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ACTA 0 PHTH A LM 0 LOG I CA 66 (1988) SUPPI. 184, 71-85
EXFOLIATION SYNDROME IN VARIOUS ETHNIC POPULATIONS
Henrik Forsius
Department of Ophthalmology (Head: P. J. Airaksinen), University of Oulu, Finland, and Population Genetics Unit (Head: H. Forsius), Samfundet Folkhalsan, Helsinki, Finland
Abstract. This introductory lecture to the epidemi- ological session in the Workshop on the Exfolia- tion Syndrome (ES) gathers together figures for the prevalence of ES around the world. Prevalence figures from published reports are shown in the text separately for each country. Four ways of comparing the preva- lences are used. 1) Prevalences in people over 60 years of age, 2) Percentages of glaucoma in persons with ES, 3) Percentages of ES in patients with glaucoma or ocular hypertension, with separate statistics for the proportion of capsular glaucoma in patients treated with laser trabeculoplasty (LTP), 4) Prevalence of ES in patients with cataract. The major differences in prevalence can partly be explained by the different techniques used in the investigations. Very few authors have studied people in different countries, which is the best way of' obtaining comparable results. The author has personally studied Finns, Lapps, Eskimos in Greenland, Canada and Alaska, Icelanders, popula- tions in Tunis, India and Peru and four populations in the USSR by the same technique. The prevalences vary from 0 070 in Eskimos to 21 Vo in Finns over 60 years of age, and are at the same high level in Lapps, Finns, Russians in Novosibirsk and Icelanders, but sig- nificantly lower in all the others. The results support the opinion that ES is not uniformly distributed in all countries, and this is confirmed by many reports from different countries in this workshop.
Key words: Exfoliation syndrome - pseudoexfolia- tion - epidemiology - geographic ophthalmology - glaucoma - capsular glaucoma.
This introductory lecture to the epidemiologi- cal section of the Workshop on Exfoliation Syndrome (ES) reviews the literature and also presents the results of my own studies on this sign in different parts of the world.
Professor Lindberg, who described the ES in 1917, was my first teacher in ophthalmology. 40 years have passed since he taught me to identify this sign, the importance of which has only been recognized in other parts of the world outside Scandinavia in recent decades.
A disease can be caused by genetic factors, by the influence of the surroundings or by a combination of these. If a disease appears in a newborn infant or a small child there is a high suspicion that it has a genetic background, but if its incidence increases with age, as that of the ES does, we must first think of the possible in- fluence of the environment. We shall analyze these two alternatives.
ES has also been said to be a pure sign of age. This is an argument without significance, how- ever, as environment and heredity also lie behind diseases which start late in life, such as macular degeneration and senile cataract.
The genetics of a disease may be relatively easy to study if it is very rare, as we can be sure that all affected members in a pedigree carry the same
71
“black” gene. If a disease is common, e.g. can- cer or exfoliation syndrome, the task is much more complicated. As 15-30 Yo of very old people in many parts of Scandinavia, Iceland, Greece and the Soviet Union have ES, family studies do not give reliable results, as can be con- cluded from investigations carried out by myself and many others. This is so because if ES is com- mon we cannot be sure from whom it has been inherited, nor do we know if a member of the family was a carrier of the gene or not if he dies before the age of 90, as the incidence doubles every decade after it starts to appear at the age of 50. The genetics of ES must thus be studied by different methods, e.g. via its occurrence in twins or through family studies carried out in countries with very low prevalences. One pre- liminary report on twin-studies has recently been published (Teikari 1987).
Population investigations where the persons studied are chosen as a random sample are es- sential for epidemiological work. Population in- vestigations sometimes concentrate on isolated groups, e.g. inhabitants of an island, in which case even if the random sample criterion is met, an accumulation of genetic markers or diseases e.g. the ES, can occur by chance or by the founder ef- fect. This may explain why the prevalence of ex- foliation is very high in the Isle of Man (Clements 1968), for instance, in spite of low prevalences in neighbouring countries. But the opposite can also happen. A gene for a disease can completely disappear by chance from a small population such as the Eskimos. We shall return to this specific problem later. Also small countries such as Iceland and Finland show many signs of genetic isolation.
