ORIGINAL ARTICLE

PATTERN OF PSEUDOEXFOLIATION SYNDROME IN LOWER TO MID HIMALAYAN REGION OF SHIMLA HILLS IN INDIA P.D. Sharma1, Yogesh Kumar2, R.N. Shasni3

HOW TO CITE THIS ARTICLE: P.D. Sharma, Yogesh Kumar, R.N. Shasni. “Pattern of PseudoexfoliationSyndrome in lower to mid Himalayan region of Shimla Hills in India”.Journal of Evolution of Medical and Dental Sciences 2013; Vol. 2, Issue 52, December 30; Page: 10098-10106.

ABSTRACT: PURPOSE: To study the prevalence and pattern of pseudo-exfoliation syndrome and its complications in lower to mid Himalayan region of Shimla Hills in India. MATERIALS AND METHODS: Thousand consecutive individuals aged ≥40 years visiting outpatient department were subjected to detailed ocular examination for signs of pseudoexfoliation. Intraocular pressure was recorded and were dilated to examine retroiridial anterior capsule. Detailed glaucoma work-up was carried out if intraocular pressure was ≥22 mm Hg. RESULTS:Ninety-three out of 1000 individuals examined were diagnosed with pseudoexfoliation syndrome. The prevalence was highest in males, and ≥80 years group, and was increasing with age. The mean age for occurrence in males and females was 65.1±9.2 and 62.3±8.98 years, respectively. Bilateral involvement was more common than unilateral (4.8:1). Pseudo-exfoliation material on anterior lens capsule, seen after dilatation of , was noticed as the commonest sign (91.7% ) followed by material on pupillary border (84.7%). Glaucoma capsulare was observed as most common (18.8% eyes) complication followed by phacodonesis and rubeosisiridis. Incidence of unilateral glaucoma capsulare was more common than bilateral, and was statistically significant (X2=P, 0.05). A statistically significant relationship was established between the number of pseudo-exfoliation signs, reduction in angle width, and raised intra-ocular pressure (t=1.32, P<0.1). Incidence of cataract was more in patients with pseudo-exfoliation syndrome than without it. CONCLUSION: Pseudoexfoliation is more prevalent in Shimla hills than rest of India and some other parts of world, but lower than Scandinavian region. Prevalence of glaucoma and senile cataract is significantly higher in pseudoexfoliation. KEY WORDS: Flaky material, glaucoma capsulare, pseudoexfoliation, rubeosisiridis.

INTRODUCTION: Pseudo-exfoliation syndrome (PES) is a complex ocular degenerative disorder characterized by production and progressive accumulation of flaky dandruff like material all over the anterior segment of , which may also involve visceral organs.1 It is recognized as a disease of abnormal basement membrane of the eye.2, 3 Characteristic presentation includes deposition of amyloid-like material and pigment on anterior lens capsule, pupillary margin, , zonules, and .4, 5 Anterior to Schwalbe’s line, a characteristic pigment deposition called Sampaolesi’s line is generally seen.1 The pigment is released from possibly by rubbing against the flaky deposits on lens capsule.6 The material is produced by various intraocular tissues and may be an indicator of impaired cellular protection mechanisms.7 The disorderhasinsidious onset, prolonged course, and is the most identifiable cause of pseudoexfoliation glaucoma (PXG) which results due to clogging oftrabecular meshwork, juxtacanalicular spaces and Schlemm’s canal by pseudoexfoliation material (PXM) and pigment

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ORIGINAL ARTICLE granules.5, 6 Other complications include subluxation and dislocation of lens, andrubeosisiridis (iris neovascularisation).1 The distribution of pseudo-exfoliation syndrome is worldwide but prevalence varies depending upon a complex mix of geographical, racial, ethnical and occupational factors. High prevalence has been reported from some parts of the world.8-11 In India, prevalence of PES varies from 1.9 % to 7.4%.12, 13 Shimla Hills are situated in lower to mid Himalayan region of North India at an altitude of 1600 to 2500 metres approximately. This study was therefore aimed at epidemiology of PES in out-door patients visiting our institute.

