Prevalence of ocular pseudoexfoliation syndrome and associated complications in Riyadh, Saudi Arabia

Histopathological Analysis of Pseudoexfoliation Material in Ocular Surgeries: Clinical Implications

BACKGROUND

Pseudoexfoliation syndrome (PEX) is a common age-related ocular condition characterized by the accumulation of a fibrillar, pseudoexfoliative material on the anterior segment of the eye. This study aims to investigate the histopathological characteristics of pseudoexfoliative material within different ocular structures, including the eyelid, conjunctiva, and anterior lens capsule.

METHODS

A total of 32 anterior lens capsules, 3 eyelid fragments, and 12 conjunctival specimens were obtained from patients clinically diagnosed with PEX during ocular surgeries at the Onioptic Hospital of Ophthalmology. The tissue specimens were subsequently processed using the classical histological technique of paraffin embedding. This process enabled the production of serial sections with a thickness of 4 microns, facilitating the microscopic examination of fine details. The sections were stained with the hematoxylin-eosin (HE) method for the observation of microscopic structures.

RESULTS

This study's findings reveal that PEX material, characterized by its fibrillar and amorphous components, is consistently present across multiple ocular structures, including the anterior lens capsule, eyelid, and conjunctiva. When stained with H&E, the PEX material typically appears as amorphous, eosinophilic deposits. Under higher magnification, these deposits exhibit a fibrillar structure, often appearing as irregular, granular, or filamentous aggregates.

CONCLUSIONS

The deposit of fibrillar material in the eyelid and conjunctiva, though less commonly emphasized compared to other structures, is a significant finding that sheds light on the systemic nature of the syndrome. The consistent identification of fibrillar eosinophilic deposits across these structures highlights the systemic distribution of PEX material, reinforcing the notion that PEX syndrome is not confined to the anterior segment of the eye.

The effect of adrenaline and trypan blue used during cataract surgery on anatomical and functional outcomes in pseudoexfoliation syndrome patients

PURPOSE

To evaluate the effect of the intracameral adrenaline and trypan blue used during cataract surgery on corneal endothelial parameters in pseudoexfoliation syndrome (PEX) patients.

METHODS

The patients were divided into four groups according to intraoperative use of agents during cataract surgery: intracameral adrenaline (1/10,000, 0.1 ml) (group 1), trypan blue (0.6 mg/ml, 0.1 ml) (group 2), combination of adrenaline and trypan blue (group 3) and none (group 4).

RESULTS

Preoperative ECD, CV, HEX and CCT parameters were similar between the groups. A mean loss of 12.7% in ECD was observed at the postoperative third months compared to the preoperative. In group 3, ECD was found to be lower in the postoperative third months compared to the preoperative (p = 0.014). In the other groups, no statistically significant difference was found in preoperative and postoperative comparisons.

CONCLUSION

In conclusion, the utilization of intracameral adrenaline or trypan blue did not cause a significant difference in corneal endothelium in PEX patients. However, their combined use may have a negative effect on endothelial cell density. In a cataract surgery performed in the presence of PEX, the increased likelihood of endothelial damage should be taken into consideration, and appropriate precautions should be taken preoperatively and intraoperatively.