PART I. THE SPEAKER’S OWN I N V EST1 GAT1 0 N S
The International Biological Programme, which started in 1967, organized medical and anthro- pological population investigations especially in remote parts of the world. The surveys were standardized to a certain degree and I had the opportunity of performing the ophthalmological parts in many of these expeditions in which the subjects were chosen by random sampling. Be- fore and after that (1962-1984) our group made other comparable studies trying to find out how
72
the eyes react to different climates. All in all, we have studied 11 .OOO eyes of Lapps, Eskimos in Greenland, Canada and Alaska, Icelanders, In- dians in Peru living at an altitude of 4000 m, different ethnic groups in the Himalayas and Hawaii, people in the deserts of southern Tunisia, four populations in the Soviet Union and several populations in Finland, all using the same tech- nique, the same microscope and the same myd- riatics. The studies included not only signs of climatic effects on the eye but also the ES. Some of the results may be seen from the tables. In summary, it can be concluded that the prevalence of exfoliation is at the same high level in persons over 60 years of age, i.e. about 20 Yo, among the Lapps, Icelanders, Finns, Russians and Aland Islanders, but low in Peru and the Himalayas and in Eskimos.
Our group studied inhabitants in homes for the aged in four places, Finns in the Aland Islands (genetically they are Swedes) and in the region of Oulu, Icelanders in Reykjavik and Russians in Novosibirsk (Forsius 1979). The prevalences were high in all four places but highest in Rey- kjavik, where the mean age also was the highest, 78 years. The age in Aland was 71 years, that in Northern Finland 76 years and that in Novosi- birsk 69 years. If we take into account the rising incidence with age the differences are not real ones. These extremely high prevalences in homes for the aged made us consider whether such in- mates really represent a normal population. As there is always a shortage of available bed in homes for the aged in Finland at least, they may represent a more sick population than normal. A population study in Kuusamo, northeastern Finland, by Alanko et al. (to be published), in which the group investigated represented a strictly random sample, nevertheless gave identical re- sults to the investigation carried out in Oulu (Krause 1973). In addition, studies in homes for the aged in Bergen by Aasved (1969) and the Framingham study (Hiller et al. 1982), among others, have resulted in low prevalence figures.
In the populations with lower prevalences of the exfoliation syndrome, the sign also tended to appear later in life. Thus if we add together the non-Scandinavian populations in India, Bashkiria and Peru, the Ziryanians and Cheremisses in USSR and the Eskimos in Canada and Green- land, for example, we have 3.11 Yo with exfolia- tion among 546 persons in the age range 50-69 years and 14.4 Yo with exfoliation among 125 per-
Table 1. Pseudoexfoliatio lentis in different populations.
50-69 years >70 years
NO I exfol. I VO NO I exfol I 7 0
Finns, N-Finland M + F 50 5 10 170 43 25.3 Finns, Aland M + F 102 13 12.7 121 30 24.6
Lapps M + F 81 12 14.8 17 6 35.3
Greenland, Canada M + F 82 0 - 14 0 Eskimos, USA and
Icelanders M + F 155 17 11.0 324 102 31.5 Indians, Peru M + F 117 1 0.8 42 6 14.3
-
Cheremisses, USSR M 45 1 2.2 Ziryanians, USSR M 54 6 11.1
Bashkirs, USSR M 92 3 3.3 Kalimpong, India M + F 76 1 1.3 24 1 4.2 Tunisians M + F 79 3 3.8 47 9 19.1
Russians, Novosibirsk M + F 143 19 13.3 70 15 21.4
sons aged 70 years or older, i.e. about 4 times more in the older age group, whereas in the three Finnish groups in Table 1 12.4 To out of 233 per- sons 50-69 years old and 25.3 To out of 308 older persons had the ES, only a doubling of the figure.
