Exfoliative glaucoma and primary open-angle glaucoma: associations with death causes and comorbidity

Aging of the skin in pseudoexfoliation syndrome

BACKGROUND

It was reported that pseudoexfoliative material deteriorates iris, brain, heart and lung functions. This material is also found in the skin.

AIMS

The purpose of this study was to investigate the possible effects of pseudoexfoliation material on the aging of the facial skin.

STUDY DESIGN

Cross-sectional study.

METHODS

Forty pseudoexfoliation syndrome (PES) cases and 40 age- and gender-matched controls were evaluated. Job, cigarette use and the presence of any systemic diseases as well as the duration of sun exposure for all the cases were recorded. All of the cases underwent facial skin examination with Wrinkle Assessment Scale as per Lemperle G et al. and Pinch Test.

RESULTS

Wrinkle Assessment Scale scores of the groups also were compared for all 8 facial locations. There were statistically significant differences found between Wrinkle Assessment Scale scores in PES and Control Group for all 8 locations. Mean Wrinkle Assessment Scale scores of women were 4.12 ± 0.74 in Control Group and 4.75 ± 0.37 in PES group (p = 0.0001). For men, mean Wrinkle Assessment Scale scores were 3.77 ± 0.72 in Control group and 4.54 ± 0.36 in PES group (p = 0.002).

CONCLUSION

These results implies that there is quicker progression in aging of facial skin in PES than normals.

Frequency of coexistent eye diseases and cognitive impairment or dementia: a systematic review and meta-analysis

OBJECTIVE

We aim to quantify the co-existence of age-related macular degeneration (AMD), glaucoma, or diabetic retinopathy (DR) and cognitive impairment or dementia.

METHOD

MEDLINE, EMBASE, PsycINFO and CINAHL were searched (to June 2020). Observational studies reporting incidence or prevalence of AMD, glaucoma, or DR in people with cognitive impairment or dementia, and of cognitive impairment or dementia among people with AMD, glaucoma, or DR were included.

RESULTS

Fifty-six studies (57 reports) were included but marked by heterogeneities in the diagnostic criteria or definitions of the diseases, study design, and case mix. Few studies reported on the incidence. Evidence was sparse but consistent in individuals with mild cognitive impairment where 7.7% glaucoma prevalence was observed. Prevalence of AMD and DR among people with cognitive impairment ranged from 3.9% to 9.4% and from 11.4% to 70.1%, respectively. Prevalence of AMD and glaucoma among people with dementia ranged from 1.4 to 53% and from 0.2% to 25.9%, respectively. Prevalence of DR among people with dementia was 11%. Prevalence of cognitive impairment in people with AMD, glaucoma, and DR ranged from 8.4% to 52.4%, 12.3% to 90.2%, and 3.9% to 77.8%, respectively, and prevalence of dementia in people with AMD, glaucoma and DR ranged from 9.9% to 62.6%, 2.5% to 3.3% and was 12.5%, respectively.

CONCLUSIONS

Frequency of comorbid eye disease and cognitive impairment or dementia varied considerably. While more population-based estimations of the co-existence are needed, interdisciplinary collaboration might be helpful in the management of these conditions to meet healthcare needs of an ageing population.

TRIAL REGISTRATION

PROSPERO registration: CRD42020189484.

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.

Comparison of Cardiovascular Risk and Events among Spanish Patients with and without Ocular Pseudoexfoliation

The purpose of this study was to calculate and compare individual cardiovascular risk (CVR) and the development of cardiovascular events and mortality in patients with and without ocular pseudoexfoliation (PEX). A cohort study was carried out to compare two groups of patients who underwent cataract surgery: patients with (n = 99) and without PEX (n = 239). The CVR factors were recorded for all the subjects, and CVR was calculated for each individual using ERICE risk assessment charts. After a six-year follow-up, the cardiovascular events and mortality rates were compared between the two groups. The mean CVR was 36.41% in the PEX group and 33.72% in the non-PEX group (p = 0.13). High blood pressure was detected in significantly more PEX patients (71.4%) than non-PEX patients (58.6%, p = 0.035), yet no differences were found in the other CVR factors. The prevalence of cardiovascular events in the PEX and non-PEX patients was 17.1% and 12.5%, respectively (p = 0.26), with 5% of patients in the PEX group and 5% in the non-PEX group suffering an acute coronary event (p = 0.9). Moreover, 12% of the PEX patients and 7.5% of the non-PEX patients experienced a stroke (p = 0.17), and the six-year mortality rate was 29.3% in the PEX group and 25.9% in the non-PEX group (p = 0.52). PEX was associated with high blood pressure in our cohort of patients, although cardiovascular risk was not shown to be higher in this group. In addition, patients with PEX did not experience more cardiovascular events or have a higher mortality rate than patients without PEX during the period studied.

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.

Descemet's membrane endothelial keratoplasty for pseudoexfoliation syndrome: a case series

Background

To evaluate the clinical outcomes and features of Descemet’s membrane endothelial keratoplasty (DMEK) for eyes with pseudoexfoliation syndrome (PEX).

Methods

In this retrospective study, 37 DMEK cases were reviewed from available medical records. Patients who exhibited endothelial dysfunction derived from PEX or Fuchs endothelial corneal dystrophy (FECD) and successfully underwent cataract surgery about four weeks before DMEK were enrolled. The best spectacle-corrected visual acuity (BSCVA), central corneal thickness (CCT), endothelial cell density (ECD), and incidence of intra-operative/post-operative complications of DMEK were analyzed.

Results

This study included 14 eyes of 14 patients (PEX: n = 6, FECD: n = 8). There was no primary graft failure. In the PEX group, BSCVA improved from 0.67 ± 0.28 at the preoperative point to 0.43 ± 0.14 at 1 month, 0.27 ± 0.10 at 3 months, and 0.19 ± 0.08 at 6 months after DMEK. The donor corneal ECD was 2704 ± 225 cells/mm² at the preoperative point and decreased to 1691 ± 498 cells/mm² at 1 month, 1425 ± 366 cells/mm² at 3 months, and 1281 ± 340 cells/mm² (52.7 ± 11.7% less than ECD of the donor graft) at 6 months after DMEK. None of the patients required rebubbling. When compared with the FECD group, no statistical difference was observed in CCT (p = 0.821); BSCVA (p = 0.001) and the reduction rate of ECD (p = 0.010) were relatively worse.

Conclusions

DMEK is effective for the treatment of endothelial dysfunction due to PEX.

Electronic supplementary material

The online version of this article (10.1186/s12886-019-1130-1) contains supplementary material, which is available to authorized users.

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.

Pulmonary functions in pseudoexfoliation syndrome

OBJECTIVES

It is well-known that pseudoexfoliative material deteriorates iris dilatation function. This material was also found in lung tissue. The aim of the study was to evaluate pulmonary function in patients with pseudoexfoliation.

METHODS

This prospective study included 60 pseudoexfoliation syndrome patients without any pulmonary diseases and 52 age- and gender-matched controls without any pulmonary diseases. Patients were asked about their cigarette use and the presence of any systemic diseases such as diabetes mellitus, arterial hypertension and asthma. All cases underwent full ophthalmologic and general medical examinations including pulmonary auscultation and pulmonary posterior-anterior X-ray. Pulmonary function tests were used for evaluation of pulmonary function. FVC, FEV₁ , FEV₁ %, FEV₁ /FVC and saturation values were recorded.

