The role of the cytokines in the pathogenesis of pseudoexfoliation syndrome

Cardiovascular Manifestations of Pseudoexfoliation Syndrome: A Narrative Review

Pseudoexfoliation syndrome (PEX) is a long-term, age-related extracellular matrix condition that causes aberrant fibrillary pseudoexfoliative material (PXM) to accumulate in various body tissues. The anterior portion of the eye is where this disorder most frequently presents. It affects the entire body. Most frequently, it is seen in older people, usually those over 50. Fibrillar deposits are a symptom of the pseudoexfoliation syndrome and are found in the anterior part of the eye. Deposition of fibrillary white flaky material is seen. The lens capsule, cornea, ciliary epithelium, lens epithelium, iris pigment epithelium, zonules, orbital soft tissues, trabecular meshwork, iris blood vessels, and iris stroma have all been reported to show such depositions. The skin, heart, lungs, liver, kidneys, and other organs have also been reported to contain these deposits. Asymmetrical and bilateral illnesses are both possible. Myocardial infarction, cerebrovascular accidents, and systemic hypertension have all been linked to it. The pseudoexfoliative condition was first reported with the characteristic findings of white or grey flakes on the anterior lens capsule, the prevalence of glaucoma rising with age, and its presence in about 50% of eyes. A few decades later, the term pseudoexfoliation was given to differentiate it from the true exfoliation syndrome. True exfoliation syndrome is characterized by lamellar delamination of the lens capsule and is caused by exposure to infrared radiation. It is commonly seen in glassblowers. Age is a risk factor for PEX once a person reaches 70. Symptoms of PEX include elevated intraocular pressure, peripapillary transillumination deficiencies, potential glaucomatous optic nerve damage, poor dilatation, Sampaolesi line, and fibrillar white flaky deposits along the pupillary border. Meanwhile, fibrillar white flaky deposits on the anterior lens capsule (Hoarfrost Ring) and pigment dispersion syndrome are not pathognomonic.

Circulating miRNAs and their functional genetic variants in pseudoexfoliative glaucoma: potential of miR-146a-5p as a diagnostic biomarker

PURPOSE

The etiology and pathogenesis of pseudoexfoliation syndrome (PEX) and its advancement into pseudoexfoliative glaucoma (PEG) are not fully understood. In this study, we aimed to evaluate the possible role played by two circulating microRNAs (miR-146a-5p and miR-196a-5p) in plasma and their functional genetic variants MIR146A rs2910164 and MIR196A2 rs11614913 in susceptibility to PEG or PEX.

METHODS

Plasma miRNA relative expression of 27 patients with PEG, 25 patients with PEX and 27 controls was determined using quantitative RT-PCR, and fold change was calculated using the 2-ΔΔCt method. Genotyping of 300 patients with PEG, 300 patients with PEX, and 300 controls was performed using a PCR-restriction fragment length polymorphism analysis.

RESULT

Plasma miR-146a-5p relative expression was significantly elevated in patients with PEG (3.9-fold) (P < .000) and patients with PEX (2.7-fold) relative to controls (P = .001). The diagnostic ability of plasma miR-146a-5p expression fold change was good for discriminating PEG vs. controls (AUC = 0.897, P < .000), and the optimal decision threshold was 1.83 (sensitivity = 74%, specificity = 93%). Plasma miR-196a-5p relative expression did not differ significantly between study groups. No significant difference in terms of the minor allele frequency or the distribution of genotypes for MIR146A rs2910164 G/C or MIR196A2 rs11614913 C/T was observed between study groups.

CONCLUSIONS

Circulating miR-146a-5p can contribute to the risk of PEX/PEG. Therefore, we propose that plasma miR-146a-5p can be developed as a potential biomarker for the minimally invasive diagnoses of PEX/PEG and as a potential therapeutic target with further studies.

Analysis of genetically determined gene expression suggests role of inflammatory processes in exfoliation syndrome

BACKGROUND

Exfoliation syndrome (XFS) is an age-related systemic disorder characterized by excessive production and progressive accumulation of abnormal extracellular material, with pathognomonic ocular manifestations. It is the most common cause of secondary glaucoma, resulting in widespread global blindness. The largest global meta-analysis of XFS in 123,457 multi-ethnic individuals from 24 countries identified seven loci with the strongest association signal in chr15q22-25 region near LOXL1. Expression analysis have so far correlated coding and a few non-coding variants in the region with LOXL1 expression levels, but functional effects of these variants is unclear. We hypothesize that analysis of the contribution of the genetically determined component of gene expression to XFS risk can provide a powerful method to elucidate potential roles of additional genes and clarify biology that underlie XFS.