Table 1 shows that the incidence of exfolia- tion syndrome increases uniformly with age. The prevalences vary significantly between popula- tions. There were only 7 persons with ES among 159 Indians in Peru living at 4000 m elevation compared with 33 out of 223 Finns of the same age and 2 out of 100 Sherpas and Lepchas in the Kalimpong region of India. On the other hand, the Arabs living close to or in the desert in South Tunisia have much more exfoliation, or 12 To out of 126 persons. A statistical difference exists between the Tunisians and Peruvians at the 2 To significance level and between the Finnish populations and all other non-Scandinavian populations at the 3 To level. The difference between the 50-69 year old Finns and the In- dians in Kalimpong was highly significant (P = 0.000).
18 out of 98 Lapps over 50 years old had ex- foliation, whereas not a single one out of 96 Eskimos did so. This difference is again highly significant (Forsius 1979).
Signs in the eye caused by the climate e.g. ultraviolet light, pterygium and the size of the
pinguecula are discussed below and compared with results from the literature.
PART II. REVIEW OF THE LITERATURE
Iris colour and exfoliation syndrome
Comparing Jews of different origin in Israel, Meyer and his colleagues (1984) found that per- sons with brown eyes had more exfoliation than those with lighter coloured eyes. We divided iris colour into 8 grades of pigmentation according to the Martin-Sallers scale comparing grades 1-4 with grades 5-8 in persons over 40 years of age, but we did not find any correlation between ES and iris colour in Lapps or Finns. The Finns belong to the least pigmented populations in the world, and their prevalence of ES is very high. The iris is very dark in Eskimos, as it probably is also in South African Bantus, but we did not find exfoliation at all in the former, whereas the latter have a high prevalence of exfoliation syndrome (Bartholomew 1979). Iris colour and exfoliation syndrome are therefore probably not correlated. We should add that Lindberg (1917) already noted iris colour in his study of depigmentation but did not draw any direct con- clusions on the degree of pigmentation.
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Table 2. Correlation of ES and size of pinguecula.
No Size of pinguecula SD
Skolt Lapps age >40
Tunis age >50
Peru age >50
P = 0.200 No exfol 1 1 1 1.77 0.60 Exfol + 18 1.73 0.74
No exfol Exfol +
88 11
1.89 1.52
0.77 0.59 P = 0.35
P = 0.53 No exfol 145 1.91 0.68 Exfol + 7 2.46 0.52
Arcus senilis and exfoliation syndrome
Arcus senilis is a sign often observed in elderly people. When divided in two degrees, a first degree representing no arcus or one only seen with a biomicroscope and a second with a weak or marked arcus (Forsius 1964), it has been observed by us to be correlated with ES in 7 populations calculated together (Lapps, Finns in the Aland Islands, Cheremisses, Ziryanians, Bashkirs and Indians in India and in Peru). There was an overrepresentation of visible arcus senilis in the exfoliation group, but with no significance over 50 years of age (Fischer’s exact test (2-tai1, P = 0.008).
Climate and exfoliation syndrome
Since the prevalences of ES show great variations in different countries some investigators have been interested in whether climatic factors can influence its appearance. One point of historical interest may be that in one of the first reports on climatic keratopathy (Lugli 1935) two cases out of 9 also had ES.
Taylor (1980), studying aborigines in Aus- tralia, who have a very high prevalence of ES, found a significant correlation between this sign and exposure to ultraviolet light, the subjects affected often also showing climatic keratopathy caused by ultraviolet radiation. Mohammed & Kazmi (1986) found more exfoliation syndrome in people living in the mountains of Pakistan than in those living on the plains, which could point in the same direction.
Zlatar (1965) working in Yugoslavia, thinks solar, mainly infrared, radiation causes lens ex- foliation.
