Comparison of Serum C3, C3a, C4 Levels Between Cataract Patients with and without Pseudoexfoliation and Normal Individuals

Comparison of Serum C3, C3a, C4 Levels Between Cataract Patients with and without Pseudoexfoliation and Normal Individuals | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparison of Serum C3, C3a, C4 Levels Between Cataract Patients with and without Pseudoexfoliation and Normal Individuals Gülce Gökgöz Özışık, Hüseyin Kayadibi, İsmail Cagatay Caglar, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9452519/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Backgrounds: We aimed to compare serum complement C3, C3a, and C4 levels between cataract patients with and without pseudoexfoliation syndrome, and to compare these groups with the control group. Methods: There were three different groups in the study. The total of 150 patients, 50 in each group, were included. Group 1 consisted of cataract patients with pseudoexfoliation, Group 2 consisted of cataract patients without pseudoexfoliation, and Group 3 consisted of healthy individuals. After centrifugation of the blood samples, the serum portion was stored at –80°C until the analysis. Complement C3, C3a, and C4 levels were evaluated in these three groups using commercially available sandwich ELISA kits. Results: There was a statistically significant difference just between Group 1 and Group 2 regarding C4 values. However, after the age correction, this significance was disappeared. Conclusions: According to this study, there may not be a relationship between the complement pathway and the immune system in cataract patients with and without pseudoexfoliation syndrome. C3 C3a C4 cataract complement pathway pseudoexfoliation Background Cataract is one of the most common causes of blindness worldwide [1]. The pathophysiology of cataract formation still needs to be clearly understood. Recently, emphasis has been placed on the complement system in cataract development [2,3]. In addition, the presence of pseudoexfoliation is thought to be a risk factor for the cataract development [4,5]. Pseudoexfoliation syndrome is an extracellular matrix anomaly characterized by the accumulation of fibrillar material in ocular tissues, skin, and various organs. It is age-related and so common worldwide. Involvement occurs in almost all tissues in the anterior segment of the eye. Thus, the risk of complications in cataract surgery increases as clinical problems such as open-angle glaucoma, phacodenesis, lens subluxation, inadequate mydriasis, blood-aqueous barrier disorder, and corneal decompensation occur in the eye [6-8]. Since the pathophysiological mechanism of this syndrome is still unclear, several biomarker studies have been conducted in patients with pseudoexfoliation [9-11]. In the study of Doudevski et al., the complement C3a level was found to be high in the aqueous humor of patients with pseudoexfoliative glaucoma. High C3a levels have been shown to indicate complement system activation in these patients [12]. The complement system is the main part of the human innate immune system. Component 3 is the central element of the complement system and is involved in the activation of all three pathways of the complement system [13]. Component 4 is an essential complement for the classical and lectin pathways of the complement system [14]. Serum complements C3, C3a, and C4 levels have not been compared in patients with cataracts with and without pseudoexfoliation. Therefore, we aimed to compare serum complement C3, C3a, and C4 levels between cataract patients with and without pseudoexfoliation syndrome, as well as to compare these groups with the healthy controls. Methods This is a case controlled cross-sectional study. The study was conducted in accordance with the Declaration of Helsinki criteria. Hitit University Faculty of Medicine Ethics Committee approval was received before the study (Decision no: 172, Date: 14/07/2020). All patients signed an informed consent form. One hundred fifty patients who applied to our clinic between September 2020 and March 2023 were included in the study. These patients were divided into three groups: 50 cataract patients with pseudoexfoliation (Group 1), 50 cataract patients without pseudoexfoliation (Group 2), and 50 healthy individuals (Group 3). The inclusion and exclusion criteria for the study are as following: Inclusion criteria: Being ages between 50-80 years. Having cataracts