Cardiovascular and cerebrovascular mortality associated with ocular pseudoexfoliation

doi:10.1016/S0002-9394(99)00255-X

American Journal of Ophthalmology

Volume 129, Issue 1, January 2000, Pages 83-86

https://doi.org/10.1016/S0002-9394(99)00255-X Get rights and content

Abstract

PURPOSE:

In recent years, several studies have shown the presence of vascular, cardiac, and other organ pseudoexfoliative material in patients with ocular pseudoexfoliation. The purpose of this study was to determine whether an association exists between ocular pseudoexfoliation and cardiovascular, cerebrovascular, or all-cause mortality.

METHODS:

This retrospective study included 472 residents of Olmsted County, Minnesota, who were diagnosed with pseudoexfoliation syndrome or pseudoexfoliative glaucoma at Mayo Clinic from 1976 through 1995. Of these 472 cases, 151 subsequently died from 1976 through 1997. Cause of death for these patients, as determined by the National Center for Health Statistics was compared with the entire Rochester, Minnesota, population using Kaplan-Meier analysis.

RESULTS:

Of the 472 patients with ocular pseudoexfoliation, 358 (76%) were female and 114 (24%) were male. The mean age at diagnosis was 74 years, with a SD of 10 years and a range from 39 to 106 years. Cardiovascular disease resulted in 40 deaths, with a 15-year cumulative probability of cardiovascular mortality of 22%, compared with an expected 20% (no significant difference with P = .19). Cerebrovascular disease resulted in 26 deaths with a 15-year cumulative probability of cerebrovascular mortality of 12%, compared with an expected 10% (no significant difference with P = .38). Finally, the 15-year observed all-cause cumulative mortality was 53% versus an expected rate of 59% (significant difference with P= .0002).

CONCLUSIONS:

No association was found between ocular pseudoexfoliation and cardiovascular or cerebrovascular mortality. All-cause mortality was significantly less in patients with ocular pseudoexfoliation.

Section snippets

Methods

This retrospective study identified all patients diagnosed by ophthalmologists at Mayo Clinic with pseudoexfoliative glaucoma or pseudoexfoliation syndrome from 1976 through 1995. After dilation of the pupil, the diagnosis of pseudoexfoliation was made by an ophthalmologist performing conventional biomicroscopy of the anterior lens capsule looking for the typical layer of grayish pseudoexfoliative material. An additional selection requirement for this population was that they be residents of

Results

Of the 472 patients with ocular pseudoexfoliation, 358 (76%) were women and 114 (24%) were men. The mean age at diagnosis was 74 years, with a SD of 10 and a range of 39 to 106 years. The total mean follow-up time was 7.4 years, with a SD of 4.7 and a range of 0 to 24.2 years. We were unable to determine cause of death for only 2 (1%) of the 151 patients with ocular pseudoexfoliation who died from 1976 through 1997. With these patients, mortality cause was assumed to be nonvascular in origin.

Discussion

Elastin is a major part of the extracellular matrix of arterioles, and studies have shown an association of vascular walls and elastosis with pseudoexfoliative material.18, 22, 29 Therefore, a possible link has been hypothesized between the presence of ocular pseudoexfoliation and vascular disease. Previous studies have revealed a moderate association between pseudoexfoliation and vascular events and an increased rate of ocular pseudoexfoliation in patients with transient ischemic attacks.24, 25

References (29)