I have also noted signs caused in the eyes by ul-
74
traviolet radiation, namely climatic keratopathy, pterygium and the size of the pinguecula. Neither the Lapps nor the mainly fishing population of the Aland Islands showed any correlation be- tween the size of the pinguecula and ES, how- ever. For two groups, both sexes included the size of the pinguecula was even smaller in those with exfoliation. (Table 2). In addition, the Indian population in Peru at an altitude of 4000 m, where exposure to ultraviolet light is extremely high, showed a low prevalence of ES, even though their pinguecula was very high and red as a result of strong radiation from the sun. This speaks against any direct correlation between UV and ES. It is interesting to note, however, that among the Peruvians studied by our group, the Australian aborigines (Taylor 1980), the moun- tain population in Pakistan (Khanzada 1986) and the populations studied by Zlatar (1965) in Yugo- slavia and Sood (1968) in India, which all are populations living in countries with high UV radiation, the men had more exfoliation syn- drome than the women, whereas in most other statistics women form the majority of all cases. Men work out of doors more than women do and show more eye changes caused by radiation in nearly all populations. If the sun were the cause of ES, men should also top the curves for its prevalence, which, as we know, they rarely do.
Simple glaucoma and capsular glaucoma
The prevalences of simple glaucoma and capsular glaucoma show great variations in population studies. Hollows and Graham (1966) reported 0 Yo for capsular glaucoma and 0.43 070 for chronic simple glaucoma in England, Bengt-
son (1980) 0.86 Vo for simple glaucoma and 0.07 Vo for capsular glaucoma in Southern Swe- den, Lindholm and Thorburn (1980) 1.28 070 for glaucoma in comparable age groups in Central Sweden, of which 60 070 were cases of capsular glaucoma, and Blika and Ringvold (1987) 0.54 070 with simple glaucoma and 0.74 Vo with capsular glaucoma in a population in Norway aged over 49 years. Valle gives figures from Finland in this journal. Bartholomew (1 976) found 1.1 070 open- angle glaucoma and 1.1 Vo capsular glaucoma in blacks in South Africa.
Prevalence of the exfoliation syndrome in elderly people
According to the literature the prevalence of ES varies very much from one country to another, and this is confirmed by my own investigations. This can partly be explained by the material chosen for the investigation or the technique used. The prevalence must be higher in a given population if mydriatics are used, as the exfolia- tion sometimes does not appear in the pupillary area. Our investigations show that you find 20 Vo more cases after dilatation of the pupil, but some authors give lower figures. Diagnosis is so easy, however, that misinterpretations can hardly cause significant differences. We did not see any case of ES in Eskimos, for instance, whereas it is present in over 20 Vo of Finns and Lapps of more than 60 years of age in northern Finland (For- sius 1973, 1979). See also Table 1.
Similarly Alsbirk (personal communication 1987) failed to find any case of exfoliation in more than 900 Greenland Eskimos studied for narrow angle glaucoma, nor did Norn see exfolia- tion syndrome during his many visits to Green- land or Sommer et al. in their extensive glaucoma investigations on the west coast of Alaska (per- sonal communication 1987). But in September 1987 a Swedish ophthalmologist, A. Akerblom- Ostenfeld, returned from Greenland reporting that she had found two cases of ES in Green- landers over 70 years of age in a home for old people. Thus ES does also exist in Eskimos. We must remember, however, that Greenland Eskimos have an admixture of 25-30 070 of foreign blood.
Exfoliation is also rare, only 1.6 Vo, in the Tchutchee, an Eskimo-related people on the Siberian coast of the Bering Sea, but much more
prevalent in immigrants to this area, as published by Lantukh and Pyatin (1982). Our own studies show (see above) that the prevalence of ES is high in Lapps. All these populations, Lapps, Eskimos and Tchutchees, live in arctic surroundings, hence the differences in climate are small.