with or without pseudoexfoliation. Exclusion criteria: Having autoimmune diseases or receiving immunosuppression therapy. Patients with glaucoma, uveitis, retinal disease, congenital cataracts, and secondary cataracts due to diabetes, trauma, steroid use, or any other reason. The retinal nerve fiber layer evaluation by Optical Coherence Tomography (Heidelberg Spectralis OCT, Heidelberg Engineering, Heidelberg, Germany) and intraocular pressure (IOP) were performed to exclude patients with glaucoma. All individuals' vision levels and body mass index (BMI) were calculated. Intraocular pressure of the individuals was measured with Canon full autotonometer TX-F, and axial lengths of eye were measured with Nidek AL-Scan optical biometry. Anterior segment and dilated fundus examinations of all individuals were performed with a biomicroscope. The presence of pseudoexfoliation and cataract was determined by biomicroscopic examination of related tropicamide (1%) dilated pupils. The cataracts of the patients were evaluated using the Lens Opacities Classification System III classification [15]. Blood samples were withdrawn from antecubital vein, and collected in clot activator tubes. After 30-minutes, these blood samples were centrifuged for 5 minutes at 4000 rpm, and then separated serum was stored at −80 ºC until the laboratory analysis. Serum complement C3, C3a, and C4 levels were analyzed with commercially available sandwich ELISA kits (Bioassay Technology Laboratory, Shanghai, China). For complement C3, sensitivity was 25 mg/L, standard curve range was between 50 and 30,000 mg/L, intra-assay CV was < 8%, and inter-assay CV was < 10%. For complement 3a, sensitivity was 240 µg/L, standard curve range was between 500 and 150,000 µg/L, intra-assay CV was < 8%, and inter-assay CV was < 10%. For complement 4, sensitivity was 2 mg/L, standard curve range was between 5 and 1,500 mg/L, intra-assay CV was < 8%, and inter-assay CV was < 10%. Statistical analysis Data was analyzed using IBM SPSS Statistics for Windows, version 24.0 (IBM Corp., Armonk, NY, USA). The suitability of the data for normal distribution was evaluated with the Shapiro-Wilk test. Since it was determined that the data did not comply with normal distribution in continuous variables, the non-parametric Kruskal-Wallis test, Spearman’s rank correlation analysis and median (minimum and maximum) values were used. Bonferroni correction for multiple comparisons was applied in this analysis. Chi-square test were applied to compare categorical variables. Quade’s ANCOVA was preferred since variance homogeneity was not provided. Quade’s ANCOVA analysis was performed in the R environment using the WRS2 package. For statistical significance evaluation, 𝑝< 0.05 was accepted as the significance limit. As a result of the power analysis by use of G*Power software, the statistical power of the study was calculated as 1- β = 0.77958 with the total sample size of 150, the effect size of 0.25, and the α error probability of 0.05. Results A total of 150 patients as three different groups for our research (Table 1). Group 1 consisted of cataract patients with pseudoexfoliation, Group 2 comprised cataract patients without pseudoexfoliation, and Group 3 comprised healthy individuals. Each group had 50 participants. The median (minimum-maximum) age of Group 1 is 73 (61−83), Group 2 is 70 (54−81), and Group 3 is 61 (56−79) years. The average BMI of Group 1 is 27.6 (19.5−34.5), Group 2 is 28.2 (21.9−43.7), and Group 3 is 29.6 (22.7−41.1). Gender distribution for Group 1 is 24 (48%) women, for Group 2 is 23 (46%) women, and for Group 3 is 26 (52%) women (Table 2). There is no statistically significant difference in terms of gender distribution among the groups (p>0.05) There was a statistically significant difference for age between group 3 and other two groups (P< 0.001). On the other hand, no statistically significant difference was found among groups for BMI (p=0.071) (Table-2). Analysis of covariance (ANCOVA) was used to examine measurement differences between groups, and the age effect was included in the model as a covariate. Multiple comparison tests with Bonferroni evaluated whether there was a difference between the groups. These results are presented in Table 3. The intergroup difference for the C3, C3a, and C4 was evaluated with the Kruskal-Wallis H test. While there was no statistically significant difference among the groups in terms of C3 