Ocular pseudoexfoliation and cardiovascular disease: a national cross-section comparison study

The role of serum biomarkers in determining systemic inflammation and cardiovascular risk in pseudoexfoliation syndrome

PURPOSE

To investigate the role of hematological and atherogenic biomarkers in evaluating systemic inflammation and cardiovascular risk in patients with pseudoexfoliation syndrome.

METHODS

This retrospective study included 200 patients, 90 with pseudoexfoliation (PEX) syndrome (Group 1) and 110 healthy controls (Group 2). Twelve-hour fasting blood samples were collected to measure complete blood count, neutrophil/lymphocyte ratio (NLR), monocyte/lymphocyte ratio (MLR), platelet/lymphocyte ratio (PLR), systemic immune-inflammation index (SII) (neutrophil x platelet/lymphocyte), systemic inflammatory response index (SIRI) (neutrophil x monocyte/lymphocyte), pan-immune inflammation value (PIV) (neutrophil x platelet x monocyte/lymphocyte), C-reactive protein (CRP), uric acid, glucose, triglycerides (TG), total cholesterol, HDL, LDL, non-HDL, and triglyceride-glucose (TyG) index (Ln (TG [mg/dL] × glucose [mg/dL]/2)). The groups were compared based on these measurements.

RESULTS

The two groups were similar in terms of age and gender (p > 0.05). No statistically significant differences were observed between the groups for PLR, SII, CRP, glucose, total cholesterol, HDL, LDL, and non-HDL (all p > 0.05). However, systemic inflammation markers-NLR, MLR, SIRI, PIV, and uric acid were significantly higher in Group 1 compared to Group 2 (all p < 0.05). Among the atherogenic biomarkers used to assess cardiovascular risk, triglycerides and the TyG index were significantly higher in Group 1 (p < 0.05, p < 0.001).

CONCLUSION

Pseudoexfoliation syndrome is characterized by the accumulation of fibrogranular material primarily on the anterior lens capsule and pupillary border. PEX deposits are not limited to ocular structures but are also found in the heart, liver, and various vascular structures. It has been suggested that PEX is an independent risk factor for cardiovascular diseases and that systemic inflammation plays a role in the disease's pathogenesis. The significant biomarkers identified in this study may provide guidance in monitoring the disease.

Candidate SNP Markers Significantly Altering the Affinity of the TATA-Binding Protein for the Promoters of Human Genes Associated with Primary Open-Angle Glaucoma

Primary open-angle glaucoma (POAG) is the most common form of glaucoma. This condition leads to optic nerve degeneration and eventually to blindness. Tobacco smoking, alcohol consumption, fast-food diets, obesity, heavy weight lifting, high-intensity physical exercises, and many other bad habits are lifestyle-related risk factors for POAG. By contrast, moderate-intensity aerobic exercise and the Mediterranean diet can alleviate POAG. In this work, we for the first time estimated the phylostratigraphic age indices (PAIs) of all 153 POAG-related human genes in the NCBI Gene Database. This allowed us to separate them into two groups: POAG-related genes that appeared before and after the phylum Chordata, that is, ophthalmologically speaking, before and after the camera-type eye evolved. Next, in the POAG-related genes' promoters, we in silico predicted all 3835 candidate SNP markers that significantly change the TATA-binding protein (TBP) affinity for these promoters and, through this molecular mechanism, the expression levels of these genes. Finally, we verified our results against five independent web services-PANTHER, DAVID, STRING, MetaScape, and GeneMANIA-as well as the ClinVar database. It was concluded that POAG is likely to be a symptom of the human self-domestication syndrome, a downside of being civilized.

