Epidemiology of pseudoexfoliation syndrome: a hospital based comparative study

Hina Kounsar, Nusrat Shaheen, Suhail R. Rather


Background: Pseudoexfoliation syndrome (PEX), is an age-related condition with generalized disorder of the extracellular matrix (ECM) characterized by a pathological accumulation of polymorphic fibrillar extracellular material in ocular tissue and various visceral organs. The search for the etiology of pseudoexfoliation syndrome has been directed towards both genetic and environmental factors. It is associated with many ocular and systemic complications.

Methods: The study was a hospital based comparative clinical study with 100 consecutive patients with pseudoexfoliation and age and sex matched 100 patients as control without pseudoexfoliation. The patients were registered on a Pre-structured Proforma which included patients’ demographic detail, history and examination. Examination protocol including visual acuity with snellen’s chart for literate patients and E-Chart for illiterate patients, intraocular pressure (by Goldmann applanation tonometry), slit lamp examination and fundus examination.

Results: The mean age of cases was 65.93± 7.82 years ranging from 49 to 85 years. The mean age of controls was 63.98± 7.06 years ranging from 50 to 80 years (p=0.139). 72% of cases were more than 60 years old. Male female ratio was 1.63:1. Most of the cases were from Budgam, Bandipora and Ganderbal areas. Spring water was proportionately more frequently used as water source in cases (χ2 =18.5, p=0.000), and tube well water in controls. The mean duration of smoking was 26.63±24.74 pack years for cases and 14.88±17.10 pack years for controls (p=0.000). Average duration of daytime exposure for cases was 6.68±2.13 hours and for controls it was 4.52±2.53 hours. Among cases 12 patients (12%) were on treatment for glaucoma whereas among controls, 1 patient (1%) was on treatment for glaucoma. With respect to dietary habits, there was no difference between cases and controls. Farmers comprised of 49% of cases, followed by House wives and government employees.

Conclusions: The study concludes that PEX is very common in our region, increasing with age and more in men. Smoking, occupations involved with sunlight exposure, spring water as water source are possible risk factors for PEX. Glaucoma and cataract are common ocular complications of the syndrome.


Age, Glaucoma, Pseudoexfoliation, Sunlight exposure

Full Text:



Lindberg JG. Kliniska Undersökningar över Depigmentering av Pupillarranden och Genomlysbarheten av Iris vid Fall av Åldersstarr samt i Normala Ögon hos Gamla Personer. Helsinki, Finland: Helsinki University, 1917.

You QS, Xu L, Wang YX, Yang H, Ma K, et al. Pseudoexfoliation: normative data and associations: the beijing eye study 2011. Ophthalmol. 2013;120:1551-8.

Miyazaki M, Kubota T, Kubo M, Kiyohara Y, Iida M, Nose Y, et al. The prevalence of pseudoexfoliation syndrome in a Japanese population The Hisayama Study. J Glaucoma. 2005;14:482-4.

Krishnadas R, Nirmalan PK, Ramakrishnan R, Thulasiraj RD, Katz J, Tielsch JM, et al. Pseudoexfoliation in a rural population of southern India: the Aravind Comprehensive Eye Survey. Ame J Ophthalmol. 2003;135(6):830-7.

Arvind H, Raju P, Paul PG, Baskaran M, Ramesh SV, George RJ, et al. Pseudoexfoliation in south India. Br J Ophthalmol. 2003;87:1321-3.

Aasved H. Mass screening for fibrillopathiaepitheliocapsu-laris, so-called senile exfoliation or pseudoexfoliation of the anterior lens capsule. Acta Ophthalmol (Copenh). 1971;49(2):334-43.

Prince AM, Ritch R. Clinical signs of the pseudoexfoliation syndrome. Ophthalmol. 1986;93:803-7.

Sollosy M. Incidence of the uvealpseudoexfoliation syndrome in patients with diabetes mellitus. Oftalmologia. 2004;48(Suppl 1):76-80.

Altintas O, Maral H, Yuksel N, Karabas VL, Dillioglugil MO, Caglar Y. Homocysteine and nitric oxide levels in plasma of patients with Pseudoexfoliation syndrome, pseudoexfoliation glaucoma, and primary open-angle glaucoma. Graefe’s Arch Clin Exp Ophthalmol. 2005;243:677-83.

Thorleifsson G, Magnusson KP, Sulem P, Walters GB, Gudbjartsson DF, Stefansson H, et al. Common sequence variant in the LOXL gene confer susceptibility to exfoliation glaucoma. Science. 2007;317(5843):1397-400.

Jonasson F. Solving the enigma of exfoliation glaucoma: a breakthrough in glaucoma research. Acta Ophthalmol. 2007;85:808-9.

Koliakos GG, Konstas AG, Schlotzer-Schrehardt U, Hollo G, Mitova D, et al. Endothelin-1 concentration is increased in the aqueous humour of patients with exfoliation syndrome. Br J Ophthalmol. 2004;88:523-7.

Lemmelä S, Forsman E, Sistonen P, Eriksson A, Forsius H, Järvelä I. Genome-wide scan of exfoliation syndrome. Investigative ophthalmology & visual science. 2007;48(9):4136-42.

Hiller R, Sperduto RD, Krueger DE. Pseudo-exfoliation, intraocularpressure,and senile lens changes in a population-based survey. Arch Ophthalmol. 1982;100:1080-2.

