Acta Ophthalmologica 2008

Frequency of systemic vascular

diseases in patients with primary
open-angle glaucoma and
exfoliation glaucoma
Ahti Tarkkanen,1 Antti Reunanen2 and Tero Kivelä1
1
Department of Ophthalmology, Helsinki University Central Hospital, Finland
2
Department of Health and Functional Capacity, National Public Health Institute,
Helsinki, Finland

ABSTRACT.
Purpose: Abnormal fibrils can be identified by electron microscopy in the
Introduction
heart, lung, liver, kidney, cerebral meninges and other tissues of patients with Exfoliation syndrome (ES) is a degen-
exfoliation syndrome (ES). However, a clinical association of ES with arterial erative disease of the eye that may
hypertension (HT), ischaemic heart disease (IHD), cerebrovascular accidents predispose to cataracts, zonular weak-
and aneurysm of the abdominal aorta is debated. We conducted a national ness and exfoliation glaucoma (EG), a
registry-based survey to further assess the first two of these associations. specific type of secondary open-angle
Methods: We reviewed the records of 519 consecutive patients to whom the glaucoma. It is associated with defined
Social Insurance Institution of Finland had granted free medication for glau- single nucleotide polymorphisms of
the lysyl oxidase-like 1 (LOXL1) gene
coma according to national common criteria. The glaucoma was classified
(Thorleifsson et al. 2007) and abnor-
either as primary open-angle glaucoma (POAG) or exfoliation glaucoma
mal elastin fibres identified by electron
(EG), masked to any systemic diseases; 20 patients with other types of glau- microscopy in the heart, lung, liver,
coma were excluded from the survey. Masked to the type of glaucoma, the kidney, gallbladder and meninges
registry provided data on free medication similarly granted for HT, IHD and (Schlötzer-Schrehardt et al. 1992;
diabetes mellitus (DM), a known modifier of risk for cardiovascular disease. Streeten et al. 1992; Naumann et al.
Data were analysed by logistic regression, modelling age, gender and DM as 1998; Schlötzer-Schrehardt & Nau-
confounders. mann 2006).
Results: The control group of 344 patients with POAG was comparable as The widespread distribution of
regards gender with the study group of 155 patients with EG, but patients with exfoliation fibres led to a search
POAG were both younger (mean 69 versus 73 years; P < 0.0001) and had of potential systemic comorbidity in
DM twice as often (10% versus 5%; P = 0.05) compared to those with EG. patients with ES. Acute and chronic
Adjusting for age, gender and presence of DM, no difference in frequency of cerebrovascular disease appeared to
HT [odds ratio (OR) 0.80 for presence of EG; 95% confidence interval (CI) be more frequent in patients with EG
0.52–1.23, P = 0.31] or IHD (OR 0.86 for presence of EG; 95% CI 0.49– than in those with primary open-angle
1.13, P = 0.66) was detected between the two groups. glaucoma (POAG) (Ritland et al.
2004). Patients with ES had cerebral
Conclusion: In this population-based registry survey, no difference in frequency
white-matter hyperintensities in mag-
of HT or IHD was noted between patients with POAG and EG who had been
netic resonance images (Yüksel et al.
granted free medication for these chronic diseases according to national com- 2006) and reduced ocular and cerebral
mon criteria. The frequency of DM was lower among patients with EG, in line blood flow (Repo et al. 1995; Sibour
with several previous reports. et al. 1997; Harju & Vesti 2001; Mistl-
berger et al. 2001; Yüksel et al. 2001a,
Key words: arterial hypertension – capsular glaucoma – coronary artery disease – diabetes 2001b, 2006; Ocakoglu et al. 2004;
mellitus – exfoliation glaucoma – exfoliation syndrome – ischaemic heart disease – primary Akarsu & Unal 2005). Arterial hyper-
open-angle glaucoma – pseudoexfoliation
tension (HT) and ischaemic heart
disease (IHD) seemed more frequent
Acta Ophthalmol. 2008: 86: 598–602 (Mitchell et al. 1997; Miyazaki et al.
ª 2008 The Authors 2005). Links with coronary artery
Journal compilation ª 2008 Acta Ophthalmol
disease, proved by coronary angio-
doi: 10.1111/j.1600-0420.2007.01122.x graphy (Citirik et al. 2007), and with