Histopathological Analysis of Pseudoexfoliation Material in Ocular Surgeries: Clinical Implications

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Systemic Vascular Parameters in Ocular Pseudoexfoliation

Background Pseudoexfoliation syndrome (PEX) is characterized by a dandruff-like substance in the anterior chamber, composed of various glycoproteins that have an unclear origin. Its deposition is observed on the pupillary margin, lens zonules, and trabecular meshwork. Proteomic studies have identified numerous proteins in the affected individuals, suggesting associations with systemic conditions like heart disease, stroke, and Alzheimer's disease. However, the systemic associations of PEX remain inconclusive, particularly in regions like southern India. Materials and methods A cross-sectional study was conducted on 114 participants. Pseudoexfoliation was graded as mild, moderate, and severe as per standard photographic grading. Systemic examinations included blood pressure measurements, electrocardiography (ECG), and blood investigations for serum lipid profile, fasting and postprandial blood sugar levels, and serum C-reactive protein levels. Small incision cataract surgery was performed for all the patients. Intraoperative complications and postoperative status were recorded. Results Thirty-eight patients (33.3%) had mild PEX, 44 (38.6%) had moderate PEX, and 32 (28.1%) had severe PEX. Hypertension was present in 54 participants (47.4%), diabetes in 21 (18.4%), coronary artery disease in nine (7.9%), and cerebrovascular accidents in three (2.6%). The mean systolic blood pressure was 140.39 mmHg and the mean diastolic blood pressure was 90.37 mmHg. Systolic blood pressure exceeded 140 mmHg in 29 participants (90.6%) with severe PEX, while diastolic blood pressure surpassed 90 mmHg in 26 participants with severe PEX, both with a p-value of 0.001. Mean fasting and postprandial blood sugar levels were 103.80 ± 31.81 mg/dl and 131.72 ± 48.24 mg/dl, respectively. Serum lipid profiles showed mean low-density lipoprotein (LDL), very low-density lipoprotein (VLDL), cholesterol, and triglyceride levels of 103.00 ± 34.49 mg/dl, 29.04 ± 15.51 mg/dl, 172.73 ± 43.34 mg/dl, and 129.33 ± 64.65 mg/dl respectively. Electrocardiographic results indicated that 54 participants (47.37%) had abnormal ECG including rate abnormality in 13.2%, conduction defects in 12.3%, ischemic changes in 10.5%, and structural defects in 11.4%. Eighty-seven percent of patients had non-dilating pupils and iris atrophy, 13.2% had zonular dialysis and intraoperatively, 78% had capsulorhexis extension, 49.12% had difficult nucleus prolapse, and 28.95% had posterior capsular rent. Conclusion This study highlights the significantly elevated parameters of systemic vascular diseases in PEX patients, like elevated blood pressure and more frequent cardiac anomalies, emphasizing the need for comprehensive systemic evaluation and careful preoperative assessment for ocular comorbidities.

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.

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.

Abdominal aortic aneurysm and exfoliation syndrome in Utah

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Exploring association between pseudoexfoliation syndrome and ocular aging

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Purpose

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

Methods

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

Results

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

Conclusion

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

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.

A new method of arterial stiffness measurement in pseudoexfoliation syndrome: cardio-ankle vascular index

PURPOSE

To investigate whether pseudoexfoliation syndrome affects arterial stiffness by using cardio-ankle vascular index measurement.

METHODS

This cross-sectional case-control study included 55 patients with pseudoexfoliation syndrome and 106 age- and gender-matched healthy control subjects. All subjects underwent a complete ophthalmic exa mination of both eyes and cardio-ankle vascular index measu rements. Echocardiographic and body mass index measurements were performed in all patients, and the results were recorded. A binary regression model was used to determine the relationship between cardio-ankle vascular index and pseudoexfoliation.