Secondary glaucoma: Toward interventions based on molecular underpinnings

Glaucoma is a heterogeneous group of progressive diseases that leads to irreversible blindness. Secondary glaucoma refers to glaucoma caused by a known underlying condition. Pseudoexfoliation and pigment dispersion syndromes are common causes of secondary glaucoma. Their respective deposits may obstruct the trabecular meshwork, leading to aqueous humor outflow resistance, ocular hypertension, and optic neuropathy. There are no disease-specific interventions available for either. Pseudoexfoliation syndrome is characterized by fibrillar deposits (pseudoexfoliative material) on anterior segment structures. Over a decade of multiomics analyses taken together with the current knowledge on pseudoexfoliative glaucoma warrant a re-think of mechanistic possibilities. We propose that the presence of nucleation centers (e.g., vitamin D binding protein), crosslinking enzymes (e.g., transglutaminase 2), aberrant extracellular matrix, flawed endocytosis, and abnormal aqueous-blood barrier contribute to the formation of proteolytically resistant pseudoexfoliative material. Pigment dispersion syndrome is characterized by abnormal iridolenticular contact that disrupts iris pigment epithelium and liberates melanin granules. Iris melanogenesis is aberrant in this condition. Cytotoxic melanogenesis intermediates leak out of melanosomes and cause iris melanocyte and pigment epithelium cell death. Targeting melanogenesis can likely decrease the risk of pigmentary glaucoma. Skin and melanoma research provides insights into potential therapeutics. We propose that specific prostanoid agonists and fenofibrates may reduce melanogenesis by inhibiting cholesterol internalization and de novo synthesis. Additionally, melatonin is a potent melanogenesis suppressor, antioxidant, and hypotensive agent, rendering it a valuable agent for pigmentary glaucoma. In pseudoexfoliative glaucoma, where environmental insults drive pseudoexfoliative material formation, melatonin's antioxidant and hypotensive properties may offer adjunct therapeutic benefits. This article is categorized under: Neurological Diseases > Molecular and Cellular Physiology.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Retinal Nerve Fiber Layer and Ganglion Cell Complex Thickness in Adult Children of Patients With Pseudoexfoliation Glaucoma

PRCIS

The adult children of patients with pseudoexfoliation glaucoma (PXG) had universally lower retinal nerve fiber layer (RNFL) thickness and ganglion cell complex (GCC) thickness values compared with individuals with a negative family history of PXG.

PURPOSE

This study aimed to evaluate RNFL and GCC thicknesses in the adult children of individuals with PXG compared with people without a parental history of PXG.

MATERIALS AND METHODS

This cross-sectional observational study included 40 eyes of 40 adults with confirmed parental history of PXG and 40 eyes of 40 healthy adults with no parental history of PXG. RNFL and macular GCC thicknesses were measured by spectral-domain optical coherence tomography (Nidek RS-3000 Advance) and compared between the groups. All subjects also underwent visual field testing (program 30-2 of the Humphrey Field Analyzer), and their mean deviation and pattern SD values were compared.

RESULTS

Compared with adults without parental PXG, those with a parental history of PXG had significantly lower RNFL thickness overall (mean 98.2 vs 109.5 µm) and in all quadrants (inferior, superior, nasal, and temporal) ( P <0.001 for all). They also had significantly lower GCC thickness overall (mean 97.9 vs 109.4 µm) and in both hemispheres (superior and inferior) ( P <0.001 for all). There was no significant difference between the groups in terms of mean deviation or pattern SD values ( P >0.05).

CONCLUSION

PXG in a parent was associated with significantly thinner RNFL and GCC compared with those with no history of PXG in a parent. Longer follow-up and prospective controlled clinical studies are needed to evaluate whether these findings may serve as an early indicator of glaucoma in the adult children of known PXG patients.

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.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Pseudoexfoliation Syndrome and Associated Factors Among Adults at Gondar University Comprehensive Specialized Hospital Tertiary Eye Care and Training Center: A Cross-Sectional Study

BACKGROUND

Pseudoexfoliation syndrome is an age-related disorder characterized by the deposition of a distinct fibrillar extracellular material in various tissues and organs of the body. Glaucoma and cataract are the consistently reported clinical consequences of Pseudoexfoliation syndrome on the eye. This study aimed to estimate the proportion of pseudo-exfoliation syndrome and associated factors in Gondar university comprehensive specialized hospital tertiary eye care and training center.

METHODS AND MATERIALS

Institution-based cross-sectional study was conducted from January to March 2019 at Gondar university comprehensive specialized hospital tertiary eye care and training center among 295 patients. Consecutive 295 participants aged above 40 years were involved in the study. A structured questionnaire and ocular examination were used to collect the data. Data were entered into EPI-INFO 3.5.1 and exported to SPSS version 20 for analysis. Factors associated with pseudoexfoliation syndrome were ascertained by chi-square and independent t-test. Statistical significance was considered when p-value <0.05.

