Table of Contents  
Year : 2021  |  Volume : 29  |  Issue : 2  |  Page : 89-93

Pattern of Presentation of Pseudo Exfoliation Deposits on the Lens Capsule in a Tertiary Eye Hospital in Dhaka, Bangladesh

1 Department of Ophthalmology, Ebonyi State University Abakiliki/Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi State, Nigeria
2 Department of Community Medicine, Ebonyi State University Abakaliki/Alex Ekwueme University Teaching Hospital, Abakaliki, Ebonyi State, Nigeria
3 Department of Ophthalmology, National Eye Hospital, Kaduna, Nigeria
4 Department of Ophthalmology, Alex Ekwueme University Teaching Hospital, Abakiliki, Ebonyi State, Nigeria
5 Ispahani Islamia Eye Institute and Hospital, Dhaka, Bangladesh

Date of Submission08-Sep-2020
Date of Decision21-Mar-2021
Date of Acceptance04-May-2021
Date of Web Publication08-Nov-2021

Correspondence Address:
Helen A Ginger-Eke
Department of Ophthalmology, Ebonyi State University Abakiliki/Alex Ekwueme University Teaching Hospital, Abakiliki, Ebonyi State
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njo.njo_34_20

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Objective: To assess the pattern of ocular presentation in patients with pseudoexfoliation syndrome and pseudoexfoliation glaucoma in Ispahani Islamia Eye Institute and Hospital, Dhaka, Bangladesh. Methods: This prospective observational study was conducted over 6 months in a glaucoma department of a tertiary eye institute in Bangladesh. All patients diagnosed with pseudoexfoliation glaucoma and pseudoexfoliation syndrome were recruited for the study. Clinical and demographic variables, pattern of presentation of pseudoexfoliation glaucoma and pseudoexfoliation syndrome, location of pseudoexfoliation deposit on the lens surface, and pupillary abnormalities observed with slit lamp examination were analyzed. Results A total of 46 eyes of 27 patients with pseudoexfoliation deposit were studied. There were 24 (88.9%) males and the mean age of the patients was 67.0 (±10.8) years. There was peripheral ring of pseudoexfoliation deposit observed on the anterior lens capsule of 12 eyes (n = 12 eyes). However, pseudoexfoliation deposits on the pupillary ruff were the most common pattern of presentation (n = 42 eyes). Poor pupillary dilation was observed in only one eye (n = 1 eye). Open-angle glaucoma was the commonest glaucoma (96.3%) associated with pseudoexfoliation syndrome and the patients had baseline intraocular pressure on the right and left eyes of 22.7 (±12.7) mmHg and 17.5 (±8.0) mmHg, respectively. Bilateral pseudoexfoliation was the most common presentation among patients with pseudoexfoliation glaucoma (n = 20). Conclusion Peripheral ring of pseudoexfoliation deposit was the classical deposit on the anterior lens capsule, whereas the central disk was absent in most cases. Poor pupillary dilation was rare.

Keywords: Bangladesh, pattern of presentation, pseudoexfoliation deposit, pseudoexfoliation glaucoma, pseudoexfoliation syndrome

How to cite this article:
Ginger-Eke HA, Una AF, Sadiq A, Iganga ON, Hasan Z, Sarker BK, Kabir SJ, Ogbonnaya CE, Ezisi CN. Pattern of Presentation of Pseudo Exfoliation Deposits on the Lens Capsule in a Tertiary Eye Hospital in Dhaka, Bangladesh. Niger J Ophthalmol 2021;29:89-93

How to cite this URL:
Ginger-Eke HA, Una AF, Sadiq A, Iganga ON, Hasan Z, Sarker BK, Kabir SJ, Ogbonnaya CE, Ezisi CN. Pattern of Presentation of Pseudo Exfoliation Deposits on the Lens Capsule in a Tertiary Eye Hospital in Dhaka, Bangladesh. Niger J Ophthalmol [serial online] 2021 [cited 2022 May 22];29:89-93. Available from:

  Introduction Top

Pseudoexfoliation syndrome (PES) is an age-related systemic microfibrillopathy, caused by progressive accumulation and gradual deposition of extracellular gray and white material over ocular tissues[1] and other tissues in the body such as meninges and liver.[2],[3] This deposits are observed more commonly in the anterior segment of the eye, mainly the anterior lens capsule.[2],[3],[4],[5] Iris is another ocular structure commonly affected, involvement of which can be evidenced by poor dilatation, transillumination defects, and exfoliative deposits at the margin of iris vessels demonstrated on electron microscopy. The deposits on the lens capsule are classically observed as a peripheral ring of dandruff-like material, an intervening clear zone, and a central disk. The central disk is reported to be absent in 20% to 60% of cases.[2],[3]

Pseudoexfoliation glaucoma (PEG) is the presence of PES in association with elevated levels of intraocular pressure (IOP), related alterations on computerized perimetry examination, and/or changes in the anatomical aspects of the optic nerve.[6] PES is considered as one of the most common causes of glaucoma.