RESULTS

There were no significant differences between the pseudoexfoliation and control groups in baseline clinical and demographic characteristics, echocardiographic measurements of left ventricular ejection fraction, and body mass index. The mean cardio-ankle vascular index value was significantly higher in the pseudoexfoliation group than in the controls (9.47 ± 1.23 vs. 8.33 ± 1.50, p<0.001). Intraocular pressure was significantly higher in the pseudoexfoliation group than in the controls (18.31 ± 1.78 vs. 15.24 ± 2.42 mm Hg, p<0.05). Although the logistic regression analysis showed that mean cardio-ankle vascular index and IOP values were positively associated with pseudoexfoliation syndrome (Odds ratios (OR) = 1.973, 95% CI, 1.051-3.706, p=0.035; OR=3.322, 95% CI = 2.000-5.520, p<0.001, respectively), the Pearson correlation analysis revealed a borderline significant positive correlation between age and mean cardio-ankle vascular index and a significant positive correlation between dyslipidemia and intraocular pressure and mean cardio-ankle vascular index (r=0.265, p=0.050; r=0.337, p=0.012; r=0.433, p=0.001, respectively).

CONCLUSION

Our findings demonstrated that cardio-ankle vascular index values increased in patients with pseudoexfoliation syndrome.

A global genetic epidemiological review of pseudoexfoliation syndrome

Pseudoexfoliation (PXF) syndrome is an important public health concern requiring individual population level analysis. Disease prevalence differs by geographic location and ethnicity, and has environmental, demographic, genetic, and molecular risk factors have been demonstrated. Epidemiological factors that have been associated with PXF include age, sex, environmental factors, and diet. Genetic and molecular components have also been identified that are associated with PXF. Underserved populations are often understudied within scientific research, including research about eye disease such as PXF, contributing to the persistence of health disparities within these populations. In each population, PXF needs may be different, and by having research that identifies individual population needs about PXF, the resources in that population can be more efficiently utilized. Otherwise, PXF intervention and care management based only on the broadest level of understanding may continue to exacerbate health disparities in populations disproportionally burdened by PXF.

The protective variant rs7173049 at LOXL1 locus impacts on retinoic acid signaling pathway in pseudoexfoliation syndrome

LOXL1 (lysyl oxidase-like 1) has been identified as the major effect locus in pseudoexfoliation (PEX) syndrome, a fibrotic disorder of the extracellular matrix and frequent cause of chronic open-angle glaucoma. However, all known PEX-associated common variants show allele effect reversal in populations of different ancestry, casting doubt on their biological significance. Based on extensive LOXL1 deep sequencing, we report here the identification of a common non-coding sequence variant, rs7173049A>G, located downstream of LOXL1, consistently associated with a decrease in PEX risk (odds ratio, OR = 0.63; P = 6.33 × 10⁻³¹) in nine different ethnic populations. We provide experimental evidence for a functional enhancer-like regulatory activity of the genomic region surrounding rs7173049 influencing expression levels of ISLR2 (immunoglobulin superfamily containing leucine-rich repeat protein 2) and STRA6 [stimulated by retinoic acid (RA) receptor 6], apparently mediated by allele-specific binding of the transcription factor thyroid hormone receptor beta. We further show that the protective rs7173049-G allele correlates with increased tissue expression levels of ISLR2 and STRA6 and that both genes are significantly downregulated in tissues of PEX patients together with other key components of the STRA6 receptor-driven RA signaling pathway. siRNA-mediated downregulation of RA signaling induces upregulation of LOXL1 and PEX-associated matrix genes in PEX-relevant cell types. These data indicate that dysregulation of STRA6 and impaired retinoid metabolism are involved in the pathophysiology of PEX syndrome and that the variant rs7173049-G, which represents the first common variant at the broad LOXL1 locus without allele effect reversal, mediates a protective effect through upregulation of STRA6 in ocular tissues.

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

PURPOSE

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

METHODS

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

MAIN OUTCOME MEASURES

Associations between XFS and systemic diseases.

