A case–cohort study of exfoliation risk factors and literature review

Abstract

The purpose of the study is to evaluate the risk factors associated with exfoliation in a case-cohort setting and literature review. This single-center, prospective, case-cohort study was carried out from January 2010 to April 2020 on patients operated for cataract surgery by a single surgeon in Lebanon. Forty-nine consecutive patients with exfoliation syndrome (XFS) and 62 consecutive control patients were identified and further investigated for selected systemic (diabetes mellitus, systemic hypertension, asthma, or atopy) and ocular variables (baseline vision, severity of nuclear sclerosis, glaucoma, eye rubbing, history of dry eye, or allergic eye disease). The mean baseline Snellen visual acuity was 20/283 in XFS versus 20/145 in control cases ( P = 0.012). XFS also demonstrated significantly denser nuclear sclerosis than controls ( P = 0.00958). By univariate analysis, allergic conjunctivitis (15 [30.6%] vs. 2 [3.2%]; P < 0.001), dry eye (20 [40.8%] vs. 13 [21.0%]; P = 0.0133), and habitual rubbing of the eyes (33 [67.3%] vs. 19 [30.6%]; P < 0.001) were associated with the presence of XFS. Habitual ocular rubbing was closely associated with allergic conjunctivitis (odds ratio [OR] = 13.0; 95% confidence interval [CI]: 2.8–58.8; P = 0.032). After multivariable analysis, the following variables showed significant results: glaucoma (OR = 34.5; 95% CI: 4.4–250; P = 0.010), duration of surgery (OR = 5.6; 95% CI 2.43–12.9; P < 0.001), and habitual ocular rubbing (OR = 4.42; 95% CI: 1.97–9.90; P = 0.029). This study shows a novel potential correlation between eye rubbing and XFS in a Lebanese cohort. Chronic eye rubbing induces or may exacerbate preexistent zonular damage in subjects with XFS, hence the need to better manage concurrent ocular surface disorder in these patients.

Risk factors for early-onset exfoliation syndrome

“…Although the mechanism is not clear, long axial length can be considered a predisposing factor for the development of early-onset XFS, while intraocular surgery serves as an environmental factor. Few case-control studies have reported the association between long axial length and XFS 9,11 , which makes it difficult to interpret our findings. This could be attributed to the fact that young patients with this condition have rarely been included in previous studies.…”

“…Furthermore, based on aqueous humour (AH) analysis from XFS eyes, transforming growth factor beta-1 (TGF-β1), pro-inflammatory cytokines, and oxidative stress have also been suggested to play an important role in the pathogenesis of XFS [6][7][8] .Considering that the prevalence of XFS increases with age and that most cases of XFS develop in individuals aged over 60 years [5][6][7][8][9] , increasing age is a definite risk factor for the development of XFS 5,9 . Interestingly, however, XFS may develop at a young age in some cases 10,11 . We believe that investigating the clinical features of patients with early-onset XFS and the associated risk factors can provide insights into the pathogenesis of XFS.…”

“…Considering that the prevalence of XFS increases with age and that most cases of XFS develop in individuals aged over 60 years [5][6][7][8][9] , increasing age is a definite risk factor for the development of XFS 5,9 . Interestingly, however, XFS may develop at a young age in some cases 10,11 . We believe that investigating the clinical features of patients with early-onset XFS and the associated risk factors can provide insights into the pathogenesis of XFS.…”

Emerging roles of oxidative stress in the pathogenesis of pseudoexfoliation syndrome (Review)

“…1 ). Several studies on the PEXS estimated a 5 to 20% prevalence in an aged population regardless of geographical features ( 26 ). Specifically, PEXS is common in individuals >50 years, with its incidence increasing with age.…”