RESULTS

Mean age was 67.1 ± 8.8 (44-82) years in the pseudoexfoliation group and 63.8 ± 9.4 (43-82) years in the control group (P > .05). Mean FEV₁ was 1.60 ± 0.62 in the pseudoexfoliation group and 1.84 ± 0.61 in the control group (P = .036). Mean FEV₁ % was 70.65 ± 23.89 in the pseudoexfoliation group and 83.46 ± 17.83 in the control group (P = .002). Mean FEV₁ /FVC ratios were 0.72 ± 0.15 in the pseudoexfoliation group and 0.77 ± 0.11 in the control group (P = .043). No statistically significant differences were found between the groups for FVC, saturation or cigarette use.

CONCLUSION

These results suggest that there is decline in some pulmonary functions in pseudoexfoliation syndrome.

[Pseudoexfoliation syndrome and pseudoexfoliation glaucoma]

Pseudoexfoliation syndrome is an age-related systemic disease that mainly affects the anterior structures of the eye. Despite a worldwide distribution, reported incidence and prevalence of this syndrome vary widely between ethnicities and geographical areas. The exfoliative material is composed mainly of abnormal cross-linked fibrils that accumulate progressively in some organs such as the heart, blood vessels, lungs or meninges, and particularly in the anterior structures of the eye. The exact pathophysiological process still remains unclear but the association of genetic and environmental factors are thought to play a role in the development and progressive extracellular accumulation of exfoliative material. Hence, LOXL1 gene polymorphisms, responsible for metabolism of some components of elastic fibers and extracellular matrix, and increased natural exposure to ambient ultraviolet or caffeine consumption have been associated with pseudoexfoliation syndrome. Ophthalmological manifestations are commonly bilateral with an asymmetric presentation and can lead to severe visual impairment and blindness more frequently than in the general population, mainly related to glaucoma and cataract. Pseudoexfoliation glaucoma is a major complication of pseudoexfoliation syndrome and represents the main cause of identifiable glaucoma worldwide. Visual field progression is more rapid than that observed in primary open angle glaucoma, and filtering surgery is more frequently required. Nuclear cataract is more frequent and occurs earlier than in the general population. Owing to poorer pupil dilation and increased zonular instability, cataract surgery with pseudoexfoliation is associated with a 5- to 10-fold increase in surgical complications compared to cataract surgery without pseudoexfoliation. Some specific treatments targeting production, formation or accumulation of exfoliative material could improve the prognosis of this syndrome.

Chosen Vascular Risk Markers in Pseudoexfoliation Syndrome: An Age-Related Disorder

Purpose

To evaluate lipids and C-reactive protein serum levels in patients with pseudoexfoliation syndrome (PEX) in the Polish population.

Methods

96 patients were studied with PEX and 79 control subjects. Total cholesterol, triglycerides, high-density lipoprotein (HDL)-cholesterol, low-density lipoprotein (LDL)-cholesterol, non-HDL-cholesterol and CRP serum levels, and TG/HDL-C and TC/HDL-C indexes were assessed.

Results

There were no significant differences in concentration of lipids and values of TC/HDL-C, TG/HDL-C, and non-HDL-C between PEX and control groups. High-sensitivity C-reactive protein was not increased in patients with PEX.

Conclusions

Our results cast doubt on the opinion on the possible PEX and vascular diseases relation. Further studies on this subject are mandatory.

Ocular Pseudoexfoliation Syndrome Linkage to Cardiovascular Disease

PURPOSE OF REVIEW

Pseudoexfoliation syndrome (PEX) is a common cause of open-angle glaucoma that is characterized by stress-induced elastic microfibrillopathy related to an accumulation of matrix metalloproteinases. The accumulation of matrix metalloproteinases increases deposition of protein substance within ocular structures and other organs including the heart. Many studies have associated the presence of cardiovascular disease with pseudoexfoliation syndrome, but much debate exists between studies in terms of significant relationships. The following meta-analysis aims to relate pseudoexfoliation syndrome with certain cardiovascular events and disorders. A thorough literature review was performed to acquire information concerning PEX patients with certain cardiovascular disorders. Diseases considered included myocardial infarction, ischemic heart disease, angina, congestive heart failure, cardiomyopathy, aortic aneurysm, hypertension, and homocystinuria. Patients without evidence of pseudoexfoliation disease were the controls of our study. Multiple forest plots were created to compile and analyze collected data for statistical comparison.

RECENT FINDINGS

From a literature review, 18 studies were selected for our analysis. Cardiovascular disorders that had a statistically significant association (within a 95 % confidence interval) with PEX included ischemic heart disease, aortic aneurysms, and homocystinuria. The association between ischemic heart disease and PEX was statistically significant (p = 0.045). Myocardial infarction, chronic ischemic heart disease, angina, and hypertension did not show a correlation of relationship with the presence of pseudoexfoliation. Patients with PEX are prone to present with ischemic heart disease in addition to abdominal aortic aneurysms and homocystinuria. Patients that present with PEX should be screened for these detrimental cardiovascular disorders.

Genetics, Diagnosis, and Monitoring of Pseudoexfoliation Glaucoma

Recent studies have shed new light on the genetic factors underlying pseudoexfoliation syndrome, growing our understanding of the role of the lysyl oxidase-like 1 (LOXL1) gene and its various polymorphisms as well as identifying new genetic associations. Recent years have brought new insight on how these genetic factors interact with other factors, including environmental, to confer risk to individuals and populations worldwide. All of these findings may hold importance to the screening, diagnosis, and monitoring of pseudoexfoliation and may also help lead to the identification of novel therapeutic targets. This review serves as an update on the recent trends and findings in pseudoexfoliation syndrome.

Immunohistochemical analysis of microsomal glutathione S-transferase 1 and clusterin expression in lens epithelial cells of patients with pseudoexfoliation syndrome

Pseudoexfoliation syndrome (PEX) is an age-associated, sight disorder affecting elastic fibers in the eye and visceral organs but its exact etiology remains unknown. The purpose of the current study was to determine the morphology and ultrastructure of lens epithelial cells (LECs), and to use immunohistochemistry to examine localization of microsomal glutathione S-transferase 1 (MGST1) and clusterin. Anterior lens capsules were obtained from 24 patients (13 PEX and 11 controls) who underwent phacoemulsification. Immunohistochemistry was performed, using antibodies against MGST1 and clusterin, to determine their expression. The morphology and ultrastructure of LECs were evaluated by light and transmission electron microscopy, respectively. The PEX LECs were characterized by significantly lower MGST1 (P=0.0001) and clusterin expression (P=0.0005) compared with the control group patients. PEX LECs were also observed to have significantly increased thickness compared with the control group patients (P=0.0002). The current findings suggest that low MGST1 and clusterin expression levels may be an early clinical indicator of PEX, and that oxidative stress may serve an important role, but that the specific etiology of this disease has yet to be revealed.

Major review: Exfoliation syndrome; advances in disease genetics, molecular biology, and epidemiology

Exfoliation syndrome (XFS) is a common age-related disorder that leads to deposition of extracellular fibrillar material throughout the body. The most recognized disease manifestation is exfoliation glaucoma (XFG), which is a common cause of blindness worldwide. Recent developments in XFS genetics, cell biology and epidemiology have greatly improved our understanding of the etiology of this complex inherited disease. This review summarizes current knowledge of XFS pathogenesis, identifies gaps in knowledge, and discusses areas for future research.