RESULTS

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

CONCLUSION

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

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

SYNOPSIS/PRECIS

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

The role of lysyl oxidase-like 1 (LOXL1) in exfoliation syndrome and glaucoma

Exfoliation syndrome (XFS) is an age-related systemic disease that affects the extracellular matrix. It increases the risk of glaucoma (exfoliation glaucoma, XFG) and susceptibility to diseases of elastin-rich connective tissues. LOXL1 (lysyl oxidase-like 1) is still recognized as the major genetic effect locus in XFS and XFG in all populations worldwide, although its genetic architecture is incompletely understood. LOXL1 is a key cross-linking enzyme in elastic fiber formation and remodeling, which is compatible with the pathogenetic concept of XFS as a specific type of elastosis. This review provides an overview on the current knowledge about the role of LOXL1 in the etiology and pathophysiology of XFS and XFG. It covers the known genetic associations at the LOXL1 locus, potential mechanisms of gene regulation, implications of LOXL1 in XFS-associated fibrosis and connective tissue homeostasis, its role in the development of glaucoma and associated systemic diseases, and the currently available LOXL1-based in vivo and in vitro models. Finally, it also identifies gaps in knowledge and suggests potential areas for future research.

Atherogenic indices in pseudoexfoliation syndrome

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Cataract surgery outcome in patients with non-glaucomatous pseudoexfoliation

Aim. To study the outcome of cataract surgery in eyes with pseudoexfoliation without signs of glaucoma. Methods. This prospective study was done over nine months on patients with pseudoexfoliation undergoing small incision cataract surgery. Only patients with normal intraocular pressure (Central Corneal Thickness Corrected), normal cup disc ratio and open angles were included. Patients on anti-glaucoma medication were excluded. Patients underwent surgery performed by a single senior surgeon. Intraoperative and postoperative day (POD) 1 findings were noted. Results. The mean age of the patients was 61.60 years +/ - 10.21 years. Males were 46% (n=16). Right eye was operated upon in 60% of the cases (n=21). The mean pupil dilation was 5.1 mm +/ - 1.47 mm. The postoperative day 1 visual acuity of the patients was logMar 1.02 +/- 0.64 and the mean POD 1 intraocular pressure was noted to be 26.23 mmHg +/ - 11.40 mmHg. Five cases had a zonular dialysis intraoperatively due to weak zonules. 11 cases had high anterior chamber reaction of 2+ or more. Four cases had unavoidable sphincter tears and two cases had iridodialysis superiorly during nucleus delivery. Conclusions. Intraoperative complications should be anticipated in patients with pseudoexfoliation even without glaucomatous changes due to poor pupillary dilation and zonular weakness. First postoperative day visual acuity in pseudoexfoliation patients undergoing cataract surgery was found to be low due to severe anterior chamber inflammation causing elevated intraocular pressure and corneal edema. Abbreviations. POD = Postoperative day, PEX = Pseudoexfoliation syndrome, LOXL 1 = Lysyl oxidase-like 1, IOP = Intraocular pressure, AC = Anterior chamber, IOL = Intraocular lens.

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.

Lysyl oxidases expression and histopathological changes of the diabetic rat nephron

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

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.

[Prevalence of exfoliation syndrome and cardiovascular diseases in patients scheduled for cataract surgery]

PURPOSE

To study the prevalence of exfoliation syndrome (XFS) and its association with cardiovascular disease in patients scheduled for cataract surgery.

MATERIAL AND METHODS

This is a retrospective, single center, descriptive study of 260 patients admitted to a tertiary teaching hospital in Rabat, Morocco, between January 2015 and March 2016 and scheduled for cataract surgery. All patients had a preoperative cardiovascular exam, an electrocardiogram and, if needed, echocardiography. Statistical analysis was performed using SPSS software. Results with a P-value<0.05 were considered statistically significant.

RESULTS

This study included 246 patients: 146 women (59.3 %) and 100 men (40.7 %). The mean age (years) was 67.6±10.1. The percentage of XFS increased with age (P=0.02). Sixty-two percent of patients with cardiovascular disease also had exfoliation syndrome (P<0.001). Patients with XFS had hypertension in 46.5 % of cases. 14 subjects (19.7 %) had ischemic heart disease and XFS. Using multivariate logistic regression and after adjusting for age, diabetes mellitus, hypertension, ischemic heart disease and arrhythmias, smoking was the only factor associated with exfoliation syndrome (P=0.01, odds ratio=5.2, confidence interval 95 %=1.35-20.15).

