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Coskun C, Çelik G, Zeki Fikret C, Çomçalı S, Evren Kemer Ö. Evaluation of corneal densitometry values with Pentacam in cases of ocular hypertension and pseudoexfoliative glaucoma. Photodiagnosis Photodyn Ther 2024; 46:103988. [PMID: 38368915 DOI: 10.1016/j.pdpdt.2024.103988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 01/19/2024] [Accepted: 01/22/2024] [Indexed: 02/20/2024]
Abstract
BACKGROUND Examination of corneal densitometry measurements using the Pentacam Scheimpflug imaging system in cases of pseudoexfoliative glaucoma (PEXG) and ocular hypertension (OHT). METHODS The study included 50 eyes of 29 PEXG patients, 25 eyes of 16 OHT patients, and 76 eyes of 38 healthy control subjects followed in the glaucoma clinic. Corneal densitometry values of all cases were measured using the Scheimpflug imaging system (Pentacam, Oculus, Germany). Corneal densitometry was assessed based on 4 concentric radial zones (0-2 mm, 2-6 mm, 6-10 mm, and 10-12 mm) and depths (anterior, central, posterior, and total) within the Scheimpflug imaging system. The results were statistically analyzed. RESULTS Corneal densitometry values examined between the OHT and control groups were higher in OHT and statistically significant (p < 0.05). Corneal densitometry values examined between the PEXG and control groups were higher in PEXG and statistically significant (p < 0.05). In comparison between the PEXG and OHT groups, corneal densitometry values in the central 0-2 mm, 2-6 mm, and 6-10 mm; posterior 0-2 mm and 2-6 mm radial zones were higher in PEXG and statistically significant (p < 0.05). CONCLUSIONS It was observed that elevated intraocular pressure levels in OHT cases could lead to changes in the cornea, consequently increasing corneal densitometry values. The higher corneal densitometry values in PEXG cases compared to OHT were attributed to the accumulation of pseudoexfoliative material in the cornea. Based on our study, corneal densitometry could serve as a potential biomarker for early glaucoma detection in OHT cases and could be employed to assess corneal transparency during the follow-up of PEXG cases.
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Affiliation(s)
- Cigdem Coskun
- Department of Ophthalmology, Ankara Bilkent City Hospital, Ankara, Turkey.
| | | | - Cenk Zeki Fikret
- Department of Ophthalmology, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Sebile Çomçalı
- Department of Ophthalmology, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Özlem Evren Kemer
- Department of Ophthalmology, University of Health Sciences, Ankara Bilkent City Hospital, Ankara, Turkey
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Swept Source Optical Coherence Tomography Analysis of a Selected Eye's Anterior Segment Parameters in Patients with Pseudoexfoliation Syndrome. J Clin Med 2022; 11:jcm11010268. [PMID: 35012009 PMCID: PMC8745779 DOI: 10.3390/jcm11010268] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 12/26/2021] [Accepted: 12/31/2021] [Indexed: 02/04/2023] Open
Abstract
Background: Pseudoexfoliation syndrome (PEX) is a systemic, age-related disorder characterized by the production and accumulation of pseudoexfoliation material. To date, detailed characteristics have not been published regarding the iridocorneal angle and cornea in patients with pseudoexfoliation syndrome determined through swept source optical coherence tomography (SS-OCT). Methods: A total of 150 eyes of patients with pseudoexfoliation syndrome (ages 69–86 years) and 166 eyes in a control group (ages 54–79 years) were analyzed. Results: The central corneal thickness in the PEX group was 549.56 μm and was slightly (insignificantly) higher than that of the control group (540.56 µm). The anterior chamber of the eye was visibly shallower in patients with PEX syndrome than in those of the control group (2.49 mm vs. 3.07 mm; p < 0.001). The Fourier analysis parameters of the cornea showed multiple differences between the PEX and control groups. With respect to iris area, the parameters showed statistically significant differences between the PEX and control groups in all four quadrants of the eye. No statistical significance was found in the PEX group for the iridocorneal angle parameters, or corneal and lens parameters depending on gender and age. Conclusions: PEX syndrome is characterized by a significant impact on the anterior eye segment, including higher anterior and posterior keratometric values, lower anterior chamber depth, higher iris thickness, and narrower angle parameters. The characteristic anterior eye segment features of PEX syndrome can be detected using SS-OCT, which could potentially assist clinicians in properly managing the disease.