A lot of advances in understanding PES have been made since Lindberg’s original description of this condition in 1917.[7] The advances include Eagle disordered extracellular matrix metabolism hypothesis[8] and the discovery of an association with common variants in the LOXL1 gene[9] and CACNA1A.[10] However, the etiology of this disorder remains unknown.

There has been wide variation in the epidemiology of PES.[11] Data are inconsistent regarding its relation with gender, age, and ethnic origin. It seems that the prevalence of this syndrome increases progressively among people over 50 years of age, ocular hypertensive patients, and glaucoma patients.[12],[13],[14]

Not much is known on the laterality of involvement of this condition.[6] Reports of findings have shown that patients with bilateral PES tend to be older.[11],[15],[16] Bilateral involvement seems to have a higher incidence of glaucoma when compared with patients with unilateral involvement.[15],[16]

Reports have shown that PES can also cause angle-closure glaucoma, lens subluxation, and blood-aqueous barrier impairment.[2]

This study aimed to provide data on the pattern of presentation of pseudoexfoliation (PE) deposits of the lens capsule in patients with PES and PEG among the Bangladesh population.

  Methods Top

This prospective observational study included all patients with PES/PEG screened in the glaucoma department of Ispahani Islamia Eye Institute and Hospital, Dhaka, Bangladesh from January 2018 to June 2018. Ethical approval for the study was obtained from the institutional review board of the hospital and it adhered to the tenet of Helsinki Declaration. Being an observational study, patients did not provide informed consent. The patients had comprehensive ophthalmic evaluation including assessing presenting visual acuity with a Snellen chart and slit lamp biomicroscopic evaluation before and after pupillary dilation. The pupils were dilated with tropicamide 0.5% for assessment of location of PE deposits on the lens surface (central or peripheral), presence (or absence) of deposits over pupillary ruff, and pupillary abnormalities such as poor pupillary dilation. IOP measurement using both Goldmann Applanation Tonometry and gonioscopy with Zeiss 4 mirror gonio lens were performed before pupillary dilation. Stereoscopic fundal evaluation with +78D lens was performed after the pupillary dilation. Visual field assessment using 24-2 SITA standard program (Carl Zeiss Inc, Dublin, California, USA) was also performed. Diagnosis of PES was made based on classical dandruff or flaky exfoliation deposits on the pupil, lens, or other ocular structures, with or without raised IOP. PEG was defined as the presence of PES in association with elevated levels of IOP, changes in the anatomical aspects of the optic nerve such as cupping, rim thinning, notch, or retinal nerve fiber defects with corresponding visual field defect. Patients’ clinicodemographic variables were also recorded. Patients with PEG received antiglaucoma medication on presentation and later underwent trabeculectomy. Patients with PEG with associated cataract underwent combined trabeculectomy with small incision cataract surgery or phacoemulsification on individual patient basis, whereas those with cataract alone had small incision cataract surgery. First day postoperative visual acuity was noted, along with IOP measurement with Goldmann Applanation Tonometry in complete sterile condition. Patient was followed up for 1 month and IOP measurement was repeated on different follow-up visits. Microsoft excel 2013 was used for data collection. Statistical analysis was carried out using Statistical Package for Social Sciences (SPSS, IBM, Chicago, Illinois, USA), version 25. The categorical variables were summarized in percentage and ratio, whereas the quantitative variables were summarized using mean and standard deviations with a P-value of <0.05 defined as statistically significant.

  Results Top

A total of 46 eyes of 27 patients with pseudoexfoliation observed in the department of glaucoma during the study period were recruited. There were 24 males and the mean age at presentation was 67.0 (±10.8). [Table 1] outlines the socio-demographic characteristic of the study participants. Most of the patients had no associated comorbidity [Table 2].
Table 1 Sociodemographic characteristics

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Table 2 Comorbidity in the ocular patient

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Most of the eyes had open-angle glaucoma. Bilateral PE was the predominant presentation. A total of 39 eyes of 22 patients had PEG, whereas seven eyes of five patients had PES. A total of 46 eyes had PE deposits on the ocular structures. Forty-four eyes had PE deposits on the pupillary margin. [Table 3] summarizes the ocular profile of the study participants.
Table 3 Ocular profile of study participants

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Mean IOP profile at baseline and 1 month follow-up are summarized in [Table 4]. The table shows a statistically significant drop in the IOP of the RE with a P-value of <0.05. Although there was also pressure drop in the LE, it was not statistically significant (P = 0.12).
Table 4 Mean intraocular pressure at baseline and following treatment

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Cataract was observed in 36 eyes with pseudoexfoliation. There were also cases with subluxated lens (n = 2), pseudophakia (n = 4), aphakia (n = 1), and retinal disease (n = 5) [Table 5].