CONCLUSION

Exfoliation syndrome is a common condition in the aging cataract population. Ischemic heart disease and hypertension are frequently associated with XFS. Smoking could be another factor associated with this syndrome.

Pseudoexfoliation syndrome-associated genetic variants affect transcription factor binding and alternative splicing of LOXL1

Although lysyl oxidase-like 1 (LOXL1) is known as the principal genetic risk factor for pseudoexfoliation (PEX) syndrome, a major cause of glaucoma and cardiovascular complications, no functional variants have been identified to date. Here, we conduct a genome-wide association scan on 771 German PEX patients and 1,350 controls, followed by independent testing of associated variants in Italian and Japanese data sets. We focus on a 3.5-kb four-component polymorphic locus positioned spanning introns 1 and 2 of LOXL1 with enhancer-like chromatin features. We find that the rs11638944:C>G transversion exerts a cis-acting effect on the expression levels of LOXL1, mediated by differential binding of the transcription factor RXRα (retinoid X receptor alpha) and by modulating alternative splicing of LOXL1, eventually leading to reduced levels of LOXL1 mRNA in cells and tissues of risk allele carriers. These findings uncover a functional mechanism by which common noncoding variants influence LOXL1 expression.

LOXL1 is a genetic risk factor for pseudoexfoliation syndrome of the eye but a causal variant has not been identified. Here, Pasutto et al., find intronic LOXL1 risk variants influence transcription factor binding and alternative splicing of LOXL1 in affected tissues reducing levels of LOXL1 mRNA.

Relationship between homocysteine and intraocular pressure in men and women: A population-based study

The relationship between homocysteine levels and glaucoma has been questioned in previous studies without conclusive results. In the current study, we assessed the relationship between homocysteine levels and intraocular pressure which is one of the main factors in the development of glaucoma in men and women.A retrospective cross-sectional analysis of a database from a screening center in Israel which assessed 11,850 subjects, within an age range 20 to 80 years. The relationship between homocysteine and intraocular pressure has been investigated by comparing intraocular pressure in subjects with elevated and normal homocysteine and by comparing homocysteine levels in subjects with elevated and normal intraocular pressure. In addition, we compared the levels of homocysteine in subjects with and without a confirmed diagnosis of glaucoma.The mean IOP (±SD) in subjects with normal homocysteine levels(≤15 μmol/L) was 13.2 ± 2.3 mm Hg and 13.4 ± 2.4 mm Hg in those with high homocysteine levels (>15 μmol/L) (P < 0.008, 95% confidence interval [CI] 0.3-0.09).Nonetheless, after multivariate adjustment for age, gender, vitamin B12, and folic acid statistical significance was no longer demonstrated (P = 0.37). Mean homocysteine levels (±SD) in subjects with normal intraocular pressure of ≤ 21 mm Hg was 11.7 ± 5.5 μmol/L and 12.09 ± 3.43 μmol/L in those with elevated intraocular pressure (P = 0.4, 95%CI 1.1-1.8). Mean homocysteine levels (±SD) in subjects with glaucoma were 11.2 ± 3.5 μmol/L compared to 11.7 ± 5.5 μmol/L in subjects without glaucoma and normal intraocular pressure ≤ 21 mm Hg (P = 0.4, 95% CI 1.2-2.1).The current study displays no clinical correlation between the homocysteine level and the intraocular pressure. Homocysteine may not be used as a predictive parameter to recognize those subjects prone to develop elevated intraocular pressure.