RESULTS

Transcriptomic Wide Association Studies (TWAS) using PrediXcan models trained in 48 GTEx tissues leveraging on results from the multi-ethnic and European ancestry GWAS were performed. To eliminate the possibility of false-positive results due to Linkage Disequilibrium (LD) contamination, we i) performed PrediXcan analysis in reduced models removing variants in LD with LOXL1 missense variants associated with XFS, and variants in LOXL1 models in both multiethnic and European ancestry individuals, ii) conducted conditional analysis of the significant signals in European ancestry individuals, and iii) filtered signals based on correlated gene expression, LD and shared eQTLs, iv) conducted expression validation analysis in human iris tissues. We observed twenty-eight genes in chr15q22-25 region that showed statistically significant associations, which were whittled down to ten genes after statistical validations. In experimental analysis, mRNA transcript levels for ARID3B, CD276, LOXL1, NEO1, SCAMP2, and UBL7 were significantly decreased in iris tissues from XFS patients compared to control samples. TWAS genes for XFS were significantly enriched for genes associated with inflammatory conditions. We also observed a higher incidence of XFS comorbidity with inflammatory and connective tissue diseases.

CONCLUSION

Our results implicate a role for connective tissues and inflammation pathways in the etiology of XFS. Targeting the inflammatory pathway may be a potential therapeutic option to reduce progression in XFS.

Does the conjunctivochalasis accompanied by pseudoexfoliation syndrome affect the ocular surface and anterior segment structures?

PURPOSE

The probability of the coexistence of conjunctivochalasis and pseudoexfoliation syndrome (PES) in the same individual may increase with aging. We investigated the effects of conjunctivochalasis accompanied by PES on the ocular surface (OS) and anterior segment (AS) structures.

METHODS

Cases with only conjunctivochalasis were determined as Group 1 (n = 62), cases with conjunctivochalasis accompanied by PES as Group 2 (n = 45), and healthy individuals as Group 3 (n = 56). The OS and AS parameters of the groups were compared.

RESULTS

There were a higher grade-3 conjunctivochalasis rate (17.7% vs. 46.7%, p = 0.039), a greater "mean grade of conjunctivochalasis" value (1.72 ± 0.24 vs. 2.29 ± 0.32, p = 0.036), and a higher "total conjunctivochalasis score" (4.27 ± 1.13 vs. 6.12 ± 1.35, p = 0.025) in Group 2 than in Group 1. Additionally, Group 2 had a shorter tear film break-up time (TBUT) (9.17 ± 2.53 vs. 5.41 ± 1.32, p = 0.010) and a greater OS disease index (OSDI) score (16.28 ± 3.15 vs. 27.36 ± 4.12, p = 0.037) than Group 1. Moreover, both Group 1 and Group 2 had shorter TBUTs (Group 1-3: p = 0.004; Group 2-3: p < 0.001) and greater OSDI scores (Group 1-3: p = 0.042; Group 2-3: p = 0.019) compared to Group 3. The groups' ocular surface staining scores, Schirmer 1 tests, central corneal thicknesses, keratometries, axial lengths, anterior chamber depths, lens thicknesses, and intraocular pressures were similar (p > 0.05).

CONCLUSIONS

To our knowledge, this was the first study comprehensively investigating the effects of conjunctivochalasis accompanied by PES on the OS and AS structures together. We found that conjunctivochalasis might cause the OS disease, while the presence of PES in conjunctivochalasis cases might worsen both the OS disease and conjunctivochalasis findings.

RNA Sequencing of Lens Capsular Epithelium Implicates Novel Pathways in Pseudoexfoliation Syndrome

Purpose

Pseudoexfoliation syndrome (PEX) is a common systemic disease that results in severe and often irreversible vision loss. Despite considerable research effort, PEX remains incompletely understood. This study sought to perform the first RNAseq study in elucidate the pathophysiology of PEX, and contribute a publicly available transcriptomic data resource for future research.

Methods

Human ocular lens capsular epithelium samples were collected from 25 patients with PEX and 39 non-PEX controls undergoing cataract surgery. RNA extracted from these specimens was subjected to polyadenylated (mRNA) selection and deep bulk RNA sequencing. Differential expression analysis investigated protein-coding gene transcripts. Exploratory analyses used pathway analysis tools, and curated class- and disease-specific gene sets.

