exfoliation syndrome ( xfs ) is an age - related generalized disease of the extracellular matrix , characterised by the production and progressive accumulation of fibrillar extracellular material in many ocular and extraocular tissues , and is often associated with glaucoma .
xfs causing an increase in trabecular outflow resistance is the most common cause of open - angle glaucoma .
extracellular fibrillar material is widely present in the skin , lungs , liver , heart , gallbladder , blood vessels , and cerebral meninges .
xfs has been reported to be associated with systemic vascular diseases such as hypertension , angina , stroke , myocardial infarction , and abdominal aortic aneurysm [ 4 , 5 ] .
xfs also has nonophthalmic manifestations such as hyperhomocysteinemia and sensorineural hearing loss [ 69 ] .
while there are two different epidemiological studies available from the eastern mediterranean ( adana province ) and middle black sea ( tokat province ) regions of turkey , no study has been conducted in central anatolia [ 10 , 11 ] .
in addition , the relationship of xfs with systemic diseases such as diabetes mellitus ( dm ) , hypertension ( ht ) , coronary artery disease ( cad ) , smoking , and alcohol intake has not been investigated in these previous two studies from turkey .
the relationship between cardiovascular diseases and xfs in turkey has been investigated , but there are no relevant epidemiological studies [ 12 , 13 ] .
this study was carried out in sivas , a province in the central anatolia region of turkey , with a population of 623,000 .
sivas has the highest number of villages in the country and is the second largest city of turkey in terms of surface area . besides
, it is the second highest city of central anatolia ( altitude : 1285  m ) .
the central anatolia region receives one of the lowest amounts of rainfall in the country and has a continental climate .
the primary aim of this hospital - based study was to investigate the xfs frequency and its relationship with systemic diseases such as dm , ht , cad , smoking , and alcohol intake .
this prospective , single blind , and hospital - based study was conducted at the sivas province numune hospital ophthalmology clinic between may 2013 and october 2013 .
this study was approved by the cumhuriyet university medical faculty clinical studies ethics committee and carried out in accordance with the principles of the helsinki declaration .
cases over the age of 45 years who presented to the clinic were included in the study .
a detailed ophthalmic and systemic history of the patients was obtained and a complete ophthalmic examination was performed .
this examination consisted of a visual acuity test with a snellen chart , slit lamp examination , intraocular pressure ( iop ) measurement with the goldmann applanation tonometer , gonioscopy , visual field analysis , and dilated fundus examination .
xfs was diagnosed with the presence of exfoliative material on the lens anterior capsule or iris on slit lamp examination .
glaucoma was diagnosed with an iop over 21  mmhg , glaucomatous optic nerve damage , visual field defect , previous history of glaucoma surgery , or the presence of a bleb .
nuclear , cortical , and posterior subcapsular cataracts were rated with the conventional 04 grading system .
age - related macular degeneration ( amd ) was diagnosed with the findings of this disease on dilated fundus examination .
information on ht , dm , cad , smoking , and alcohol intake was obtained from the patients with standard queries .
the patients were divided into two groups as an xfs group and non - xfs group according to the presence of exfoliative material .
the groups were compared in terms of glaucoma , cataract , amd , phacodonesis , ht , dm , cad , and frequency of smoking and alcohol intake . 
 statistical method .
the data were evaluated by means of the spss 20.0 program and the descriptive statistics were evaluated using chi - square , t - test , and logistic regression analyses .
the appropriateness of the model used in logistic regression analysis was evaluated with the hosmer - lemeshow goodness - of - fit test and the  was 0.95 with p > 0.05 .
table 1 shows the relationship between xfs and age , gender , and the other related factors .
a statistically significant relationship was found between xfs and advancing age in both males and females ( p = 0.001 , table 2 ) .
xfs was found in 140 male patients ( 14.0% ) and in 72 female patients ( 6.5% ) ( table 3 ) .
the xfs was bilateral in 108 of the 140 male cases ( 77.1% ) and 53 of the 72 female cases ( 73.6 ) .
xfs was bilateral in 161 ( 75.9% ) and unilateral in 51 ( 24.1% ) of the total number of 212 cases .
glaucoma was found at a significantly higher frequency in the xfs group than in the non - xfs group .
the mean age of the glaucoma cases was 72.0  9.0 years in the xfs group and 62.7  9.9 years in the non - xfs group .
the mean iop was 15.02  5.07  mmhg in the xfs group and 14.17  2.80  mmhg in the non - xfs group .
this difference between two groups for iop was found to be statistically significant ( p = 0.001 , table 1 ) .
the mean iop in the affected eye ( 16.85  6.16  mmhg ) was found to be significantly higher ( 14.65  3.82  mmhg ) than the other eye in unilateral xfs cases ( p = 0.037 ) .
the relationship between xfs and cataract , phacodonesis , and amd was found to be statistically significant ( p = 0.001 ) .