Plasma adropin level in patients with pseudoexfoliation

The aim of this study was to evaluate plasma adropin levels in patients with pseudoexfoliation (PEX). This retrospective case-control study included 35 patients with PEX and 35 individuals without PEX who served as controls. Plasma adropin levels with triglycerides, total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein (HDL), and haemoglobin A1c (HGBA1C) concentrations were measured in both groups. The mean serum adropin levels were 3.24 ± 0.95 ng/mL (range, 1.90-7.88 ng/mL) in patients with PEX syndrome and 5.78 ± 2.85 ng/mL (range, 2.08-5.41 ng/mL) in PEX glaucoma patients. There was no statistically significant difference in mean adropin levels between PEX syndrome and PEX glaucoma patients. However, similar adropin levels were found in the PEX glaucoma patients and the control group (P > 0.05). The mean serum adropin levels were 3.34 ± 0.89 ng/mL (range, 1.90-5.39 ng/mL) in the PEX group and 5.78 ± 2.85 ng/mL (range, 3.08-11.06 ng/mL) in the control group. The mean serum adropin level of the PEX group was significantly lower than that of the control group (P < 0.001). There were no significant differences between the two groups in terms of serum glucose, total cholesterol, LDL, HDL, HGBA1C, triglycerides levels, or body mass index (all P > 0.05). Adropin level is lower in patients with PEX.

Serum Uric Acid, Alanine Aminotransferase, Hemoglobin and Red Blood Cell Count Levels in Pseudoexfoliation Syndrome

Purpose. The pathogenesis of pseudoexfoliation (PEX), the most common cause of secondary glaucoma, has not been clearly identified, but there is increasing evidence that points out the role of oxidative stress. The aim of this study is to evaluate some of the most commonly used blood parameters, hemoglobin (Hb), red blood cell count (RBC), alanine aminotransferase (ALT), and uric acid (UA) levels, in subjects with PEX. Materials and Methods. This study is performed in a state hospital between November 2011 and December 2012. Retrospective chart review of subjects who underwent cataract surgery was performed. Thirty-one healthy subjects with PEX and 34 healthy subjects without PEX were evaluated. Hb, RBC, ALT, and UA levels were recorded. Student's t-test was used to compare the two groups. Results. The mean age was 73.6 ± 14.1 years in PEX group and 70.1 ± 12.7 in control group (p = 0.293). Hb, RBC, ALT, and UA levels did not show a statistically significant difference among PEX and control groups (p > 0.05 for all). Conclusion. Serum levels of Hb, RBC, ALT, and UA levels were similar in subjects with and without PEX. Further studies are needed to clarify the precise role of Hb, RBC, ALT, and UA in the pathogenesis of PEX.

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.

Exfoliation syndrome and systemic cardiovascular diseases

Exfoliation syndrome (XFS) is a systemic condition. Intraocular alterations represent only a part of the exfoliation-related clinical signs. Exfoliation material has been identified in the visceral organs, skin, and vessel walls. This triggered several studies that investigated association between XFS and cardiovascular diseases. In many populations, significant associations between XFS and various systemic vascular diseases including elevated plasma homocysteine level, myocardial dysfunction, stroke, aortic aneurysm, and white matter lesions were found. Some of these XFS-associated vascular diseases are caused by elastosis of the vessel wall, which may be directly related to general extracellular dysfunction in XFS. Another part of the pathologic vascular alterations (reduced cutaneous capillary flow reactions, impaired baroreflex sensitivity, parasympathetic cardiovascular neuropathy, and pathologic heart rate variability indices), however, suggests that vascular dysregulation beyond the age-related normal decline may also play a role both in the development and worsening of the systemic cardiovascular diseases in XFS. The exact mechanism of the development of systemic vascular dysregulation associated with XFS is currently unknown.

Pseudoexfoliation and mortality: a population-based 30-year follow-up study

PURPOSE

To study the relationship between pseudoexfoliation (PEX) and all-cause mortality in a population in which PEX is a common finding.

METHODS

Survival analyses were performed in a cohort of 760 residents 65-74 years of age, examined in a population survey in the municipality of Tierp, Sweden, 1984-86. To expand the cohort, participants in other studies in Tierp were enrolled. Additionally, people were recruited by means of glaucoma case records established at the Eye Department in Tierp in 1978-2007. In this way, the cohort comprised 1524 subjects, representing more than 21,100 person-years at risk. Information on deaths was obtained from the local population register.