and C3a, there was a statistically significant difference among the groups in terms of C4 (Kruskal-Wallis χ2 value= 7.136 and P = 0.028). As a result of the Bonferroni correction made to determine the source of this difference, a statistically significant significant difference was detected between Group 1 and Group 2 in terms of C4 values ( P < 0.017, Table 4). This result shows that the total variance arises especially from the difference between these two groups. Analysis of covariance (ANCOVA) was performed for complement values by correcting the age effect. Multiple comparison tests with Bonferroni evaluated whether there was a difference between the groups. No significant difference was found between the groups for C3, C3a and C4 values (P= 0.233, P= 0.713 and P= 0.346, respectively, Table 5). Discussion In the present cross-sectional case-control study no statistically significant difference was found among the three groups for serum complement C3 and its active form, C3a. However, serum C4 value was statistically significantly different between Group 1 and Group 2. Since there was a statistically significant age difference between the groups, correcting for the age effect revealed no differences in terms of complement C3, C3a, and C4. The complement system is a critical regulator of the immune response. Complement activation occurs through three pathways: classical pathway, alternative pathway, and lectin pathway [16]. While C3 activates these three pathways and forms the center of the complement system, C4 is found only in the classical and lectin pathways [13-14]. Pseudoexfoliation is associated with age, but the underlying mechanism is unclear [17]. It is thought to be a multifactorial mechanism, and oxidative stress and genetic and environmental factors may play a role [18]. Single nucleotide polymorphisms in the LOXL1 gene are related to pseudoexfoliation [19]. The aqueous humor is the extracellular fluid in the eye. It nourishes avascular structures such as the lens and cornea and removes metabolic waste from the eye [20]. The composition of the aqueous humor is similar to plasma, except for its low protein and high ascorbate concentration. The content of this fluid can be altered in some diseases [21]. Complement C3 has been previously demonstrated on the surface of the lens capsule in pseudoexfoliation material [22]. In a study with limited participants evaluating the aqueous humor, the protein content was different in cataract patients with and without pseudoexfoliation. The group with pseudoexfoliation had a higher protein content than the other group. Authors attributed this to the breakdown of the blood-aqueous barrier. In that study, C3 and C4a were detected in the control group, not in pseudoexfoliation patients [21]. In another study, the aqueous humor was evaluated in the same two groups, and it was found that complement C3 was higher in patients with pseudoexfoliation [18]. In another study, the aqueous humor of glaucoma patients with and without pseudoexfoliation was evaluated. In this study, C3a concentration in the aqueous humor of glaucoma patients with pseudoexfoliation was higher than the patients without pseudoexfoliation [12]. The relationship between the complement pathway and pseudoexfoliation can be discussed in light of all these studies. Ovodenko et al . also discussed the relationship between pseudoexfoliation and the complement system. This study suggested that the presence of C1q and the activation-derived fragments C3c and C4c in pseudoexfoliative material indicates activation of the classical pathway. It is not known whether this activation is triggered by pseudoexfoliative deposits or is related to nongenetic conditions such as viral infections [23]. Shao et al . compared plasma complement C3 levels in patients with cataract and non-cataract. In patients with cataract, plasma complement C3 concentration was statistically significantly lower than the other group (cataract group: 101 ± 18.2 mg/dL, control group: 123 ± 22.5 mg/dL). Authors interpreted the result of this study as the systemic weakness of the immune pathway, making patients susceptible to infections, and infections contributing to the development and progression of cataracts [3]. In our study, however, plasma complement C3 and C3a were not statistically significantly different among the three groups. However, in Shao et al .'s study, BMI, diastolic and systolic blood pressures