the results are shown in table 1 . according to the results of the logistic regression analysis adjusted for age , a strong relationship was found between xfs and glaucoma , cataract , phacodonesis , and amd ( table 4 ) .
after adjusting for age , the relationship between xfs and age , male gender , and cad was found to be statistically significant ( p = 0.001 , p = 0.001 , and p = 0.016 , resp . ) .
it is reported to show a wide variation with a frequency of 0% in eskimos , 0.4% in china , 3.4% in japan , 9.1% in jordan , 16.1% in greece , and 23% in sweden [ 1419 ] .
the xfs frequency in the other two studies conducted in turkey was 7.2% in the eastern mediterranean region in the yalaz et al .  
reported an increased xfs frequency with increase in the annual number of sunny days , decreased mean high july temperature , decreased mean january low temperature , and lower elevation above sea level . according to data from the turkey general directorate of meteorology , the mean temperatures of july and january in sivas province were 20.2c and 3.3c , respectively , and the duration of sunshine was 2421 hours / year with an altitude of 1285 meters . however , a high xfs rate has been reported in navajo indians living in arizona at an altitude of about 1500  m .
sivas has relatively low july and january mean temperatures and also a relatively high altitude .
this study has shown a significant increase in xfs frequency with advancing age along with other studies [ 1618 ] .
xfs was also found to be more frequent in male patients than in females and this difference was statistically significant .
.   found xfs to be more common in males , but cumurcu et al .   found no relationship between gender and xfs .
there are studies reporting a higher xfs frequency in males and in females [ 18 , 19 ] .
however , many studies have reported no significant relationship between gender and xfs [ 16 , 17 , 22 ] . as in previously reported studies ,
as 6.9% in xfs patients . the high frequency of glaucoma in this hospital - based study may be due to the regular follow - ups attended by glaucoma patients .
similarly a high frequency of glaucoma has been found in hospital - based studies with reported rates of 33.1% by al - bdour et al .
kaljurand and teesalu   reported a high frequency of 35.7% for glaucoma in their population - based study although the glaucoma frequency is generally lower in population - based studies [ 4 , 26 , 27 ] .
there is a well - known relationship between cataracts and xfs [ 17 , 25 , 28 ] . regarding the cataract frequency in xfs cases in studies conducted in turkey , yalaz et al
.   found a frequency of 84.6% similar to our result while cumurcu et al .   reported a lower rate at 43.6% .
similarly , al - bdour et al .   reported a phacodonesis frequency of 7.9% in xfs patients .
a statistically significant relationship was found between amd and xfs in our study , similar to other studies [ 31 , 32 ] . the blue mountains eye study reported a significant relationship between xfs and a history of ht , a history of angina or combined angina or myocardial infarction , and a history of stroke .
while no relationship was found between xfs and ht or dm in our study , a significant relationship was found with cad . of the studies from turkey ,
citirik et al .   showed a significant relationship between cad and xfs , but emiroglu et al
many studies have shown a positive relationship between cardiovascular diseases and xfs [ 4 , 3335 ] .
furthermore , elevated blood homocysteine levels have been reported to be a risk factor in terms of cardiovascular disease in xfs patients .
however , other studies have found no relationship between xfs and cardiovascular disease [ 3638 ] . in conclusion
as far as we are aware , this hospital - based study is the first from turkey to investigate the relationship between xfs and ht , dm , and cad .
the frequency of unilateral and bilateral xfs was 10.1% in this hospital - based study .
a statistically significant relationship was found between xfs and advancing age , gender , and cad .
 
 aim . 
 the aim of this study was to investigate the frequency of exfoliation syndrome in the central anatolia region of turkey and to evaluate its relationship with cardiovascular and ocular diseases . 
 methods . 
 patients over the age of 45 years who presented to the clinic were included in the study . 
 all cases underwent a comprehensive ophthalmology examination . 
 exfoliation syndrome was diagnosed with the presence of exfoliative material on the lens anterior capsule or iris on slit lamp examination . 
 the patients were divided into two groups as the exfoliation syndrome group and nonexfoliation syndrome group according to the presence of exfoliative material . results . 
 exfoliative material was found in one or both eyes of 212 of the 2103 patients ( 10.1% ) evaluated within the scope of the study . 
 a significant relationship was found between exfoliation syndrome and increasing age and male gender . 
 a significant relationship was found between exfoliation syndrome and glaucoma , cataracts , age - related macular degeneration , and phacodonesis . while no relationship was found between exfoliation syndrome and hypertension or diabetes mellitus , a significant relationship was found with coronary artery disease . 
 conclusion . 
 
 the unilateral or bilateral exfoliation syndrome frequency was 10.1% in this hospital - based study . 
 a statistically significant relationship was found between exfoliation syndrome and advancing age , gender , and coronary artery disease . 
1. Introduction
2. Materials and Methods
3. Results
4. Discussion