subjects (P = 0.025). There was also a significant difference in the severityand presence of asymptomatic CTS (P < 0.05). Adjusting other variables, including; age and sex, having severe ED-CTS showed a 3.07fold higher chance in the PEX group (P = 0.005).

CONCLUSION

According to our finding, it seems there is a direct association between PEX and the occurrence, as well as severity of ED-CTS.

Exfoliation Syndrome in Baja Verapaz Guatemala: A Cross-Sectional Study and Review of the Literature

There are little epidemiologic data on exfoliation syndrome (XFS) or exfoliation glaucoma (XFG) in Guatemala, especially in the underserved Baja Verapaz region. This observational study assessing XFS/XFG and demographic factors of this region aims to better understand unique exogenous and endogenous risk factors associated with XFS/XFG in Guatemala. During Moran Eye Center's global outreach medical eye camps from 2016-2017, 181 patients age 15 years and older presented for complete eye exams. These individuals were screened for eye disease and evaluated for possible surgical interventions that could occur during the camps to improve eyesight. During the dilated exams, XFS was noted as missing or present. Of those 181, 10 had insufficient data and 18 lacked a definitive diagnosis of XFS or XFG, resulting in 153 evaluable patients; 46 XFS and 9 XFG were identified. Age, gender, hometown, ancestry (languages spoken by parents and grandparents), past medical history, family medical history, and occupational data (only 2017 trip) were obtained for each patient. The most common occupations of these individuals were farming and housekeeping. Higher rates of XFS/XFG were noted in individuals of rural compared to urban settings and Mayan speaking people compared with Spanish speakers. Based on this subset of patients, with various ocular pathologies being evaluated during medical eye outreach camps, the prevalence of XFS/XFG appeared to be 36%, a high prevalence compared to other world populations. Location and higher altitude, along with a farming occupation, may contribute to XFS development and subsequent progression to XFG. To our knowledge, this is the largest study looking at the epidemiology of XFS/XFG in the Baja Verapaz region of Guatemala for those over the age of 15 years seeking eye exams and interventions.

Comparison of long-term results of trabeculectomy and phacotrabeculectomy in patients with pseudoexfoliation glaucoma and primary open-angle glaucoma: a single-center study

PURPOSE

To evaluate long-term surgical success and complications in pseudoexfoliation glaucoma (PEXG) and primary open-angle glaucoma (POAG) after trabeculectomy or phacotrabeculectomy.

METHODS

96 PEXG eyes and 114 POAG eyes who underwent primary trabeculectomy and phacotrabeculectomy were retrospectively evaluated considering intraocular pressure (IOP), the number of glaucoma medications, surgical success, and rate of complications. Two success criteria were used: Complete success comprised IOP of 5-18 mmHg and 20% reduction of baseline IOP without medication. Qualified success comprised IOP of 5-18 mmHg and 20% reduction of baseline IOP irrespective of medication. Success rates in PEXG and POAG groups, trabeculectomy and phacotrabeculectomy groups, and four groups divided according to surgery and etiology were analyzed via Kaplan-Meier survival analysis.

RESULTS

The complete and qualified success were not different between PEXG and POAG groups. The qualified success curves show a similar pattern among the four groups throughout the follow-up of 1,2,3,5,7 and 9 years. Baseline IOP and the number of medications were similar in all four groups (p = 0.275 and p = 0.209, respectively). IOP levels and the number of medications were not statistically different between the four groups during the follow-up of 2,5 and 7 years. The total number of complications and interventions were similar between PEXG and POAG groups (p = 0.258).

CONCLUSIONS

Phacotrabeculectomy is an effective procedure as trabeculectomy with similar surgical success rates and few surgical complications when it comes to treating PAOG and PEXG patients. Both approaches resulted in similar postoperative IOP levels and medication numbers in both groups.

Ganglion cell complex and macular thickness layers in primary open-angle glaucoma, pseudoexfoliation glaucoma and healthy eyes: A comparative study

PURPOSE

To investigate the differences in the ganglion cell complex (GCC) and macular thickness measurements between primary open-angle glaucoma (POAG), pseudoexfoliation glaucoma (PXG), and healthy eyes with optical coherence tomography (OCT)optovue.

METHODS

In this non-randomized comparative cross-sectional study, 43 healthy eyes, 68 POAG eyes, and 57 PXG eyes were included. Patients were matched for age and disease severity. OCT angiography images were obtained for automated measurement of the GCC and macular thickness layers (inner and outer).

RESULTS

All GCC parameters were significantly difference between healthy and glaucomatous eyes (mild, and moderate to severe disease).There were no significant differences in GCC parameters between POAG and PXG patients except focal loss volume (FLV) after adjustment. Moderate to severe PXG eyes exhibited significantly lower GCC, larger global loss volume (GLV) values, and FLV values when compared with mild PXG eyes (p<= 0.05). We found significant thinning patterns in inner retinal thickness (fovea, parafovea, and perifovea), and total retinal thickness (parafovea, and perifovea) in moderate to severe PXG eyes when comparing with POAG eyes. Patients with moderate to severe PXG also showed significantly thinning patterns in inner retinal layers (fovea, parafovea and perifovea) and total retinal thickness (nasal parafovea) in compared to mild PXG.

CONCLUSION

It appears that GCC thickness is not significantly different between POAG and PXG except FLV. Despite similar retinal thickness in mild disease, a significant reduction in total and inner retinal thickness was demonstrated in moderate to severe PXG compared to moderate to severe POAG, in fovea, parafovea and perifovea region.

Comparison of Choroidal Vascularity Index in Patients with Pseudoexfoliation Glaucoma, Pseudoexfoliation Syndrome, and Healthy Controls

PURPOSE

To compare peripapillary choroidal vascularity index (CVI) parameters in pseudoexfoliation glaucoma (PEG), pseudoexfoliation (PEX) syndrome, and healthy controls.

METHODS

A total of 240 eyes of 240 patients were included in this cross-sectional prospective study, and the three groups consisted of (i) 80 eyes of 80 patients with PEG, (ii) 80 eyes of 80 patients with PEX syndrome, and (iii) 80 healthy control eyes. Peripapillary enhanced depth imaging optical coherence tomography images were binarized via standard protocols with the ImageJ software. CVI was analyzed in all sectors of the peripapillary region.