Cost of glaucoma treatment in a developing country over a 5-year period

The aim of the study was to disclose a realistic estimate of primary open-angle glaucoma treatment, follow-up costs, and patients' monthly glaucoma-economic burden in an ophthalmology hospital in Mexico City.Prospective survey of 462 primary open-angle glaucoma patients from 2007 to 2012 was carried out. Costs from visits, glaucoma follow-up studies, laser, and glaucoma surgical procedures were obtained from hospital pricings. Education, employment, and monthly income were interrogated. Total cost was divided into hypotensive treatment cost, nonpharmacologic treatment cost (laser and surgeries), and follow-up studies and consults. Average wholesale price for drugs analyzed was obtained from IMS Health data; monthly cost was calculated using: Monthly cost  = ([average wholesale price/number of drops per eye dropper] × number of daily applications) × 30 days.Patients were classified according to their glaucoma severity, and data were analyzed based on monthly income (average annual exchange rate: 12.85 Mexican pesos = 1 USD).The mean age was 70 ± 10 years, women = 81%, elementary school = 39%, and unemployed = 53%. Low-income group = 266 patients (57%), 146 with mild glaucoma; moderate-income group = 176 patients (38%), 81 with mild glaucoma; high-income group = 20 patients (4.3%), 10 with mild glaucoma. Patients' monthly average economic burden in glaucoma treatment: low-income patients = 61.5%, moderate-income patients = 19.5%, and high-income patients = 7.9%.Glaucoma-economic burden is substantial not only for health systems, but for the family and the patient. Therefore, screening plans for earlier diagnosis, and health policies that lessen the cost of disease management and increase adherence to treatment, and reduce the prevalence of blindness attributed to glaucoma are essential. These would improve quality of life, reduce personal and national expenditure, and help increase national economy.

Prevalence of Pseudoexfoliation Syndrome in Turkish Patients with Senile Cataract

PURPOSE

To investigate the prevalence of pseudoexfoliation syndrome (PEX) among Turkish patients with senile cataract.

MATERIALS AND METHODS

Records of 352 eyes of 352 patients who underwent cataract surgery were analyzed in this retrospective study. The presence of PEX, type of cataract, intraocular pressure (IOP), glaucoma, age-related macular degeneration, and systemic diseases (coronary artery disease, hypertension, diabetes mellitus) were recorded.

RESULTS

The overall prevalence of PEX syndrome was detected to be 11%. The mean age of PEX patients was significantly higher than without PEX (74.4 ± 7.2 years and 69.3 ± 11.4 years, respectively, p = 0.004). The most common cataract type in the PEX patients was mixed-type cataract determined in 51.2% of patients. IOP was significantly higher in eyes with PEX than in eyes without it (16.1 ± 4.5 mmHg and 14.7 ± 3.8 mmHg, respectively; p = 0.03). Moreover, the prevalence of age-related macular degeneration was found to be significantly higher, and prevalence of glaucoma slightly higher in PEX patients than without PEX.

CONCLUSION

Pseudoexfoliation syndrome is a common condition in Turkish people. PEX is associated with mixed type of cataract, age-related macular degeneration, and elevated IOP. Therefore, PEX patients should be checked for concomitant diseases.

Systemic Associations of Exfoliation Syndrome

Exfoliation syndrome (XFS) is an age-related disease characterized by the production, deposition, and progressive accumulation of a white, fibrillar, extracellular material in many ocular tissues, most prominent on the anterior lens surface and pupillary border. Its prevalence increases steadily with age in all populations. It is the most common identifiable cause of open-angle glaucoma worldwide and is a potentially reversible or even curable disease. First described in Finland in 1917 by Lindberg, it has long been associated with open-angle glaucoma. However, in recent years, it is being increasingly reported in conjunction with a multiplicity of both ocular and systemic disorders, and the number of these is expected to grow, particularly with investigations based on attempts to associate other diseases with those genes known to be associated with XFS. Despite the focus on XFS as a cause of open-angle glaucoma for nearly a century, in reality it is still only an ocular manifestation of a protean systemic disease. It is a unique disorder with extensive and often serious ocular and systemic manifestations and not, as it has long been termed, a "form" or "type" of glaucoma. This misconception has delayed research into the molecular and cellular processes involved in its development, and the underestimation of its overall importance and its underlying causative mechanisms have largely been long ignored. The purpose of this article is to review the systemic disorders which are becoming increasingly associated with XFS. Reviews of epidemiology, genetics, biomarkers, molecular mechanisms of development, and ocular findings may be found elsewhere.

Ocular pseudoexfoliation syndrome and life span

Background

To compare life span of persons with and without ocular pseudoexfoliation syndrome (PES).

Methods

The study is based on an epidemiological survey conducted in Sør-Trøndelag county, Norway, in 1985–86. All inhabitants over 64 years of age (2109 individuals) were invited. Mortality information was obtained from The Norwegian Institute of Public Health in 2014, by which time 99% of the participants were deceased.

Results

When adjusting for age and gender, life span was not statistically different in persons with and without PES. Following the diagnosis of PES, patients' survival was up to, and beyond, 30 years.

Conclusions

Our observations suggest that, despite all the systemic aberrations reported in persons with ocular PES, none or only marginal functional changes are caused in extraocular organs and tissues. The present study supports the notion that systemic PES is not a life-threatening condition.

•

Over the years several attempts have been made to link pseudoexfoliation syndrome to a number of serious systemic diseases.

•

The present study shows no difference in life span between persons with and without pseudoexfoliation in our cohort.

Is Pseudoexfoliation Syndrome a Risk Factor for Cerebro Vascular Disease?

PURPOSE

To determine the relationship between cerebro vascular disease and pseudoexfoliation syndrome.

MATERIALS AND METHODS

This cross-sectional case control study consisted of 50 patients with ischemic-type cerebro vascular disease and 50 control subjects. All subjects were investigated for diabetes mellitus and hypertension status and underwent a detailed ophthalmic examination. A diagnosis of pseudoexfoliation syndrome was made if characteristic greyish particulate matter was found on the anterior lens capsule after pupillary dilatation by slit-lamp examination. All subjects were compared in terms of pseudoexfoliation syndrome, diabetes mellitus, and hypertension. Pearson Chi Square and Student's t test were used for statistical analysis. Logistic regression analyses of the risk factors between groups were also made.

RESULTS

The presence of pseudoexfoliation syndrome was significantly higher in patients with cerebro vascular disease when compared to the control subjects (p = 0.02). The frequency of diabetes mellitus was similar between the two groups. Arterial hypertension was significantly more frequent in the patient group when compared to the control subjects (p < 0.01). The logistic regression analysis showed that both pseudoexfoliation syndrome and hypertension were significantly associated with cerebro vascular disease.

CONCLUSION

In the present study, we found that pseudoexfoliation syndrome frequency was found to be higher in patients with cerebro vascular disease than in control subjects. A slit-lamp examination of the eye could be an important marker that indicates the risk of cerebro vascular disease. We recommend an evaluation of all subjects with pseudoexfoliation syndrome for the presence of cerebro vascular disease. Longitudinal studies with larger populations are needed to confirm this relationship.