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Hsueh YJ, Meir YJJ, Lai JY, Huang CC, Lu TT, Ma DHK, Cheng CM, Wu WC, Chen HC. Ascorbic acid ameliorates corneal endothelial dysfunction and enhances cell proliferation via the noncanonical GLUT1-ERK axis. Biomed Pharmacother 2021; 144:112306. [PMID: 34656060 DOI: 10.1016/j.biopha.2021.112306] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 10/01/2021] [Accepted: 10/05/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The pumping function of corneal endothelial cells (CECs) plays a pivotal role in the maintenance of corneal water homeostasis. Corneal endothelial dysfunction (CED) leads to corneal edema and opacity, but with the exception of keratoplasty, no optimal therapeutic strategies have been established for CED. In this study, we aimed to investigate the ameliorative effect of ascorbic acid (AA) on CED and the underlying mechanism of action in the corneal endothelium. METHODS Rabbit corneal endothelial damage was induced by anterior chamber injection of benzalkonium chloride (BAK). AA was topically administered to the corneal surface, and the transparency and thickness of the cornea were assessed by external eye photography, slit-lamp photography, and ultrasonic pachymetry. To further analyze the mechanism, rabbit CECs and immortalized human CECs (B4G12 cells) were cultured. A ferric reducing/antioxidant and AA (FRASC) assay was performed to measure the AA concentration. Cell proliferation was evaluated by cell counting and bromodeoxyuridine (BrdU) labeling assays, and protein expression was examined by liquid chromatography-mass spectrometry (LC/MS) and immunoblotting. The involvement of glucose transporter 1 (GLUT1) and phospho-ERK was evaluated via GLUT1-siRNA and phospho-ERK inhibitor (PD98059) treatment. INTERPRETATION We observed that topical AA ameliorates BAK-induced rabbit corneal endothelial damage. Furthermore, we demonstrated that AA is transported into B4G12 cells via GLUT1, and afterward, AA increases ERK phosphorylation and promotes cell proliferation. Our findings indicate that CEC proliferation stimulated via the noncanonical AA-GLUT1-ERK axis contributes to AA-enhanced healing of CED.
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Affiliation(s)
- Yi-Jen Hsueh
- Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou, Taiwan; Center for Tissue Engineering, Chang Gung Memorial Hospital, Linkou, Taiwan.
| | - Yaa-Jyuhn James Meir
- Center for Tissue Engineering, Chang Gung Memorial Hospital, Linkou, Taiwan; Department of Biomedical Sciences, Chang Gung University, Taoyuan, Taiwan.
| | - Jui-Yang Lai
- Graduate Institute of Biomedical Engineering, Chang Gung University, Taoyuan, Taiwan; Department of Materials Engineering, Ming Chi University of Technology, New Taipei City, Taiwan; Research Center for Chinese Herbal Medicine, College of Human Ecology, Chang Gung University of Science and Technology, Taoyuan, Taiwan.
| | - Chieh-Cheng Huang
- Center for Tissue Engineering, Chang Gung Memorial Hospital, Linkou, Taiwan; Institute of Biomedical Engineering, National Tsing Hua University, Hsinchu, Taiwan.
| | - Tsai-Te Lu
- Center for Tissue Engineering, Chang Gung Memorial Hospital, Linkou, Taiwan; Institute of Biomedical Engineering, National Tsing Hua University, Hsinchu, Taiwan.
| | - David Hui-Kang Ma
- Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou, Taiwan; Center for Tissue Engineering, Chang Gung Memorial Hospital, Linkou, Taiwan; Department of Chinese Medicine, Chang Gung University, Taoyuan, Taiwan.
| | - Chao-Min Cheng
- Center for Tissue Engineering, Chang Gung Memorial Hospital, Linkou, Taiwan; Institute of Biomedical Engineering, National Tsing Hua University, Hsinchu, Taiwan.
| | - Wei-Chi Wu
- Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou, Taiwan; Department of Medicine, Chang Gung University, Taoyuan, Taiwan.