MATERIALS AND METHODS: One-thousand consecutive patients, aged ≥ 40 years, visiting the ophthalmic department of Indira Gandhi Medical College Hospital, Shimla for sub-normal vision due to cataract or refractive errors were recruited for the study. Patients having traumatic, infective or inflammatory ocular conditions were excluded. Cases of PES with posterior synechiae, insufficiently dilating pupil, and pseudophakia or aphakia after extracapsular cataract extraction (ECCE) were also excluded. Visual acuity was recorded and signs of PES like greyish white flaky deposits on pupillary margin, anterior capsule of lens, zonules if visible and anterior hyaloid (in aphakes) were looked for. Pigment dispersion over posterior surface of , anterior capsule of lens and iris atrophic patches were noted. Intraocular pressure (IOP) of both eyes was recorded withapplanation tonometer after anaesthetizing cornea with 4% xylocaine drops. Gonioscopy was performed to look for PXM and pigment deposits over trabecular meshwork, for Sampaolesi’s line and anterior chamber angle width as per classification by Shaffer.14 Pupils were then dilated with phenylepherine (10%) and tropicamide (1%) drops. The eyes were re-examined for deposits of PXM and pigment over the retro-iridial portion of anterior lens capsule, zonules if visible, and anterior hyaloid in aphakes. Iridodonesis, phacodonesis, cataract or lens displacement were noted. and were evaluated and glaucoma suspects were subjected to complete glaucoma work-up. The guidelines of the Declaration of Helsinki were adhered to, and the study was conducted with informed consent of the participants after approval by the institutional ethics committee.

RESULTS: Out of 1000 individuals examined, 572 (57.2%) were males and 428 (42.8%) were females. Ninety three (9.3%) showed varying degree of PES in one or both eyes with a total of 170 eyes being affected. Prevalence was more in males (11.7%) than females (6.07%), with highest male (26.4%) and female (25 %) prevalence in 70-79 and ≥ 80 years age groups, respectively.[Table 1] Bilateral manifestation was seen in 77 (82.8%), and unilateral in 16 (17.2%) individuals. With advancing age, unilateral to bilateral manifestation was found to increase.[Table 2] Most common sign of PES was pseudoexfoliation material (PXM) on anterior capsule of lens (91.7% eyes) followed by PXM on pupillary margin (84.7% eyes). Phacodonesis, rubeosisiridis, PXM on zonules and subluxated lens were also observed in few patients.[Table 3] Thirty two (18.8%) eyes (24 patients) had pseudoexfoliation glaucoma (PXG) while 3 (1.76%) had ocular hypertension (OH).[Table 4] PXG was more common in females than males. Unilateral glaucoma (16 cases) was twice more common than bilateral (8 cases). Eleven (34.4%) eyes with PXG also had senile cataract. Visual acuity in PXG was generally poor; majority (65.6% of PXG eyes) had just perception of light to nil vision and only2 (6.3 %) eyes had 6/24 or better vision.[Figure 1]

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Prevalence of glaucoma was higher in patients with PES (93 patients) than without it (907 patients). Twenty four (25.8%) patients with PEX showed glaucoma in at least one eye compared to 34(3.7%) patients without PEX. Similarly, senile cataract changes were seen in 67(72.0%) patients with PEX in comparison to 370(40.8%) individuals without PES.[Figure.2]