Astrom S, Stenlund H, Linden C. Incidence and prevalence of pseudoexfoliation syndrome and open-angle glaucoma in northern Sweden. Part I and II. Acta Ophthalmol Scand. 2007;85:828-37.

McCarty CA, Taylor HR. Pseudoexfoliation syndrome in Australian adults. Am J Ophthalmol. 2000;129:629-33.

Taylor HR. The environment and the lens. Brit J Ophthalmol. 1980;64:303-10.

Nouri-Mahdavi K, Nosrat N, Sahebghalam R, Jahanmard M. Pseudoexfoliation syndrome in central Iran: a population-based survey. Acta Ophthalmol. 1999;77:581-4.

Colin J, Le Gall G, Le Jeune B, Cambrai MD. The prevalence of exfoliation syndrome in different areas in France. Acta Ophthalmol. 1988;66(Suppl 184):86-9.

Thomas R, Nirmalan PK, Krishnaiah S. Pseudoexfoliation in Southern India: The Andhra Pradesh Eye Disease Study. Invest Ophthalmol Vis Sci. 2005;46:1170-76.

Stein JD, Pasquale LR, Talwar N, Kim DS, Reed DM, Nan B, et al. Geographic and climatic factors associated with exfoliation syndrome. Archives of ophthalmology. 2011;129(8):1053-60.

Koliakos GG, Befani CD, Mikropoulos D, Ziakas NG, Konstas AGP. Prooxidant-antioxidant balance, peroxide and catalase activity in the aqueous humour and serum of patients with exfoliation syndrome or exfoliativeglaucoma. Graefes Arch Clin Exp Ophthalmol. 2008;246:1477-83.

Arnarsson AM. Epidemiology of exfoliation syndrome in the Reykjavik Eye Study, Acta Ophthalmol. 2009;87.

Pasquale LR, Wiggs JL, Willett WC, Kang JH. The Relationship between caffeine and coffee consumption and exfoliation glaucoma or glaucoma suspect: a prospective study in two cohorts. Investigative ophthalmology visual science. 2012;53(10):6427-33.

Mitchell P, Wang JJ, Smith W. Association of pseudoexfoliation syndrome with increased vascular risk. Am J Ophthalmol. 1997;124:685-7.

Arnarsson A, Sasaki H, Jonasson F. Twelve‐year Incidence of Exfoliation Syndrome in the Reykjavik Eye Study. Acta ophthalmologica. 2013;91(2):157-62.

Speckauskas M, Tamosiunas A, Jasinskas V. Association of ocular pseudoexfoliation syndrome with ischaemic heart disease, arterial hypertension and diabetes mellitus. Actaophthalmol. 2012;90(6):e470-475.

Shrum KR, Hattenhauer MG, Hodge D. Cardiovascular and cerebrovascular mortality associated with ocular pseudoexfo-liation. Am J Ophthalmol. 2000;129(1):83-6.

Linner E, Popovic V, Gottfries CG, Jonsson M, Sjogren M, Wallin A. The exfoliation syndrome in cognitive impairment of cerebrovascular or Alzheimer’s type. Acta Ophthalmol Scand. 2001;79(3):283-5.

Ritch R, Schlotzer-Schrehardt U, Konstas AG. Why is glaucoma associated with exfoliation syndrome? Prog Retin Eye Res. 2003;22:253-75.

Jones W, White RE, Magnus DE. Increased occurrence of exfoliation in the male, Spanish American population of New Mexico. Journal of the American Optometric Association. 1992;63(9):643-8.

Schlötzer-Schrehardt U, Naumann GO. Ocular and systemic pseudoexfoliation syndrome. Ame J Ophthalmology. 2006;141(5):921-37.

Rouhiainen H, Terasvirta M. Presence of pseudoexfoliation on clear and opacified crystalline lenses in an aged population. Ophthalmologica. 1992;204:67-70.

Žoriý L. Pseudoexfoliation syndrome and cataract extraction operation complications. Anali. 1997;1(1):28-30.

Damji KF, Bains HS, Amjadi K, Dohadwala AA, Valberg JD, Chevrier R, et al. Familial occurrence of pseudoexfoliation in Canada. Can J Ophthalmol. 1999;34(5):257-65.

Anastasopoulos E, Topouzis F, Wilson MR, Harris A, Pappas T, Yu F, et al. Characteristics of pseudoexfoliation in the Thessaloniki Eye Study. J Glaucoma. 2011;20:160-66.

Sufi AR, Mufti AA, Nazir N, Qureshi T, Ramzan R. Prevalence of pseudoexfoliation syndrome in patients scheduled for cataract surgery in eye camps in Kashmir. J Clin Ophthalmol Res. 2014;2:137-9.

Kozart DM, Yanoff M. Intraocular pressure status in 100 consecutive patients with exfoliation syndrome. Ophthalmol. 1982;89:214-18.

Schlötzer-Schrehardt U, Naumann GO. Trabecular meshwork in pseudoexfoliation syndrome with and without open-angle glaucoma. A morphometric, ultrastructural study. Invest Ophthalmol Vis Sci. 1995;36:1750-64.

Psilas KG, Stefaniotou MJ, Aspiotis MB. Pseudoexfoliation syndrome and diabetes mellitus. Actaophthalmologica. 1991;69(5):664-6.