598

asymptomatic myocardial dysfunction
(Bojic et al. 2005) have been reported,
as well as an association with aneu-
rysms of the abdominal aorta (Schum-
acher et al. 2001).
In other studies, however, no asso-
ciation was found between cardiovas-
cular and cerebrovascular mortality
and ES among 472 patients (Shrum
et al. 2000). ES was not associated
with arterial HT, IHD or cerebrovas-
cular disease in large-series patients
(Allingham et al. 2001; Brajkovic
et al. 2007). Frequency of HT in 724
patients with cataract was higher in
those without ES (Shingleton et al.
2003), and similar among 170 patients
with POAG and 85 with EG (Jonas &
Gründler 1998) and among 646
patients with and without ES seen in
one eye clinic (Brajkovic et al. 2007).
ES was as frequent in 77 patients
operated for aneurysm of the abdomi-
nal aorta as it was in the general pop-
ulation (Hietanen et al. 2002). Overall
mortality rates were comparable, or
even lower, among patients with ES
compared to those without ES
(Ringvold et al. 1997; Shrum et al.
2000; Ritland et al. 2004).
Given the conflicting results, espe-
cially on cardiovascular disease and
ES, we report the frequency of HT
and IHD in Finnish patients with
POAG and EG using national registry
data.
Multivariate analysis was used to
control for age, gender and presence
of diabetes mellitus (DM) as con-
founding factors regarding risk of car-
diovascular disease.
Materials and Methods
Patients registered with the Social
Insurance Institution of Finland (SII)
as having been granted free medica-
tion for chronic glaucoma between
June 2004 and December 2005 were
eligible for this study. Patients were
excluded if they had a type of glau-
coma other than POAG or EG. The
study was approved by the Research
and Ethics Committees of the
National Public Health Institute, and
it followed the tenets of the Helsinki
Declaration.
The SII reimburses all citizens for
the cost of medication that is needed
to treat chronic debilitating diseases,
which are specified by the Finnish
Parliament. These include glaucoma,
Acta Ophthalmologica 2008
Table 1. Criteria for diagnosing glaucoma, diabetes mellitus, arterial hypertension and ischae-
mic heart disease employed by the Social Insurance Institution of Finland for granting free
medication.
Glaucoma
• Intraocular pressure >30 mmHg
• Two of three criteria are met: intraocular pressure >21 mmHg in repeated measurements;
glaucomatous cupping of the optic disc; glaucomatous visual field defect
Arterial hypertension
• Systolic blood pressure >200 mmHg
• Diastolic blood pressure >105 mmHg in repeated measurements over several months
• Systolic blood pressure >180 mmHg or diastolic pressure >95 mmHg, if combined with
one of the following: a male £50 years of age; a female £40 years of age; several family
members <55 years of age with serious vascular disease; coexisting diabetes mellitus,
hypercholesterolaemia or other dyslipidaemia
• If diastolic pressure is <95 mmHg, evidence of organ damage such as cardiac insufficiency;
ischaemic heart, cerebrovascular or renal disease, or retinal haemorrhages
Ischaemic heart disease
• Chronic angina pectoris, which responds to medical therapy
• If electrocardiogram fails to show signs of coronary artery disease at rest, diagnosis must be
supported by a clinical exercise test
• History of myocardial infarction, cardiac bypass surgery or coronary angioplasty
Diabetes mellitus
• Insulin-dependent diabetes type 1 and 2
• Symptomatic diabetes type 2 with polydipsia, polyuria or glucosuria and either fasting blood
glucose >7 mm or plasma glucose >8 mm in repeated measurements
• Dietary therapy, body mass index and any diabetic end organ damage must be reported
HT, IHD and DM. To be granted a statistician of the SII to confirm
free medication, the patient must file whether these patients had also been
an application together with a certifi- granted free medication to treat HT,
cate from a physician. This certificate IHD or DM. The statistician who per-
must document the fulfilment of pre- formed the search was masked to the
defined criteria for each diagnosis type of glaucoma of the patients. In
(Table 1). In the case of glaucoma, addition, the age at the time when free
the certificate must be written by a medication for glaucoma was granted
specialist or resident in ophthalmol- and the gender of the patient were
ogy. The application is reviewed by registered.
the medical authority of the SII. If the The null hypothesis was that fre-
certificate meets the common criteria quency of HT and IHD did not differ
for a diagnosis, reimbursement for between POAG and EG. The alterna-
medication is granted and the patient tive hypothesis was that EG was asso-
is listed in the registry of the SII. ciated with a higher frequency of HT
Altogether, 519 consecutive patients and IHC than POAG.
fulfilled the eligibility criterion. The Contingency tables were compared
SII provided a copy of the medical with Fisher’s exact tests and continu-
documentation received on glaucoma. ous variables with Student’s t-test.
The documents were reviewed by the The type of glaucoma as a predictor
senior author without any knowledge of HT and IHD was analysed by bin-
on the systemic diseases of the ary logistic regression using the likeli-
patients. A total of 20 patients who hood ratio test. The study had 80%
had primary angle-closure and sec- power to detect an odds ratio of 0.6
ondary glaucoma after ocular injury and 0.5 as significant for HT and
and uveitis were excluded from the IHD, respectively. Age, gender and
study. The remaining 499 patients presence of DM were modelled as
were classified into POAG or EG. confounding variables. All tests were
The diagnosis of exfoliation was based two-tailed. Analysis was performed
on records of observing typical greyish using the stata statistical software
flakes at the papillary margin, surface (version 7; Stata Co., College Station,
of the lens, or both. Typically, charts Texas, USA).
on POAG contained a specific state-
ment ‘no exfoliation deposits’, which
contributed to classification.
Results
The records of the 499 patients with Of the 499 registered patients with
POAG or EG were then compared by open-angle glaucoma, 344 (69%) had
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Acta Ophthalmologica 2008