| | - Hung-Chi Chen
- Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou, Taiwan; Center for Tissue Engineering, Chang Gung Memorial Hospital, Linkou, Taiwan; Department of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Ucar F, Kadıoğlu E, Seyrek L. The effects of trypan blue use on the corneal endothelium during cataract surgery in patients with pseudoexfoliation syndrome (PEX). Cutan Ocul Toxicol 2021; 40:332-337. [PMID: 34342246 DOI: 10.1080/15569527.2021.1958224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE In the present clinical study, it was aimed to investigate the possible effects of Trypan blue (TB) use on the corneal endothelium during cataract surgery in eyes with pseudoexfoliation syndrome (PEX) during a three-month follow-up period using the contralateral eye control design. METHODS This prospective, randomised controlled, individual cohort study included 92 eyes of 46 patients with bilateral PEX and cataracts. While 1% TB was applied to one eye of the patients before capsulorhexis (study group), it was not applied to the other eye (control group). Both groups were compared preoperatively and postoperatively in terms of endothelial cell density (ECD), endothelial cell loss (%), pleomorphism, polymegathism and central corneal thickness (CCT) using specular microscopy. RESULTS Preoperative corneal ECD was measured as 2362.56 ± 253.27 in the study group, 2380.84 ± 220.54 in the control group, and 2145.58 ± 221.71 in the study group and 2184.97 ± 200.94 cells/mm2 in the control group in the postoperative 3rd-month follow-up (p = 0.71 and = 0.37, respectively). In addition, there were no significant differences between the two groups in terms of the percentage of hexagonal cells, coefficient of variation (CV), and CCT both preoperatively and postoperatively 3 months later (p = 0.78, =0.39, =0.95 preoperatively and p = 0.31, =0.26, =0.83 postoperatively, respectively). CONCLUSION This study demonstrated that the injection of 1% TB into the anterior chamber for staining the anterior capsule during cataract surgery did not cause significant corneal endothelial changes at postoperative 3rd months, despite the increased fragility of corneal endothelial cells in patients with PEX.
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Bhattacharya P, Edwards K, Harkin D, Schmid KL. Central corneal basal cell density and nerve parameters in ocular surface disease and limbal stem cell deficiency: a review and meta-analysis. Br J Ophthalmol 2020; 104:1633-1639. [PMID: 32139501 DOI: 10.1136/bjophthalmol-2019-315231] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 01/03/2020] [Accepted: 02/13/2020] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To conduct a review and meta-analysis for investigating the relative reduction of central corneal basal cell density (BCD) and nerve parameters in ocular surface disease (OSD) and limbal stem cell deficiency (LSCD). METHODS A systematic literature search using the terms ((1) "ocular surface disease" or "ocular surface disorder"; (2) "in vivo confocal microscopy"; (3) "limbal stem cell deficiency"; (4) "basal cell density" or "corneal basal cell density" or "central corneal basal cell density"; (5) "corneal nerves" or "corneal nerve parameters" or "central corneal nerve parameters") was performed. The results are presented as weighted mean difference (WMD) with corresponding 95% CI. RESULTS 16 studies that reported the central corneal BCD and 21 studies that reported the central corneal nerve parameters in OSD (including LSCD) were included. A significant reduction in central corneal BCD was observed in patients with various OSDs (WMD=-9.50, 95% CI -14.04 to -4.97, p<0.01) as well as in patients with LSCD (WMD=-22.14, 95% CI -37.91 to -6.37, p<0.01) compared with healthy controls, however, no significant difference in BCD was observed between the two groups (WMD=-11.61, 95% CI -15.96 to -7.26, p=0.13). There was no conclusive difference in various central corneal nerve parameters between OSDs and LSCD. CONCLUSION Central corneal BCD and nerve parameters are reduced in LSCD, there is a similar reduction in other OSDs.