DISCUSSION: Pseudoexfoliation syndrome is seen worldwide, although prevalence is found to vary.8-13, 15, 16 High prevalence has been reported from Scandinavia and Iceland(about 25%), and Finland (over 20%) in patients ≥ 60 years while prevalence in Norway and Sweden was about one- third of that.8, 9, 10In Saudi Arabia also, Summanen et al reported high prevalence (13%) of PES.16However, no case has been reported in Eskimos.17 Varying with age, Taylor et alfound prevalence of 1.3% to 16% in Australian aborigines.18Ritch attributed these wide variations to factors like race, ethnicity, age and sex of population group examined, clinical criteria of diagnosis of exfoliation syndrome, the ability of examiner to detect subtle manifestations of PES in early stages and thoroughness of examination. 5 Many cases go undetected because of failure to dilate the pupils or to examine on slit-lamp after dilation, and because of a low index of suspicion.5, 19 In this Himalayan region, cold climate with good sunshine prevails for better part of the year against longer hot periods in most regions of India. Therefore, variation in prevalence of PES was anticipated. We found 9.3% prevalence of PES in hospital visiting population aged ≥ 40.[Table 1] Comparable prevalence of 9% has been reported by Sood et al, while in other parts of India, reported range is 2 to 8 %.12, 13, 15, 20Since, most of the studies have been conducted in≥ 50 or≥ 60 years of age, the comparable prevalence in this study turned out to be 10.2% and 12.2%, respectively. The higher prevalence rate could be due to the factors like high-altitude, solar radiation and ethnic characteristics of population. Taylor has implicated solar radiation and occupation as etiological factors.18 Mohammed et al found greater prevalence of PES in tribals living in mountainous regions of Pakistan than those in lowland valleys.21Forsiusalso observed exfoliation syndrome to be more common in men in populations with high ultraviolet exposure including Yugoslavs, Australian aborigines, Peruvian and Asian Indians. 15, 17Vassilios et al noticed a correlation between increased prevalence of PES and high altitude.11 This Himalayan region perhaps receives more solar ultraviolet radiation to contribute to higher prevalence of pseudoexfoliation. The PES prevalence increases markedly with age.15The mean age of patients having PES in our study was 64.4±9.2 years [Table 1] which is in concurrence with the observation (64.7±9.63 years) made by Arvind et al. 22 Smith, shimizu and Klemetti have reported the higher mean ages (74.6±6.6, 70±8.38 and 70.13 years, respectively), while Summanen et al have reported the lower mean age (56.1±1.2). 23, 24, 25, 16 The reported prevalence in older individuals is as low as 0% in Eskimos to as high as 38% in Navajo Indians.26With advancing age, we found the prevalence increased markedly from 1.1% in age group 40–49 to 7.6% in 50–59, and 22.2% in ≥ 80 years. Many authorshave made nearly similar observations. 12, 13, 27In Finnish population, PES was reported 10%in aged 60–69 years, 21% in 70–79, and 33% in 80–89.9Arsaell A et el also found significantly greater prevalence with age, varying from 2.5% in 50–59 years age group to 40.6% in ≥ 80 years.28Forsius observed PES incidence to double every decade after 50 years.15 Authors are divided in opinion about predominance of PES in either sex. Male predominance was observed by Yalaz 29and many other authors.11, 12, 13 We also found higher prevalence in males (11.7%) than females (6.1%) in the ratio of 1.9:1[Table 1], with significant difference (χ2, p<0.05).