Results

Differential expression analysis demonstrated that 2882 genes were differentially expressed according to PEX status. Genes associated with viral gene expression pathways were among the most upregulated, alongside genes encoding ribosomal and mitochondrial respiratory transport chain proteins. Cell adhesion protein transcripts including type 4 collagen subunits were downregulated.

Conclusions

This comparative transcriptomic dataset highlights novel and previously recognized pathogenic pathways in PEX and provides the first comprehensive transcriptomic resource, adding an additional layer to build further understanding of PEX pathophysiology.

Neutrophil lymphocyte ratio as a predictor of perioperative complications in patients with PEX Syndrome during cataract surgery

INTRODUCTION

Pseudoexfoliation syndrome (PES) is an age-related process associated with glaucoma and cataracts. It increases the risk of complications during cataract surgery. Blood neutrophil-to-lymphocyte ratio (NLR) is shown to be an effective biomarker of inflammation in PES. We aimed to investigate association of NLR and pseudoexfoliation (PEX) related cataract surgery complications.

METHODS

A total of 210 eyes who underwent cataract surgery between January 2016 and January 2020 in our department were analyzed retrospectively. Patients were grouped with respect to developing complications and the two groups were compared. Medical records were reached to obtain neutrophil and lymphocyte values to calculate NLR. Data obtained were analyzed using chi-square test. Receiver operating characteristics curve analysis was performed to determine cutoff, sensitivity and specificity values. p value of ≤ 0.05 was considered statistically significant.

RESULTS

The mean age was 68.1 ± 7.2 years and mean NLR was 2.11 ± 0.81. Complications were observed in 32 (15.2%) of the patients (group 1). Neutrophil counts (5.19 ± 0.64 vs. 4.43 ± 0.86, p < 0.001) and the NLR (2.68 ± 0.73 vs. 2.01 ± 0.81, p < 0.001) of group 1 were significantly higher than group 2. The ROC analysis revealed a cutoff value of 2.33 for NLR to predict cataract surgery complications with sensitivity of 87.5% and specificity of 78.1%.

CONCLUSION

There is an association between NLR and increased risk of complications during cataract surgery in PES patients. NLR can be used as an easy method to help ophthalmologists in predicting the risks associated with cataract surgery in PEX eyes.

Evaluation of lacrimal drainage system in Pseudoexfoliation syndrome

Purpose

To evaluate the prevalence of the obstruction of lacrimal drainage system (LDS) in patients with pseudoexfoliation (PXF) syndrome.

Materials and Methods

This cross-sectional study included 152 eyes of 76 consecutive patients with bilateral PXF syndrome and 170 eyes of 85 age and gender-matched controls. The LDS evaluation was performed based on dye disappearance test, slit-lamp examination, diagnostic probing, and irrigation test. The presence of punctal stenosis and canalicular obstruction were considered as the obstruction of proximal LDS; and complete or incomplete nasolacrimal duct obstruction was considered as obstruction of distal LDS. Demographic characteristics, ophthalmologic findings, and prevalence and site of obstruction of LDS were compared among the groups.

Results

The prevalence of obstruction of LDS was higher in the PXF syndrome group when compared to controls (21.1% vs 12.2%), but the difference was not statistically significant (p = 0.061). The obstruction of proximal LDS was found to be more frequent in the PXF syndrome (17.7%) group when compared to controls (10.0%), and this difference was statistically significant (p = 0.041). There was significantly more punctal stenosis in the PXF syndrome group when compared to controls (15.1% vs 7.6%, p = 0.033). The prevalence of canalicular stenosis and obstruction of distal LDS was similar in the PXF and the control groups (p = 0.596 and p = 0.741, respectively).

Conclusion

The prevalence of punctal stenosis was statistically significantly higher in the PXF syndrome group when compared to the controls. This association is probably related to increased local ocular surface inflammation which is triggered by the accumulation of PXF material.