Some of the differences in the prevalence of ES must depend on different techniques of in- vestigation, e.g. whether they are from the same hospital, as when Horven (1966) found 22 Vo exfoliation in Boston and Roth and Epstein (1980) only 12 Vo some years later. It is there- fore very valuable to perform examinations per- sonally in a number of countries, as Aasved has done in Norway, England and Germany. He did not find any great differences, whereas much more noticeable differences are seen between his figures from Bergen and those from other areas of Norway, e.g. Slagsvold’s rate of 18 070 for ex- foliation syndrome in persons over 60 years of age in Southern Norway compared with the 6 Vo of Aasved in Bergen. This may be explained by the historical differences between the popula- tions. Ringvold et al. have shown recently (1987) that the prevalence of exfoliation may be mark- edly different in areas in Central Norway situated not far from each other, e.g. figures of 10.2 070, 19.6 Vo and 21 070 in person over 65 years of age.
Correspondingly, prevalence figures of ES are lower in the southern part of Great Britain than in northern districts (Hayreh 1968), as is also the case in Sweden according to Linner (personal communication 1987). Only 10 070 of persons with open angle glaucoma have ES in south Sweden (Stromberg 1962) but more month the majority has ES. (Lindblom and Thorburn 1982). In Fin- land the prevalence continues to be very high in the middle and north of the country, as it also is in the Aland Islands in South Finland with its Swedish population. (See also Krause et a1 in this journal.)
Map 1 shows the prevalence figures found in the literature. If two or more sets of statistics have been published from the same geographical area, either all the figures are given or a mean of them. Mostly the percentage given concerns people older than 60 years of age.
The highest prevalence of ES is that found by Faulkner in the Navajo Indians of New Mexico, 38 To, and the lowest rates are from Central Europe, where several authors give figures around 2 Yo.
Other high prevalences have been reported in
75
3 (Cook Islands)
12-37 (USSR)
Percentage of exfoliation syndrome in patients over 60 years
PERCENTAGE OF EXFOLIATION SYNDROME IN PATIENTS OVER 60
IRELAND Madden & Crowley
Travi et al
Nanba et a1 Kinoshita (figures not available)
NORWAY Horven (50-90 yrs) Klouman Aasved Slagsvold Blika et a1
PAKISTAN Mohammad & Kazmi in males in females
Own investigations in Indians
SOUTH AFRICA Bartholomew in blacks
SWEDEN Lydahl Ekstrom (65-74 yrs)
SWITZERLAND Rehsteiner
TURKEY Oergens
USA Hiller et al, Framingham 65-74 yrs)
(75-85 yrs) Faulkner, New Mexico, Indians
Frolova & Khamitova
ITALY
JAPAN
PERU
USSR
11 070 1982
1947
1980
1979
AUSTRIA Fellner & Benedict
CHILE
COOK ISLANDS
Bitran & Villalobos
Heriot et al: 3 persons out of 77 over 65 years
DENMARK Ladehall Bockhaus & Lorentzen
in > 60 yrs >70 yrs
ENGLAND Aasved
FINLAND Krause et al, Oulu Alanko et al, Kuusamo Karna et al, Helsinki
> 7.5 070
5.1 070
1.7 070 1973
7 070 1959
1983 6 070 7.6 070 6.3 070
18 070
56 070
1936 1967 1969 1983 1984
2 070 1965
1.9 vo 1966 4.8 To
4.7 070 1969 11 070
1.9 070 1986
21.8 070 1973 20.9 070 (in preparation) 23.3 070 (in preparation) 8.7 Vo 1983
FRANCE Colin et a1
> 70 yrs in Toulon 3.6 70 in Brest 20.6 070
GERMANY
10 % 1971 1985
5-6 070
18 vo 1979 1987
Aasved Ruprecht et al
4 Yo 0.74- 2.82 070
1969
1985
2 To 1928
18 070 1949 GREECE
Trantas Joannides
ICELAND Forsius
>15 vo 10 vo
24.7 070
1929 1961 2.6 070
5 1982
1979 38 070 1971
INDIA Sood 3.1 To Lamba & Giridhar (figures not available)
1968
1984 12.5- 36.8 To 1984
Finland, Iceland, Ireland, Norway, the Soviet Union, Greece, Turkey, Pakistan, Australia and South Africa. High prevalence figures for ES were also given from Saudi Arabia and Brittany in France in this workshop and are published in this journal.