Burden of undetected and untreated glaucoma in the United States

PURPOSE

To determine the burden of undetected and untreated glaucoma in the noninstitutionalized population over the age of 40 years in the United States of America (US).

DESIGN

Cross-sectional study.

METHODS

setting: US civilian, noninstitutionalized population from the 2005-2006 and 2007-2008 administrations of the National Health and Nutrition Examination Survey that were 40 years old or older with completed retinal photographs, completed interview question regarding prior diagnosis of glaucoma, and a negative response to questions regarding comorbidities. main outcome measures: Prevalence of self-reported glaucoma history; signs of glaucoma damage seen in retinal photographs and perimetry; prevalence of undiagnosed glaucoma; and comparison of demographic factors using odds ratios to identify populations with highest burden of previously undiagnosed glaucoma.

RESULTS

The study population included 3850 participants who met the inclusion criteria. The 99.5th percentile of the vertical cup-to-disc ratio was 0.67 and the 99.5th percentile of the vertical cup-to-disc ratio asymmetry between eyes was 0.26. Prevalence of undiagnosed glaucoma was 2.9%, increasing with age to 6.6% of the population over 70 years old. Among those with glaucoma, 78% were previously undiagnosed and untreated. Blacks have roughly 4.4 times (95% confidence interval [CI]: 2.9-6.7; P < .0001) and Hispanics have roughly 2.5 times (95%CI: 1.5-4.3; P = .0012) greater odds of having undiagnosed and untreated glaucoma than non-Hispanic whites.

CONCLUSIONS

Approximately 2.4 million persons in the US have undetected and untreated glaucoma. Overall, prevalence of both diagnosed and undiagnosed glaucoma is much higher in minorities and the elderly. Among those with definite glaucoma, individuals younger than 60 years of age have a greater proportion of undetected disease.

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.

Association of LOXL1 polymorphisms with pseudoexfoliation, glaucoma, intraocular pressure, and systemic diseases in a Greek population. The Thessaloniki eye study

PURPOSE

To investigate the association of the two single-nucleotide polymorphisms (SNPs) in the lysyl oxidase-like 1 (LOXL1) gene with pseudoexfoliation syndrome (PEX), pseudoexfoliative glaucoma (PEXG), and primary open-angle glaucoma (POAG) in a Greek population-based setting, from the Thessaloniki Eye study.

METHODS

A total of 233 subjects with successful DNA extraction, PCR amplification, and genotyping were included in the genetic analysis of G153D and R141L SNPs of LOXL1 gene and classified into four groups: controls (n = 93); subjects with PEX (n = 40); POAG (n = 66); and PEXG (n = 34). Multinomial logistic regression was used to test their association with LOXL1 SNPs with adjustment for covariates. The association of LOXL1 with IOP (in untreated subjects) and with systemic diseases was explored.

RESULTS

Both LOXL1 SNPs were present in high frequencies in controls and cases. The G153D was strongly associated with both PEX (odds ratio [OR] = 23.2, P = 0.003 for allele G) and PEXG (OR = 24.75, P = 0.003 for allele G) and was not associated with POAG (P = 0.451). In contrast, the R141L was not associated with PEX (P = 0.81), PEXG (P = 0.063), or POAG (P = 0.113). No association of the G153D with either intraocular pressure (IOP) or systemic diseases was found.

CONCLUSIONS

In the Thessaloniki Eye Study, the G153D SNP of LOXL1 gene was strongly associated with both PEX and PEXG, whereas the R141L was not associated. No association of the LOXL1 with IOP or with systemic diseases was found. These findings further support the hypothesis that the LOXL1 gene contributes to onset of PEXG through PEX. Gene variants of LOXL1 do not help to identify those with PEX at increased risk for glaucoma development.

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

Objective

Many studies have assessed the association between ocular pseudoexfoliation syndrome (PEX) and vascular disease and produced controversial results. We performed a meta-analysis of epidemiologic studies to evaluate this relationship.

Methods

Eligible studies that reported the incidence of vascular disease among PEX and control groups were identified via computer searches and reviewing the reference lists of the key articles. The summary odds ratio (OR) and 95% confidence interval (CI) were pooled using a random-effects model. Meta-regression to assess heterogeneity by several covariates and a subgroup analysis on study design and population were performed. Publication bias was tested by Begg's funnel plot and Egger's regression test.

Results

Sixteen eligible studies involving 8,533 PEX patients and 135,720 control patients were included in the meta-analysis. All studies were performed primarily in whites with a mean age between 54.7 and 77.1 years. The overall combined ORs for patients with PEX compared with the reference group were 1.72 (95% CI: 1.31 to 2.26) for any vascular disease, 1.61 (95% CI: 1.22 to 2.14) for coronary heart disease, 1.59 (95% CI: 1.12 to 2.23) for cerebrovascular disease, and 2.48 (95% CI: 1.30 to 4.72) for aortic aneurysm. There was evidence of statistical heterogeneity; however, subgroup and sensitivity analyses showed this result to be robust. No evidence of publication bias was observed.

Conclusions

The overall current literature suggests that PEX was associated with increased risk of vascular disease. Because of the limitations of the included studies and meta-analysis, the findings need to be confirmed in future research via well-designed cohort studies.

Mortality in Primary Open-Angle Glaucoma and Exfoliative Glaucoma

Purpose

To study mortality among unselected Finnish patients with either primary open-angle glaucoma (POAG) or exfoliative glaucoma (EG) after a minimum follow-up of 7 years after enrollment.

Methods

A total of 344 patients with POAG and 155 patients with EG had received free medication for the treatment of glaucoma from the Finnish National Social Insurance Institution (FSII). The FSII operates national health insurance, which is compulsory for all Finnish citizens. To be granted free medication, the patient has to file an application with a certificate from an ophthalmologist. If the predefined criteria for glaucoma specified by the Finnish Parliament are met, full reimbursement for glaucoma medications is granted and the patient is listed in the registry of FSII. We reviewed the records of 519 consecutive patients who had been diagnosed with glaucoma and to whom free medication had been granted between June 2004 and December 2005. Patients with acute glaucoma or secondary glaucoma were excluded. Those with open angles were classified into POAG or EG. The quality of the ophthalmologists’ records was high. The Finnish Population Registry, a governmental institute, provided information on those patients who had died before January 2013.

Results

At enrollment, the groups with POAG and EG were comparable as regards sex: 66% female with POAG and 68% with EG. The patients with POAG were younger (median 68 years) than those with EG (median 74 years). By January 2013, 59 patients with POAG and 48 with EG had died. At death, the patients with POAG were younger (median 81.8 years) than those with EG (87.9 years). In both groups, the women lived longer than the men, but among patients with POAG, women and men died at a younger age than those with EG.

Conclusions

As has been reported previously, life expectancy of patients with EG was longer when compared to those with POAG. Higher death rate among patients with EG is explained by higher median age at baseline.

[New pathogenetic insights into pseudoexfoliation syndrome/glaucoma. Therapeutically relevant?]

