Abstract
To analyse the disease burden of pseudoexfoliation (PXF) disease stages from East and South India. Prospective hospital based study of patients seen at 4 tertiary centres. Consecutive old and new patients of pseudoexfoliation with normal intraocular pressure (IOP), raised IOP (PXF with Ocular hypertension, OHT) and irreversible disc/field changes (pseudoexfoliation glaucoma, PXG) seen from April 2016-March 2017 at a tertiary centre in Odisha, East India and 3 centres in Andhra Pradesh and Telangana, South India, recruited into the prospective study were screened for baseline characteristics. The clinical and demographic details including visual acuity, laterality, intraocular pressure (IOP) with details of medical/surgical therapy at presentation were collected from the hospital database at all 4 centres. The World Health Organization WHO visual criteria were used for defining visual impairment/absolute blindness in different disease stages. The visual impairment/blindness rates with comorbidities in the anterior/posterior segment in PXF, OHT and PXG at baseline were compared and the influence of age, IOP fluctuations and laterality was analysed using multivariate logistic regression. Of 6284 PXF eyes (of 3142 patients) included from all centres, OHT and PXG was seen in 2.1% and 29% respectively which included 3676 (>50%) bilateral PXF eyes. Reversible visual impairment rates caused by PXF associated co-morbidities in PXF and OHT were 33% and 26% respectively with cataract being the major cause (67% in PXF and 74% in OHT). Irreversible blindness rate was higher in bilateral PXG eyes (30.5%) compared to bilateral PXF (23.2%) or bilateral OHT (21.6%) with overall absolute blindness rates of 28.2% at presentation. Older age (p<0.001), bilaterality and higher baseline IOP were significantly associated with higher rates of blindness in PXF eyes. Pseudoexfoliation is associated with ≥30% visual impairment across all stages and 28% absolute blindness rate which is a huge hidden burden of glaucoma. Adequate disease staging and assessment of comorbidities is required for accurate prognostication at baseline and reducing avoidable pseudoexfoliation blindness.
Highlights
Of 6284 PXF eyes included from all centres, ocular hypertension (OHT) and pseudoexfoliation glaucoma (PXG) was seen in 2.1% and 29% respectively which included 3676 (>50%) bilateral PXF eyes
Reversible visual impairment rates caused by PXF associated co-morbidities in PXF and OHT were 33% and 26% respectively with cataract being the major cause (67% in PXF and 74% in OHT)
The worldwide prevalence of pseudoexfoliation (PXF) and pseudoexfoliation glaucoma (PXG) varies widely ranging from 0–80% with maximal prevalence in Scandinavian countries. [1,2,3,4] Its unique clinical feature of flaky white pseudoexfoliative material (XFM) on different ocular structures combined with progressive neurodegeneration and systemic associations mandates its recognition as a unique identity among all forms of glaucoma
Summary
The worldwide prevalence of pseudoexfoliation (PXF) and pseudoexfoliation glaucoma (PXG) varies widely ranging from 0–80% with maximal prevalence in Scandinavian countries. [1,2,3,4] Its unique clinical feature of flaky white pseudoexfoliative material (XFM) on different ocular structures combined with progressive neurodegeneration and systemic associations mandates its recognition as a unique identity among all forms of glaucoma. [5] Recognition of this entity is important to identify possible surgery related devastating complications in routine cataract surgery and aids in identifying eyes at risk for developing long term irreversible ocular hypertension or glaucoma related blindness. [3,5,6,7] Early recognition and prognostication of this entity remains the only means for preventing onset of glaucoma since the pathogenesis of the irreversible glaucoma still remains a mystery. [1] Details on the vast clinical spectrum of the disease and the frequency of blindness due to PXF at presentation are scarce in literature with most studies focussing on genetic aetiology, pathogenesis or prevalence of the disease in a particular geographical location or country. [5,8,9,10]The long term progression from glaucoma suspect to ocular hypertension or established glaucoma is well characterised in randomised controlled trials for primary open angle glaucoma (POAG) and primary angle closure glaucoma (PACG). [11,12] Yet parallel epidemiological studies on pseudoexfoliation focus mostly on prevalence rates in specific geographical locations with minimal or no reference to its different stages or blindness rates in different disease stages like PXF only, ocular hypertension (OHT) and pseudoexfoliation glaucoma (PXG). [8,9,10] This disease is very well characterised clinically with detailed description of the complications associated with cataract surgery performed in eyes with PXF. [1,5,6] known is the faster rate of visual field progression in eyes with PXF which is partly explained by refractoriness to conventional therapy in these eyes. [6] This information is crucial to prognosticate an eye with PXF to prevent disease progression and irreversible damage over long term This risk needs to be compared across geographical locations to compare the effect of Blindness in pseudoexfoliation stages environment on baseline risks since PXF is known to be highly influenced by climatic and environmental conditions. [5,6] In brief, the institutional electronic medical record (EMR) captures all data including demographic, clinical details including Goldmann applanation intraocular pressure (IOP), slit lamp findings, gonioscopy, fundus biomicroscopy findings, medications, surgeries and visual fields data.
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