We know from several authors that the preva- lence of exfoliation syndrome is low in American blacks (Cradle and Sugar 1947; Ball and Shields, see their articles in this journal), but high in Bantus in South Africa (Bartholomew 1979), in spite of the fact that most of the slaves taken to America were Bantus. Dr. A. Ihalainen from my own department in Oulu, at which ES is seen every day, but who is now working in Tanzania,
has recently reported to me that exfoliation is very rare in this part of Africa, also inhabited by Bantu tribes. The ES is thus not uniformly distributed in Africa, either.
Percentage of capsular glaucoma
An interesting discussion on the role of ES in glaucoma was held in Munich, as reported in Genesis of Glaucoma, edited by H-J. Merte (1978). The participants, well-known specialists in glaucoma, Goldmann, Francois, Armaly and Kolker, estimated the proportion of exfoliation in the glaucoma population in their areas to be
77
24-66 (Finland
34-54 (USSR)
18 (New Zealand)
Percentage of exfoliation syndrome in olpen-angle glaucoma
PERCENTAGE O F EXFOLIATION SYNDROME JUGOSLAVIA IN OPEN-ANGLE GLAUCOMA Zlatar 48 Vo 1965
NEW ZEALAND 18 7 0 1953 If after the nercentage is written LTP, the figure is taken from Wilson
reports of trabeculoplastics
ARGENTINA Zavalia Sampaolesi
AUSTRALIA Taylor in aborigines Gillies et al
BULGARIA Dragonov
ENGLAND Thomassen Hollows & Graham Aasved Horns
FINLAND Lindberg Kaivonen Krause Tuulonen & Airaksinen Pohjanpelto Valle Rouhiainen & Terasvirta Perasalo & Raitta
Demailly et al
GERMANY Barkhoff Leydhecker
GREECE Trantas Joannides
Als
ISLE OF MAN Clements
INDIA Irvine Sood
ITALY Bussaca Travi et al
Ogino et al Eguchi et al
FRANCE
ICELAND
JAPAN
44 Vo 14 v o
8 Vo 20 Vo LTP
-25 "70
2 070
0-5.5 VO 11.5 Vo 14 Vo LTP?
50 Vo 24 Vo 42 Vo 66 Vo LTP 52 Vo LTP 40 Vo 58 Vo LTP 50 Vo LTP
15 Vo LTP
11 Vo 0 Vo
46.6 Vo 40 Vo
72 Vo
55 To
24 Vu 18 v o
60 Vo 15.5 Vo
10.6 Vo 26 Vo LTP
1950 1961
1980 1983
1987
1949 1966 1971 1983
1917 1961 1973 1983 1985 1985 1986 1987
1985
1969 1973
1929 1961
1980
1968
1940 1968
1927 1947
1963 1985
at most 20 70, probably closer to 5 Yo, which shows capsular glaucoma to be of much less im- portance in Central Europe and parts of the USA than in Scandinavia.