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Affiliation(s)
- Pradipta Bhattacharya
- School of Optometry and Vision Science, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Katie Edwards
- School of Optometry and Vision Science, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Damien Harkin
- School of Biomedical Science, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Katrina L Schmid
- School of Optometry and Vision Science, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
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Tekce A, Gulmez M. Corneal sublayer thickness in patients with pseudoexfoliation syndrome evaluated by anterior segment optical coherence tomography. Int Ophthalmol 2019; 40:563-570. [PMID: 31701362 DOI: 10.1007/s10792-019-01214-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 10/28/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE The aim of the study was to evaluate the thickness of each corneal sublayer in patients with pseudoexfoliation syndrome (PXS). METHODS The study's sample consisted of the 74 eyes of 74 patients with PXS (group 1) and the 80 eyes of 80 individuals without PXS (group 2). Each participant was performed anterior segment optical coherence tomography (AS-OCT) and Pentacam-Scheimpflug imaging. The thicknesses of corneal epithelium, Bowman's layer, stroma, and Descemet membrane-endothelial complex were measured separately from the AS-OCT images, on the central, 2 mm superior and inferior of the cornea. Central corneal thickness (CCT), apical corneal thickness (ACT), thinnest corneal thickness (TCT), and corneal volume were also evaluated. RESULTS According to the measurements of corneal topography, in group 1 versus group 2, mean CCT (529.85 ± 32.33 µm vs 551.36 ± 39.12 µm, p < 0.001), mean ACT (532.21 ± 35.56 µm vs 552.26 ± 49.24 µm, p < 0.001), and mean TCT (527.54 ± 51.45 µm vs 546.20 ± 49.20 µm, p = 0.002) were significantly thinner in group 1. In AS-OCT, the thickness of the epithelium, stroma, and Descemet membrane-endothelial complex in the central, inferior, and superior cornea were significantly thinner in group 1 than in group 2. However, the thickness of Bowman's layer did not significantly differ between the groups. CONCLUSIONS Our results indicate that all corneal sublayers except Bowman's layer were thinner in eyes with PXS than in healthy ones. Therefore, caution should be exercised for corneal involvement in patients with PXS.
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Affiliation(s)
- Abdulhakim Tekce
- Department of Ophthalmology, The Lazer Goz Eye Hospital, Kayseri, Turkey.
| | - Mehmet Gulmez
- Department of Ophthalmology, The Dunya Goz Eye Hospital, Konya, Turkey
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Tekin K, Inanc M, Elgin U. Monitoring and management of the patient with pseudoexfoliation syndrome: current perspectives. Clin Ophthalmol 2019; 13:453-464. [PMID: 30880906 PMCID: PMC6402616 DOI: 10.2147/opth.s181444] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Pseudoexfoliation syndrome (PES) is a complex and age-related systemic disorder characterized by the progressive accumulation and granular deposition of pseudoexfoliative material in various intraocular and extraocular tissues. The diagnosis of PES is so important because it is a major risk factor for complications during cataract surgery and the most frequent cause of secondary glaucoma. In addition to ocular complications, PES is related with numerous systemic abnormalities, for which the list is growing steadily. Therefore, management and monitoring of patients with PES are crucial. The aim of this paper was to review current perspectives on monitoring patients with PES and addressing management of ocular and systemic associations of this clinically important and biologically fascinating disease.
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Affiliation(s)
- Kemal Tekin
- Ophthalmology Department, Erciş State Hospital, Erciş, Van, Turkey,
| | - Merve Inanc
- Ophthalmology Department, Erciş State Hospital, Erciş, Van, Turkey,
| | - Ufuk Elgin
- Ophthalmology Department, Ulucanlar Eye Training and Research Hospital, University of Health Sciences, Ankara, Turkey
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Kokot J, Wylęgała A, Wowra B, Wójcik Ł, Dobrowolski D, Wylęgała E. Corneal confocal sub-basal nerve plexus evaluation: a review. Acta Ophthalmol 2018; 96:232-242. [PMID: 28741902 DOI: 10.1111/aos.13518] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 06/01/2017] [Indexed: 12/12/2022]
Abstract
The aim of this study was to review the most recent data about corneal sub-basal nerve plexus (SNP) evaluated with the use of corneal confocal microscopy (CCM). For this purpose, an electronic search was conducted based on PubMed and Google Scholar and Web of Science databases from 2008 up to the end of 2016. Ninety-eight articles in English were cited, as well as abstracts in other languages, concerning the morphology and function of corneal SNP in various diseases. Changes in corneal SNP as a result of local treatment were also introduced. Figures with scans from confocal microscopy from our Department were included. The main conclusion of this review was that both corneal SNP diminishment and high tortuosity as well as low sensitivity are in principle related to the presence or level of pathology. In addition, increased nerve tortuosity may represent a morphological determinant of nerve regeneration. However, the presented literature shows that SNP changes are not characteristic for one unified corneal pathology; rather, they reflect the non-specific pathological process present in many diseases. Future studies should use automatized biometric software and also examine the effects of new treatments on SNP.
