Delta Journal of Ophthalmology

: 2016  |  Volume : 17  |  Issue : 3  |  Page : 133--136

Pseudoexfoliation cataract: possible systemic associations

Ahmed F Gabr 
 Department of Ophthalmology, Faculty of Medicine, Aswan University, Aswan, Egypt; Department of Ophthalmology, King Khaled Hospital, Najran, KSA

Correspondence Address:
Ahmed F Gabr
Department of Ophthalmology, Faculty of Medicine, Aswan University, Aswan 81111, Egypt


Aim The aim of this study was to report the prevalence and possible systemic associations of pseudoexfoliation syndrome (PXF) in patients with age-related cataract scheduled for surgery in Najran District, South Saudi Arabia. Patients and methods In this retrospective study, the medical records of 681 consecutive patients scheduled for routine cataract surgeries were reviewed. All patients were 60 years old or more. A comprehensive ophthalmic examination was performed for all patients, including visual acuity assessment, refraction, Goldmann applanation tonometry, gonioscopy, assessment of type of cataract, as well as fundus examination. Systemic conditions were reported, and a possible relation with PXF was assessed and analyzed. Results Pseudoexfoliation was diagnosed in 192 patients, with an overall incidence of 28.19%. The occurrence of pseudoexfoliation was found to be higher in older age groups. Possible associations with several systemic conditions were documented and discussed. Conclusion PXF is a common age-related disorder in patients with age-related cataract in Najran area, South Saudi Arabia, with an overall incidence of 28.19%. More research is needed before using PXF as an indicator for the presence of systemic diseases.

How to cite this article:
Gabr AF. Pseudoexfoliation cataract: possible systemic associations.Delta J Ophthalmol 2016;17:133-136

How to cite this URL:
Gabr AF. Pseudoexfoliation cataract: possible systemic associations. Delta J Ophthalmol [serial online] 2016 [cited 2021 Nov 29 ];17:133-136
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Full Text


Pseudoexfoliation syndrome (PXF) is an age-related disorder that is frequently correlated with chronic secondary open-angle glaucoma and cataract. Its etiology and pathogenesis are not precisely identified; however, it is thought to be a systemic process [1]. A number of clinical observations indicate that PXF may have functional implications beyond the eye [2],[3],[4].

In patients with ocular involvement, aggregates of material similar to that of pseudoexfoliation were identified in the skin, as well as in some internal organs (e.g. heart, lung, liver, and kidney). This supports the concept that pseudoexfoliation could be a systemic condition with ocular manifestations [5],[6].

 Patients and methods

In this retrospective study, 681 consecutive patients with age-related cataract scheduled for cataract surgery at King Khaled Hospital in Najran District, South Saudi Arabia were included. Patients below the age of 60 years and those having congenital, developmental, traumatic, as well as complicated, cataract were excluded from the study. Written consent was signed by each participant as a routine procedure after a simple explanation about the probability to use their clinical and demographic data in research. All collected data were securely saved in the Research Unit, whereas all analyses were performed anonymously. The study was approved by the Local Committee for Research and Ethics.

Full ophthalmological examination including visual acuity, refraction, slit-lamp examination, Goldmann applanation tonometry, gonioscopy, and fundus examination was performed. Pseudoexfoliation was diagnosed on slit-lamp biomicroscopy by the presence of white dandruff-like material at the pupillary margin, on the anterior lens capsule, and trabecular meshwork, in one or both eyes. Definition of the type of cataract was guided by the lens opacities classification system III [7].

Systemic diseases − identified by reviewing the detailed medical records of the patients comprising history, specific investigations, as well as prescribed medications of such conditions − were verified and registered.

Statistical analysis

Data were analyzed using SPSS (V.16 program; IBM Corp., New York, New York, USA). Quantitative data were presented as mean±SD; χ2-test and test of significance were used for comparison between groups. P-value less than 0.05 was considered statistically significant.


Out of 681 patients included in this study, pseudoexfoliation was diagnosed in 192 patients, with an overall incidence of 28.19%. There were 321 (47.1%) male patients and 360 (52.9%) female patients, with no significant difference. In the PXF group, there were 91 (47.4%) male and 101 (52.6%) female patients, whereas in the non-PXF group there were 230 (47.03%) male and 259 (52.96%) female patients, also with no statistically significant difference. The mean age was 73.47±22.36 years in the PXF group and 72.36±21.63 years in the non-PXF group, with no significant difference. The occurrence of pseudoexfoliation was found to be higher in older age groups ([Table 1]). Pseudoexfoliation was found unilaterally in 90 (46.87%) patients, whereas bilateral occurrence was found in 102 (53.13%) patients.{Table 1}

A list of systemic conditions found throughout this study included ischemic heart disease (IHD), diabetes mellitus (DM), arterial hypertension (AH), rheumatoid arthritis, osteoporosis, bronchial asthma, anemia, as well as hypothyroidism.