I t has not always been possible to separate hypertension and types of glaucoma other than open-angle glaucoma from the figures given, and often the figures are taken from statistics
NORWAY Malling Horven Holst Thomassen Klouman Aasved Slagsvold Blika et al Bergei Anmarkrud et al
POLAND Smolenska-Janicova
SCOTLAND Garrow Bartholomew
SOUTH AFRICA Luntz in blacks
in whites Bartholomew
Benjumeda
Stromberg Linner, North Sweden Lindblom & Thorburn, Hudiksvall Bengtsson, Dalby Olivius & Thorburn, U m e i
SPAIN
SWEDEN
SWITZERLAND Vogt
Irvine Gradle & Sugar Lemoine Horven Layden & Shaffer Roth & Epstein Kozart & Yamoff Thomas et al Horns et al Lieberman et al
Forsius, Siberia Musabejli Mamedov et al
USA
USSR
41 Vo 93 Vo 82 070 79 Vo 46.9 70 32.9 Vo 37.2 Vo 44 Vo LTP 38.3 Vo LTP 54 70 LTP
11.9 Yo
16 Vo 62 Vo
41 Vo
50 To 4.3 Vo
1.4 Vo
10 Vo 50 Vo
75 Vo
65 Vo 7.4 Vo
8.6 Vo
4 Vo 12 Vo 3.7 Vo
28 Vo 3 Vo
12 070
7 Vo 12 70 LTP
8 70 LTP 12 v0 LrP
47 Vu 34 Vu 54 Vo LTP
1923 1935 1947 1949 1967 1971 1984 1984 1986 1987
1978
1938 1979
1970
1976
1978
1962 1978
1982 1981 1978
1930
1940 1947 1950 1966 1974 1980 1982 1982 1983 1983
1979 1950 1986
on the results of laser trabeculoplasty (LTP) in both capsular glaucoma and simple glaucoma cases. Capsular glaucoma more often leads to laser trabeculoplasty and surgery than does sim- ple glaucoma, so that the prevalence figures taken this way may be too high. We have two sets of statistics from our department, Oulu Uni- versity Central Hospital, for example, Krause's
79
00 0
- Percentage of glaucoma in patients with exfoliation syndrome
PERCENTAGE O F GLAUCOMA IN PATIENTS WITH ISRAEL EXFOLlATION SYNDROME Meyer et a1 31.8 Vo 1984
ARGENTINA Maggi, Zavalia & Ferrero Sampaolesi
AUSTRALIA Gillies in whites Taylor in abrogines
Tarkkanen
Audibert
GERMANY Haydon
GREECE Trantas Joannides et al
ICELAND Als
INDIA Sood
IRELAND Madden
FlNLAND
FRANCE
lTALY Bussaca
NORWAY Klouman Hansen & Sellevold Slagsvold
PAKISTAN Mohammad & Kazni
SOUTH AFRICA Bartholomew in blacks
SWEDEN Stromberg
Vogt TURKEY
Oergens USA
Hiller et al, Framingham Faulkner, New Mexico in Indians Gradle & Sugar, Philadelphia
Frolova & Khamitova
SWITZERLAND
USSR
76 Vo 1927 83 Vo
80 1950 1968 25 Vo
41 Vo 37.2 Vo
1967 1968 1984 60 Vo
A 1978 1980
31 Vo 1986 60 Vo 1962
51 '70 1979 48 Vn 1957
10 Vo 1962 60 Vo 1986
75 Vo 1930 33 Vo 40 Vo
1929 1968 42 Vn 1949
30.8 '70 1980 0 vo 16 Vo
81.8 Vo
1982 1971 1947 32.5 Vo 1968
75 '70 1982 43 Vo 1984
figure of 42.3 070 from 1973 based on all glauco- ma cases and Tuulonen & Airaksinen's 66 'T'o for trabeculoplastic cases from 1983.
Several sets of statistics are given for Finland, covering 5 central hospitals with prevalence rates varying between 24 'T'o and 66 "70 (Kaivonen 1962, Tuulonen & Airaksinen 1983), with an arith- metical mean of 49 "70. We should add, too, that Lindberg's original prevalence figure (1917) was 50 'T'n (see map 2).
al. 1982) had glaucoma, whereas 81.8 'T'o of the patients in an ophthalmological hospital did so according to Gradle and Sugar (1947).