Investigation of Possible Role of Chlamydia in Pseudoexfoliation Syndrome

Background: Pseudoexfoliation syndrome (PES) is a systemic disease characterized by the aggregation of fibrillar extracellular material in intraocular and extraocular tissues with unknown etiology. Clarifying the etiopathogenesis of PES would be important for public health. Objectives: We aimed to investigate the possible role of Chlamydia in the etiology of PES. Methods: This cross-sectional study was carried out in the ophthalmology clinic of a tertiary hospital. The study included two groups, including the patient group (PES patients with nuclear cataracts) and the control group (patients with nuclear cataracts). Patients with other ophthalmic problems and systemic diseases were excluded. Blood samples and conjunctival swabs taken from 49 patients and 42 controls were used in the study. Anti-Chlamydia trachomatis IgG and IgM, anti-C. pneumoniae IgG and IgM, Interleukin (IL)-6, and IL-20 were studied in the serum samples. The PCR study was performed with conjunctival swab samples and sequence analysis of PCR-positive samples was performed. Results: According to the results of the study, there was no statistically significant difference between the groups in terms of anti-C. trachmatis IgG, anti-C. trachmatis IgM, anti-C. pneumoniae IgM, IL-6, and PCR results. There was a statistically significant difference between patient and control groups in terms of anti-C. pneumoniae IgG and IL-20 levels. The DNA sequencing of all PCR products was found to be compatible with C. pneumoniae. Conclusions: It seems that C. pneumoniae might have an important role in the etiology and development of PES. However, further studies in larger groups are needed to clarify these results.

Evaluation of aqueous humor and serum clusterin levels in patients with glaucoma

Background

To compare the aqueous humor (AH) and the serum clusterin levels of patients with pseudoexfoliation syndrome (PEX), pseudoexfoliation glaucoma (PEXG), and primary open-angle glaucoma (POAG) with each other and with an age- and sex-matched control group.

Methods

This prospective, cross-sectionalstudy evaluated 92 eyes from 92 adult cases of uncomplicated phacoemulsification and posterior chamber intraocular lens (IOL) implantation. The cases were divided into PEX, PEXG, POAG, and control groups. Serum samples were taken from the antecubital vein just before the surgery, and the AH samples were aspirated at the beginning of the surgery. Kruskal-Wallis H, One-way ANOVA, Mann-Whitney U with Bonferroni correction and Chi-Square tests were used for statistical analysis.

Results

The serum clusterin levels were the highest in the PEXG group, but no statistically significant differences were observed between the groups (p=0.633). The mean AH clusterin levels were 286.79±29.64 μg/mL in the PEXG group, 263.92±31.70 μg/mL in the PEX group, 272.59±49.71 μg/mL in the POAG group, and 193.50±62.38 μg/mL in the control group (p< 0.001). This came out to be 1.48 times increase for the PEXG group, 1.36 for the PEX group, and 1.41 for the POAG group when compared with the control subjects.

Conclusions

A higher level of clusterin in the anterior chamber was found to be associated with PEX and PEXG. In addition, a high level of anterior chamber clusterin in POAG, which is a new finding, showed that this molecule might be important not only in pseudoexfoliation, but also other types of glaucoma like POAG.

YKL-40 is a local marker for inflammation in patients with pseudoexfoliation syndrome

PURPOSE

To investigate the YKL-40, as a marker of inflammation, in aqueous humor and serum of cataract patients with and without pseudoexfoliation syndrome (PEX).

METHODS

Aqueous humor and serum samples were obtained from 44 patients who underwent phacoemulsification surgery. All patients were divided into two groups: PEX (n = 24) and control (n = 20). YKL-40 levels were measured with enzyme-linked immunosorbent assay (ELISA). The differences between the groups were assessed by using Chi-square and independent sample t-tests. The Pearson correlation coefficient was used to evaluate the correlation between variables.

RESULTS

There was a significant difference between the mean YKL-40 levels in the aqueous humor of PEX group (112.0 ± 35.8 ng/mL) and control subjects (88.2 ± 30.6 ng/mL) (P = 0.025). However, the difference between the mean YKL-40 levels in the serum of PEX group (53.5 ± 29.1 ng/mL) and control subjects (44.6 ± 30.2 ng/mL) was non-significant (P = 0.326). The correlation between aqueous humor and serum YKL-40 concentrations was significant in both the groups (r = 0.833, P < 0.001; r = 0.840, P < 0.001, respectively).

CONCLUSIONS

Increased aqueous humor levels of YKL-40 demonstrate that it is local, but not a systemic marker for inflammation in patients with PEX.

Comparison of cytokine profiles in the aqueous humor of eyes with pseudoexfoliation syndrome and glaucoma

PURPOSE

To compare the cyto- and chemokine profiles in the aqueous humor of PEXS eyes in the absence or presence of secondary glaucoma with or without luxation of the intraocular lens (IOL).