RESULTS

By the conclusion of the study, in August 2013, 1280 deaths had been reported. Of these cases, 350 were affected by PEX at baseline. No association between PEX and mortality was found (hazard ratio 1.00; 95% confidence interval 0.88-1.14).

CONCLUSION

The results strongly suggest that PEX had no effect on all-cause mortality in the population under study.

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.

Corneal biomechanical comparison of pseudoexfoliation syndrome, pseudoexfoliative glaucoma and healthy subjects

PURPOSE

To evaluate the differences in corneal biomechanical properties between healthy subjects and patients with pseudoexfoliation syndrome (PEX) and pseudoexfoliative glaucoma (PEXG) using the ocular response analyzer (ORA).

MATERIALS AND METHODS

One hundred eighteen eyes of 45 healthy, 43 PEX and 30 PEXG eyes were included in to the study. Corneal biomechanical parameters measurements were obtained using ORA. The main parameters assessed were corneal hysteresis (CH), corneal resistance factor (CRF), Goldmann-correlated pressure measurement (IOPg) and corneal compensated intraocular pressure (IOPcc). Ultrasound pachymetry was used for measurement of central corneal thickness (CCT).

RESULTS

In healthy subjects, PEX and PEXG eyes' mean CH values were 10.3 ± 1.4, 8.2 ± 1.4 and 6.8 ± 1.7 mmHg, respectively. The difference in mean CH between the PEXG and other two groups were statistically significant (p < 0.001). Mean CRF values were 10.3 ± 0.7, 7.9 ± 1.6 and 7.9 ± 1.9 mmHg, in healthy subjects PEX and PEXG, respectively. The difference in mean CRF between the PEX and PEXG was not statistically significant (p = 0.630), however the mean CRF was significantly higher in healthy subjects, compared to other two groups. Mean CCT were 546.3 ± 28, 525.5 ± 35 and 509 ± 36 μ, in healthy subjects, PEX and PEXG, respectively. The differences on CCT were also significant among the three groups (p < 0.001).

CONCLUSION

In this study, the corneal biomechanical features of subjects with PEX were found to be changed as compared to healthy controls. In these patients; CH, CRF and CCT were decreased which was more obvious in patients with PEXG in comparison to PEX patients.

Pseudoexfoliation syndrome and coronary artery ectasia

AIMS

To determine whether pseudoexfoliation syndrome is associated with coronary artery ectasia or not.

METHODS

This cross-sectional study was undertaken at Bulent Ecevit University's Ophthalmology Department with the participation of the Cardiology Department. Eighty consecutive patients who underwent coronary angiography and were classified into two groups-those diagnosed with a normal coronary artery (n=40) and those diagnosed with coronary artery ectasia (n=40)-were included in the study. Pseudoexfoliation was diagnosed if typical exfoliation material was found to be present on the anterior surface of the lens, the iris, or at the pupillary border on slit-lamp examination. Age, sex, presence of pseudoexfoliation material, hypertension, diabetes mellitus, hyperlipidemia rates, cigarette smoking history, and family history of coronary artery disease were compared between the two groups. The continuous variables were compared by using the independent sample t-test or the Mann-Whitney U-test, and the categorical variables were compared using Pearson's χ(2)-test or Fisher's Exact χ(2)-test for the two groups.

RESULTS

There was no difference in demographic data of both groups. The presence of pseudoexfoliation material was more common in patients with coronary ectasia compared with controls [(n=21 (52.5%) vs n=8 (20%), P=0.005)]. In all patients, there was a higher glaucoma rate in the patients with pseudoexfoliation syndrome [n=7 (24.1%), 6 CAE (+), 1 CAE (-)] than in the normal patients [n=2 (3.9%), 2 CAE (-)] (P=0.010).

CONCLUSIONS

In this study, we found a possible association of pseudoexfoliation and coronary artery ectasia. Coronary artery ectasia patients had higher prevalence of pseudoexfoliation.

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.