RESULTS

Peripapillary CVI was found to be significantly lower in the PEG group (61.6 ± 2.32) compared with the PEX group (64.7 ± 3.15) and the control group (67.5 ± 2.44) (p < .001), and patients with PEX also had significantly lower values compared to controls (p < .001). Peripapillary CVI values were significantly lower in the temporal, nasal, superotemporal, superonasal, inferotemporal and inferonasal sectors of the PEG group compared to both the PEX group and controls (p < .001). Peripapillary CVI was also found to be lower in all sectors in the PEX group compared to controls (p < .001). Global peripapillary choroidal thickness was significantly thinner in the PEG group than the PEX and control groups (133.37 ± 39.16, 154.36 ± 33.28 and 157.82 ± 36.77 μm, respectively, p < .001).

CONCLUSIONS

In the current study, it was shown that the presence of PEX caused a decrease in CVI value and this decrease was highest in patients with PEG. CVI may be a useful parameter to show vascular dysfunction in PEG and PEX syndrome.

Exfoliation syndrome: association with systemic diseases-the Maccabi glaucoma study

PURPOSE

To investigate the relationship between exfoliation syndrome (XFS) and systemic diseases.

METHODS

A population-based, retrospective study with control group was conducted using the electronic medical database of Maccabi Health Services, the second largest Health Maintenance Organization (HMO) in Israel. Study population included Maccabi members from January 2003 to April 2016. Cases consisted of patients diagnosed with XFS regardless of glaucoma. The control group included Maccabi members without XFS, matched on age, sex, and ancestry, that were examined by an ophthalmologist within the last year.

MAIN OUTCOME MEASURES

Associations between XFS and systemic diseases.

RESULTS

We identified 16,388 patients with XFS, in whom 40.3% (n = 6613) had glaucoma. The control group included 14,015 patients. Mean age was 78.3 ± 8.9 years and 76.2 ± 8.5 years for the XFS and control group, respectively. In unconditional logistic regression analyses, after adjusting for age, sex, and ancestry, XFS was significantly associated with risk of cardiovascular diseases including hypertension (OR 1.07, 95% CI 1.01-1.13, p = 0.02), myocardial infarction (OR 1.21, 95% CI 1.17-1.31, p < 0.0001), and congestive heart failure (OR 1.70, 95% CI 1.55-1.88, p < 0.0001) as well as higher risk for high creatinine (OR 1.28, 95% CI 1.2-1.37, p < 0.0001). Diabetes mellitus and body mass index were inversely associated with XFS (OR 0.70, 95% CI 0.67-0.73, p < 0.0001 and OR 0.88, 95% CI 0.84-0.93, p < 0.0001, respectively). Overall cancer diagnoses were more common in the XFS group (OR 1.05, 95% CI 1.0-1.1, p = 0.05). XFS was associated with more hospitalizations (mean 5 ± 5.3 hospitalizations in the XFS group and 3.3 ± 4.0 in the controls, p < 0.0001).

CONCLUSION

XFS is significantly associated with cardiovascular systemic diseases (in a population living in Israel and predominantly born in Russia).

The Role of Trace Elements in Pseudoexfoliation Syndrome: A Cross-sectional Study

Purpose

Pseudoexfoliation syndrome (PXF) is an age-related condition, characterized by deposition of whitish flake-shaped materials in the anterior segment of the eye. Although it occurs all over the world, a considerable racial variation exists. According to the high frequency of PXF in Iran and the importance of prevention and early treatment, we evaluated the plasma level of iron, zinc, copper, and magnesium in patients with PXF.

Methods

In this study, 83 individuals were enrolled; 40 patients with cataract and PXF as the case group and 43 age- and sex-matched individuals with cataract but without PXF as the control group. The serum levels of the mentioned microelements were compared in two groups.

Results

In the case group, 25 (62.5%) male and 15 (37.5%) female subjects participated. In the control group, the corresponding figures were 22 (51.2%) and 21 (48.8%), respectively. The mean age of the case group was 66.07 ± 9.46 and that for the control group was 66.88 ± 8.04 years. Regarding the case group, the serum levels of iron, zinc, copper, and magnesium were 60.58 ± 21.04, 84.7 ± 14.37, 120.23 ± 14.43, and 2.11 ± 0.23, respectively. These serum levels in the control group were 89.07 ± 26.06, 97.51 ± 17.42, 123.33 ± 19.01, and 2.14 ± 0.16. The serum levels of iron and zinc were significantly lower in the case group than the control group (P< 0.0001); however, such a difference was not observed in terms of copper and magnesium serum levels.

Conclusion

Our study demonstrated that the serum iron and zinc levels were lower in PXF patients. Nutritional deficiency may be a cause of zonular weakness in these patients. Heme is a cofactor for the enzyme which contributes to the biosynthesis of fibrillin, the major protein in zonular fibers. Therefore, iron can play a substantial role in the biosynthesis of the fibrils and also in the zonular stability.

A Case-Cohort Study of Exfoliation Risk Factors and Literature Review

The purpose of the study is to evaluate the risk factors associated with exfoliation in a case-cohort setting and literature review. This single-center, prospective, case-cohort study was carried out from January 2010 to April 2020 on patients operated for cataract surgery by a single surgeon in Lebanon. Forty-nine consecutive patients with exfoliation syndrome (XFS) and 62 consecutive control patients were identified and further investigated for selected systemic (diabetes mellitus, systemic hypertension, asthma, or atopy) and ocular variables (baseline vision, severity of nuclear sclerosis, glaucoma, eye rubbing, history of dry eye, or allergic eye disease). The mean baseline Snellen visual acuity was 20/283 in XFS versus 20/145 in control cases (P = 0.012). XFS also demonstrated significantly denser nuclear sclerosis than controls (P = 0.00958). By univariate analysis, allergic conjunctivitis (15 [30.6%] vs. 2 [3.2%]; P < 0.001), dry eye (20 [40.8%] vs. 13 [21.0%]; P = 0.0133), and habitual rubbing of the eyes (33 [67.3%] vs. 19 [30.6%]; P < 0.001) were associated with the presence of XFS. Habitual ocular rubbing was closely associated with allergic conjunctivitis (odds ratio [OR] = 13.0; 95% confidence interval [CI]: 2.8–58.8; P = 0.032). After multivariable analysis, the following variables showed significant results: glaucoma (OR = 34.5; 95% CI: 4.4–250; P = 0.010), duration of surgery (OR = 5.6; 95% CI 2.43–12.9; P < 0.001), and habitual ocular rubbing (OR = 4.42; 95% CI: 1.97–9.90; P = 0.029). This study shows a novel potential correlation between eye rubbing and XFS in a Lebanese cohort. Chronic eye rubbing induces or may exacerbate preexistent zonular damage in subjects with XFS, hence the need to better manage concurrent ocular surface disorder in these patients.