were statistically significantly different between the two groups. The difference in complement C3 values in this study may be related to this [3]. The relationship between BMI and complement has been mentioned before, showing increased complements in obese patients [24]. Vergroesen et al . showed that a higher neutrophil-lymphocyte ratio, C3, and systemic immune-inflammation index I are associated with increased cataract risk [25]. Others argue that the immune response is a response to damage in the lens, and plays a role in lens degeneration [26]. These studies have discussed the relationship between immunity and cataracts. In the present study, we found high serum concentrations of C4 in the pseudoexfoliation group, while there was no statistically significant difference in C3 and C3a levels between groups. Group 1 consists of significantly older patients. It is known that pseudoexfoliation is associated with age [17]. Considering this, no difference was observed when the age effect was corrected between the groups for serum C3, C3a and C4. Pseudoexfoliation formation appears to be associated with a proteolytic imbalance of the extracellular matrix, low-level of inflammation, hypoxia, ischemia, and oxidative stress [23]. We cannot consider these processes independently of the complement pathway. As a matter of fact, although there is no evidence, there are some published articles discussing infection in the etiology of pseudoexfoliation [27]. Evaluation of complement concentrations only in serum in our study may have led us to this conclusion. Our study is the first in the literature to investigate serum complement concentrations among these three groups. The cross-sectional nature and the statistically significant age difference between patient and control groups can be considered limitations of our study. Evaluation of the complement level only in serum can be considered as a limitation. In future studies, complement levels can be evaluated together in aqueous humor and serum samples of patients. In our study, the evaluation of complement levels only in serum may be considered a limitation. In future studies, complement levels can be evaluated in aqueous humor and serum. Conducting a power analysis for the number of patients and controls before starting the study, including a gender-matched control group, and using strict exclusion criteria are strengths of the present study. In conclusion, in our study investigating serum complement C3, C3a and C4 values among three groups, there was no statistically significant difference for these parameters. Serum complement concentrations were not significantly different in patients with cataracts and pseudoexfoliation. According to our study, a relationship between the complement pathway and immune system in these groups could not have been demonstrated. Future studies may clarify the points that need to be made on this subject Abbreviations AL: Axial length ANCOVA: Analysis of covariance BMI: Body mass index C1q: Component 1q C3: Component 3 C3a: Component 3a C4: Component 4 CV: Coefficient of variation ELISA: Enzyme-Linked ImmunoSorbent Assay IOP: Intraocular pressure LOXL1: Lysyl Oxidase Like 1 OCT: Optical Coherence Tomography Declarations Ethics approval and consent to participate This study was approved by the Ethics Committee of Hitit University Medical Faculty (Approval No: 2020-172) Written informed consent for participation was obtained from the parents or legal guardians of all participants in accordance with the Declaration of Helsinki. Consent for publication: Written informed consent for publication was obtained from the parents or legal guardians of all participants. Availability of data and materials: The datasets generated and/or analyzed during the current study are not publicly available due to concerns about patient privacy but are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests Authors' contributions. Funding: This work was supported by the Hitit University Coordinatorship of Scientific Projects under Grant [number TIP1901.20.004]. Authors' contributions Conceptualization: GGO and HK; resource: GGO, HK, ICC and HBC; methodology: GGO, HBC; formal analysis: GGO, HK, ICC and HBC; investigation : GGO, HK, ICC and HBC; writing—original draft preparation : GGO and HK; writing—review and editing : GGO, HK, ICC. Acknowledgements: Not applicable. References Bourne RR, Stevens GA, White RA, Smith JL, Flaxman SR, Price H, et al. Vision Loss Expert Group. Causes of vision loss worldwide, 1990-2010: a systematic analysis. Lancet Glob Health. 