Pseudoexfoliation (PEX) syndrome is a genetically determined, generalized disease of the extracellular matrix leading to the progressive deposition of an abnormal fibrillar material in various intraocular and extraocular tissues including the trabecular meshwork. It thus represents the most common identifiable cause of open-angle glaucoma and a leading cause of blindness worldwide. The PEX-specific fibrotic matrix process, a stress-induced elastosis, is characterized by an excessive production and abnormal cross-linking of elastic microfibrils into fibrillar PEX aggregates. Co-modulating factors triggering this fibrotic process include elevated concentrations of fibrogenic growth factors, such as TGF-β1, reduced activity of proteolytic enzymes, subtle inflammatory processes and various external stress factors, such as oxidative stress. Genetic studies identified a highly significant association between several polymorphisms in the LOXL1 (lysyl oxidase-like 1) gene with both PEX syndrome and PEX glaucoma. As these LOXL1 risk variants were found to occur in almost 100% of PEX patients throughout all geographical populations worldwide, LOXL1 appears to represent a principal risk factor for manifestation of the PEX phenotype. LOXL1 is a pivotal cross-linking enzyme in extracellular matrix metabolism and seems to be specifically required for elastic fiber formation and stabilization. The available data suggest that LOXL1 enzyme function and expression are dysregulated in PEX tissues and thereby play a central role in glaucoma development. On the one hand, increased expression of LOXL1 and elastic fiber components contributes to the formation of abnormally cross-linked PEX aggregates in the outflow pathways leading to increased outflow resistance and intraocular pressure. On the other hand, reduced expression and inadequate tissue levels of LOXL1 may lead to degenerative tissue alterations, particularly in the lamina cribrosa adversely affecting the biomechanical properties of this critical tissue. This PEX-specific elastinopathy of the lamina cribrosa rendering PEX eyes more vulnerable to pressure-induced optic nerve damage may constitute an independent risk factor for glaucoma development. The findings may have direct consequences for the clinical management of PEX patients underlining the need for an exact diagnosis, a strict IOP-reducing therapy and a close and regular follow-up.

[PEX syndrome. Clinical diagnosis and systemic manifestations]

As a result of demographic changes pseudoexfoliation (PEX) syndrome, an age-related systemic disorder of the extracellular matrix, will become an increasingly important issue in clinical practice. Apart from its well-known association with cataract and glaucoma, PEX syndrome predisposes to a broad spectrum of spontaneous and surgical ocular complications due to characteristic alterations of all anterior segment tissues. In view of the high risk of glaucoma development and potential complications during cataract surgery, an accurate and early diagnosis of PEX syndrome is of considerable clinical relevance. Since the characteristic central PEX deposits are lacking in up to 50 % of patients, a reliable diagnosis requires pupillary dilation. Early stages of the disease may be recognized on the basis of subtle alterations of the lens surface in addition to poor pupillary dilation and pigment-related signs including pigment dispersion and peripupillary atrophy. Any asymmetric clinical signs, e.g., regarding pupil width, pigmentation, cataract and intraocular pressure, should alert the ophthalmologist to the potential presence of PEX syndrome. Although the description of PEX syndrome as a systemic disorder of the extracellular matrix associated with the deposition of PEX material in the skin, blood vessel walls and various organ systems dates back to the early 1990s, a causal relationship between the abnormal material deposits and systemic diseases has not yet been clearly established. A growing number of smaller studies have found suggestive evidence for associations between PEX syndrome and cardiovascular/cerebrovascular diseases. The current evidence, however, is ambiguous and requires further investigation through multicenter or population-based, prospective, randomized clinical studies.

Renal artery stenosis and abdominal aorta aneurysm in patients with pseudoexfoliation syndrome

PURPOSE

To evaluate the renal arteries and abdominal aorta in patients with pseudoexfoliation syndrome (PEX).

DESIGN

Prospective, case-control study.

METHODS

The study involved 49 patients with PEX and 42 control subjects. Abdominal aorta and renal arteries were examined by Doppler ultrasonography. In both renal arteries (proximal and distal portions) and abdominal aorta, the peak systolic velocity (PSV) was measured. Renal artery stenosis (RAS) was defined as the renal artery PSV >150 cm/s or renal-to-aortic ratio (RAR) >3.0. Patients who had an abdominal aortic diameter >3 cm were recorded. Computed tomographic angiography was performed to confirm these findings in patients with RAS and/or abdominal aorta aneurysm.

RESULTS

The mean PSV in the proximal renal artery was 88.3 cm/s in PEX group and 79.5 cm/s in control group (P=0.314); in distal renal artery was 91.7 cm/s in PEX group and 93.0 cm/s in control group (P=0.794); in abdominal aorta was 76.0 cm/s in PEX group and 65.2 cm/s in control group (P=0.046). RAS was observed in nine patients with PEX and in only one patient without PEX (P=0.017). Seven out of 10 patients with RAS (six patients in PEX group; one patient in control group) had hypertension. Abdominal aorta aneurysm was observed in four patients in PEX group but not in control group (P=0.061).

CONCLUSIONS

Our study has demonstrated that there is a significant association between PEX and RAS. The abdominal aorta aneurysm may be seen in patients with PEX.

Serum vitamin D deficiency and its association with systemic disease in exfoliation syndrome

PURPOSE

To determine the association of serum vitamin D levels with exfoliation syndrome (XFS) and evaluate its impact on co-associated systemic diseases.

METHODS

Forty patients with XFS and 40 control subjects without XFS were recruited for this study. Se-rum concentrations of 25-hydroxy vitamin D [25(OH) D] were measured by high-performance liquid chromatography. Vitamin D deficiency was defined as a serum 25(OH) D concentration of <20 ng/mL. A detailed medical history including hypertension, diabetes mellitus, ischemic heart disease, cerebrovascular stroke, autoimmune disease, and neurologic disorders such as Parkinson disease and Alzheimer disease was recorded. Student t test and chi-square test was used for statistical evaluations.

RESULTS

The mean age of patients with XFS and control subjects was 69.6 ± 8.1 years (range 58-90 years) and 67.1 ± 6.3 years (range 60-86 years), respectively (p>0.05). Mean 25(OH) D levels did not differ between XFS (19.8 ± 8.3 ng/mL) and control (19.9 ± 10.3 ng/mL) groups (p = 0.978). Patients with XFS had higher prevalence of cerebrovascular (p = 0.026) and cardiovascular disease (p = 0.001). There was no association between the systemic disease status and serum vitamin D levels of patients with XFS.

CONCLUSIONS

Although vitamin D levels were similar between XFS and control subjects, the levels were found to be decreased in both groups. Patients with XFS had a significantly higher prevalence of cerebrovascular and cardiovascular disease as compared to controls independent of their serum 25(OH) D levels. Low vitamin D level does not appear to be linked to XFS in the studied population.

Pseudoexfoliation syndrome, a systemic disorder with ocular manifestations

Pseudoexfoliation syndrome (PXS) is a systemic condition with eye manifestations. In the eye, pseudoexfoliation material deposits on various structures of the anterior segment. The nature of this material is mostly fibrillar with fibers made up of microfibrils and coated with amorphous material. The composition of these fibrils is diverse and includes basement membrane components as well as enzymes involved in extracellular matrix maintenance. Pseudoexfoliation is the most common cause of secondary open-angle glaucoma (pseudoexfoliation glaucoma, PXG) worldwide. The goal of this review is to summarize our knowledge on the genetics of this systemic disorder and its resultant ocular manifestations. PXS familial aggregation suggests genetic inheritance. PXS has been strongly associated with single nucleotide polymorphisms (SNPs) of the lysyl oxidase-like 1 (LOXL1) gene on chromosome 15q24.1. Two of these SNPs confer a higher than 99% population attributable risk for PXS and PXG in the Nordic population; however, they carry different risks in different populations. The high risk haplotypes also vary among different populations. LOXL1 is one of group of the enzymes involved in the cross-linking of collagen and elastin in the extracellular matrix. Its function in connective tissue maintenance has been confirmed in mice; however, its actual role in PXS remains unclear. Contactin-associated protein-like 2 also has a strong genetic association with PXS in a German cohort and is an attractive candidate molecule. It encodes for a protein involved in potassium channel trafficking. Other candidate genes linked to PXS include lysosomal trafficking regulator, clusterin, adenosine receptors, matrix metalloproteinase-1 (MMP1), and glutathione transferase. These genes may be modifying genes for development of PXS and PXG.