RESULTS

A total of 295 adults participated in the study with a response rate of 92.8%. The median (±IQR) age of study respondents was 64(±9) years and 67.8% were males. The proportion pseudoexfoliation syndrome was 34.6% [95% CI: 29.2-40.7%]. The mean IOP and mean age were significantly higher among patients with pseudoexfoliation syndrome. Age, sex, high IOP, glaucoma, outdoor work, and rural residence were significantly associated with the proportion of pseudoexfoliation syndrome.

CONCLUSION

The proportion of pseudoexfoliation syndrome among participants aged ≥40 years was high. Age, sex, high IOP, glaucoma, outdoor work, and rural residence were factors having a significant association with the proportion of pseudoexfoliation syndrome.

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.

Glaucoma Diagnoses and Legal Blindness from Glaucoma among Bedouin Patients of Central Saudi Arabia: A Hospital-Based Study

PURPOSE:

The current study aims to know the glaucoma diagnoses and legal blindness from glaucoma among a tertiary referral center in Riyadh (King Abdulaziz Medical City [KAMC]-Riyadh patients).

METHODS:

This is a retrospective cohort study on chart review, where all eligible glaucoma patients attending the ophthalmology clinic at KAMC-Riyadh, between 2018 and 2019; were included.

RESULTS:

A total of 248 patients were included in the study; 142 patients (57.3%) were females and 106 (42.7%) were males. The mean age of the patients was 62.2 ± 18 years and most of them (93.5%) did not have a family history of glaucoma. Nearly one-quarter (26.6%; n = 66) of the included patients were legally blind, out of those, 36.4% had their right eye affected, 34.8% had their left eye affected, and 28.8% had both eyes affected. Legally, blind patients (LBGs) did not show a statistically significant reduction in the intraocular pressure (IOP) in the right eye (P = 0.103), on comparing the IOP in both visits. Nevertheless, there was a statistically significant reduction in the IOP of the left eye among the LBGs in both visits (P = 0.016). Regarding the nonblind group of patients, there were highly statistically significant reductions in both eyes (P < 0.001).

CONCLUSION:

The present findings show a high prevalence rate of legal blindness among glaucoma patients, with IOP reduction, age, and glaucoma diagnoses being the most important predictors among the study population.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Effect of capsular tension ring implantation on predicted refractive error after cataract surgery in patients with pseudoexfoliation syndrome

AIM

To investigate the effect of capsular tension ring (CTR) implantation on predicted refractive error after cataract surgery in patients with pseudoexfoliation (PEX) syndrome.

METHODS

This double-blind randomized clinical trial was conducted on 60 patients with PEX syndrome referring to Imam Khomeini Hospital affiliated to Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran, for undergoing cataract surgery. The study population was divided into two groups, namely CTR group (n=30) and non-CTR group (control group; n=30). The refractive error and anterior chamber depth (ACD) were measured 1wk, 1mo, and 3mo after phacoemulsification (PE) surgery.

RESULTS

The results indicated no statistically significant difference between the two groups in terms of predicted refractive error (obtained by subtracting preoperative predicted refractive error from actual postoperative refractive error) 1wk (P=0.47), 1mo (P=0.30), and 3mo (P=0.06) after the PE surgery. Regarding the CTR group, the changes of ACD was statistically significant 1 and 3mo after the PE surgery, compared to those obtained 1wk post-surgery (P=0.005).

CONCLUSION

The CTR implantation in PEX cataractous patients without zonulysis has no statistically significant effect on the predicted refraction and ACD changes after PE. The predicted refraction error has a hyperopic shift in both groups. The results reveal the unnecessary of calculating modified IOL in CTR implantation.

Frequency and surgical difficulties associated with pseudoexfoliation syndrome among Indian rural population scheduled for cataract surgery: Hospital-based data

Purpose:

To study the frequency and intraoperative difficulties associated with pseudoexfoliation (PXF) syndrome at a tertiary eye care center in a rural central India.

Methods:

This study included patients scheduled for cataract surgery who were diagnosed with PXF syndrome. All patients underwent a complete ophthalmologic evaluation, including slit-lamp examination, tonometry, gonioscopy, and ophthalmoscopy before the surgery. Cataract surgeries were performed by a single surgeon who reported the intraoperative difficulties.