POAG and 155 (31%) had EG. The
two groups were comparable as
regards gender (66% female versus
70% female, POAG versus EG,
P = 0.47, Fisher’s exact test), but
patients with POAG were younger
than patients with EG (mean 69 versus
73 years, P = 0.0001, Student’s t-test).
The frequency of medically treated
DM was 8% [95% confidence inter-
val (CI) 6–11], and was twice as high
among patients with POAG com-
pared to those with EG (Fig. 1A;
10% versus 5%, P = 0.052, Fisher’s
exact test). The difference persisted
after adjusting for age and gender
using logistic regression (Fig. 1B; OR
0.42, P = 0.047, likelihood ratio
test).
Fig. 1. (A) Percentage of subjects with diabetes mellitus (DM), arterial hypertension (HT) and
ischaemic heart disease (IHD) among 499 patients who received free medication for primary
open-angle glaucoma (POAG) and exfoliation glaucoma (EG). (B) Unadjusted and adjusted
odds ratios for being affected by DM, HT and IHD. The crossbars show 95% confidence
intervals.
The frequency of medically treated
arterial HT was high in the study pop-
ulation (32%; 95% CI 28–36), and
comparable for patients with POAG
and EG (Fig. 1A; 33% versus 29%,
respectively, unadjusted OR 0.83 for
presence of EG, P = 0.36, likelihood
ratio test; Table 2). The presence of
HT was associated with increasing age
(OR 1.24 for each decade, P = 0.022)
and DM (OR 3.78, P < 0.0001).
Controlling for age, gender and DM
decreased the OR of HT, which
remained not significant [OR 0.80
(95% CI 0.52–1.23) for presence of
EG, P = 0.31; Fig. 1B and Table 2].
The frequency of medically treated
IHD was 13% (95% CI 10–16) and
comparable for patients with POAG
and EG (Fig. 1A; 13% for both
groups, unadjusted OR 1.04 for pres-
ence of EG, P = 0.90, likelihood
ratio test; Table 2). The presence of
IHD was associated with increasing
age (OR 1.59 for each decade,
P = 0.001) and, after controlling for
age, with male gender (OR 1.80,
P = 0.038). Controlling for age, gen-
der and DM decreased the OR of
IHD, which was still not significant
[OR 0.86 (95% CI 0.49–1.13) for pres-
ence of EG, P = 0.61; Fig. 1B and
Table 2].
Discussion
The nationwide registry of the SII of
Finland did not provide evidence for
a different frequency of HT among
patients with EG and POAG; this led
to the acceptance of the null hypothe-
sis of no difference, in contrast to sev-
eral previous reports on this subject
(Table 3). A strength of the present
study compared to previous ones was
that all diagnoses were made by uni-
form, national criteria.
Two of the four conflicting reports
on HT were large epidemiological
studies, each of which included <100
patients with ES or EG and reported
a higher frequency of HT in patients
with ES (Table 3). Our registry data
also disagreed with two referral-based
studies that documented a lower
frequency, or a trend toward lower
frequency, of HT in patients with
ES and cataract and EG (Jonas &

