Skip to main content

Thank you for visiting You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

Analysis of the choroidal vascularity in asymmetric pseudoexfoliative glaucoma using optical coherence tomography-based image binarization



To analyse choroidal vascular properties using an image binarization tool in patients with asymmetric pseudoexfoliative glaucoma (PXG) and compare them with healthy individuals.


This cross-sectional study included 144 eyes of 96 patients. The eyes were divided into three groups: 48 glaucomatous eyes and 48 non-glaucomatous contralateral eyes with no clinically observable pseudoexfoliation material of patients with asymmetric PXG, and 48 control eyes. Enhanced depth imaging optical coherence tomography scans of the macula and 3.4-mm diameter, 360-degree circle scans of the optic nerve head were binarized using ImageJ software (National Institutes of Health, Bethesda, MD, USA). The choroidal vascularity index (CVI) was calculated as the ratio of the luminal area to the total circumscribed choroidal area.


The macular CVI (mCVI) was significantly lower in the glaucomatous eyes than in the fellow eyes (p = 0.007) and the control eyes (p = 0.001). The peripapillary CVI (pCVI) in all sectors was significantly lower in the glaucomatous eyes than in the other two groups (all p < 0.05). Non-glaucomatous fellow eyes had lower CVI values in the macula and in the peripapillary region, except for the superior-nasal and nasal sectors, compared to the control eyes (all p < 0.05). In multivariate regression analysis, while the cup-to-disc ratio was negatively associated with the pCVI, AL was negatively associated with the mCVI in both eyes of patients with PXG.


CVI was decreased in the macula and peripapillary area in glaucomatous eyes. Furthermore, the CVI tended to decrease in non-glaucomatous fellow eyes of PXG patients. This finding may suggest subclinical involvement and require further exploration into the pathogenesis of glaucoma.

This is a preview of subscription content, access via your institution

Access options

Buy article

Get time limited or full article access on ReadCube.


All prices are NET prices.

Fig. 1: The horizontal macular scan centred on the central foveal region with EDI mode of SD-OCT (Spectralis, Heidelberg Engineering GmbH, Heidelberg, Germany).
Fig. 2: The 3.4-mm-diameter 360-degree-circle scan centred on the optic nerve head with RNFL analysis mode of SD-OCT (Spectralis, Heidelberg Engineering GmbH, Heidelberg, Germany).


  1. Chauhan BC. Detection of glaucoma: the role of new functional and structural tests. Curr Opin Ophthalmol. 2004;15:93–5.

    Article  Google Scholar 

  2. Grieshaber MC, Mozaffarieh M, Flammer J. What is the link between vascular dysregulation and glaucoma? Surv Ophthalmol. 2007;52:S144–154.

    Article  Google Scholar 

  3. Wareham LK, Calkins DJ. The neurovascular unit in glaucomatous neurodegeneration. Front Cell Dev Biol. 2020;8:452.

    Article  Google Scholar 

  4. Cherecheanu AP, Garhofer G, Schmidl D, Werkmeister R, Schmetterer L. Ocular perfusion pressure and ocular blood flow in glaucoma. Curr Opin Pharmacol. 2013;13:36–42.

    Article  CAS  Google Scholar 

  5. Schlötzer-Schrehardt U, Zenkel M. The role of lysyl oxidase-like 1 (LOXL1) in exfoliation syndrome and glaucoma. Exp Eye Res. 2019;189:107818.

    Article  Google Scholar 

  6. Elhawy E, Kamthan G, Dong CQ, Danias J. Pseudoexfoliation syndrome, a systemic disorder with ocular manifestations. Hum Genom. 2012;6:22.

    Article  Google Scholar 

  7. Holló G. Vascular dysfunction in exfoliation syndrome. J Glaucom. 2018;27:S72–S74.

    Article  Google Scholar 

  8. Parekh P, Green WR, Stark WJ, Akpek EK. Electron microscopic investigation of the lens capsule and conjunctival tissues in individuals with clinically unilateral pseudoexfoliation syndrome. Ophthalmology. 2008;115:614–9.e2.

    Article  Google Scholar 

  9. Zheng X, Sakai H, Goto T, Namiguchi K, Mizoue S, Shiraishi A, et al. Anterior segment optical coherence tomography analysis of clinically unilateral pseudoexfoliation syndrome: evidence of bilateral involvement and morphologic factors related to asymmetry. Investig Ophthalmol Vis Sci. 2011;52:5679–84.

    Article  Google Scholar 

  10. Arnarsson A, Sasaki H, Jonasson F. Twelve-year incidence of exfoliation syndrome in the Reykjavik eye study. Acta Ophthalmol. 2013;91:157–62.