H.W. Faulkner
Pseudo-exfoliation of the lens among the Navajo Indians
Am J Ophthalmol
(1971)
F. Amari et al.
Electron microscopic immunohistochemistry of ocular and extraocular pseudoexfoliative material
Exp Eye Res
(1997)
W.E. Layden et al.
Exfoliation syndrome
Am J Ophthalmol
(1974)
B.W. Streeten et al.
Pseudoexfoliative fibrillopathy in the conjunctivaa relation to elastic fibers and elastosis
Ophthalmology
(1987)
B.W. Streeten et al.
Pseudoexfoliative fibrillopathy in the skin of patients with ocular pseudoexfoliation
Am J Ophthalmol
(1990)
L.P. Repo et al.
Color Doppler imaging of the ophthalmic artery blood flow spectra of patients who have had a transient ischemic attack
Ophthalmology
(1995)
P. Mitchell et al.
Association of pseudoexfoliation syndrome with increased vascular risk
Am J Ophthalmol
(1997)
Lindberg JG. Clinical studies of depigmentation of the pupillary margin and transillumination of the iris in cases of...
H. Aasved
Mass screening for fibrillopathia epitheliocapsularis, so-called senile exfoliation or pseudoexfoliation of the anterior lens capsule
Acta Ophthalmologica
(1971)
H. Aasved
The geographical distribution of fibrillopathia epitheliocapsularis
Acta Ophthalmologica
(1969)

H. Forsius

Prevalence of pseudoexfoliation of the lens in Finns, Lapps, Icelanders, Eskimos, and Russians

Trans Ophthalmol Soc U K

(1979)

R. Ritch

Exfoliation syndromethe most common identifiable cause of open-angle glaucoma

J Glaucoma

(1994)

Z.Y. Li et al.

Association of elastin with pseudoexfoliative materialan immunoelectron microscopic study

Curr Eye Res

(1988)

J.C. Morrison et al.

Light microscopy of the exfoliation syndrome

Acta Ophthalmologica

(1988)

Cited by (109)