In the PXF group, 39 (20.31%) patients were found to have evidence of IHD, whereas 37 (7.56%) patients were reported in the group without PXF, and this finding was highly statistically significant (P<0.001). DM was encountered in 82 (42.7%) patients with PXF and in 175 (35.78%) patients without PXF, and this was also highly statistically significant (P<0.001). AH was reported in 75 (39.06%) patients with pseudoexfoliation and in 145 (29.65%) patients in the group without pseudoexfoliation (P=0.002). Moreover, rheumatoid arthritis was encountered in six (3.12%) patients with PXF, but only in one (0.2%) patient without PXF, and this was also statistically significant (P=0.014). Although not significant, osteoporosis was found in five (2.6%) patients with pseudoexfoliation and in another five (1.02%) patients in the non-PXF group. No association could be ascertained between pseudoexfoliation and other systemic conditions reported in the study groups such as bronchial asthma, anemia, hearing loss, and hypothyroidism ([Table 2]).{Table 2}


This study was conducted in parallel to another study investigating the ocular associations, as well as the perioperative complications, in the same group of patients [8]. In the current study, the prevalence of PXF in patients scheduled for cataract surgery over the age of 60 years was found to be 28.19%. As reported by other investigators, PXF was found to occur predominantly in older patients with age-related increase in the frequency of the syndrome [9],[10].

No sex prevalence was noted between patients with PXF and those without PXF − a finding that was also supported by other authors [9],[11]. Although some studies suggested increased male affection with pseudoexfoliation [11],[12], others reported female preponderance among affected patients [13],[14].

PXF supervened unilaterally in 46.87% and bilaterally in 53.13% of patients in the present study. Comparable results were obtained by many authors [9],[15],[16]. Puska [17] stated that unilateral involvement may be just a forerunner to bilateral involvement, but this may take prolonged time to appear.

There is a debate about a possible association of pseudoexfoliation (PEX) with various systemic disorders, as pseudoexfoliative material has been also identified by electron microscopy in visceral organs such as lung, heart, liver, kidney, gall bladder, and meninges. This widespread distribution led to the hypothesis of a possible association of PEX with several systemic diseases, but other studies do not agree with such an assumption [18],[19].

Patients with evidence of IHDs were found more frequently in the PXF group compared with the non-PXF group (20.31 and 7.56%, respectively). Citirik et al. [20] showed significant mutual correlation between prevalence of PXF and coronary heart diseases. Comparable results were also reported by more recent investigators who analyzed the correlation between prevalence of PXF and the risk of coronary heart diseases in patients over 50 years or older [21],[22]. They also demonstrated an increased incidence of cardiovascular disorders in PXF patients [23],[24]. On the other hand, several reports revealed no correlation between pseudoexfoliation and IHDs primarily or after multivariate adjustment, including age, sex, and vascular risk factors [2],[25],[26],[27].

In the present study, DM was found to be significantly more in patients with pseudoexfoliation than in those without pseudoexfoliation. This was also supported by the findings of Sollosy [28]. On the other hand, DM was found to be less associated with PXF in many other reports [2],[10],[26].

Several studies have correlated PXF with AH; two of them were based on a large number of patients: the Australian Blue Mountains Eye Study, which included a total of 3654 patients and showed that PXF is significantly associated with a history of hypertension, angina, or both [13], and the other large cross-sectional study of Miyazaki et al. [29], which included 1884 patients and revealed higher prevalence of AH in patients with PXF. Contrary to those studies and the present study, no correlation between PXF and AH was reported by many authors. Moreover, Spečkauskas et al. [10] revealed no association between PXF and IHD, AH, and DM after controlling for the effect of age.

Although reported in previous studies [30],[31],[32], the association of pseudoexfoliation with sensory neural deafness could not be assessed in the current study, as only one case was found in the PXF group and no cases were recorded in patients without pseudoexfoliation. In addition, to the best of the author’s knowledge, no claimed association of PXF with osteoporosis was found in the literature.

The current study found no association between pseudoexfoliation and a number of systemic diseases such as bronchial asthma, anemia, and hypothyroidism, which suggests coincidental occurrence only.


PXF is a common age-related disorder in patients with age-related cataract in Najran area, South Saudi Arabia, with an overall incidence of 28.19%. More research is needed before using PXF as an indicator for the presence of systemic diseases.


The author extends gratitude to all staff members of Ophthalmology Department, King Khaled Hospital, Najran, KSA for their great help and support.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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