    Article  Google Scholar 

  11. Puska PM. Unilateral exfoliation syndrome: conversion to bilateral exfoliation and to glaucoma: a prospective 10-year follow-up study. J Glaucom. 2002;11:517–24.

    Article  Google Scholar 

  12. Schlötzer-Schrehardt U, Küchle M, Naumann GO. Electron-microscopic identification of pseudoexfoliation material in extrabulbar tissue. Arch Ophthalmol. 1991;109:565–70.

    Article  Google Scholar 

  13. Yüksel N, Karabaş VL, Arslan A, Demirci A, Cağlar Y. Ocular hemodynamics in pseudoexfoliation syndrome and pseudoexfoliation glaucoma. Ophthalmology. 2001;108:1043–9.

    Article  Google Scholar 

  14. Dayanir V, Topaloğlu A, Ozsunar Y, Keceli M, Okyay P, Harris A. Orbital blood flow parameters in unilateral pseudoexfoliation syndrome. Int Ophthalmol. 2009;29:27–32.

    Article  Google Scholar 

  15. Çınar E, Yüce B, Aslan F. Retinal and choroidal vascular changes in eyes with pseudoexfoliation syndrome: a comparative study using optical coherence tomography angiography. Balk Med J. 2019;37:9–14.

    Google Scholar 

  16. Li F, Ma L, Geng Y, Yan X, Zhang H, Tang G, et al. Comparison of macular choroidal thickness and volume between pseudoexfoliative glaucoma and pseudoexfoliative syndrome. J Ophthalmol. 2020;2020:8886398.

    PubMed  PubMed Central  Google Scholar 

  17. Goharian I, Sehi M. Is there any role for the choroid in glaucoma? J Glaucom. 2016;25:452–8.

    Article  Google Scholar 

  18. Hayreh SS. Blood supply of the optic nerve head and its role in optic atrophy, glaucoma, and oedema of the optic disc. Br J Ophthalmol. 1969;53:721–48.

    Article  CAS  Google Scholar 

  19. Iovino C, Pellegrini M, Bernabei F, Borrelli E, Sacconi R, Govetto A, et al. Choroidal vascularity index: an in-depth analysis of this novel optical coherence tomography parameter. J Clin Med. 2020;9:595.

    Article  CAS  Google Scholar 

  20. Agrawal R, Ding J, Sen P, Rousselot A, Chan A, Nivison-Smith L, et al. Exploring choroidal angioarchitecture in health and disease using choroidal vascularity index. Prog Retin Eye Res. 2020;77:100829.

    Article  CAS  Google Scholar 

  21. Demircan S, Yılmaz U, Küçük E, Ulusoy MD, Ataş M, Gülhan A, et al. The effect of pseudoexfoliation syndrome on the retinal nerve fiber layer and choroid thickness. Semin Ophthalmol. 2017;32:341–7.

    Article  Google Scholar 

  22. Bayhan HA, Aslan Bayhan S, Can I. Evaluation of the macular choroidal thickness using spectral optical coherence tomography in pseudoexfoliation glaucoma. J Glaucom. 2016;25:184–7.

    Article  Google Scholar 

  23. Dursun A, Ozec AV, Dogan O, Dursun FG, Toker MI, Topalkara A, et al. Evaluation of choroidal thickness in patients with pseudoexfoliation syndrome and pseudoexfoliation glaucoma. J Ophthalmol. 2016;2016:3545180.

    PubMed  PubMed Central  Google Scholar 

  24. Moghimi S, Nekoozadeh S, Motamed-Gorji N, Chen R, Fard MA, Mohammadi M, et al. Lamina cribrosa and choroid features and their relationship to stage of pseudoexfoliation glaucoma. Investig Ophthalmol Vis Sci 2018;59:5355–65.

    Article  Google Scholar 

  25. Sarrafpour S, Adhi M, Zhang JY, Duker JS, Krishnan C. Choroidal vessel diameters in pseudoexfoliation and pseudoexfoliation glaucoma analyzed using spectral-domain optical coherence tomography. J Glaucom. 2017;26:383–9.

    Article  Google Scholar 

  26. European Glaucoma Society Terminology and Guidelines for Glaucoma, 4th Edition—Chapter 2: classification and terminology supported by the EGS foundation: part 1: foreword; introduction; glossary; chapter 2 classification and terminology. Br J Ophthalmol. 2017;101:73–127.

  27. Agrawal R, Salman M, Tan KA, Karampelas M, Sim DA, Keane PA, et al. Choroidal vascularity index (CVI)—a novel optical coherence tomography parameter for monitoring patients with panuveitis? PLoS ONE. 2016;11:e0146344.