Table 2. Univariate and multivariate binary logistic regression of presence of arterial hypertension (HT) and ischaemic heart disease (IHD),
adjusted for age, gender and presence of diabetes mellitus (DM), in 499 patients with free medication for primary open-angle glaucoma and exfo-
liation glaucoma.

Dependent variable Independent variable Coefficient (SE) Chi-square P Odds ratio (95% CI)

Univariate
HT Type of glaucoma* )0.192 (0.211) 0.83 0.36 0.83 (0.55–1.25)
IHD Type of glaucoma* 0.036 (0.290) 0.017 0.90 1.04 (0.59–1.83)
Multivariate
HT Type of glaucoma* )0.224 (0.220) 1.04 0.31 0.80 (0.52–1.23)
Age  0.233 (0.098) 5.62 0.018 1.26 (1.04–1.53)
Genderà )0.178 (0.216) 0.67 0.41 0.84 (0.55–1.28)
DM§ 1.345 (0.343) 15.4 <0.0001 3.84 (1.96–7.52)
IHD Type of glaucoma* )0.152 (0.298) 0.26 0.66 0.88 (0.49–1.13)
Age  0.522 (0.150) 12.3 <0.0001 1.69 (1.26–2.26)
Genderà 0.607 (0.285) 4.54 0.033 1.83 (1.05–3.21)
DM§ 0.445 (0.556) 0.64 0.61 0.64 (0.22–1.90)

SE, standard error; CI, confidence interval.

*Categorical variable: 0 = primary open-angle glaucoma; 1 = exfoliation glaucoma.
 
Continuous variable, per 10 years.
à
Categorical variable: 0 = female; 1 = male.
§
Categorical variable: 0 = no; 1 = yes.

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 Acta Ophthalmologica 2008

Table 3. Percentage of subjects with diabetes mellitus (DM), arterial hypertension (HT) and ischaemic heart disease (IHD) according to presence
or absence of exfoliation syndrome.