Two-year efficacy after first transscleral controlled cyclophotocoagulation in patients with and without pseudoexfoliation

Purpose

Transscleral controlled cyclophotocoagulation (COCO) is a transscleral 810-nm diode laser cyclophotocoagulation that automatically adjusts the applied laser energy utilizing an optical feedback loop. The present study investigates the influence of pseudoexfoliation (PEX) on the efficacy of COCO in a Caucasian study population.

Methods

Retrospective data from 130 consecutive eyes were analyzed during a 2-year follow-up. Baseline characteristics, intraocular pressure (IOP), number of IOP-lowering medications, visual field, best-corrected visual acuity (BCVA), and secondary surgical interventions (SSI) were analyzed. The primary endpoint was IOP reduction at M24 compared to baseline, and the secondary endpoints were IOP course, reduction of IOP-lowering medications, surgical success, and IOP-lowering SSIs stratified by PEX and baseline IOP.

Results

IOP reductions of −35, −39, −25, −25, −23, −34, and −36% could be achieved from baseline to D1, W1, M1, M3, M6, M12, and M24 (all p < 0.001), respectively, while there was a significant overall reduction over time (p < 0.001) in the number of topical IOP-lowering medications postoperatively. The proportion of eyes requiring additional systemic IOP-lowering medication reduced from 31 to 0% at M24 (p = 0.025). Eyes without PEX and IOP < 30 mmHg at baseline had the lowest risk for IOP-lowering SSIs (p < 0.03). BCVA dropped at M12 (0.25 [95% CI: 0.12–0.38]), and the drop persisted during the following 12 months.

Conclusion

The present study demonstrates a midterm IOP-lowering effect after COCO while reducing the burden for topical and systemic IOP-lowering medications. Patients without PEX and IOP < 30 mmHg have a lower risk of SSI. The procedure per se cannot be excluded as causative for the decreased postoperative BCVA. Further prospective investigations are suggested.

Automated Evaluation of Parapapillary Choroidal Microvasculature in Pseudoexfoliation Syndrome and Pseudoexfoliation Glaucoma

OBJECTIVE

To determine whether parapapillary choroidal microvasculature (PPCMv) density as measured by optical coherence tomography angiography differs between pseudoexfoliation syndrome (PXS) and pseudoexfoliation glaucoma (PXG).

DESIGN

Cross-sectional study.

METHODS

One hundred ninety-two eyes of 120 subjects from 2 academic referral institutions were enrolled. Automated PPCMv density was calculated using custom Matlab software in inner and outer annuli around the optic nerve region in addition to peripapillary superficial vasculature. Linear modeling was used to compare vessel densities among groups.

RESULTS

Data from 64 eyes with PXS, 84 eyes with PXG, and 44 eyes healthy control subjects were analyzed. The differences of visual field mean deviation and peripapillary retinal nerve fiber layer thickness among study groups were statistically significant with lower values in PXG eyes compared with the PXS and control groups. Peripapillary superficial retinal vessel densities were significantly reduced in patients with PXG compared with patients with PXS and normal control subjects (all P < .001) without a difference between PXS and control eyes. Customized outer annular PPCMv density in the PXG group with a value of 11.1% (SD 5.1%) was lower than that in PXS with a value of 13.2% (SD 5.3%; P = .001). Similarly, PXS values were lower than those of control eyes with a value of 18.6% (SD 5.1%; P < .001).

CONCLUSION

A progressive decrease in outer PPCMv from the control group to those with PXS without glaucoma to those with PXS and glaucoma (PXG) showed deep peripapillary vasculopathy in pseudoexfoliation syndrome. Choroidal vessel density may be affected early in the course of pseudoexfoliation before glaucoma develops.

Significant lifespan difference between primary open-angle glaucoma and pseudoexfoliation glaucoma

PURPOSE

Open-angle glaucoma (OAG) is a collective term for various subgroups of glaucoma of which primary open-angle glaucoma (POAG) and pseudoexfoliation glaucoma (PEG) are the most common. There is increasing evidence that both conditions have systemic ramifications. We wanted to examine to what extent lifespan and cause of death are influenced by POAG, pseudoexfoliation syndrome (PES), and PEG.

MATERIALS AND METHODS

Of 1864 people who underwent an eye examination in 1985-86, the presence of PES and/or glaucoma, along with date and cause of death were recorded. Based on information from the National Death Registry, the individuals were classified into the following groups of systemic diseases regarded as causing death: Cardiovascular disease (with two subgroups), cerebrovascular disease and neoplasms.

RESULTS

All 1864 persons were followed to death, up to 30 years after examination. No difference in lifespan was observed when comparing OAG (i.e. POAG and PEG together) with the rest of the population. When adjusting for gender and age at inclusion, patients with POAG showed a reduced lifespan in the cardiovascular death group (2.44 years, p = 0.043). When comparing lifespan in the neoplastic group in the glaucoma patients, POAG and PEG, directly against each other, a mean age difference of 6.87 years (p = 0.017) was found.

CONCLUSIONS

POAG patients showed reduced lifespan due to neoplasia and cardiovascular disease. Persons with PES and PEG did not show these lifespan reductions. Our main conclusion is that POAG and PEG, the two main OAG subgroups, are very different disease entities both from an ocular and a systemic point of view.

Peripapillary perfused capillary density in true versus pseudoexfoliation syndrome: An OCTA study

PURPOSE

To compare peripapillary perfused capillary density (PCD) among eyes with true exfoliation syndrome (TEX), eyes with pseudoexfoliation syndrome (PEX), and healthy control eyes.

MATERIALS AND METHODS

In this observational cross-sectional study, eyes with and without TEX or PEX were assessed by optical coherence tomography angiography (OCTA) imaging. Bilateral OCTA images (4.5 × 4.5 mm2) centered at the optic nerve head were obtained using a commercial spectral domain OCTA system. Optic nerve head perfusion was quantified using the split-spectrum amplitude decorrelation angiography algorithm. Categorical and continuous variables were compared using the chi-squared test and one-way analysis of variance, respectively. The generalized estimating equation was used to adjust for confounding factors and determine inter-ocular associations.

RESULTS

We enrolled 39 eyes with TEX, 31 eyes with PEX, and 32 control eyes. There were no significant differences among the three groups regarding age, intraocular pressure, cup-to-disc ratio, blood pressure, or axial length (all p>0.05). There were significant differences in global PCD among the three groups (p = 0.01). There were significant differences in annular PCD between the TEX and PEX groups (p = 0.027).

CONCLUSIONS

While both global and annular PCDs did not differ between the TEX and control groups, greater loss of annular PCD in the PEX group than in the TEX and control groups suggests more pronounced microvascular disturbance in PEX.

SYNOPSIS/PRECIS

Greater microvascular attenuation in PEX compared with TEX and normal control measured by OCTA.