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Affiliation(s)
- Joanna Kokot
- Ophthalmology Department; Railway Hospital Katowice; II School of Medicine with the Division of Dentistry in Zabrze; Medical University of Silesia; Katowice Poland
| | - Adam Wylęgała
- Ophthalmology Department; Railway Hospital Katowice; II School of Medicine with the Division of Dentistry in Zabrze; Medical University of Silesia; Katowice Poland
| | - Bogumił Wowra
- Ophthalmology Department; Railway Hospital Katowice; II School of Medicine with the Division of Dentistry in Zabrze; Medical University of Silesia; Katowice Poland
| | - Łukasz Wójcik
- Ophthalmology Department; Railway Hospital Katowice; II School of Medicine with the Division of Dentistry in Zabrze; Medical University of Silesia; Katowice Poland
| | - Dariusz Dobrowolski
- Ophthalmology Department; Railway Hospital Katowice; II School of Medicine with the Division of Dentistry in Zabrze; Medical University of Silesia; Katowice Poland
| | - Edward Wylęgała
- Ophthalmology Department; Railway Hospital Katowice; II School of Medicine with the Division of Dentistry in Zabrze; Medical University of Silesia; Katowice Poland
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Nathan N, Kuchtey RW. Genetics, Diagnosis, and Monitoring of Pseudoexfoliation Glaucoma. CURRENT OPHTHALMOLOGY REPORTS 2017; 4:206-212. [PMID: 28503365 DOI: 10.1007/s40135-016-0113-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Niraj Nathan
- 2311 Pierce Ave, Nashville, TN 37232-8808, 615-936-2020, 615-936-1540 (Fax),
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EVALUATION OF VITRECTOMY AND REIMPLANTATION FOLLOWING LATE DISLOCATION OF THE INTRAOCULAR LENS-CAPSULAR BAG COMPLEX. Retina 2017; 37:925-929. [DOI: 10.1097/iae.0000000000001300] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Palko JR, Qi O, Sheybani A. Corneal Alterations Associated with Pseudoexfoliation Syndrome and Glaucoma: A Literature Review. J Ophthalmic Vis Res 2017; 12:312-324. [PMID: 28791066 PMCID: PMC5525502 DOI: 10.4103/jovr.jovr_28_17] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
A systematic literature review was performed evaluating articles examining the effects of pseudoexfoliation syndrome (PEX) and glaucoma (PEXG) on the cornea with a focus on the corneal endothelium. We searched for articles relevant to pseudoexfoliation syndrome, pseudoexfoliation glaucoma and corneal endothelial cell counts using Pubmed, Google Scholar Database, Web of Science and Cochrane Library databases published prior to September of 2016. We then screened the references of these retrieved papers and performed a Web of Science cited reference search. Corneal characteristics analyzed included central corneal thickness (CCT), corneal nerve density, endothelial cell density (ECD), polymegathism, and pleomorphism. These parameters were compared in the following populations: control, PEX, PEXG, and primary open angle glaucoma (POAG). Over 30 observational studies were reviewed. Most studies showed a statistically significant lower ECD in PEX and PEXG populations compared to controls. Overall, PEX eyes had a non-statistically significant trend of lower ECDs compared to PEXG eyes. No consistent trends were found when analyzing differences in CCT amongst control, PEX and PEXG groups. For the few studies that looked at corneal nerve characteristics, the control groups were found to have statistically significantly greater nerve densities than PEX eyes, which had significantly greater densities than PEXG eyes. ECD and corneal nerve densities may be potential metrics for risk-stratifying patients with PEX and PEXG. Our literature review provided further evidence of the significant negative influence PEX has on the cornea, worsening as patients convert to PEXG.
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Affiliation(s)
- Joel R Palko
- Department of Ophthalmology and Visual Sciences, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Owen Qi
- Department of Internal Medicine, Mercy Hospital, St. Louis, MO, USA
| | - Arsham Sheybani
- Department of Ophthalmology and Visual Sciences, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
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