METHODS

Samples of aqueous humor were collected intraoperatively from 20 healthy controls and from 73 eyes with PEX-syndrome, which was manifested in the absence of any other local or systemic desease. The latter group was sub-devided into eyes with an early form of PEX-syndrome in the absence of complications (PEX, n = 33), those with a late form of PEX-syndrome and glaucoma (PEXG, n = 30), and those with a late form of PEX-syndrome with luxation of the IOL that required surgery (PEXL, n = 10). The samples were analyzed in parallel after storage at -80°C. The levels of 40 cytokines were simultaneously quantified using the Bio-Plex® multiplex beads system. The inter-group data were statistically compared using the Kruskal-Wallis test (p ≤ 0.01).

RESULTS

PEX and PEXG were comparable in their cytokine profiles for all 40 cytokines, whereas the cytokine profile in PEXL-eyes revealed higher levels of all but 5 cytokines (CXCL13, CCL27, IL-2, CCL3, CCL20; p ≤ 0.01). This latter finding is indicative of a non-specific inflammatory reaction in the context of IOL-luxation. The concentrations of 6 cytokines lay below the detection limit in all groups.

CONCLUSIONS

The local up-regulation of 85% of the detectable cytokines in the aqueous humor of PEXL-eyes may be linked either with a progression of the disease or a breakdown of the antero-posterior barrier in the context of IOL-luxation.

Nitric oxide and tumour necrosis factor alpha in the process of pseudoexfoliation glaucoma

AIM

To establish the role of nitric oxide (NO), ascorbic acid and tumour necrosis factor-α (TNF-α) in the pathogenesis of pseudoexfoliation glaucoma (XFG).

METHODS

Our study included 120 patients who were referred for cataract surgery. All patients were divided into four groups according to clinical findings: XFG, early and late pseudoexfoliation syndrome (XFS), and cataract (without pseudoexfoliation). Serum and aqueous humour levels of the ascorbic acid, NO and TNF-α were measured. The concentrations of the ascorbic acid and NO were measured by an appropriate spectrophotometric method. Enzyme-linked immunosorbent assay (ELISA) was used to determine TNF-α level.

RESULTS

Aqueous humour concentration of ascorbic acid was significantly lower in patients with late XFS (0.61±0.11 mmol/L) and XFG (0.48±0.15 mmol/L) compared to patients with early XFS (0.9±0.15 mmol/L) and cataract (1.16±0.22 mmol/L), while there was no difference in serum concentration in all examined groups. Aqueous humour concentration of NO was significantly higher in patients with XFG (77.7±11.4 µmol/L) compared to patients with early XFS (50.27±9.34 µmol/L) and cataract (49.77±7.1 µmol/L), while serum concentration was increased in the early stage of XFS (73.26±8.29 µmol/L). Aqueous humour level of proinflammatory cytokine TNF-α was increased in patients with XFS (early 460.04±18.32 pg/mL; late 502.42±53.23 pg/mL) and XFG (510.34±43.07 pg/mL), while there was no difference in serum level in all examined groups of patients.

CONCLUSION

Reduced ascorbic acid and elevated NO and inflammation related cytokine TNF-α level in aqueous humour of the patients with developed XFG suggest that oxidative stress induces local inflammation.

Elevated neutrophil-to-lymphocyte ratio in pseudoexfoliation syndrome

PurposeTo investigate the relationship between serum neutrophil/lymphocyte ratio and pseudoexfoliation syndrome.Materials and methodsThis study was designed as a retrospective analysis. Patients were divided into three groups: 55 patients with pseudoexfoliation syndrome (group 1), 19 patients with pseudoexfoliation glaucoma (group 2), and 48 control subjects without pseudoexfoliation syndrome or pseudoexfoliation glaucoma (group 3). The levels of neutrophils and lymphocytes were measured by ABX Pentra DF120/USA biochemical analyzer. The neutrophil/lymphocyte ratio was measured by dividing neutrophil count by lymphocyte count.ResultsThe mean ages of patients were 67.9±8.1 in group 1, 70.6±7.4 in group 2, and 67.3±7.6 in group 3 (P=0.172). Baseline clinical characteristics, such as diabetes and hypertension, were similar among groups. The mean neutrophil/lymphocyte ratio values were 2.08±0.61 in group 1, 2.20±0.58 in group 2, and 1.51±0.57 in group 3. The neutrophil/lymphocyte ratio was significantly higher in group 1 and 2 than the group 3 (P<0.001). In receiver operating characteristics analysis, the area under the curve for neutrophil/lymphocyte ratio was 0.776, and a neutrophil/lymphocyte ratio of >1.72 predicted pseudoexfoliation syndrome with a sensitivity of 77% and specificity of 71%.ConclusionThe elevated neutrophil/lymphocyte ratio is significantly associated with pseudoexfoliation syndrome. This novel and low-cost parameter can provide useful information for the relevant risk evaluation in these patients.