Peripapillary and macular choroidal vascularity index in patients with clinically unilateral pseudoexfoliation syndrome

PURPOSE

To investigate choroidal vascular changes using an image binarization tool in patients with clinically unilateral pseudoexfoliation syndrome (XFS).

METHODS

This cross-sectional study included 150 eyes of 100 patients. The eyes were divided into three groups: (1) 50 affected eyes of patients with clinically unilateral XFS; (2) 50 unaffected fellow eyes; and (3) 50 healthy control eyes. Enhanced depth imaging optical coherence tomography scans of the macula and peripapillary regions were acquired. Images were binarized using ImageJ software (National Institutes of Health, Bethesda, MD, USA). The choroidal vascularity index (CVI) was defined as proportion of the luminal area to the total circumscribed choroidal area.

RESULTS

Horizontal and vertical scans revealed that the macular CVI values of the affected eyes (60.08 ± 2.06 and 62.21 ± 2.10, respectively) were lower compared with control eyes (67.31 ± 2.24; p = 0.001 and 68.11 ± 2.36; p < 0.001, respectively). Conversely, no significant difference in the macular CVI was found between unaffected fellow and control eyes (p = 0.094 and p = 0.120, respectively). The mean peripapillary CVI values of the temporal (58.73 ± 3.15), superior (59.84 ± 3.09), and inferior (56.94 ± 2.47) sectors were significantly lower in affected eyes compared to control eyes (63.21 ± 3.00, 62.07 ± 3.05, and 60.78 ± 2.88, respectively; p < 0.05 for all). In addition, the unaffected fellow eyes had significantly lower CVI values in the temporal (61.42 ± 3.07) and inferior (57.61 ± 2.56) peripapillary sectors compared with the control eyes (p = 0.007 and p = 0.005, respectively).

CONCLUSIONS

These findings suggest that XFS is associated with decreased macular and peripapillary choroidal vascularity. Furthermore, the unaffected eyes of patients with unilateral XFS may show vascularity changes in the peripapillary choroid.

Comparison of vessel density in macular and peripapillary regions between primary open-angle glaucoma and pseudoexfoliation glaucoma using OCTA

PURPOSE

The aim of our study was to compare macular and peripapillary vessel density using optical coherence tomography angiography (OCTA) between eyes with primary open-angle glaucoma (POAG) and pseudoexfoliation glaucoma (PXG).

METHODS

Thirty-six POAG and 34 PXG eyes with similar visual field defect (no statistically significant difference between average mean deviation and pattern standard deviation scores) were included. Macular superficial vessel density (msVD) in the superficial macular layer and foveal avascular zone (FAZ) parameters were assessed with (6 × 6 mm) and peripapillary vessel density (ppVD) in the radial peripapillary capillary (RPC) with (4.5 × 4.5 mm) OCTA scans. Area under the receiver operating curve was used for assessing diagnostic capability.

RESULTS

In PXG group, all msVD parameters had lesser values, and especially in parafoveal region, statistically significant decrease was shown (p = 0.008) in all subdivisions except nasal (p = 0.053). FAZ area was more larger in PXG [0.32(0.25-0.36)] than POAG [0.28(0.22-0.39)],(p = 0.944). FAZ density - 300 μm had statistically significant decrease in PXG (47.22 ± 6.92) according to POAG groups (50.63 ± 7.25) (p = 0.048). Most of RPC VD parameters had decreasing values in PXG group (p > 0.05). VDs and corresponding thicknesses had significant remarkable positive correlation in both macular and peripapillary regions. Significant remarkable negative correlations were observed between fovea VD and FAZ area, FAZ perimeter and between fovea thickness and FAZ area, FAZ perimeter.

CONCLUSION

PXG eyes were found to have lesser values in terms of VD in the macular area, especially in the parafoveal and FD-300 regions, compared to POAG eyes which had similar functional and structural glaucomatous damage. Patients whose etiology was PXG and who seemed to have the same functional damage as those with POAG were actually found to have greater macular vascular damage. In addition, it was observed that macular vascular parameters correlated with peripapillary vascular parameters.

Evaluation of the optic nerve head vessel density in the patients with asymmetric pseudoexfoliative glaucoma: an OCT angiography study

PURPOSE

To evaluate vascular microcirculation changes of the optic nerve head (ONH) in the patients with asymmetric pseudoexfoliative glaucoma (XFG) using optical coherence tomography angiography (OCTA) and to compare vessel density (VD) results with healthy individuals.

METHODS

This prospective study enrolled 120 eyes in total. The eyes were divided into 3 groups: 40 glaucomatous and 40 non-glaucomatous fellow eyes without clinically pseudoexfoliation material (XFM) of patients with asymmetric XFG, and 40 healthy eyes as controls. The optic disc region was evaluated with OCTA (Optovue, Inc., Fremont, CA). VD was assessed as the ratio of the area formed by the vessels in 3 different regions: (1) inside disc; (2) in the peripapillary area defined as a 1-mm wide elliptical annulus around the disc; and (3) in the whole image defined as a 4-mm wide papillary region.

RESULTS

There were significant decreases in VD values of all regions in XFG eyes compared to fellow and control eyes (p < 0.05 for all comparisons). The mean VD values of peripapillary area and whole image were lower in the non-glaucomatous fellow eyes compared with control eyes (p = 0.011 and p = 0.015, respectively). The receiver operating characteristic analysis for differentiating fellow eyes from healthy eyes had highest area under the curve and sensitivity at 90% specificity for superior-hemi (0.811, 65.2%), followed by ppVD (0.775, 61.8%) and whole image (0.743, 55.9%).

CONCLUSIONS

OCTA as a novel imaging may be a valuable structural test in diagnosis and follow-up of glaucoma.

Nailfold Capillaroscopy of Resting Peripheral Blood Flow in Exfoliation Glaucoma and Primary Open-Angle Glaucoma

Importance

Systemic blood flow alterations have been described using video nailfold capillaroscopy (NFC) in high-tension glaucoma (HTG) and normal-tension glaucoma (NTG) variants of primary open-angle glaucoma (POAG). To date, no previous studies have explored alterations in nailfold capillary blood flow in exfoliation glaucoma (XFG).

Objective

To investigate the measure of peripheral blood flow as a surrogate marker of systemic vascular involvement in patients with XFG, HTG, and NTG, as well as in individuals serving as controls, using NFC.

Design, Setting, and Participants

A cross-sectional clinic-based study at the New York Eye and Ear Infirmary of Mount Sinai was conducted from July 6, 2017, to May 18, 2018. A total of 111 participants (30 XFG, 30 NTG, 30 HTG, and 21 controls) received a comprehensive ophthalmic examination to confirm eligibility. Exclusion criteria were the presence of connective tissue disease, uncontrolled diabetes, history of bleeding disorders, and/or history of trauma or surgery to the nondominant hand.