Association of ocular pseudoexfoliation syndrome with ischaemic heart disease, arterial hypertension and diabetes mellitus

PURPOSE

To determine the prevalence of pseudoexfoliation syndrome (PEX) in Lithuanian urban population and its association with ischaemic heart disease (IHD), arterial hypertension (AH) and diabetes mellitus (DM).

METHODS

In this population-based study, 1065 participants aged 45-72 years were randomly drawn from the population register of Kaunas, Lithuania. They were classified as having PEX if any pseudoexfoliation material was determined by a slit-lamp examination in at least one eye. The data were acquired from questionnaire; register of myocardial infarction, electrocardiogram, biochemical blood analyses and blood pressure measurement were used to determine IHD, AH, DM and smoking habits. Poststratification weights based on Kaunas population sex and age distribution were applied.

RESULTS

Pseudoexfoliation syndrome was estimated in 9% of a population. The AH rate was higher in PEX subjects than in non-PEX subjects (p=0.017) and the rates of IHD, DM and cholesterol levels did not differ statistically significantly. Chi-square linear-by-linear association test found higher AH rate in unilateral PEX subjects and even higher AH rate in bilateral PEX subjects than in non-PEX subjects (p=0.014). Pseudoexfoliation syndrome increased odds for AH by 1.8 times (p=0.021). Median of systolic blood pressure was higher in the PEX group than in non-PEX group (p=0.04). But all associations could not be confirmed after adjusting for age. Smoking duration increased age-adjusted odds for PEX. Pseudoexfoliation syndrome did not increase risk for IHD, AH or DM.

CONCLUSIONS

Pseudoexfoliation syndrome prevalence is high in Lithuania. No clear PEX association with IHD, AH and DM was proven after controlling for effect of age.

Systemic high-sensitivity C-reactive protein level in pseudoexfoliation syndrome and pseudoexfoliation glaucoma

PURPOSE

To evaluate the systemic high sensitivity C-reactive protein (hsCRP) levels in patients with pseudoexfoliation syndrome (XFS) and pseudoexfoliation glaucoma (XFG).

MATERIALS AND METHODS

We prospectively examined 31 patients with XFS, 26 with XFG, and 25 controls. To the study patients with the exclusion of serious hypertension that do not have any cardiovascular and cerebrovascular disease and that diagnosed as XFS and XFG have been included. Each patient passed through a detailed blood sampling including hsCRP, biochemistry, and lipid profile. Plasma C-reactive protein (CRP) levels were measured with nephelometric method by using Beckman IMMAGE hsCRP reagent.

RESULTS

Each group had similar demographic parameters including age, sex, body mass index, heart rate, and blood pressure. When we compared with controls, there was no statistically significant difference in the hsCRP and biochemistry results between the 3 groups. When all patients with pseudoexfoliation (PEX) compared with controls there was no difference.

CONCLUSIONS

Our findings indicated no difference in the hsCRP level between XFS, XFG, and controls. This study suggests that CRP is not a predictive marker of inflammation and peripheral endothelial dysfunction in XFS, which is accepted as a systemic disorder.

Epidemiology of exfoliation syndrome in the Reykjavik Eye Study

Exfoliation syndrome (XFS) is a major risk factor for glaucoma. It is characterized by a pathological accumulation of polymorphic fibrillar material in the anterior segment of the eye. It is likely that the increase in intraocular pressure (IOP) seen in XFS patients is at least in part because of flakes of material clogging up the trabecular meshwork, and thereby increasing the resistance to outflow and increasing IOP. XFS glaucoma progresses more rapidly, is more resistant to medical treatment and has worse prognosis than other glaucomas. The prevalence of XFS has been found to vary greatly between different studies, raising the possibility of racial and/or environmental modulators. XFS has also been linked to other changes in ophthalmological structures such as; changes in central corneal thickness (CCT), steeper corneal curvature (CC) and nuclear lens opacifications. Some studies have found XFS to be associated with systemic diseases, mostly cardiovascular and cerebrovascular. Exposure to ultra-violet (UV) light has also been investigated as a possible culprit, along with several other plausible factors. The aim of the present study was to determine the prevalence and 5-year incidence of XFS, to establish possible risk factors and/or concomitant symptoms and finally to investigate the relationship between XFS and glaucomatous changes. The Reykjavík Eye Study (RES) is a prospective study based on a random sample from the Icelandic national population sample. The baseline examination was performed in the autumn of 1996, when 1045 persons older than 50 years participated. Of these, 846 (88.2% of survivors) participated in a follow-up 5 years later. All participants went through a standard examination protocol, and answered a comprehensive questionnaire on health and life style. In the prevalence study, XFS was found in 10.7% of subjects, more frequently in women and older persons. Five years later, a further 5.2% of those that participated in the follow-up study and had no signs of XFS at baseline were diagnosed having XFS. We found a strong correlation between IOP and XFS. No difference was found in the anterior segment parameters measured, but there was a significant loss of neural tissue in the XFS as demonstrated by measurements of cup/disk ratio. In conclusion, we find XFS to be frequent among Icelanders, increasing with age and more in women. Our diagnostic criteria are reliable over time. We have also identified possible risk factors that point to a role of antioxidants in the development of XFS. We find changes in corneal curvature and thickness more related to age than XFS.

Analysis of glaucoma-related mortality in the United States using death certificate data

PURPOSE

Recent studies have reported a connection between glaucoma and decreased survival. To evaluate the underlying causes of glaucoma-related mortality, we searched vital records data for deaths citing glaucoma and reviewed the demographic variables and comorbidities contained on these records.

MATERIALS AND METHODS

Deaths including glaucoma, as either an underlying cause or a contributing cause of death, were selected from US multiple-cause-of-death data for the years 1990 to 2003 and combined with population data from the US Census Bureau to calculate mortality rates. Logistic regression was used to determine whether reporting of accidents and/or selected systemic disorders are associated with glaucoma on the death certificate.

RESULTS

Fifteen thousand two hundred twenty-eight glaucoma-related deaths (0.05%) were identified during the years under study. Black males had the highest glaucoma-related mortality rate with 9.4 deaths per 1,000,000 persons annually, whereas Hispanic females had the lowest mortality rate at 1.8 deaths per 1,000,000. After adjusting for age, sex, and race/ethnicity, positive associations were found between glaucoma and hypertension [Odds ratio (OR): 4.89; 95% confidence interval (CI)=4.73-5.05], diabetes (OR: 2.60; 95% CI=2.50-2.71), asthma (OR: 3.14; 95% CI=2.72-3.62), and accidents of all types (OR: 1.45; 95% CI=1.35-1.55).