Incidence of exfoliation syndrome in cataract patients
Since a number of authors have reported that they observe lens opacities disproportionally often in patients with exfoliation syndrome, we tried to use published percentages for exfoliation in cataract patients (Fig. 4). The incidence varies from 0.3 07n in Poland (Smolenska-Janicowa 1978) to 33 "70 in Finland, the latter study being a histological one by Krause and Tarkkanen (1978) (map 4).
Glaucoma in patients with exfoliation
It seems logicai that exfoliation syndrome should not result in high eye pressure in the first years after it has appeared. It takes time before enough particles have formed and have found their way to the trabeculae. This means that if exfoliation is found only after dilatation of the pupil it has probably not yet reached clinical importance.
The figures collected (map 3) vary so much that they probably are not in themselves reliable. Population studies give much lower figures than series collected from hospitals, where the cases are probably selected. To show this, we can choose works from the USA. Not one out of the patients with exfoliation syndrome in the well- known Framingham population study (Hiller et
6
Con c I u si o n s
We have now collected enough data to con- clude that there is great variation in the preva- lences of ES in the world. Reliable prevalences can best be obtained from population investiga- tions based on random samples, whereas figures from eye hospitals are much higher, probably because most of those with ES who arrive at the hospital have experienced trouble as a result of
81
Percentage of exfoliation syndrome in patients with senile cataract
PERCENTAGE OF EXFOLIATION SYNDROME IN PATIENTS WITH SENILE CATARACT
AUSTRALIA Taylor in aborigines 20 070 1980
Lindberg (Helsinki and Leningrad) 20 '70 1917 Tarkkanen 26 070 1962 Krause & Tarkkanen 33 "70 1978
FINLAND
FRANCE Paufigue 3.5 070 1958
INDIA lrvine (Madras)
Bussaca ITALY
8 '70 1940
26 070 1927
their exfoliation. The danger associated with the exfoliation syndrome is therefore highly overestimated in departments which handle hypertension and perform eye surgery.
ES is a problem with great human and econo- mic consequences in some countries. W e know from official statistical records tha t 3-4 '70 of people over 60 years of age in Finland re- ceive free medication fo r glaucoma, of which as many as 50 '70 may have capsular glaucoma. To give a n example, 21 070 of the beds in the oph- thalmological department of Kotka Central Hospital are occupied by glaucoma patients (Valle 1985). In many hospitals in Scandinavia capsular glaucoma patients form the majority of all glaucoma operations. W e have additionally to consider the costs of such medical treatment.
References
Older works not in the list o f references given below are t o be found in the almost complete reference list in Joannides et al. (1969) in Tark- kanen's dissertation 1962, or in Aasved's work from 1969.
References
Aasved H (1969): The geographical distribution of fibrillopathia epitheliocapsularis, so-called senile ex- foliation or pseudoexfoliation of the anterior lens capsule. Acta Ophthalmol (Copenh) 47: 792-810.
Aasved H (1971): The frequency of fibrillopathia epitheliocapsularis (so-called senile exfoliation or pseudoexfoliation) in patients with open-angle glaucoma. Acta Ophthalmol (Copenh) 49: 194-210.
Alanko H I , Jaanio E, Miettinen R, Ollila 0 - P & Takala J: Unpublished data.
NORWAY Horven
POLAND Smolenska-Janicova
Guzec et a1 SCOTLAND
Bartholomew SOUTH AFRICA
Bartholomew in blacks
Bettman & Albuquerque, New Mexico in Indians Irvine, California Layden & Shaffer, California
SAUDI ARABIA
USA
18 070
0.3 070
25 070
2.5 070
26 "70
9 070
3 To 20 070
1966
1978
1987
1979
1979
1972 1940 1974
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Author’s address: H. Forsius, Population Genetics Unit, Samfundet Folkhalsan, Stationsv. 13, 02700 Grankulla.
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