2013;1(6):e339-49. 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Clinical characteristics of all patients in the study Parameters Median (Minimum - Maximum) Age (year) 67 (54 - 83) BMI (kg/m 2 ) 28 (20 - 44) Right AL (mm) 23 (21 - 26) Left AL (mm) 23 (20 - 26) Right IOP (mmHg) 15 (10 - 22) Left IOP (mmHg) 15 (9 - 22) C3 (mg/L) 2860 (970 - 8380) C3a (ng/L) 1170 (394 - 4919) C4 (mg/L) 80 (31 - 606) BMI: Body Mass Index; AL: axial length; IOP: Intraocular Pressure; C3: complement component 3; C3a: complement component 3a; C4: complement component 4 Table 2. Comparison of the measurements between groups. Group 1 Median (min-max) Group 2 Median (min-max) Group 3 Median (min-max) P Age (year) 73 (61−83) a 70 (54−81) a 61 (56−79) b <0.001* BMI (kg/m 2 ) 27.6 (19.5−34.5) 28.2 (21.9−43.7) 29.6 (22.7−41.1) 0.071 Right AL (mm) 23.2 (21.6−26.1) 23.4 (21.3−25.4) 23.0 (21.7−25.0) 0.118 Left AL (mm) 23.2 (21.6−25.8) 23.4 (20.2−26.0) 23.0 (21.7−25.0) 0.085 Right IOP (mmHg) 15 (10−20) 15 (10−22) 15 (11−21) 0.234 Left IOP (mmHg) 16 (10−22) 15 (9−22) 15 (10−21) 0.468 Data are presented as median (minimum-maximum). Kruskal-Wallis H test was used. P<0.05 was accepted as the significance level. Different groups were shown with different asterisks( a , b ) BMI: Body Mass Index; AL: axial length; IOP: Intraocular Pressure; min: minimum; max : maximum *The significant difference was between group 3 and others. Table 3: Results of Covariance Analysis of Measurement Values Between Groups, Controlling for Age. Group 1 Estimated Mean ± SE Group 2 Estimated Mean ± SE Group 3 Estimated Mean ± SE P BMI (kg/m 2 ) 28.0±0.70 28.4±0.65 29.1±0.74 0.607 Right AL (mm) 23.3±0.13 23.4±0.12 23.0±0.14 0.116 Left AL (mm) 23.2±0.14 23.4±0.13 22.9±0.14 0.083 Right IOP (mmHg) 15.7±0.43 14.8±0.40 15.6±0.46 0.212 Left IOP (mmHg) 16.1±0.45 15.3±0.42 15.9±0.48 0.403 Estimated marginal means (mean ± standard error). It was calculated by Analysis of Covariance (ANCOVA) by controlling the age effect. Differences between groups were evaluated by multiple comparisons with Bonferroni correction. p<0.05 level was considered statistically significant. BMI: Body Mass Index; AL: axial length; IOP: Intraocular Pressure; min: minimum; max : maximum Table 4. Comparison of the C3, C3a, and C4 values between groups with the Kruskal-Wallis H test. Complement Group 1 Median (min-max) Group 2 Median (min-max) Group 3 Median (min-max) p C3 (mg/L) 2860 (970−8380) 2980 (1030−6250) 2720 (1010−7910) 0.181 C3a (ng/L) 1170 (390−4920) 1220 (470−3950) 1150 (400−4190) 0.827 C4 (mg/L) 90 (30−610) 70 (30−220) 80 (30−190) 0.028* Data are presented as median (minimum-maximum). Comparisons between groups were made with the Kruskal-Wallis test. p<0.05 was accepted as the significance level. P values marked * are statistically significant. C3: complement component 3; C3a: complement component 3a; C4: complement component 4; min: minimum; max : maximum *The significant difference between group 1 and group 2. Table 5: Comparison of Complement Values Between Groups, Controlling for Age (Covariance Analysis Results) Complement Group 1 (Mean ± SE) Group 2 (Mean± SE) Group 3 (Mean ± SE) P C3 (mg/L) 3170±180 3250±160 2820±190 0.233 C3a (ng/L) 1420±100 1310±90 1320±110 0.713 C4 (mg/L) 90±10 70±10 80±10 0.346 Estimated marginal means (mean ± standard error) were calculated by Analysis of Covariance (ANCOVA), controlling for the effect of age. Differences between groups were evaluated by multiple comparisons with Bonferroni correction. p<0.05 level was considered statistically significant. C3: complement component 3; C3a: complement component 3a; C4: complement component 4 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 17 May, 2026 Reviewers agreed at journal 13 May, 2026 Reviewers agreed at journal 28 Apr, 2026 Reviewers invited by journal 27 Apr, 2026 Editor assigned by journal 27 Apr, 2026 Editor invited by journal 27 Apr, 2026 Submission checks completed at journal 26 Apr, 2026 First submitted to journal 26 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9452519","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":631324561,"identity":"bc1418ae-3258-4617-babb-4f628646058d","order_by":0,"name":"Gülce Gökgöz