Results:

In total, 1022 phakic eyes of 1823 patients were evaluated, 226 of whom (22.1%) were diagnosed with PXF syndrome. Most eyes (n = 81, 35.8%) with PXF syndrome were ≥81 years old. Eighty-six eyes (38.1%) had bilateral involvement, whereas 70 (30.9%) had right or left eye involvement. Further, PXF material was distributed on the iris, pupil, and lens in 70 eyes (30.9%) and on the pupillary margin in 36 eyes (15.9%). The mean pupillary dilation was 5.1 (±1.4) mm in patients with PXF syndrome compared with 7.2 (±1.6) mm in those without it (P = 0.03). Grade VI cataract was observed in 93 eyes (41.2%) and hypermature cataract was the most commonly observed cataract stage. Twenty-one eyes (9.3%) had increased intraocular pressure. Intraoperative difficulties were encountered in 62 eyes (27.4%) with poor pupillary dilation being the most common problem (32 eyes, 14.2%), followed by zonular dehiscence (18 eyes, 8%).

Conclusion:

This hospital-based study showed that PXF syndrome is common in Indian rural population and that the intraoperative complication rate in these patients is high.

Clinical spectrum of pseudoexfoliation syndrome-An electronic records audit

PURPOSE

To evaluate different clinical variants of pseudoexfoliation syndrome and their risk of developing ocular hypertension (OHT) or glaucoma (PXG).

DESIGN

Cross sectional hospital based study.

SETTING

All patients seen at glaucoma services of a tertiary eye care center in east India.

METHODS

Electronic medical records search of hospital database including consecutive new and old cases seen during April 2013 to March 2015 was done to retrieve case sensitive words including pseudoexfoliation, PXF, PEX, PXG and pseudoexfoliative glaucoma over any part of the clinical electronic sheet of the patient. All demographic and clinical details including laterality, the pattern of deposits, need for medicines and disc damage at presentation was compared in eyes with radial pigmentary, classical or combined forms of PXF phenotypes.

RESULTS

Of 110313 PXF patients seen during the period of 2013-2015, a total of 2297 eyes of 1150 PXF patients were identified including 525 unilateral PXF (meaning a total of 1775 PXF eyes with 625 patients having bilateral disease, n = 1250 eyes, other clinically normal eye, n = 522) at presentation. Of 525 unilateral PXF eyes, 105 had OHT and 131 had glaucoma while bilateral cases had more >50% (675 eyes of 1250 eyes) with glaucoma. Glaucoma with significant changes in IOP with or without disc damage was seen in 32% of pigmentary and 39% of classical PXF forms with eyes with combined forms of PXF having around 50% with glaucoma at presentation compared to other forms, p<0.001.

CONCLUSION

Different phenotypic variants of PXF in this Indian cohort was associated with 30-50% risk of OHT or glaucoma respectively. Adequate care is required while examining the pattern of PXF in each case to prognosticate each patient/eye.

Bone Mineral Density and 25-Hydroxyvitamin D Levels in Patients With Ocular Pseudoexfoliation Syndrome: A Case-Control Study

The objective of this study was to evaluate bone mineral density (BMD) and 25-hydroxyvitamin D (25(OH)D) levels in patients with ocular pseudoexfoliation (PEX) syndrome. Subjects with ocular PEX syndrome were included in the PEX group and subjects without PEX syndrome were defined as the control group. 25(OH)D levels were measured by chemiluminescence microparticle immunoassay method. BMD measurements were obtained from the femoral neck and lumbar spine by using dual-energy X-ray absorptiometry. The results were expressed as gram per square centimeter, T-scores (standard deviation compared to a healthy 30-yr-old male), and Z-scores (standard deviation compared to the subject's age). Independent t-test was used to compare the mean and medians of the groups. The PEX group consisted of 23 subjects with a mean age of 71.09 ± 2.02 yr and the control group consisted 46 subjects with a mean age of 67.04 ± 1.34 yr. There was no significant difference between the groups as regards the BMD measurements (gram per square meter), T-scores, and Z-scores. Both groups have low 25(OH)D, yet vitamin 25(OH)D levels were similar in the groups (p > 0.05). In the light of our results, although patients with ocular PEX have low BMD and 25(OH)D, BMD and 25(OH)D do not appear to be linked to ocular PEX syndrome in our study population.