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However, some studies have shown higher prevalence in females, 22, 28, 30while few others had no sex variation. 16, 27 Pseudoexfoliation is essentially a bilateral disorder. Initially, one eye may be affected but over the time, it becomes bilateral. In the present study, bilateral predominance was seen in all age groups. Overall, bilateral presentation (82.8%) was nearly five times the unilateral (17.3%) involvement.[Table 2] As the age advanced, there was a shift towards bilaterality: 66.7% in age group 40-49 to 100% in ≥ 80 years. Most authors agree that unilateral cases of PES convert to bilateral over time.13, 16, 22, 31 It is the flaky dandruff like material on pupillary margin that alerts the examiner about PES on slit-lamp biomicroscopy. We detected this sign in 144(84.7%) eyes. However, on pupillary dilation, the PXM was seen more commonly on anterior lens capsule (91.7% eyes) than on pupillary margin. Many authorshave made similar observation.12, 16, 19, 22, 32Therefore, some cases of PES can be missed unless pupils are dilated to examine retroiridial anterior lens capsule. Other signs commonly observed were pupillary ruff degranulation, trabecular-meshwork pigmentation, Sampaolesi’s line and pigment over corneal endothelium.[Table 3] The pigment deposition was diffuse and wide spread. Sugar et aland Prince et al have described similar incidence and pattern of pigment dispersion.32, 33 Out of 10 eyes with congenital/surgical coloboma or lens subluxation, in which zonules could be visualised, eight (80%) eyes revealed PXM over zonules. Mizuno reported 100% incidence of pseudo-exfoliation material over zonules and ciliary body on cycloscopic examination. 34 Our observation was based on clinical examination only, yet showed higher incidence.[Table 3] Nearly same incidence (84.6% of aphakic eyes) of PXM on anterior hyaloid surface in aphakic (13) eyes (ICCE performed long ago) was observed. Phacodonesis was seen in 14(8.2%) eyes, probably occurring as a result of weaken and brittle zonules due to enzymatic degradation. Rubeosisiridis was also seen in 4(2.4%) eyes. PEX-glaucoma (PXG), the most important complication, was observed in 32(18.8%) eyes while ocular hypertension (OH) in 3(1.76%)of the eyes with PES.[Table 4] The reported figures are 9% and 1.7% by Lamba et al, and 7% and 15% by Kozart et al, respectively. 13, 35 However, Klemetti found PXG in only 4% and OH in 44% eyes. 25 Low figures of OH in comparison to PXG in the present study and that by Lamba et al13 could be due to the fact that in Indian milieu, patients report very late to an ophthalmic center, by which time considerable number of OH patients convert to manifest glaucoma. Moreover, the conversion of ocular hypertensives with PES to glaucoma was found to be more common than that of ocular hypertensives without PES.36 In present study, mean age of involvement by PXG was 63.04±7.4 years, which compares well with the findings of Shimizu et al.24 However, a higher mean age of 69 and 75.6 years has been reported by Smithand Pohjanpelto.23, 37The prevalence of PXG is reportedly higher in females than males.13, 23 Present study showed 34.6% (9/26) prevalence of PXG in females with PES, and 22.38% (15/67) in males with PES, having a ratio of 1.5:1. Two third (66.67%) of them had unilateral while rest had bilateral glaucoma. Hiller et al observed comparable figures of 69% and 31%, respectively.30Kozart et al also found unilateral glaucoma (76%) more commonly than bilateral glaucoma (24%).35 Higher IOP has been recorded in PXG patients as compared to primary open angle glaucoma (POAG).19, 37, 38Christopher et al stated that IOP tends to escalate faster in patients with

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ORIGINAL ARTICLE pseudoexfoliation glaucoma than primary open-angle glaucoma.39We also found higher mean IOP of 39.5±12.8 mm Hg in PXG eyes. Klemetti,and Kozart et al have concluded that minute pigment granules of PXM cause more severe blockade of aqueous draining channels in PES than POAG.25, 35 PXG has worse prognosis than POAG because of higher IOP and poor response to medication, resulting in more severe and faster damage to optic nerve and visual fields. These effects culminate into poor vision. Summanen et al have reported poor to worse vision in 35% eyes in PXG.16 In the present study, patients with PXG also had very poor vision ; only two(6.2%) eyes had 6/24 or better vision, 20(62.4%) were economically blind and 10(31.2%) eyes had no light perception. [Figure.1] Patients with PES are not only at increased risk of developing glaucoma but also senile cataract.39Topouzis et al found 15.2% prevalence of glaucoma in PES and 4.7% in those without PES.40 In comparison, in the present study, the prevalence of PXG was much higher, although that of POAG in non–PES patients was not much different. The prevalence of glaucoma in patients with PES was 25.8% compared to meagre 3.8% (POAG) in those without PES [Figure 2] which was highly significant (z score 8.412, p < 0.01). Similarly, senile cataract was found in 67(77.4%) of patients with PES in comparison to 370 (40.6%) patients having cataract without PES [Figure 2], and the difference was highly significant (z score 4.342, p < 0.01). Thus PES patients were nearly two times more prone to senile cataract than those without it, which indicates a probable etiological association of cataract and PES. Since both are essentially age related degenerative disorders, it is possible that co-existence of the latter leads to aggravation of the former. Association of senile cataract with PES has been observed by Layden et al and Mohammed et alas well.19, 21Such patients as this are more prone to various complications at the time of .39 It must be born in mind that in POAG, pseudoexfoliation may be a coincidental finding, not responsible for raised intraocular pressure per se. However delineation of such cases has not attempted routinely as it requires elaborate genetic profiling procedures not yet considered foolproof.