Significant lifespan difference between primary open-angle glaucoma and pseudoexfoliation glaucoma
2021, Heliyon
Citation Excerpt :
One recent study found increased cardiovascular disease, as well as increased risk of pulmonary and urogenital disorders among PES-positive persons [30]. This is contradicted by other papers that failed to show any link between cardiovascular disease related mortality with PES [24, 26]. Indeed, the present study did not indicate any difference in lifespan or cause of death diagnoses in the PESTotal group versus the control in cardiovascular disease (Table 2, p = 0.592; Table 3, p = 0.482, respectively).
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.
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.
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.
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.
Twelve-Year Incidence and Baseline Risk Factors for Pseudoexfoliation: The Thessaloniki Eye Study (An American Ophthalmological Society Thesis)
2019, American Journal of Ophthalmology
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.
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).
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.
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.
Lifespan reduction due to neoplasia is nullified by pseudoexfoliation syndrome
2018, Heliyon
Citation Excerpt :
Still, impact of PES on survival in certain subgroups could not be excluded. Increased risk of vascular disease has been associated with PES in some studies [15], whereas others found no association between ocular PES and cardiovascular or cerebrovascular mortality [16]. The latter authors added that all-cause mortality was significantly less in patients with ocular PES.
Pseudoexfoliation syndrome (PES) is a common eye condition, indicating a risk of various eye diseases. Whether or not PES has extra-ocular physiological or even pathophysiological implications has been a matter of controversy for years.
In total 1888 persons were examined for PES in 1985–86. Of these, 1864 (98·7%) had died and were therefore available for analysis by 01.01.2016. Age and cause(s) of death were recorded. 9 diagnostic groups (cardiovascular disease, cerebrovascular disease, neoplasms, systemic hypertension, diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD), Parkinson's disease, aortic aneurysm (AA), and amyloidosis) based on ICD-coding were analyzed for both a possible association between PES and lifespan, as well as PES and specific systemic diseases.
In the cardiovascular group, PES was not associated with an alteration in longevity. The subgroups acute myocardial infarction and other cardiovascular diseases revealed significantly reduced and increased lifespan, respectively, compared to the rest of the population. These deviations were independent of PES. The impact of PES on the neoplasm group showed that PES-positive persons lived 1·81 years (p < 0·001) longer than PES-negative persons. No significant differences in the PES prevalence were found in any of the cause of death diagnostic groups.
The present study suggests that lifespan reduction due to neoplasia is nullified by PES, and that this phenomenon is not restricted to one specific neoplasm type. Thus, the paradoxical conclusion emerges that PES provides a lifespan benefit to the patient with a neoplasm. For the remaining diagnostic groups, PES was neither associated with an altered lifespan, nor with any cause of death diagnoses.
Prevalence of exfoliation syndrome and cardiovascular diseases in patients scheduled for cataract surgery
2017, Journal Francais d'Ophtalmologie
Évaluer la prévalence du syndrome exfoliatif (PEC) et son association aux pathologies cardiovasculaires chez des patients programmés pour une chirurgie de cataracte.
Il s’agit d’une étude rétrospective, monocentrique, descriptive qui concernait 260 patients admis pour une chirurgie de cataracte, au sein du centre hospitalier tertiaire universitaire de Rabat (Maroc), de janvier 2015 à mars 2016. Tous les patients ont bénéficié en préopératoire d’un examen cardiovasculaire, d’un électrocardiogramme et selon l’indication, d’une échocardiographie. L’analyse statistique était réalisée à l’aide du logiciel SPSS. Un p < 0,05 était considéré comme statistiquement significatif.
Cette étude incluait 246 patients : 146 femmes (59,3 %) et 100 hommes (40,7 %). La moyenne d’âge (en années) était de 67,6 ± 10,1. Le pourcentage de la PEC augmente avec l’âge (p = 0,02). Soixante-deux pour cent des patients présentant des pathologies cardiovasculaires avaient aussi un syndrome pseudoexfoliatif (p < 0,001). Chez les patients ayant une PEC, 46,5 % étaient également hypertendus. La cardiopathie ischémique était retrouvée chez 14 patients ayant un syndrome exfoliatif (19,7 %). En analyse multivariée, et en ajustant sur l’âge, le diabète, l’HTA, la cardiopathie ischémique et les troubles du rythme, seul le tabagisme était associé au syndrome pseudoexfoliatif (p = 0,01, odds ratio = 5,2, intervalle de confiance 95 % = 1,35–20,15).
le syndrome exfoliatif reste une pathologie fréquente des sujets âgés ayant des cataractes. La cardiopathie ischémique et l’hypertension artérielle sont plus fréquentes en cas de PEC. Le tabagisme serait un facteur associé à ce syndrome.
To study the prevalence of exfoliation syndrome (XFS) and its association with cardiovascular disease in patients scheduled for cataract surgery.
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.
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).
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.
Major review: Exfoliation syndrome; advances in disease genetics, molecular biology, and epidemiology
2017, Experimental Eye Research
Exfoliation syndrome (XFS) is a common age-related disorder that leads to deposition of extracellular fibrillar material throughout the body. The most recognized disease manifestation is exfoliation glaucoma (XFG), which is a common cause of blindness worldwide. Recent developments in XFS genetics, cell biology and epidemiology have greatly improved our understanding of the etiology of this complex inherited disease. This review summarizes current knowledge of XFS pathogenesis, identifies gaps in knowledge, and discusses areas for future research.
Pseudoexfoliation Glaucoma: Clinical Presentation and Therapeutic Options
2023, Turkish Journal of Ophthalmology

View all citing articles on Scopus

View full text

Cardiovascular and cerebrovascular mortality associated with ocular pseudoexfoliation

Abstract

Section snippets

Methods

Results

Discussion

Am J Ophthalmol

Exp Eye Res

Am J Ophthalmol

Ophthalmology

Am J Ophthalmol

Ophthalmology

Am J Ophthalmol

Mass screening for fibrillopathia epitheliocapsularis, so-called senile exfoliation or pseudoexfoliation of the anterior lens capsule

Acta Ophthalmologica

The geographical distribution of fibrillopathia epitheliocapsularis

Acta Ophthalmologica

Prevalence of pseudoexfoliation of the lens in Finns, Lapps, Icelanders, Eskimos, and Russians

Trans Ophthalmol Soc U K

Exfoliation syndromethe most common identifiable cause of open-angle glaucoma

J Glaucoma

Association of elastin with pseudoexfoliative materialan immunoelectron microscopic study

Curr Eye Res

Light microscopy of the exfoliation syndrome

Acta Ophthalmologica