Özışık","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3klEQVRIiWNgGAWjYFAC5gYwxcbOfICBsYEoLVBlbMxsCSRqYWDmMSBOi3xEYuOHDwzb5PmYeb5J/NxhI8fAfvjoBnxaDG8kNkvOYLht2MbMu02y90yaMQNPWtoNvFpmJLYx8zDcZgRpkeBtO5zYIMFjRljLH4bb9kCNzyT/EqNFXgKohYHhNsguNmmibDHgedgs2cNwO7mNmc3YWrYtzZiNkF/k25MPfvjBcNt2fnvzw5tv22zk+NkPH8NvywEgwfgPzGaRAJFs+JSDbWlAsJk/EFI9CkbBKBgFIxMAAFgPRdt2vX08AAAAAElFTkSuQmCC","orcid":"","institution":"Hitit University","correspondingAuthor":true,"prefix":"","firstName":"Gülce","middleName":"Gökgöz","lastName":"Özışık","suffix":""},{"id":631324562,"identity":"146e00b1-eece-4d0b-b86d-6db5b3fa2c68","order_by":1,"name":"Hüseyin Kayadibi","email":"","orcid":"","institution":"Eskişehir Osmangazi University","correspondingAuthor":false,"prefix":"","firstName":"Hüseyin","middleName":"","lastName":"Kayadibi","suffix":""},{"id":631324563,"identity":"10c98166-ab84-4e79-b004-76a8e0a6ff83","order_by":2,"name":"İsmail Cagatay Caglar","email":"","orcid":"","institution":"Maltepe University","correspondingAuthor":false,"prefix":"","firstName":"İsmail","middleName":"Cagatay","lastName":"Caglar","suffix":""},{"id":631324564,"identity":"6d3be784-7dc1-40fb-93e5-f5ef56f80da1","order_by":3,"name":"Hasan Basri Cakmak","email":"","orcid":"","institution":"Yüzüncü Yıl Hastanesi","correspondingAuthor":false,"prefix":"","firstName":"Hasan","middleName":"Basri","lastName":"Cakmak","suffix":""}],"badges":[],"createdAt":"2026-04-17 20:23:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9452519/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9452519/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108805700,"identity":"4da8725c-c9b2-4014-ba4c-14d2dfd50545","added_by":"auto","created_at":"2026-05-08 15:26:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":296522,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9452519/v1/cf9ce9ac-93c8-4130-9353-d20db1c166ea.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparison of Serum C3, C3a, C4 Levels Between Cataract Patients with and without Pseudoexfoliation and Normal Individuals","fulltext":[{"header":"Background","content":"\u003cp\u003eCataract is one of the most common causes of blindness worldwide [1]. The pathophysiology of cataract formation still needs to be clearly understood. Recently, emphasis has been placed on the complement system in cataract development [2,3]. In addition, the presence of pseudoexfoliation is thought to be a risk factor for the cataract development [4,5].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePseudoexfoliation syndrome\u0026nbsp;is an extracellular matrix anomaly characterized by the accumulation of fibrillar material in ocular tissues, skin, and various organs. It is age-related and so common worldwide. Involvement occurs in almost all tissues in the anterior segment of the eye. Thus, the risk of complications in cataract surgery increases as clinical problems such as open-angle glaucoma, phacodenesis, lens subluxation, inadequate mydriasis, blood-aqueous barrier disorder, and corneal decompensation occur in the eye [6-8]. Since the pathophysiological mechanism of this syndrome is still unclear, several biomarker studies have been conducted in patients with pseudoexfoliation [9-11]. In the study of Doudevski et al., the complement C3a level was found to be high in the aqueous humor of patients with pseudoexfoliative glaucoma. High C3a levels have been shown to indicate complement system activation in these patients [12].\u003c/p\u003e\n\u003cp\u003eThe complement system is the main part of the human innate immune system. Component 3 is the central element of the complement system and is involved in the activation of all three pathways of the complement system [13]. Component 4 is an essential complement for the classical and lectin pathways of the complement system [14].\u003c/p\u003e\n\u003cp\u003eSerum complements C3, C3a, and C4 levels have not been compared in patients with cataracts with and without pseudoexfoliation. Therefore, we aimed to compare serum complement C3, C3a, and C4 levels between cataract patients with and without pseudoexfoliation syndrome, as well as to compare these groups with the healthy controls.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis is a case controlled cross-sectional study. The study was conducted in accordance with the Declaration of Helsinki criteria. Hitit University Faculty of Medicine Ethics Committee approval was received before the study (Decision no: 172, Date: 14/07/2020). All patients signed an informed consent form.