CONCLUSION: Prevalence of pseudoexfoliation syndrome in OPD-visitingnormal population is high in Shimla Hills perhaps due to more ultraviolet radiation and geo-climatic conditions. However clinical features are not very different than most of other studies. Prevalence of pseudoexfoliation glaucoma is considerably higher than generally mentioned. Heightened awareness of clinical signs of PES and PXG is therefore important for early detection and effective management of the disorder to prevent profound visual morbidity. Since incidence of senile cataract is nearly two folds in patients with PES than non–PES patients, it further aggravates visual disability in this disorder.Furthermore, the patients with pseudoexfoliation are at increased risk of cataract surgery related complications.

REFERENCES: 1. Lahners WJ, Samuelson TW. Pseudoexfoliative glaucoma. In: Yanoff M, Duker JS Eds. Ophthalmology, 2nd edition, Mosby; 2004:1499-503. 2. Eagle RC, Font RL, Fine BS. The basement membrane exfoliation syndrome. Arch ophthal 1979;97:510-5. 3. Ghosh M, Speakman JS. The origin of senile lens exfoliation. Can J Ophthal 1983;18:7-10. 4. Pons ME, Eliassi-Rad B, Shingleton B, et al. In http://emedicine.medscape.com/article/1206366-overview#a0104, Aug 2011.

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5. Ritch R. Exfoliation syndrome and occludable angles. Trans Am Ophthalmol Soc. 1994;92:845– 944. 6. Ahmed IK. The art of managing PXF glaucoma. In http://www.revophth.com/content/d/glaucoma_management/c/33327/. April 2012. 7. Schlötzer-Schrehardt U, Naumann GOH. Ocular and systemic pseudoexfoliation syndrome. Am J Ophthalmol2006; 141: 921–37. 8. Sveinsson D. The frequency of senile exfoliation in Iceland. ActaOphthalmol 1974;52:596-602. 9. Krause U, Alanko HI, Karma J. Prevalence of exfoliation syndrome in Finland. ActaOphthalmol 1988;66(184):120-2. 10. Ringvold A, Blika S, Elsas T. The middle-Norway eye screening study II. Prevalence of simple and capsular glaucoma. ActaOphthalmol 1991; 69: 273-80. 11. Vassilios P, Kozobolis, Maria P, et al. Epidemiology of pseudoexfoliation in the island of Crete (Greece). ActaOphthalmolScandinavica1997;77:726–9. 12. Sood NN, Ratnaraj A. Pseudo-exfoliation of the lens capsule. Orient Arch Ophthal 1968; 6:62-7. 13. Lamba PA, Giridhar A. Pseudo-exfoliation syndrome. Ind J Ophthal 1984; 32:169-73. 14. Shaffer RN. In Stereoscopic manual of gonioscopy. St Louis co. 1962. 15. Forsius H. Exfoliation syndrome in various ethenic populations. ActaOphtal 1988 (66);184:71- 85. 16. Summanen P, TonjumAM. Exfoliation syndrome among Saudi’s. ActaOphthal Supple 1988;184:107-11. 17. Forsius H. Prevalence of pseudoexfoliation of the lens in Finns, Lapps, Icelanders, Eskimos, and Russians. Trans OphthalmolSoc UK 1979;99:296-8. 18. Taylor HR, Hollows FC, Moran. Pseudoexfoliation of the lens in Australian aborigines. Br J Ophthalmlol 1977;61:473-5. 19. Layden WE, Shaffer RN: Exfoliation syndrome. Am J Ophlthalmlol 1974; 78:835- 41. 20. Sood G C, Sofat B K, Mehrotra S K. Capsular exfoliation syndrome. Br J Ophthalmol. 1973;57:120-24. 21. Mohammed S, Kazmi N.Subluxation of the lens and ocular hypertension in exfoliation syndrome. Pak J Ophthalmlol 1986;2:77-8. 22. Arvind H, Raju P, Paul PG, et al. Pseudoexfoliation in south India. Br J Ophthalmol 2003;87(11):1321-3. 23. Smith RJH. Nature of glaucoma in the pseudo-exfoliatiion syndrome. Trans Ophthal Soc. UK. 1979;99:308-12. 24. Shimizu K, Kimura Y, Aoki K. Prevalence of exfoliation syndrome in the Japanese. ActaOphthal 1988;66(184):112-5. 25. KlemettiA. Intraocular pressure in exfoliation syndrome.ActaOphthamol. 1988; 66(184):54-8. 26. Faulkner HW. Pseudo-exfoliation of the lens among the Navajo Indians. AmJ Oplhthalmol 1971;72:206-8. 27. Stefaniotou M, Petraoutsos G, Psilas K. The frequency of pseudoexfoliation in a region of Greece (Epirus). Actaophthal 1990;68:307-9. 28. Arsaell A, Karim F D, Thordur S, et al.Pseudoexfoliation in the Reykjavik Eye Study: prevalence and related ophthalmological variables. ActaOphthalmol. 2007, 85:822–7.

