What have we learned about exfoliation syndrome since its discovery by John Lindberg 100 years ago?

Exfoliation syndrome (XFS) is a systemic disease with significant ocular manifestations, including glaucoma and cataract. The disease impacts close to 70 million people globally and is now recognised as the most common identifiable cause of open-angle glaucoma. Since the discovery of XFS 100 years ago by Dr John G. Lindberg, there has been considerable advancement in understanding its pathogenesis and resulting clinical implications. The purpose of this paper is to summarise information regarding the epidemiology, pathophysiology, ocular manifestations and systemic associations of XFS with the objective of sharing clinical pearls to assist in early detection and enhanced management of patients.

Exfoliation syndrome in Nigeria

Purpose:

The purpose of this study was to estimate the prevalence of exfoliation syndrome (XFS) and its association with ocular disease in patients attending the eye clinic of the University College Hospital (UCH) in Ibadan, Nigeria.

Materials and Methods:

A total of 448 consecutive new patients, aged 30-90 years who presented to the eye clinic of UCH between December 2009 and November 2010 were evaluated. Each patient had a complete ophthalmic examination. Patients with exfoliative material on the anterior lens surface and/or pupillary margin in either or both eyes were considered to have XFS. Means, standard deviation, and 95% confidence intervals were calculated.

Results:

All the patients examined were from the southern part of Nigeria. Majority (94.2%) were of the Yoruba tribe from southwestern Nigeria, while 5.8% were from southeastern Nigeria. The mean age of the study cohort was 58.5 ± 13.8, 54.8% were males, 12 (2.7%) had XFS. All patients with XFS were of the Yoruba tribe, with a mean age 65.6 ± 5.6 years. There was a male predilection (66.7%). All eyes with XFS had lenticular opacities. XFS was bilateral in eight patients (66.7%) of whom seven patients (87.5%) had glaucoma and lenticular opacities bilaterally.

Conclusion:

This is the first report of the existence of XFS in Nigeria. Larger studies are necessary in this population to further investigate the disease.

Early-onset Pseudoexfoliation Syndrome following Multiple Intraocular Procedures

PURPOSE

To present early-onset ocular manifestations of pseudoexfoliation syndrome in young patients who had undergone multiple intraocular procedures.

METHODS

This is an observational case series, introducing four cases with histories of multiple intraocular procedures for glaucoma.

RESULTS

All reported cases demonstrated typical manifestations of pseudoexfoliation unilaterally in the eye that had undergone multiple surgeries. The diagnosis of pseudoexfoliation was made prior to the age of 50 in all subjects and the earliest manifestation was at the age of 18 in a case with primary congenital glaucoma

CONCLUSION

The role of multiple surgical procedures, in addition to genetic predisposition, should be further investigated as a possible inciting factor predisposing to pseudoexfoliation in younger individuals.

Directed Therapy: An Approach to the Improved Treatment of Exfoliation syndrome

Exfoliation syndrome (XFS) is an age-related, generalized disorder of the extracellular matrix characterized by the production and progressive accumulation of a fibrillar extracellular material in many ocular tissues and is the most common identifiable cause of open-angle glaucoma worldwide. Exfoliation syndrome plays an etiologic role in open-angle glaucoma, angle-closure glaucoma, cataract, and retinal vein occlusion. It is accompanied by an increase in serious complications at the time of cataract extraction, such as zonular dialysis, capsular rupture, and vitreous loss. It is associated systemically with an increasing number of vascular disorders, hearing loss, and Alzheimer's disease. Exfoliation syndrome appears to be a disease of elastic tissue microfibrils. Directed therapy simply means devising specific treatments for specific diseases. There was little incentive to attempt to distinguish between various open-angle glaucomas if the treatments were essentially the same. However, this view also prevented the application of directed therapy in those instances in which such was available and applicable. Pilocarpine has multiple beneficial actions in eyes with XFS. Not only does it lower IOP, but by increasing aqueous outflow, it should enable the trabecular meshwork to clear more rapidly, and by limiting pupillary movement, should slow the progression of the disease. Theoretically, miotics should be the first line of treatment. Pilocarpine 2% q.h.s. can provide sufficient limitation of pupillary mobility without causing these side effects. In 2007, two common single nucleotide polymorphisms in the coding region of the lysyl oxidase-like 1 (LOXL1) gene located on chromosome 15 were specifically associated with XFS and XFG. LOXL1 is a member of the lysyl oxidase family of enzymes, which are essential for the formation, stabilization, maintenance, and remodelling of elastic fibers and prevent age-related loss of elasticity of tissues. LOXL1 protein is a major component of exfoliation deposits and appears to play a role in its accumulation and in concomitant elastotic processes in intra- and extraocular tissues of XFS patients. This discovery should open the way to new approaches and directions of therapy for this protean disorder.