Main Outcomes and Measures

Resting capillary blood flow at the nailfold of the fourth digit of the nondominant hand in patients with NTG, HTG, XFG, and controls, using NFC.

Results

Two participants were excluded owing to poor nailfold image quality, resulting in 109 participants. Sixty-two participants (57%) were women and 79 (72%) were white. Mean (SD) age of the participants was 67.9 (11.7) years. Mean (SD) resting peripheral capillary blood flow at the nailfold for controls was 70.9 (52.4) picoliters/s (pL/s); HTG, 47.5 (41.9) pL/s; NTG, 40.1 (16.6) pL/s; and XFG, 30.6 (20.0) pL/s. Multivariable analysis of the differences of flow in HTG vs control participants showed values of -18.97 (95% CI, -39.22 to 1.27; P = .07) pL/s, NTG vs controls of -25.17 (95% CI, -45.92 to -4.41; P = .02) pL/s, and XFG vs controls of -28.99 (95% CI, -51.35 to -6.63; P = .01) pL/s.

Conclusions and Relevance

Decreased resting peripheral capillary blood flow may occur in patients with XFG and NTG compared with individuals without glaucoma. These findings may contribute to understanding the possible systemic nature of glaucoma.

Link of ocular pseudoexfoliation syndrome and vascular system changes: results from 10-year follow-up study

PURPOSE

To examine the 10-year incidence of the pseudoexfoliation syndrome (PEX) in adults in a population-based follow-up study, to determine its link with vascular diseases, and to identify possible risk factors of the PEX.

METHODS

The baseline examination was performed in 2006 on a random sample of 1033 participants from Kaunas city (Lithuania) population. In 2016, a follow-up study of 686 participants who returned for the examination was conducted. The respondents filled out a questionnaire, an ophthalmological examination was performed, and the presence of vascular diseases was determined by the anamnesis and electrocardiogram evaluation data. Binary univariate and multivariate logistic regression analyses were conducted with the PEX and vascular diseases as predictors, controlling for age. Odds ratios (OR) and 95% confidence intervals of OR were calculated for the risk of new PEX cases.

RESULTS

During 10 years, the prevalence of the PEX in the study population increased from 10.3 to 34.2%. The rates of ischemic heart disease (IHD) and IHD combined with stroke were significantly higher in the PEX subjects than in the non-PEX subjects. The risk of the PEX among persons with IHD was, on the average, by 1.5-fold higher, and among those with IHD and stroke, on the average, by 1.6-fold higher as compared to persons without the aforementioned pathologies (accordingly, p = 0.014 and p = 0.010).

CONCLUSION

The prevalence of the PEX increased significantly with age. The risk of the PEX was significantly higher among persons with IHD and even higher among persons with IHD and stroke. In the future, a greater understanding of the cardiovascular, metabolic, and environmental components associated with the PEX may lead to more specific lifestyle-related preventive strategies to decrease the disease burden.

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

Purpose

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

Materials and methods

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

Results

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

Conclusions

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

Association of Exfoliation Syndrome With Risk of Indirect Inguinal Hernia: The Utah Project on Exfoliation Syndrome

Importance

Exfoliation syndrome (XFS) is a systemic connective tissue disease, and abnormal connective tissue metabolism is implicated in inguinal hernias (IH). Associating XFS with comorbid conditions may illuminate their underlying pathophysiology and affect clinical screening and treatment. Exfoliation syndrome involves altered systemic extracellular matrix (ECM) homeostasis involving elastin metabolism. Hernias occur owing to abnormal ECM synthesis, metabolism, or repair. Inguinal hernias involve weakening or rupture of the abdominal/groin wall.

Objective

To determine an association between patients with XFS and patients with IH in Utah, possibly differing between direct or indirect hernia.

Design, Setting, and Participants

Cross-sectional study in a large health care system of Utah hospitals and clinics. Conditional logistic regression odds ratios were used to estimate risk of XFS in patients with IH overall and by subtype (direct or indirect) compared with control individuals. Codes specific to direct and indirect IH with additional medical records review of 186 procedures were used to classify IH subtypes that were not prespecified. Bootstrap resampling with jackknife estimation used to calculate 95% confidence intervals. The model accounted for matching on sex and age and adjusted for body mass index and tobacco use. Population-based sample using medical records from 1996 to 2015 that identified 2594 patients 40 years or older on January 1, 1996, with surgical IH repair and 12 966 random control patients with no IH history matched 5:1 on sex and birth year. Data were analyzed between September 10, 2017, and October 23, 2017.

Main Outcomes and Measures

Exfoliation syndrome outcome defined by diagnosis codes for XFS or exfoliation glaucoma from 1996 to 2015.

Results

Participants were primarily white (2532 of 2594 patients, [96.1%]; 12 454 of 12 966 control individuals [97.6%]) and non-Hispanic (2396 of 2594 patients [92.4%]); 250 participants were women (9.6%). Of study participants, 22 patients with IH and 43 control individuals were diagnosed as having XFS, respectively. Patients with IH had a 2.3-fold risk for an XFS diagnosis compared with control individuals (95% CI, 1.4-3.5; P = .03), and XFS risk with indirect IH appeared especially pronounced.

Conclusions and Relevance

Inguinal hernia was associated with an increased risk of XFS in this Utah population. Further work is needed to understand the pathophysiology, genetics, and environmental factors contributing to both diseases.

Twelve-Year Incidence and Baseline Risk Factors for Pseudoexfoliation: The Thessaloniki Eye Study (An American Ophthalmological Society Thesis)

PURPOSE

To determine the 12-year incidence of pseudoexfoliation (PEX), baseline risk factors for incident PEX and risk factors for incident pseudoexfoliative glaucoma (PEXG) among those with PEX in an elderly white population.

METHODS

Longitudinal, population-based study in Thessaloniki, the major urban center in Northern Greece. The baseline cohort included 2554 participants ≥60 years old. The surviving cohort was re-examined 12 years later using the same methodology. PEX was defined as typical fibrillar material at the pupil margin and/or on the lens capsule. Glaucoma was defined as both structural and functional damage, irrespective of intraocular pressure (IOP).