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29. Yalaz M, Othman I, Nas K, et al. The frequency of pseudoexfoliation syndrome in the Eastern Mediterranean area of Turkey. ActaOphlthalmnol 1992;70:209-13. 30. Hiller R, Sperduto RD, Krueger DE. Pseudo-exfoliation, intraocular pressure and senile lens changes in a population–based survey. Arch Ophthal 1982; 100:1080-2. 31. Tarkkanen A, Kivelä T. Cumulative incidence of converting from clinically unilateral to bilateral exfoliation syndrome. J Glaucoma2004, 13: 181–4. 32. Sugar S. Pigmentary glaucoma and the glaucoma associated with the exfoliation–pseudo- exfoliation syndrome update. Ophthalmology 1984; 91: 307-10. 33. Prince AM, Ritch R. Clinical signs of the pseudo-exfoliation syndrome. Ophthalmology 1986; 93: 803-7. 34. Mizuno K, Muroi S. Cycloscopy of pseudo-exfoliation. Am J Ophthal 1979; 87: 513-8. 35. Kozart DM, Yanoff M. Intra-ocular pressure status in consecutive patients with exfoliation syndrome. Ophthalmology. 1982; 89(3) : 214-8. 36. Grödum K, Heijl A, Bengtson.Risk of glaucoma in ocular hypertension with and without PEX. Ophthalmology2005; 112: 386 - 90. 37. Pohjanpelto PEJ. The fellow eye in unilateral hypertensive pseudo-exfoliation.Am J Ophthalmol. 1973; 75 : 216- 20. 38. Aasved H. The geographical distribution of fibrillopathiaepitheliocapsularis, so called senile exfoliation or pseudo-exfoliation of the anterior lens capsule. ActaOphthal 1969; 47:729-809. 39. Christopher P M, Pratap C. Diagnosis and Management of pseudoexfoliation glaucoma. In http://www.aao.org/publications/eyenet/200606/pearls.cfm. June 2006. 40. Topouzis F, Harris A, Wilson MR, et al. Increased likelihood of glaucoma at the same screening intraocular pressure in subjects with pseudoexfoliation: the Thessaloniki Eye Study Am J Ophthalmol 2009;148(4):606-13.

Age Group Males Females Total (Years) N n (%) N n (%) N n (%) 40-49 156 2 (1.3) 117 1 (0.8) 273 3 (1.1) 50-59 155 14 (9) 120 6 (5.8) 275 20 (7.6) 60-69 155 24 (15.5) 126 14 (11.1) 281 38 (13.5) 70-79 87 23 (26.4) 57 3 (5.1) 144 26 (18.1) ≥80 19 4 (21.1) 8 2 (25) 27 8 (22.2) Total 572(57.2) 67 (11.7) 428(42.8) 26 (6.1) 1000 93(9.3) Mean age 65.1+ 9.2 ------62.3+8.9 ------64.4+ 9.2 ------Table 1: Age and sex-wise prevalence of pseudo-exfoliation syndrome (PES)

Prevalence in Males : Females= 67/572: 26/428 = 1.9 : 1 N= total number of individuals examined in particular age group. n = number of patients having PES. %= percentage of patients having PES out of total individuals of the particular group (age and sex-wise) examined.