CONCLUSIONS

Glaucoma is an important contributor to mortality for certain individuals. The disparities in mortality rates observed among race/ethnic strata may be attributed to differences in access to care as well as true differences in disease incidence and/or severity among racial groups. Despite limitations with the data, our findings suggest associations between glaucoma and a number of comorbid conditions. These associations should be explored in future studies and serve to guide strategies for disease management and prevention.

Is exfoliation syndrome a sign of systemic vascular disease?

Exfoliation syndrome (ES) is an age-related disorder in which greyish-white flakes accumulate in different tissues in the anterior eye. Its pathogenesis is not completely known, but it results in electron-dense microfibrils. The finding that these can be seen outside the eye in many visceral organs inspired the theory that ES might be a part of a generalized disorder. It was postulated that ES might contribute to increased morbidity, mainly of systemic vascular diseases. This review is a summary of the existing knowledge. The prevalence of arterial hypertension (AHT) in elderly populations is > 30%. No differences have been found in the frequency of AHT among patients with ES or exfoliative glaucoma (EG) compared with those with primary open-angle glaucoma (POAG) or no ES. There are conflicting reports of frequencies of ischaemic heart disease (IHD). A recent registry-based study that used uniform criteria for IHD found no difference in the rate of IHD between patients with EG and those with POAG. However, findings of elevated homocysteine levels in the plasma and aqueous humour of patients with ES or EG suggest an increased vascular risk. No studies have yet been conducted to assess possible links between ES and systemic vascular diseases. In a single-blind study, ES was associated with abdominal aortic aneurysm, but this was not found in a large, cross-sectional investigation. The frequency of ES in patients with diabetes mellitus (DM) is only about half of that when compared in patients with no ES or with POAG. This finding warrants further studies. Molecular genetics research has found no common denominator for ES and the vascular diseases. There is no evidence that ES or EG are related to increased mortality for cardiovascular diseases. Further large-scale, randomized clinical studies are required. At present there are no known medical indications that infer an increased systemic vascular risk or imply a need for the complete internal medical examination of a symptom-free patient with newly diagnosed ES in the eye.

Systemic associations and prevalence of exfoliation syndrome in patients scheduled for cataract surgery

PURPOSE

To study the frequency of exfoliation syndrome (XFS) and its association with intraocular pressure (IOP) and systemic diseases in patients with age-related cataract scheduled for surgery.

METHODS

All 1480 cataract patients had a comprehensive systemic and eye examination, including slit-lamp biomicroscopy before and after mydriasis, IOP measurement, gonioscopy, and fundus examination.

RESULTS

The percentage of XFS among patients scheduled for cataract surgery was 16.4, with no gender difference (p=0.833). The mean age of XFS patients (74.3+/-7.0 years) was significantly higher when compared to the ones without XFS (66.5+/-10.9 years) (p<0.001). XFS was unilateral in 41.3% of the subjects and bilateral in 58.7%. The number of subjects with XFS increased significantly with aging (p<0.001) (OR=1.093, 95% CI=1.073-1.14) (p<0.001). The most common type of cataract was nuclear in the XFS group (33.5%) and 24.6% of patients with mature cataract had XFS. In the XFS group, 11.2% of the subjects had glaucoma, which was statistically higher than the non-XFS group (4.6%) (p<0.001) (OR=2.67, 95% CI=1.65-4.32). Eighty-four patients had glaucoma and 27 of them (32.1%) had exfoliative glaucoma. The only systemic disease that was found to be associated with XFS was coronary heart disease with an OR of 1.49 (95% CI=1.068-2.072) (p=0.019).

CONCLUSIONS

XFS is a common problem in the aging cataract population of Turkey and increased IOP, glaucomatous optic neuropathy, and coronary heart disease occur more frequently in patients with XFS compared with subjects without XFS.

Frequency of systemic vascular diseases in patients with primary open-angle glaucoma and exfoliation glaucoma

PURPOSE

Abnormal fibrils can be identified by electron microscopy in the heart, lung, liver, kidney, cerebral meninges and other tissues of patients with exfoliation syndrome (ES). However, a clinical association of ES with arterial hypertension (HT), ischaemic heart disease (IHD), cerebrovascular accidents and aneurysm of the abdominal aorta is debated. We conducted a national registry-based survey to further assess the first two of these associations.

METHODS

We reviewed the records of 519 consecutive patients to whom the Social Insurance Institution of Finland had granted free medication for glaucoma according to national common criteria. The glaucoma was classified either as primary open-angle glaucoma (POAG) or exfoliation glaucoma (EG), masked to any systemic diseases; 20 patients with other types of glaucoma were excluded from the survey. Masked to the type of glaucoma, the registry provided data on free medication similarly granted for HT, IHD and diabetes mellitus (DM), a known modifier of risk for cardiovascular disease. Data were analysed by logistic regression, modelling age, gender and DM as confounders.

RESULTS

The control group of 344 patients with POAG was comparable as regards gender with the study group of 155 patients with EG, but patients with POAG were both younger (mean 69 versus 73 years; P < 0.0001) and had DM twice as often (10% versus 5%; P = 0.05) compared to those with EG. Adjusting for age, gender and presence of DM, no difference in frequency of HT [odds ratio (OR) 0.80 for presence of EG; 95% confidence interval (CI) 0.52-1.23, P = 0.31] or IHD (OR 0.86 for presence of EG; 95% CI 0.49-1.13, P = 0.66) was detected between the two groups.

CONCLUSION

In this population-based registry survey, no difference in frequency of HT or IHD was noted between patients with POAG and EG who had been granted free medication for these chronic diseases according to national common criteria. The frequency of DM was lower among patients with EG, in line with several previous reports.

Decreased cardiovagal regulation in exfoliation syndrome

PURPOSE

To investigate the parasympathetic cardiovascular regulation, baroreflex sensitivity (BRS), and pulse wave velocity (PWV) in exfoliation syndrome (XFS).

METHODS

Heart rate variability indices [standard deviation of all RR intervals (SDNN); the mean of absolute successive differences (RMSSD); the percentage of intervals differing by >50 ms from the preceding interval (pNN50); low frequency power, and high frequency power], as well as BRS and PWV, were determined on 27 consecutive white XFS patients and 20 white control subjects under standard circumstances, with controlled breath rate of 0.25 Hz. The paired t test, the Mann-Whitney U test, and the Fisher exact test were used for comparisons.

RESULTS

There was no significant difference between the XFS and control groups in sex distribution, age, heart rate, blood pressure, body mass index, systemic diseases, or medication. But in XFS patients, SDNN (mean+/-SD, 24+/-7.3 vs. 49+/-16.5 ms), RMSSD (17+/-7.3 vs. 45+/-29.1 ms), pNN50 (1.6%+/-2.5% vs. 17.7%+/-25.9%), high frequency (112+/-109 vs. 479+/-554 ms), and BRS (4.64+/-2.12 vs. 9.49+/-4.76 ms/mm Hg for BRS+ and 5.28+/-2.16 vs. 10.29+/-4.62 ms/mm Hg for BRS-) were all significantly lower than in the control group (P<0.01 for each parameter). Low frequency was also reduced in XFS (72+/-55 vs. 253+/-241 ms) (P=0.027). In XFS, PWV was significantly increased compared with the control group (11.6+/-4.1 vs. 9.3+/-2.2 m/s) (P=0.023).