Controls without exfoliation Exfoliation syndrome

Source Total Affected (%) Total Affected (%) P* Study design

HT
Mitchell et al. (1997) 3465 81 NS Population-based
Miyazaki et al. (2005) 1414 40.0 50 50.2 0.19§ Population-based
Brajkovic et al. (2007) 485 50.9 161 55.9 0.28 Referral-based
Shingleton et al. (2003) 409 49.6 364 38.5 0.002 Referral-basedà
Jonas & Gründler (1998) 290 27.9 85 18.8 0.09 Age-matched 
Present study 344 33.1 155 29.0 0.41 Population-based 
IHD
Ritland et al. (2004) 429 22.1 718 23.4 NS Diabetics excluded 
Brajkovic et al. (2007) 485 4.9 161 7.4 0.24 Referral-based
Present study 344 12.5 155 12.9 0.89 Population-based 
DM
Miyazaki et al. (2003) 1414 13.0 50 8.7 0.39 Population-based
Brajkovic et al. (2007) 485 22.1 161 18.0 0.32 Referral-based
Shingleton et al. (2003) 409 11.5 364 4.9 0.001 Referral-basedà
Jonas & Gründler (1998) 290 15.2 85 8.2 0.10 Age-matched 
Present study 344 9.9 155 4.5 0.05 Population-based 

NS, not significant.

*Fisher’s exact test, recalculated.
 
Patients with primary open-angle glaucoma or exfoliation glaucoma.
à
Patients with cataract.
§
Significant in multivariate analysis adjusting for age and gender.

Gründler 1998; Shingleton et al.
2003). Taking all studies together,
there is no convincing evidence to sug-
gest that HT may increase risk of ES
and EG, or vice versa.
Our registry data agree with a Nor-
wegian study (Ritland et al. 2004),
which found no difference in the rate
of IHD among 1147 patients with
POAG and EG (Table 3). Moreover,
a 22% mortality rate from cardiovas-
cular disease was reported for 472
patients with ES, which did not differ
significantly from the expected mortal-
ity rate of 20% (Shrum et al. 2000).
These studies and a Croatian referral-
based series (Brajkovic et al. 2007) are
consistent with the view that ES and
EG are not associated with risk
of IHD. Taken together, they appear
to contradict a case–control study
in which ES was more common in
50 patients referred to coronary
angiography than among age- and
sex-matched controls (Citirik et al.
2007).
DM, which carries an increased risk
of cardiovascular complications and
consequently was modelled as a con-
founding factor in the present study,
was twice as common among patients
with POAG compared to those with
EG, even when adjusting for gender
and age differences. Previous studies
of patients with ES and cataract and
EG (Jonas & Gründler 1998; Shingle-
ton et al. 2003; Miyazaki et al. 2005)
support the trend toward less frequent
DM among patients with ES and the
effect size of about 50% lower fre-
quency (Table 3), although not all
were large enough to detect the differ-
ence as significant. ES was also found
in 11% of 325 diabetic patients older
than 50 years of age compared to
24% of 489 controls (Psilas et al.
1991). No difference in frequency of
DM was reported between patients
with and without ES in three other
studies of varying size and design,
some of which did not provide explicit
statistics (Allingham et al. 2001; Sol-
losy 2004; Brajkovic et al. 2007).
Ultrastructural and immunohisto-
chemical studies suggest that ES
involves abnormal accumulation of
elastin fibres, extracellular matrix and
proteoglycans (Eagle et al. 1979;
Streeten et al. 1992; Uusitalo et al.
1993; Kubota et al. 1997). Biochemi-
cal analysis will be needed to resolve
whether abnormal glycation of base-
ment membrane components can
modify deposition of exfoliation mate-
rial in patients with DM, leading to a
lower frequency of clinical ES and,
hence, a lower frequency of EG in this
group of patients.
Acknowledgements
The authors are indebted to Ms
Kristiina Tyrkkö, the statistician at
the Social Insurance Institution of
Finland, for expert assistance in com-
piling the registry data.
References
Akarsu C & Unal B (2005): Cerebral haemo-
dynamics in patients with pseudoexfolia-
tion glaucoma. Eye 19: 1297–1300.
Allingham RR, Loftsdottir M, Gottfredsdot-
tir MS et al. (2001): Pseudoexfoliation
syndrome in Icelandic families. Br J
Ophthalmol 85: 702–707.
Bojic L, Ermacora R, Polic S, Ivaniševic M,
Mandic Z, Rogošic V & Lešin M (2005):
Pseudoexfoliation syndrome and asymp-
tomatic myocardial dysfunction. Graefes
Arch Clin Exp Ophthalmol 243: 446–449.
Brajkovic J, Kalauz-Surac I, Ercegovic A,
Miletic-Juric A, Sušic N & Buric Ž (2007):
Ocular pseudoexfoliation syndrome and
internal systemic diseases. Acta Clin Croat
46 (Suppl): 57–61.
Citirik M, Acaroglu G, Batman C, Yildiran
L & Zilelioglu O (2007): A possible link
between the pseudoexfoliation syndrome
and coronary artery disease. Eye 21: 11–
15.
Eagle RCJ, Font RL & Fine BS (1979): The
basement membrane exfoliation syndrome.
Arch Ophthalmol 97: 510–515.
Harju M & Vesti E (2001): Blood flow of the
optic nerve head and peripapillary retina