RESULTS

Of 1468 eligible subjects in the surviving cohort, 1092 (74%) participated in the follow-up study. The mean age ± standard deviation (SD) at baseline was 68.9 ± 4.6 years. The mean follow-up time was 11.6 ± 1.6 years. The 12-year incidence of PEX was 19.6% (95% confidence interval (CI), 17.1-22.2), with women more likely to be affected than men (Fisher's exact test, P = .0197). Higher axial length was associated with lower odds of incident PEX (odds ratio [OR], 0.72 per mm; 95% CI, 0.57-0.92). PEX at baseline was not associated with an increased likelihood of major vascular disease (P = .9038). Higher baseline IOP (OR, 1.26 per mm Hg; 95% CI, 1.07-1.48) and history of heart attack at baseline (OR, 13.49; 95% CI, 2.85-63.87) were associated with a greater likelihood of developing PEXG among those with PEX. A history of alcohol consumption at baseline was protective of individuals developing PEXG if they had PEX at baseline.

CONCLUSION

This is one of the very few longitudinal population-based studies that has specifically assessed the incidence of PEX. The association with axial length was previously found only in a cross-sectional study. The associations with heart attack and alcohol consumption are new findings. In individuals with baseline PEX, higher IOP at baseline, history of heart attack at baseline, and no alcohol consumption were associated with a greater likelihood of developing glaucomatous damage approximately 12 years later. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Pseudoexfoliation syndrome: analysis of systemic comorbidities of 325 PEX-positive patients compared with 911 PEX-negative patients

PURPOSE

Pseudoexfoliation syndrome (PEX) is an age-related systemic elastic fibrillopathy disorder featuring an excessive production and accumulation of elastic fibre components in the extracellular matrix and is associated with impaired protective mechanisms against oxidative and cellular stress. PEX is diagnosed solely by ophthalmologists; however, PEX deposits have been detected in the connective tissues of many extraocular organ systems. This large, retrospective case-control study investigates whether patients with PEX have an increased risk of extraocular comorbidities.

METHODS

Cases and controls were drawn from consecutive patients over 50 years of age undergoing in-house ophthalmological operations under general anaesthesia or in standby preparedness for general anaesthesia. The participants were grouped based solely on PEX-positive (n = 325) or PEX-negative (n = 911) status. The same teams of ophthalmologists and anaesthesiologists uniformly documented every known systemic comorbidity of each patient through two independent rounds of standard anamnestic procedure and protocols in preparation for general anaesthesia. For the purpose of this study, every systemic comorbidity was registered from these forms and subsequently categorized into 17 disease groups based on the International Classification of Diseases (ICD-10) of the World Health Organization (WHO). Odds ratios (ORs) comparing comorbidities in cases and controls were adjusted for age and gender using logistic regression.

RESULTS

After adjustment for multiple testing, patients with PEX had an increased odds ratio for respiratory OR 2.1 [1.4; 3.0], cardiac OR 2.5 [1.6; 4.2], vascular OR 2.0 [1.4; 2.8], and urogenital conditions OR 2.3 [1.4; 3.7]. Renal and psychiatric comorbidities were nominally significant. While no substantially higher frequency was found for hernias, aneurysms, aortic dissection, or varicose veins among PEX-positive patients, higher rates of cardiac valve disorders and benign prostate hyperplasia were found among the PEX-positive individuals.

CONCLUSION

In addition to confirming an increased risk of respiratory, cardiovascular, and urogenital comorbidities, our data found an increased risk of cardiac valve disorders and benign prostate hyperplasia among PEX-positive patients, which may be manifestations of the underlying systemic elastotic fibrillopathy and warrants further exploration, including future histological study.

Atherogenic indices in pseudoexfoliation syndrome

OBJECTIVES

Evaluation of atherogenic indices in patients with pseudoexfoliation syndrome (PEXS) by traditional serum lipid profiles [total cholesterol (TC), triglyceride (TG), low-density lipoprotein cholesterol (LDL-c), high-density lipoprotein cholesterol (HDL-c) and non-HDL-c] and non-traditional serum lipid ratios [TC/HDL-c, TG/HDL-c, LDL-c/HDL-c and non-HDL-c/HDL-c].

METHODS

A total of 100 patients were included in the study. Fifty patients diagnosed with PEXS were regarded as group 1 and 50 patients without PEXS were regarded as group 2, respectively.

RESULTS

The median TC, TG, LDL-c, HDL-c and non-HDL-c values were significantly higher in group 1 compared to group 2 (p = 0.007, p = 0.025, p = 0.016, p = 0.015 and p = 0.042, respectively). But there were no significant differences in the TC/HDL-c, TG/HDL-c, LDL-c/HDL-c and non-HDL-c/HDL-c ratios among the two groups (p = 0.581, p = 0.617, p = 0.292 and p = 0.583, respectively).

CONCLUSIONS

Non-traditional serum lipid ratios are superior to traditional serum lipid profiles for identifying the risk of vascular disease and this study did not demonstrate a complete relationship between PEXS and increased risk of vascular disease.

Identification of Candidate miRNA Biomarkers for Glaucoma

Purpose

Glaucoma, a leading cause of blindness worldwide, often remains undetected until irreversible vision loss has occurred. Treatments focus on lowering intraocular pressure (IOP), the only modifiable and readily measurable risk factor. However, IOP can vary and does not always predict disease progression. MicroRNAs (miRNAs) are promising biomarkers. They are abundant and stable in biological fluids, including plasma and aqueous humor (AqH). We aimed to identify differentially expressed miRNAs in AqH and plasma from glaucoma, exfoliation syndrome (XFS), and control subjects.

Methods

Plasma and AqH from two ethnic cohorts were harvested from glaucoma or XFS (often associated with glaucoma, n = 33) and control (n = 31) patients undergoing elective surgery. A custom miRNA array measured 372 miRNAs. Molecular target prediction and pathway analysis were performed with Ingenuity Pathway Analysis (IPA) and DIANA bioinformatical tools.

Results

Levels of miRNAs in plasma, a readily accessible biomarker source, correlated with miRNA levels in AqH. Twenty circulating miRNAs were at least 1.5-fold higher in glaucoma or XFS patients than in controls across two ethnic cohorts: miR-4667-5p (P = 4.1 × 10⁻⁵), miR-99b-3p (P = 4.8 × 10⁻⁵), miR-637 (P = 5.1 × 10⁻⁵), miR-4490 (P = 5.7 × 10⁻⁵), miR-1253 (P = 6.0 × 10⁻⁵), miR-3190-3p (P = 3.1 × 10⁻⁴), miR-3173-3p (P = 0.001), miR-608 (P = 0.001), miR-4725-3p (P = 0.002), miR-4448 (P = 0.002), and miR-323b-5p (P = 0.002), miR-4538 (P = 0.003), miR-3913-3p (P = 0.003), miR-3159 (P = 0.003), miR-4663 (P = 0.003), miR-4767 (P = 0.003), miR-4724-5p (P = 0.003), miR-1306-5p (P = 0.003), miR-181b-3p (P = 0.004), and miR-433-3p (P = 0.004). miR-637, miR-1306-5p, and miR-3159, in combination, allowed discrimination between glaucoma patients and control subjects (AUC = 0.91 ± 0.008, sensitivity 85.0%, specificity 87.5%).