  Discussion Top

The male preponderance (88.9%) in this study may be due to sociocultural factors related to the lifestyle in the region. This finding is in keeping with the study by Rao et al.[17] in Pakistan but differs from findings from two studies in the United States that showed a female preponderance.[18],[19] However, some studies have reported no difference in gender distribution.[20],[21] It is believed that sociocultural factor is a serious barrier encountered by women in accessing eye-care services. Men’s health is often prioritized due to the social perception that the potential benefits to both the household and the community are higher for men than women. Women being the primary caretakers, often negotiates with their husbands and/or family to organize their childcare and household duties to access health care.[22]

Place of residence has been shown to be an important predisposing factor in this study as majority of the patients were residents in south-central region of Bangladesh (88.9%), pointing to the possibility that major environmental or climatic factors may be important in the etiology. This finding differs from results of Hang et al. who reported a 47% to 75% reduced risk among those consistently living in the middle and southern tiers.[19]

The reason for these differences between our study and Hang et al.’s finding may be attributed to ethnic differences in the predisposition. However, another study among non-Caucasians found results that were similar to those of Hang et al.[23]

We observed a positive family history of glaucoma in all the patients. Hang et al. reported that a positive family history was associated with a doubling in risk of PE.[19] The PE is associated with older age in all studies. [15, 16, 24, 26, –276] In this study, the mean age of patients with PE was 67.0 ± 10.8 years.

In this study, hypertension (3.7%) and diabetes (25.9%) were not significantly associated with PE risk. They were also no systemic comorbidity in most of the patients (63%) in this study. The relationship of PEG with cardiovascular disease was less demonstrable relative to primary open-angle glaucoma in the literature.[27],[28]

In our study, 19 (70.4%) of 27 patients diagnosed with PE had bilateral involvement and eight (29.6%) had a unilateral involvement. Higher percentage in the result in our study was similar to the findings of Madden and Crowley,[24] whereas lower percentages in results were found by Hirvela et al.[25] and Summanen and Tönjum.[26] Higher percentage in the result in our study may be explained by the possibility of our study being a hospital-based study. However, the mono or bilateral involvement of the condition is still unclear. Some authors describe a more frequent bilateral involvement of PES,[24],[25],[26] whereas others report a predominantly bilateral involvement.[13] However, other studies have reported that unilateral involvement is more common.[29],[30]

This study also found open-angle glaucoma to be the common presentation in eyes with PE associated with glaucoma. This finding is consistent with previous studies.[29],[31] Angle closure glaucoma (three eyes) in eyes with PE deposit was also found in this study. These is consistent with previous reports.[2],[14] It has been widely demonstrated that PES can cause chronic open-angle glaucoma, angle closure, and lens subluxation.[2]

This study found a low mean level of IOP at presentation in eyes with PE deposit that was associated with glaucoma. This was in keeping with Rao and Padhy’s finding of lower baseline IOP.[32]

This is contrary to other reports of higher IOP in bilateral PE when compared with unilateral case.[4],[33],[34],[35],[36],[37] This contrary finding could be attributed to the fact that our study lacked adequate power to compare IOP levels between the two groups.

In this study, peripheral ring of PE deposit was the common pattern classically observed on the anterior lens capsule (12 eyes), whereas the central disk of PE deposit was observed in only two eyes. Previous studies have reported similar findings.[12],[38] PE deposits on the pupillary margin were observed in almost all the eyes (44 eyes) in this study. This is in keeping with Naik and Gadewar’s finding.[39] This finding is contrary to the report by Rao and Padhy, where only 20 eyes out of 84 eyes studied had pupillary PE deposits.[32]

Our study and that of Naik and Gadewar are both prospective observational studies, whereas that of Rao and Padhy is a retrospective study. This could explain the disparity in our findings, as poor documentation of findings in the case notes may pose a challenge in retrieving of data in the retrospective study than the former.

Poor pupillary dilation was observed in only one eye in our study. Rao and Padhy[32] also found only 30 eyes with poor pupillary dilation. This disparity may be because of a small sample size used in our study. Poor pupillary dilation may not be a universal pattern of presentation in patients with this condition as previously believed.

We observed cases of PE deposit that occurred in pseudophakic (four eyes) and aphakic (one eye) eyes. This finding is in keeping with Krause’s findings.[40]

A high incidence of cataract (33 eyes) was found in this study. These have been widely reported.[41],[42],[43] Cataract development is believed to be age related; however, they have been reports of cataract being more advanced on the affected eyes than the unaffected eye.[41]

This study also found lens subluxation in two eyes which is consistent with previous report by Naumann et al.[2] In this study, five eyes had a retinal comorbidity. This is in keeping with Griffith’s finding.[44] Higher mean age is believed to be a risk factor for retinal disease.[44] These ocular comorbidities were observed more in patients with PEG. To the best of our knowledge, no study has compared the prevalence of comorbid ocular disease in patients with PEG and PES.

  Conclusion Top

Peripheral ring of pseudoexfoliation deposit was the classical deposit on the anterior lens capsule, whereas the central ring of deposit was absent in most cases. Poor pupillary dilation was rare. There was a higher incidence of ocular comorbidity in patients with PEG.

Limitation of the study

Limitation of this study is that sample size is too small to extrapolate findings to the general population. This study is a hospital-based prospective study and the findings may not reflect the true population-based study in this region to some extent. Large, prospective studies are required to confirm findings.

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Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4]


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