Serum and aqueous xanthine oxidase levels, and mRNA expression in anterior lens epithelial cells in pseudoexfoliation

PURPOSE

The aim of this study was to determine serum and aqueous xanthine oxidase (XO) levels, and mRNA expression in anterior lens epithelial cells in pseudoexfoliation (PEX).

METHODS

In this prospective study, serum, aqueous and anterior lens capsules were taken from 21 patients with PEX and 23 normal subjects who had undergone routine cataract surgery. Serum and aqueous XO levels were analyzed using the colorimetric method. mRNA expression of XO in anterior lens epithelial cells was evaluated using reverse transcription polymerase chain reaction analysis.

RESULTS

Serum XO levels (means ± standard deviations) were 207.0 ± 86.1 IU/mL and 240.6 ± 114.1 IU/mL in the normal and PEX groups, respectively (p = 0.310). Aqueous XO levels (means ± standard deviations) were 65.5 ± 54.3 IU/mL in the normal group and 130.5 ± 117.4 IU/mL in the PEX group (p = 0.028). There was a 2.9 fold decrease in mRNA expression in anterior lens epithelial cells of PEX, which is significantly lower than the normal group (p = 0.01).

CONCLUSIONS

Higher aqueous XO levels lacking associated different serum XO suggests higher oxidative stress in the aqueous. Higher aqueous XO levels in PEX with decreased mRNA expression in anterior lens epithelial cells indicate possible overexpression of XO in other structures related to the aqueous.

Bilateral pseudoexfoliation deposits on intraocular lens implants

We present a rare case of bilateral pseudoexfoliative deposits on both intraocular lens (IOL) implants in an 83-year-old woman with no other associated pathology, 5 years after cataract surgery. Pseudoexfoliation syndrome is the most common cause of secondary open-angle glaucoma worldwide and these deposits are usually found on the natural lens. The fact that pseudoexfoliative deposits have been found on IOL implants implies the need for a thorough examination in pseudophakic patients, for it could be the only sign of secondary glaucoma.

Pseudoexfoliation syndrome and cardiovascular diseases

Pseudoexfoliation (PEX) syndrome is a well-recognized late-onset disease caused by a generalized fibrillopathy. It is linked to a broad spectrum of ocular complications including glaucoma and perioperative problems during cataract surgery. Apart from the long-known intraocular manifestations, PEX deposits have been found in a variety of extraocular locations and they appear to represent a systemic process associated with increased cardiovascular and cerebrovascular morbidity. However, as published results are inconsistent, the clinical significance of the extraocular PEX deposits remains controversial. Identification of PEX deposits in the heart and the vessel wall, epidemiologic studies, as well as, similarities in pathogenetic mechanisms have led to the hypothesis of a possible relation between fibrillar material and cardiovascular disease. Recent studies suggest that PEX syndrome is frequently linked to impaired heart and blood vessels function. Systemic and ocular blood flow changes, altered parasympathetic vascular control and baroreflex sensitivity, increased vascular resistance and decreased blood flow velocity, arterial endothelial dysfunction, high levels of plasma homocysteine and arterial hypertension have all been demonstrated in PEX subjects. Common features in the pathogenesis of both atherosclerosis and PEX, like oxidative stress and inflammation and a possible higher frequency of abdominal aorta aneurysm in PEX patients, could imply that these grey-white deposits and cardiovascular disorders are related or reflect different manifestations of the same process.

Cardiovascular repercussions of the pseudoexfoliation syndrome

Pseudoexfoliation syndrome is a primarily ophthalmological disorder caused by deposition of whitish-gray protein on the lens, iris, and multiple other eye tissues. There is increasing evidence over the previous years that pseudoexfoliation syndrome is a systemic disorder with various extraocular manifestations and has recently been linked to several cardiovascular disorders. The present article aims to summarize the current knowledge on cardiovascular implications of this well-described clinical entity.