Conclusions

These results identify specific miRNAs as potential biomarkers and provide insight into the molecular processes underlying glaucoma.

Association of pseudoexfoliation syndrome with cardiovascular and cerebrovascular disease: a systematic review and meta-analysis

OBJECTIVE

Pseudoexfoliation syndrome (PEX) is a systemic disease, but evidence of its association with cardiovascular disease (CVD) and cerebrovascular disease (CVA) is controversial. A quantitative systematic review will provide an accurate summary of the current body of the literature.

DESIGN

Meta-analysis.

PARTICIPANTS

Not applicable.

METHODS

A comprehensive literature search of published and unpublished English-language studies was performed. Summary statistics were calculated using inverse variance weighting and are presented in forest plots. Sources of variance were evaluated statistically.

RESULTS

After screening 4547 studies, 47 articles were reviewed, and 25 eligible studies were selected that reported patients from around the world. Twenty studies enrolling 9583 individuals with PEX evaluated CVD, providing a summary odds ratio (OR) of 1.61 (95% CI 1.37-1.90). Eleven studies, enrolling 1308 PEX patients, evaluated CVA and generated a summary OR of 1.76 (1.40-2.22). For any vascular event (AVE) using all 25 studies, there were 9716 PEX patients and 363,312 control patients, yielding a summary OR of 1.64 (95% CI 1.39-1.92). Analysis for publication bias with the Egger's test was not significant for studies reporting CVD and AVE (p = 0.92 and 0.64, respectively) but was significant for CVA (p = 0.03). Asymmetry of Begg's funnel plot was noted for the CVA and AVE analyses. Multiple sensitivity analyses were performed, including assessment of study quality; the OR for all 3 outcomes varied minimally and remained significant in all analyses.

CONCLUSION

There is strong evidence that PEX is significantly associated with both CVD and CVA.

Monitoring and management of the patient with pseudoexfoliation syndrome: current perspectives

Pseudoexfoliation syndrome (PES) is a complex and age-related systemic disorder characterized by the progressive accumulation and granular deposition of pseudoexfoliative material in various intraocular and extraocular tissues. The diagnosis of PES is so important because it is a major risk factor for complications during cataract surgery and the most frequent cause of secondary glaucoma. In addition to ocular complications, PES is related with numerous systemic abnormalities, for which the list is growing steadily. Therefore, management and monitoring of patients with PES are crucial. The aim of this paper was to review current perspectives on monitoring patients with PES and addressing management of ocular and systemic associations of this clinically important and biologically fascinating disease.

Pseudoexfoliation and aortic aneurysm: a long-term follow-up study

PURPOSE

To study the relationship between pseudoexfoliation (PEX) and aortic aneurysm in a population with a high prevalence of PEX.

METHODS

Survival analyses were performed in a cohort of 735 residents aged 65-74 years, examined in a population survey in the municipality of Tierp, Sweden, 1984-1986. To expand the sample size, 1040 people were recruited by means of glaucoma case records established at the Eye Department in Tierp in 1978-2007. In this way, the cohort comprised 1775 subjects, representing more than 25 400 person-years at risk. Medical records and autopsy reports were reviewed to identify subjects diagnosed with aneurysm. Those with a follow-up time shorter than 1 year were excluded.

RESULTS

By the end of the study in September 2017, 60 new cases of aortic aneurysm had been found. Of these cases, 23% (14 subjects) were affected by PEX at baseline, compared with 28% among subjects without aneurysm. No association between PEX and aortic aneurysm was found (hazard ratio 0.97; 95% confidence interval 0.53-1.77).

CONCLUSION

In this population-based study, we were unable to verify a relationship between PEX and the development of aortic aneurysm.

Novel protein constituents of pathological ocular pseudoexfoliation syndrome deposits identified with mass spectrometry

Purpose

Pseudoexfoliation (PEX) syndrome is an age-related progressive disease of the extracellular matrix with ocular manifestations. PEX is clinically diagnosed by the presence of extracellular exfoliative deposits on the anterior surface of the ocular lens. PEX syndrome is a major risk factor for developing glaucoma, the leading cause of irreversible blindness in the world, and is often associated with the development of cataract. PEX reportedly coexists with Alzheimer disease and increases the risk of heart disease and stroke. PEX material deposited on the anterior surface of the ocular lens is highly proteinaceous, complex, and insoluble, making deciphering the protein composition of the material challenging. Thus, to date, only a small proportion of the protein composition of PEX material is known. The aim of this study was to decipher the protein composition of pathological PEX material deposited on the ocular lens in patients and advance the understanding of pathophysiology of PEX syndrome.

Methods

Liquid-chromatography and tandem mass spectrometry (LC-MS/MS) was employed to discover novel proteins in extracts of neat PEX material surgically isolated from patients (n = 4) with PEX syndrome undergoing cataract surgery. A sub-set of the identified proteins was validated with immunohistochemistry using lens capsule specimens from independent patients (n=3); lens capsules from patients with cataract but without PEX syndrome were used as controls (n=4). Expression of transcripts of the validated proteins in the human lens epithelium was analyzed with reverse transcription PCR (RT-PCR). Functional relationships among the proteins identified in this study and genes and proteins previously implicated in the disease were bioinformatically determined using InnateDB.

Results

Peptides corresponding to 66 proteins, including ten proteins previously known to be present in PEX material, were identified. Thirteen newly identified proteins were chosen for validation. Of those proteins, 12 were found to be genuine components of the material. The novel protein constituents include apolipoproteins (APOA1 and APOA4), stress response proteins (CRYAA and PRDX2), and blood-related proteins (fibrinogen and hemoglobin subunits), including iron-free hemoglobin. The gene expression data suggest that the identified stress-response proteins and hemoglobin are contributed by the lens epithelium and apolipoproteins and fibrinogen by the aqueous humor to the PEX material. Pathway analysis of the identified novel protein constituents and genes or proteins previously implicated in the disease reiterated the involvement of extracellular matrix organization and degradation, elastic fiber formation, and complement cascade in PEX syndrome. Network analysis suggested a central role of fibronectin in the pathophysiology of the disease. The identified novel protein constituents of PEX material also shed light on the molecular basis of the association of PEX syndrome with heart disease, stroke, and Alzheimer disease.