    Article  Google Scholar 

  28. Pellegrini M, Giannaccare G, Bernabei F, Moscardelli F, Schiavi C, Campos EC. Choroidal vascular changes in arteritic and nonarteritic anterior ischemic optic neuropathy. Am J Ophthalmol. 2019;205:43–9.

    Article  Google Scholar 

  29. Park JW, Suh MH, Agrawal R, Khandelwal N. Peripapillary choroidal vascularity index in glaucoma—a comparison between spectral-domain OCT and OCT angiography. Invest Ophthalmol Vis Sci. 2018;59:3694–701.

    Article  Google Scholar 

  30. Koo TK, Li MY. A guideline of selecting and reporting intraclass correlation coefficients for reliability research. J Chiropr Med. 2016;15:155–63.

    Article  Google Scholar 

  31. Rodriguez-Una I, Azuara-Blanco A. New technologies for glaucoma detection. Asia Pac J Ophthalmol. 2018;7:394–404.

    Google Scholar 

  32. Desai MA, Lee RK. The medical and surgical management of pseudoexfoliation glaucoma. Int Ophthalmol Clin. 2008;48:95–113.

    Article  Google Scholar 

  33. Konstas AG, Hollo G, Astakhov YS, Teus MA, Akopov EL, Jenkins JN, et al. Factors associated with long-term progression or stability in exfoliation glaucoma. Arch Ophthalmol. 2004;122:29–33.

    Article  Google Scholar 

  34. Park JH, Yoo C, Girard MJA, Mari JM, Kim YY. Peripapillary vessel density in glaucomatous eyes: comparison between pseudoexfoliation glaucoma and primary open-angle glaucoma. J Glaucoma. 2018;27:1009–16.

    Article  Google Scholar 

  35. Rebolleda G, Pérez-Sarriegui A, De Juan V, Ortiz-Toquero S, Muñoz-Negrete FJ. A comparison of two optical coherence tomography-angiography devices in pseudoexfoliation glaucoma versus primary open-angle glaucoma and healthy subjects. Eur J Ophthalmol. 2019;29:636–44.

    Article  Google Scholar 

  36. Ritch R, Schlötzer-Schrehardt U. Exfoliation syndrome. Surv Ophthalmol. 2001;45:265–315.

    Article  CAS  Google Scholar 

  37. Egrilmez ED, Karadeniz Ugurlu S, Sahin Atik S, Guven YZ. The effect of pseudoexfoliation syndrome on choroidal thickness in open-angle glaucoma. Arq Bras Oftalmol. 2019;82:400–6.

    Article  Google Scholar 

  38. Ozge G, Koylu MT, Mumcuoglu T, Gundogan FC, Ozgonul C, Ayyildiz O, et al. Evaluation of retinal nerve fiber layer thickness and choroidal thickness in pseudoexfoliative glaucoma and pseudoexfoliative syndrome. Postgrad Med. 2016;128:444–8.

    Article  Google Scholar 

  39. Suh MH, Park JW, Khandelwal N, Agrawal R. Peripapillary choroidal vascularity ındex and microstructure of parapapillary atrophy. Investig Ophthalmol Vis Sci. 2019;60:3768–75.

    Article  Google Scholar 

Download references


The authors indicate they have no financial disclosures. The authors, their families, their employers and their business associates have no financial or proprietary interest in any product or company associated with any device, instrument or drug mentioned in this article. The authors have not received any payment as consultants, reviewers or evaluators of any of the devices, instruments or drugs mentioned in this article.

Author information

Authors and Affiliations



MS was responsible for designing the study conceptualisation, conducting the search, applying the ethical committee, screening potentially relevant studies, collecting the data and patient’s information, extracting and analysing data, interpreting results, writing the draft. OI was responsible for designing the study conceptualisation, conducting the search, screening potentially relevant studies, collecting the data and patient’s information, extracting and analysing data. ES was responsible for performing statistical analysis and supervision, providing potentially eligible participants, correcting and revising the final version of the manuscript. UE was responsible for performing supervision and feedback, providing potentially eligible participants, correcting and revising the final version of the manuscript.

Corresponding authors

Correspondence to Mert Simsek or Onur Inam.

Ethics declarations

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the Ankara Education and Research Hospital and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Disclosure statement

The authors indicate no financial support, budget, or payment. This article has been read and approved by all the authors. The authors indicate no financial support, budget, grant, or payment.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Simsek, M., Inam, O., Sen, E. et al. Analysis of the choroidal vascularity in asymmetric pseudoexfoliative glaucoma using optical coherence tomography-based image binarization. Eye 36, 1615–1622 (2022).

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:

This article is cited by


Quick links