\u003c/p\u003e\n\u003cp\u003eOne hundred fifty patients who applied to our clinic between September 2020 and March 2023 were included in the study. These patients were divided into three groups: 50 cataract patients with pseudoexfoliation (Group 1), 50 cataract patients without pseudoexfoliation (Group 2), and 50 healthy individuals (Group 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe inclusion and exclusion criteria for the study are as following:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eInclusion criteria:\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBeing ages between 50-80 years. Having cataracts with or without pseudoexfoliation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eExclusion criteria:\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHaving autoimmune diseases or receiving immunosuppression therapy. Patients with glaucoma, uveitis, retinal disease, congenital cataracts, and secondary cataracts due to diabetes, trauma, steroid use, or any other reason.\u003c/p\u003e\n\u003cp\u003eThe retinal nerve fiber layer evaluation by Optical Coherence Tomography (Heidelberg Spectralis OCT, Heidelberg Engineering, Heidelberg, Germany) and intraocular pressure (IOP) were performed to exclude patients with glaucoma.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll individuals\u0026apos; vision levels and body mass index (BMI) were calculated. Intraocular pressure of the individuals was measured with Canon full autotonometer TX-F, and axial lengths of eye were measured with Nidek AL-Scan optical biometry. Anterior segment and dilated fundus examinations of all individuals were performed with a biomicroscope. The presence of pseudoexfoliation and cataract was determined by biomicroscopic examination of related tropicamide (1%) dilated pupils. The cataracts of the patients were evaluated using the Lens Opacities Classification System III classification [15]. Blood samples were withdrawn from antecubital vein, and collected in clot activator tubes. After 30-minutes, these blood samples were centrifuged for 5 minutes at 4000 rpm, and then separated serum was stored at \u0026minus;80 \u0026ordm;C until the laboratory analysis.\u003c/p\u003e\n\u003cp\u003eSerum complement C3, C3a, and C4 levels were analyzed with commercially available sandwich ELISA kits (Bioassay Technology Laboratory, Shanghai, China). For complement C3, sensitivity was 25 mg/L, standard curve range was between 50 and 30,000 mg/L, intra-assay CV was \u0026lt; 8%, and inter-assay CV was \u0026lt; 10%. For complement 3a, sensitivity was 240 \u0026micro;g/L, standard curve range was between 500 and 150,000 \u0026micro;g/L, intra-assay CV was \u0026lt; 8%, and inter-assay CV was \u0026lt; 10%. For complement 4, sensitivity was 2 mg/L, standard curve range was between 5 and 1,500 mg/L, intra-assay CV was \u0026lt; 8%, and inter-assay CV was \u0026lt; 10%.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData was analyzed using IBM SPSS Statistics for Windows, version 24.0 (IBM Corp., Armonk, NY, USA). The suitability of the data for normal distribution was evaluated with the Shapiro-Wilk test. Since it was determined that the data did not comply with normal distribution in continuous variables, the non-parametric Kruskal-Wallis test, Spearman\u0026rsquo;s rank correlation analysis and median (minimum and maximum) values were used. Bonferroni correction for multiple comparisons was applied in this analysis. Chi-square test were applied to compare categorical variables. Quade\u0026rsquo;s ANCOVA was preferred since variance homogeneity was not provided. Quade\u0026rsquo;s ANCOVA analysis was performed in the R environment using the WRS2 package. For statistical significance evaluation, 𝑝\u0026lt; 0.05 was accepted as the significance limit. As a result of the power analysis by use of G*Power software, the statistical power of the study was calculated as 1- \u0026beta; = 0.77958 with the total sample size of 150, the effect size of 0.25, and the \u0026alpha; error probability of 0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 150 patients as three different groups for our research (Table 1). Group 1 consisted of cataract patients with pseudoexfoliation, Group 2 comprised cataract patients without pseudoexfoliation, and Group 3 comprised healthy individuals. Each group had 50 participants. The median (minimum-maximum) age of Group 1 is 73 (61−83), Group 2 is 70 (54−81), and Group 3 is 61 (56−79) years. \u0026nbsp;The average BMI of Group 1 is 27.6 (19.5−34.5), Group 2 is 28.2 (21.9−43.7), and Group 3 is 29.6 (22.7−41.1). Gender distribution for Group 1 is 24 (48%) women, for Group 2 is 23 (46%) women, and for Group 3 is 26 (52%) women (Table 2). There is no statistically significant difference in terms of gender distribution among the groups (p\u0026gt;0.05)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere was a statistically significant difference for age between group 3 and other two groups (P\u0026lt; 0.001). On the other hand, no statistically significant difference was found among groups for BMI (p=0.071) (Table-2).