601
Acta Ophthalmologica 2008
in exfoliation syndrome with unilateral
glaucoma or ocular hypertension. Graefes
Arch Clin Exp Ophthalmol 239: 271–277.
Hietanen J, Soisalon-Soininen S, Kivelä T &
Tarkkanen A (2002): Evaluation of the
clinical association between exfoliation syn-
drome and abdominal aortic aneurysm.
Acta Ophthalmol Scand 80: 617–619.
Jonas JB & Gründler AE (1998): Prevalence
of diabetes mellitus and arterial hyperten-
sion in primary and secondary open-angle
glaucomas. Graefes Arch Clin Exp Oph-
thalmol 236: 202–206.
Kubota T, Schlötzer-Schrehardt U, Inomata
H & Naumann GO (1997): Immunoelec-
tron microscopic localization of the HNK-1
carbohydrate epitope in the anterior seg-
ment of pseudoexfoliation and normal
eyes. Curr Eye Res 16: 231–238.
Mistlberger A, Gruchmann M, Hitzl W &
Grabner G (2001): Pulsatile ocular blood
flow in patients with pseudoexfoliation. Int
Ophthalmol 23: 337–342.
Mitchell P, Wang JJ & Smith W (1997):
Association of pseudoexfoliation syndrome
with increased vascular risk. Am J Oph-
thalmol 124: 685–687.
Miyazaki M, Kubota T, Kubo M, Kiyohara
Y, Iida M, Nose Y & Ishibashi T (2005):
The prevalence of pseudoexfoliation syn-
drome in a Japanese population: the Hisay-
ama study. J Glaucoma 14: 482–484.
Naumann GO, Schlötzer-Schrehardt U &
Küchle M (1998): Pseudoexfoliation
syndrome for the comprehensive ophthal-
mologist. Intraocular and systemic manifes-
tations. Ophthalmology 105: 951–968.
Ocakoglu O, Koyluoglu N, Kayiran A,
Tamcelik N & Ozkan S (2004): Microvas-
cular blood flow of the optic nerve head
and peripapillary retina in unilateral exfoli-
ation syndrome. Acta Ophthalmol Scand
82: 49–53.
Psilas KG, Stefaniotou MJ & Aspiotis MB
(1991): Pseudoexfoliation syndrome and
diabetes mellitus. Acta Ophthalmol 69:
664–666.
602
Repo LP, Suhonen MT, Teshome T & Koiv-
isto KJ (1995): Color Doppler imaging of
the ophthalmic artery blood flow spectra of
patients who have had a transient ischemic
attack. Correlations with generalized iris
transluminance and pseudoexfoliation syn-
drome. Ophthalmology 102: 1199–1205.
Ringvold A, Blika S & Sandvik L (1997):
Pseudo-exfoliation and mortality. Acta
Ophthalmol Scand 75: 255–256.
Ritland JS, Egge K, Lydersen S, Juul R &
Semb SO (2004): Exfoliative glaucoma and
primary open-angle glaucoma: associations
with death causes and comorbidity. Acta
Ophthalmol Scand 82: 401–404.
Schlötzer-Schrehardt U & Naumann GO
(2006): Ocular and systemic pseudoexfolia-
tion syndrome. Am J Ophthalmol 141:
921–937.
Schlötzer-Schrehardt UM, Koca MR, Nau-
mann GO & Volkholz H (1992): Pseudoex-
foliation syndrome. Ocular manifestation
of a systemic disorder? Arch Ophthalmol
110: 1752–1756.
Schumacher S, Schlötzer-Schrehardt U, Mar-
tus P, Lang W & Naumann GOH (2001):
Pseudoexfoliation syndrome and aneurysms
of the abdominal aorta. Lancet 357: 359–
360.
Shingleton BJ, Heltzer J & O’Donoghue MW
(2003): Outcomes of phacoemulsification in
patients with and without pseudoexfolia-
tion syndrome. J Cataract Refract Surg 29:
1080–1086.
Shrum KR, Hattenhauer MG & Hodge D
(2000): Cardiovascular and cerebrovascular
mortality associated with ocular pseudoex-
foliation. Am J Ophthalmol 129: 83–86.
Sibour G, Finazzo C & Boles C (1997):
Monolateral pseudoexfoliatio capsulae: a
study of choroidal blood flow. Acta Oph-
thalmol Scand 224 (Suppl): 13–14.
Sollosy M (2004): Incidenta sindromului de
pseudoexfoliere uveala la pacientii cu dia-
bet zaharat [Incidence of uveal pseudexfo-
liation syndrome in patients with diabetes
mellitus]. Oftalmologia 48: 76–80.
Streeten BW, Li ZY, Wallace RN, Eagle RCJ
& Keshgegian AA (1992): Pseudoexfolia-
tive fibrillopathy in visceral organs of a
patient with pseudoexfoliation syndrome.
Arch Ophthalmol 110: 1757–1762.
Thorleifsson G, Magnusson KP, Sulem P
et al. (2007): Common sequence variants in
the LOXL1 gene confer susceptibility to
exfoliation glaucoma. Science 317: 1397–
1400.
Uusitalo M, Kivelä T & Tarkkanen A (1993):
Immunoreactivity of exfoliation material
for the cell adhesion-related HNK-1 carbo-
hydrate epitope. Arch Ophthalmol 111:
1419–1423.
Yüksel N, Karabas VL, Arslan A, Demirci A
& Çaglar Y (2001a): Ocular hemodynamics
in pseudoexfoliation syndrome and pseudo-
exfoliation glaucoma. Ophthalmology 108:
1043–1049.
Yüksel N, Karabas VL, Demirci A, Arslan
A, Altintas O & Çaglar Y (2001b): Com-
parison of blood flow velocities of the
extraocular vessels in patients with pseud-
oexfoliation or primary open-angle glau-
coma. Ophthalmologica 215: 424–429.
Yüksel N, Anik Y, Kiliç A, Karabas V,
Demirci A & Çaglar Y (2006): Cerebrovas-
cular blood flow velocities in pseudoexfoli-
ation. Graefes Arch Clin Exp Ophthalmol
244: 316–321.
Received on August 23rd, 2007.
Accepted on October 5th, 2007.
Correspondence:
Professor Ahti Tarkkanen
Department of Ophthalmology
Helsinki University Central Hospital
PL 220, FI-00029 HUS
Helsinki
Finland
Tel: + 358 400 709 804
Fax: + 358 9 4717 5100
Email: ahti.tarkkanen@kolumbus.fi