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Age group Unilateral Bilateral Ratio No. of PES cases (years) n (%) n (%) B/L:U/L 40-49 3 1 (33.4) 2 (66.6) 2:1 50-59 20 5 (25.0) 15(75.0) 3:1 60-69 38 7 (18.4) 31 (81.6) 4.4:1 70-79 26 3 (11.5) 23 (88.5) 7.7:1 ≥80 6 0(0) 6 (100) 0 Total 93 16 (17.2) 77 (82.8) 4.8:1 Mean age 60.28+ 8.2 65.03 +9.2 Table 2: Relationship of age to laterality in pseudo-exfoliation syndrome %=percentage of individuals with unilateral/bilateral involvement among total cases of PES in respective groups. B/L:U/L= blilateral: unilateral cases.

S.No Signs No. of Eyes % 1. PEX on anterior capsule of lens (pupil dilated) 156 91.7 2. PEX on pupillary margin (undilated pupil) 144 84.7 3. Degranulation of pupillary ruff 127 74.7 4. Pigment deposition on Trabeculum 105 61.7 5. Pseudo-exfoliation at angle 82 48.2 6. Pigment on corneal Endothelium 84 49.4 7. Sampaolesi’s line 80 47.5 8. Pigment on anterior surface of lens 56 32.9 9. Phacodonesis 14 8.23 10. RubeosisIrides 4 2.35 11. PEX on anterior hyaloid (ICCE) 11/13 eyes 84.6** 12. PEX on Zonule* 8/10 eyes 80.0** Table 3: Signs of pseudo-exfoliation syndrome in 170 Eyes. %=percentage of eyes with particular sign out of total 170 eyes having PES except ** *Subluxated lens – 2, Congenital iris coloboma - 1, surgical iris coloboma – 5 **percent of 13 and 10 eyes, not 170 eyes

IOP No. of eyes % Normal (≤ 22 mm Hg with normal optic cupand visual fields) 135 79.4 Ocular Hypertension (> 22 mm Hg with normal and visual fields) 3 1.8 Glaucoma (> 22 mm Hg with enlarged optic cup and visual field defects) 32 18.8 Total eyes of 93 individuals with PES 170 100 Table 4: IOP Status in 170 eyes (93 individuals) with PES

Mean Age - 63.04 +7.4 years, mean IOP- 39.5 +12.8 mm of Hg, Prevalence of PXG in Females with PES: Males with PES = 9/26: 15/67 = 1.5:1

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Fig. 1: Best visual status in 32 eyes Fig. 2: Percentage of glaucoma and senile cataract withpseudoexfoliation glaucoma. in individuals with PEX versus non-PEX

3. Senior Ophthalmologist, Department of AUTHORS: Ophthalmology, DDU Hospital, Shimla, 1. P. D. Sharma Himachal Pradesh. 2. Yogesh Kumar 3. R.N. Shasni NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR: Dr.Yogesh Kumar, PARTICULARS OF CONTRIBUTORS: Assistant Professor, 1. Professor and Head, Department of Department of Ophthalmology, Ophthalmology, VCSG Government Medical SGRRIH & MS, Dehradun, Sciences Research Institute, Srinagar, Uttarakhand, India. Uttarakhand, India. [email protected] 2. Assistant Professor, Department Of Ophthalmology, Shri Guru Ram Rai Institute of Date of Submission: 27/11/2013. Health & Medical Sciences Dehradun, Date of Peer Review: 29/11/2013. Uttarakhand, India. Date of Acceptance: 10/12/2013. Date of Publishing: 24/12/2013

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