DISCUSSION

Our results suggest a clinically and statistically significant impairment of cardiovagal regulation and impairment of conduit artery function in XFS patients.

Ocular perfusion pressure and retrobulbar haemodynamics in pseudoexfoliative glaucoma

BACKGROUND

Previous investigations have shown that vascular factors are involved in pseudoexfoliative glaucoma (XFG). The present study aims at comparing ocular perfusion pressure (OPP), diastolic ocular perfusion pressure (dOPP), and retrobulbar haemodynamics in pseudoexfoliative glaucoma and primary open-angle glaucoma (POAG).

METHODS

Forty-seven XFGs, 41 POAGs, and 38 healthy controls were evaluated. OPP and dOPP were calculated. Peak systolic velocity (PSV), end-diastolic velocity (EDV), and resistivity index (RI) were recorded in ophthalmic artery (OA), central retinal artery (CRA), and short posterior ciliary arteries (SPCAs) by color Doppler imaging (CDI). Correlations between OPP and CDI parameters and between dOPP and CDI parameters were determined.

RESULTS

OPP and dOPP were significantly lower in XFGs than in POAGs and controls (p < 0.001). CDI investigation revealed decreased EDV of OA, SPCAs, and CRA (p < 0.001) and increased RI of all the three considered vessels in XFGs compared with POAGs and controls (p < 0.001). A negative correlation between OPP and RI of OA and between dOPP and RI of OA was found in XFGs (p = 0.022 and p = 0.015 respectively).

CONCLUSIONS

Ocular perfusion pressure is decreased and retrobulbar haemodynamics are worse in pseudoexfoliative glaucoma patients than in primary open-angle glaucoma patients and healthy controls. An impaired ocular vascular regulation is suggested in pseudoexfoliative glaucoma.

Pseudoexfoliation syndrome and its antioxidative protection deficiency as risk factors for age-related cataract

PURPOSE

Pseudoexfoliation syndrome (PES) seems to be a systemic condition. However, to an ophthalmologist it represents a continual challenge, due to unclear etiology and patho-genesis, and because of a potential for development of an aggressive glaucoma, and cataract surgery complications. According to some findings, PES could be a factor of hastened aging, which means that it could be considered as a secondary aging factor.

METHODS

Frequencies of secondary aging diseases (non-insulin dependent diabetes mellitus, atherosclerotic myocardiopathy, chronic obstructive lung diseases, arterial hypertension, and PES) were investigated in 162 patients with age-related cataract and 55 age- and sex-matched control subjects, and analyzed by a logistic regression. The authors also determined elements of antioxidative protection in a group of sera from patients with cataract and PES, and compared them to those obtained from patients with cataract without PES (activity of catalase and peroxidase, glutathione, vitamins C and E), and total antioxidative protection (%iMDA). Antioxidant defense of aqueous humors, expressed as a rate of induced malondialdehyde (%iMDA), and total thiol groups in the lens corticonuclear blocks (TSH) were estimated in samples of 17 patients with PES and cataract and 55 patients with cataract only.

RESULTS

Logistic regression showed the highest odds ratio for PES (OR=4.516; p<0.05). Catalytic activity of serum catalase had significantly lower values in patients with PES (p<0.05). Anti oxidative defense of aqueous humor and lens had lower values in patients with PES.

CONCLUSIONS

The results indicate that PES might be a significant factor for cataractogenesis. At least a part of pathogenesis alterations in an eye with PES could be the result of higher intensity of oxidative stress.

Open-Angle Glaucoma and Cardiovascular Mortality

PURPOSE

To evaluate the association between open-angle glaucoma (termed glaucoma) and 9-year mortality in an older population-based cohort.

DESIGN

Population-based cohort.

PARTICIPANTS

Three thousand six hundred fifty-four persons aged 49 to 97 years (82.4% of the eligible population), residents of the Blue Mountains, west of Sydney, Australia.

METHODS

At baseline (1992-1994), glaucoma was diagnosed from congruous typical glaucomatous visual field changes (full-threshold fields) and optic disc cupping (stereo-optic disc photography). Demographic information from baseline participants was matched with the Australian National Death Index data (December 2001) to obtain the number and causes of deaths. Cox proportional hazards regression analysis, controlling for age, male gender, diabetes, hypertension, heart disease, stroke, use of oral beta-blockers, current smoking history, alcohol use, myopia, and nuclear cataract were performed to assess hazard ratios for cardiovascular mortality. Adjustments for all-cause mortality also included history of cancer.

MAIN OUTCOME MEASURES

Cardiovascular and all-cause mortality.

RESULTS

At baseline, glaucoma was diagnosed in 108 participants (3.0%). Of 873 deaths (23.9%) before January, 2002, 312 people (8.5%) died of cardiovascular events. The age-standardized all-cause mortality was 24.3% in persons with and 23.8% in those without glaucoma, whereas cardiovascular mortality was 14.6% in persons with and 8.4% in those without glaucoma. After multivariate adjustment, those with glaucoma had a nonsignificant increased risk of cardiovascular death (relative risk [RR], 1.46; 95% confidence interval [CI], 0.95-2.23). Increased cardiovascular mortality was observed mainly in glaucoma patients aged <75 years (RR, 2.78; 95% CI, 1.20-6.47). Further stratified analyses showed that cardiovascular mortality was higher among those with previously diagnosed glaucoma (RR, 1.85; 95% CI, 1.12-3.04), particularly in those also treated with topical timolol (RR, 2.14; 95% CI, 1.18-3.89).

CONCLUSIONS

Findings from the Blue Mountains Eye Study demonstrate an increased cardiovascular mortality in persons with previously diagnosed glaucoma. There was a suggestion of higher cardiovascular mortality in glaucoma patients using topical timolol that merits further study.

Ocular and systemic pseudoexfoliation syndrome

PURPOSE

To provide an update on most recent developments regarding ocular and systemic manifestations and complications, clinical diagnosis and management, and molecular pathophysiology of pseudoexfoliation (PEX) syndrome, and to discuss future tasks and challenges in this field.

DESIGN

Perspective.

METHODS

Review of recent literature and authors' own clinical and laboratory studies.

RESULTS

PEX syndrome is a common age-related generalized fibrotic matrix process of worldwide significance, which may not only cause severe chronic open-angle glaucoma and cataract, but also a spectrum of other serious spontaneous and surgical intraocular complications. Recent progress and advances have led to (1) improvements in clinical management by understanding the effects of the PEX process on ocular tissues, by refining diagnostic criteria, by applying new treatment regimes, and by developing preventive strategies to reduce surgical complications; (2) increasing evidence for systemic associations of PEX with cardiovascular and cerebrovascular morbidity; and (3) new insights into the molecular pathophysiology by analyzing the composition of PEX material, the differential gene expression of affected tissues, and key factors involved in pathogenesis. The current pathogenetic concept describes PEX syndrome as an elastic microfibrillopathy involving transforming growth factor-beta1, oxidative stress, and impaired cellular protection mechanisms as key pathogenetic factors.

CONCLUSIONS

Future tasks and challenges comprise epidemiologic prevalence and genetic studies of PEX syndrome, prospective randomized clinical and histopathological screening studies on its systemic manifestations and associations, and intensified basic research on differential protein and gene expression, animal and in vitro models, as well as potential biomarkers for PEX syndrome and its associated glaucoma.