In Vivo Confocal Microscopic Evaluation of Corneas in Patients With Exfoliation Syndrome Sibel Kocabeyoglu, MD,* Mehmet C. Mocan,* Murat Irkec,* and Jale Karakayaw

Purpose: To evaluate the corneal microstructure in patients with exfoliation syndrome (XFS) with in vivo confocal microscopy (IVCM) and to compare their results with those of healthy subjects. Material and Methods: Fifty-five corneas of patients with XFS and 55 corneas of age-matched control subjects were included in this study. Basal epithelial cell, keratocyte, endothelial cell densities, as well as sub-basal nerves were evaluated. Central corneal thickness (CCT) was measured by ultrasonic pachymeter. Results: Eyes with XFS had lower cell densities in the basal epithelium (P = 0.03), posterior stroma (Pr0.001), and endothelium (P = 0.008) compared with normal eyes. The number of subbasal long nerve fibers, entire subbasal nerves, as well as nerve fiber density were found to be significantly lower in the corneas of patients with XFS (2.5 ± 1.1 nerve/frame, 5.6 ± 2.9 nerve/frame, and 918.9 ± 338.5 mm/frame, respectively) as compared with those of controls (2.8 ± 0.9 nerve/frame, 7.3 ± 3.1 nerve/frame, and 1089.1 ± 590.0 mm/frame, respectively, P = 0.026, P = 0.002, and P = 0.022, respectively). There was no significant difference among eyes with XFS (537.6 ± 36.7 mm) and control group (541.8 ± 29.9 mm) with respect to the CCT (P = 0.142). Conclusions: Subjects with XFS have subnormal endothelial, keratocyte, and subbasal nerve densities. Cornea appears to be diffusely altered in the setting of XFS even without overt deposition of exfoliation material on the corneal endothelium. IVCM may be helpful in the evaluation and follow-up of patients with XFS in assessing the impact of surgical interventions and topical antiglaucomatous medications on the corneal cell densities and subbasal nerve plexus. Key Words: exfoliation syndrome, in vivo confocal microscopy, corneal morphology

(J Glaucoma 2016;25:193–197)


xfoliation syndrome (XFS) is a common age-related systemic extracellular matrix disorder characterized by the accumulation of abnormal fibrillar material in ocular and nonocular tissues.1 Exfoliation material is produced by various intraocular cell types including lens epithelium, ciliary epithelium, trabecular endothelium, vascular endothelial cells, iris, basement membrane of the corneal epithelium, and corneal endothelium.2,3 The tissue alterations predispose to several potentially disastrous intraocular and

Received for publication October 1, 2013; accepted August 1, 2014. From the Departments of *Ophthalmology; and wBiostatistics, Hacettepe University School of Medicine, Ankara, Turkey. Disclosure: The authors declare no conflict of interest. Reprints: Murat Irkec, Hacettepe University, Department of Ophthalmology, Hacettepe University School of Medicine, Ankara, 06100, Turkey (e-mail: [email protected]). Copyright r 2014 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/IJG.0000000000000110

J Glaucoma

Volume 25, Number 2, February 2016

surgical complications such as glaucoma, phacodonesis and lens subluxation, zonular dehiscence, capsular rupture or vitreous loss during cataract extraction, blood-aqueous barrier dysfunction, and corneal endothelial decompensation.4,5 In previous studies, deposition of exfoliation material on the corneal endothelium, decreased endothelial cell density, alterations of the basal epithelium with concomitant changes of the subepithelial nerve plexus, changes in corneal sensation, and disturbances of the precorneal tear film together with dry eye have been reported.6–9 In vivo confocal microscopy (IVCM) is a noninvasive technique of examining the human cornea and enables microscopic examination of all corneal layers in healthy and diseased corneas including epithelial disorders, stromal degenerative and dystrophic disease, endothelial pathologies, corneal deposits, infections, and traumatic changes.10 There is only 1 published study looking into the corneal changes of patients with XFS using IVCM.11 Thus, this study was undertaken to evaluate cell densities in different corneal layers, endothelial cell morphology, and subbasal nerve densities using IVCM, to correlate these microstructural findings with central corneal thickness (CCT) and to compare the results of patients with XFS with those of age-matched normal subjects.

MATERIALS AND METHODS Fifty-five eyes of 55 patients with diagnosis of XFS and 55 eyes of 55 healthy control subjects without XFS were included in this prospective study undertaken at a single university-based hospital between January 2012 and January 2013. The Tenets of the Declaration of Helsinki was followed throughout the study. Informed consent was obtained from all patients and the study was carried out with approval from the Institutional Review Board. All patients underwent a complete ophthalmic examination including refraction, undilated and dilated slit-lamp examination, intraocular pressure determination, and fundus examination. Diagnosis of XFS was based on the presence of a classic exfoliation deposition pattern on the anterior lens capsule as a central gray disc, mid-peripheral clear ring, and peripheral gray rim, normal appearance of the optic disc, normal visual fields, and repeated intraocular pressure (IOP) measurements of

In Vivo Confocal Microscopic Evaluation of Corneas in Patients With Exfoliation Syndrome.

To evaluate the corneal microstructure in patients with exfoliation syndrome (XFS) with in vivo confocal microscopy (IVCM) and to compare their result...
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