Conclusions

This study expands the understanding of the protein composition of pathological PEX material deposited on the ocular lens in patients with PEX syndrome and provides useful insights into the pathophysiology of this disease. This study together with the previous study by our group (Sharma et al. Experimental Eye Research 2009;89(4):479-85) demonstrate that using neat PEX material, devoid of the underlying lens capsule, for proteomics analysis is an effective approach for deciphering the protein composition of complex and highly insoluble extracellular pathological ocular deposits present in patients with PEX syndrome.

Lifespan reduction due to neoplasia is nullified by pseudoexfoliation syndrome

BACKGROUND

Pseudoexfoliation syndrome (PES) is a common eye condition, indicating a risk of various eye diseases. Whether or not PES has extra-ocular physiological or even pathophysiological implications has been a matter of controversy for years.

METHODS

In total 1888 persons were examined for PES in 1985-86. Of these, 1864 (98·7%) had died and were therefore available for analysis by 01.01.2016. Age and cause(s) of death were recorded. 9 diagnostic groups (cardiovascular disease, cerebrovascular disease, neoplasms, systemic hypertension, diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD), Parkinson's disease, aortic aneurysm (AA), and amyloidosis) based on ICD-coding were analyzed for both a possible association between PES and lifespan, as well as PES and specific systemic diseases.

FINDINGS

In the cardiovascular group, PES was not associated with an alteration in longevity. The subgroups acute myocardial infarction and other cardiovascular diseases revealed significantly reduced and increased lifespan, respectively, compared to the rest of the population. These deviations were independent of PES. The impact of PES on the neoplasm group showed that PES-positive persons lived 1·81 years (p < 0·001) longer than PES-negative persons. No significant differences in the PES prevalence were found in any of the cause of death diagnostic groups.

INTERPRETATIONS

The present study suggests that lifespan reduction due to neoplasia is nullified by PES, and that this phenomenon is not restricted to one specific neoplasm type. Thus, the paradoxical conclusion emerges that PES provides a lifespan benefit to the patient with a neoplasm. For the remaining diagnostic groups, PES was neither associated with an altered lifespan, nor with any cause of death diagnoses.

What have we learned about exfoliation syndrome since its discovery by John Lindberg 100 years ago?

Exfoliation syndrome (XFS) is a systemic disease with significant ocular manifestations, including glaucoma and cataract. The disease impacts close to 70 million people globally and is now recognised as the most common identifiable cause of open-angle glaucoma. Since the discovery of XFS 100 years ago by Dr John G. Lindberg, there has been considerable advancement in understanding its pathogenesis and resulting clinical implications. The purpose of this paper is to summarise information regarding the epidemiology, pathophysiology, ocular manifestations and systemic associations of XFS with the objective of sharing clinical pearls to assist in early detection and enhanced management of patients.

Peripapillary Perfused Capillary Density in Exfoliation Syndrome and Exfoliation Glaucoma versus POAG and Healthy Controls: An OCTA Study

PURPOSE

To compare the peripapillary perfused capillary density (PCD) among eyes with exfoliation syndrome (XFS), exfoliation glaucoma (XFG), primary open-angle glaucoma (POAG), and controls.

DESIGN

Observational, cross-sectional study.

METHODS

Optical coherence tomography angiography (OCTA) images (4.5×4.5 mm) of the optic nerve head were obtained using a commercial spectral domain OCTA system (AngioVue Avanti RTVue-XR, OptoVue, Fremont, CA). Two concentric circles with 1.95-mm (inner) and 3.45-mm (outer) diameters were placed manually, producing an annulus of width 0.75 mm centered at the optic disc. PCD was calculated as the ratio of pixels associated with capillaries to the pixels in the annulus after large blood vessel removal. Continuous variables were assessed by analysis of variance and Tukey honest significant difference (HSD) test. Multiple linear regression analysis was performed to adjust for confounding factors.

RESULTS

Forty-three XFG eyes, 31 POAG eyes matched for visual field mean deviation, 33 XFS eyes, and 45 control eyes were analyzed. PCD demonstrated a progressive decrease from controls to XFS to POAG to XFG. Pairwise comparisons revealed significant differences in PCD between each pair of groups (all P<0.01) except for PCD between XFS and POAG (P = 0.08). A multivariable model adjusting for age and stage showed a more significant decrease in PCD in XFG compared with POAG (P = 0.001).

CONCLUSIONS

PCD was more significantly decreased in XFG compared with POAG eyes and in XFS compared with control eyes. OCTA provides the first quantitative evidence of the microvascular disturbance that accompanies XFS.

Lysyl oxidases expression and histopathological changes of the diabetic rat nephron

Diabetic nephropathy (DN) is a major complication of diabetes, the accumulation of extracellular matrix (ECM) is considered an indication of nephropathological changes. Lysyl oxidases (LOXs) are also associated with ECM. However, the majority of studies on LOXs have focused on their potential role in renal fibrogenesis and there has no examination of LOXs expression or the correlation with histopathological changes of DN, including glomerular basement membrane (GBM) thickening and glomerulosclerosis. In this study, the association between histological changes and LOXs was explored using a type 2 diabetes model of male Zucker diabetic fatty rats. The expression of LOX and lysyl oxidase-like 1 to 3 (LOXL1 to 3) levels were evaluated by immunohistochemical staining. The expression levels of LOX and LOXL2 in the kidney tissue in the diabetic group were significantly higher compared with those of the control group, but LOXL1 and LOXL3 expression levels were not significantly different between the two groups. These results indicated that LOXL2 and LOX may be critical factors involved in the progression of DN.

Carotid Arterial Flow in Pseudoexfoliation Glaucoma and its Role in Diagnosing the Disease

OBJECTIVE OF THE STUDY

The objective of the study was to investigate the change in carotid arterial flow in pseudoexfoliation glaucoma (XFG) for determining its diagnostic value.

MATERIALS AND METHODS

Patients with XFG (N=30) and control subjects (N=22) were recruited. Common carotid artery (CCA) and internal carotid artery of each participant were examined using color Doppler and B-mode ultrasonography. Resistivity index (RI), as a flow parameter of interest, was measured and statistically compared between the 2 groups. Receiver operating characteristic was also produced to assess its diagnostic value.

RESULTS

The measured RI values from the controls were within the expected range. Among CCA and internal carotid artery, only RI of CCA exhibited statistically significant changes in XFG (0.75±0.04 vs. 0.70±0.03 cm/s). Threshold value of RI=0.72 yielded 90% sensitivity and 73% specificity in distinguishing the cases of XFG from the controls.

CONCLUSIONS

Flow dynamics of carotid arterial system exhibits different characteristics in individuals with XFG than controls. Such differences may serve as a basis for developing potentially new diagnostic biomarkers of XFG. Further studies are justified for examining the carotid flow in pseudoexfoliation syndrome and compare it against XFG for determining its power in differential diagnosis.