\u003c/p\u003e\n\u003cp\u003eAnalysis of covariance (ANCOVA) was used to examine measurement differences between groups, and the age effect was included in the model as a covariate. Multiple comparison tests with Bonferroni evaluated whether there was a difference between the groups. These results are presented in Table 3.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe intergroup difference for the C3, C3a, and C4 was evaluated with the Kruskal-Wallis H test. While there was no statistically significant difference among the groups in terms of C3 and C3a, there was a statistically significant difference among the groups in terms of C4 (Kruskal-Wallis χ2 value= 7.136 and \u003cem\u003eP\u003c/em\u003e= 0.028). As a result of the Bonferroni correction made to determine the source of this difference, a statistically significant significant difference was detected between Group 1 and Group 2 in terms of C4 values (\u003cem\u003eP\u003c/em\u003e\u0026lt; 0.017, Table 4). This result shows that the total variance arises especially from the difference between these two groups. Analysis of covariance (ANCOVA) was performed for complement values by correcting the age effect. Multiple comparison tests with Bonferroni evaluated whether there was a difference between the groups. No significant difference was found between the groups for C3, C3a and C4 values (P= 0.233, P= 0.713 and P= 0.346, respectively, Table 5).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn the present cross-sectional case-control study no statistically significant difference was found among the three groups for serum complement C3 and its active form, C3a. However, serum C4 value was statistically significantly different between Group 1 and Group 2. Since there was a statistically significant age difference between the groups, correcting for the age effect revealed no differences in terms of complement C3, C3a, and C4.\u003c/p\u003e\n\u003cp\u003eThe complement system is a critical regulator of the immune response. Complement activation occurs through three pathways: classical pathway, alternative pathway, and lectin pathway [16]. While C3 activates these three pathways and forms the center of the complement system, C4 is found only in the classical and lectin pathways [13-14].\u003c/p\u003e\n\u003cp\u003ePseudoexfoliation is associated with age, but the underlying mechanism is unclear [17]. It is thought to be a multifactorial mechanism, and oxidative stress and genetic and environmental factors may play a role [18]. Single nucleotide polymorphisms in the LOXL1 gene are related to pseudoexfoliation [19].\u003c/p\u003e\n\u003cp\u003eThe aqueous humor is the extracellular fluid in the eye. It nourishes avascular structures such as the lens and cornea and removes metabolic waste from the eye [20]. The composition of the aqueous humor is similar to plasma, except for its low protein and high ascorbate concentration. The content of this fluid can be altered in some diseases [21].\u003c/p\u003e\n\u003cp\u003eComplement C3 has been previously demonstrated on the surface of the lens capsule in pseudoexfoliation material [22]. In a study with limited participants evaluating the aqueous humor, the protein content was different in cataract patients with and without pseudoexfoliation. The group with pseudoexfoliation had a higher protein content than the other group. Authors attributed this to the breakdown of the blood-aqueous barrier. In that study, C3 and C4a were detected in the control group, not in pseudoexfoliation patients [21].\u003c/p\u003e\n\u003cp\u003eIn another study, the aqueous humor was evaluated in the same two groups, and it was found that complement C3 was higher in patients with pseudoexfoliation [18]. In another study, the aqueous humor of glaucoma patients with and without pseudoexfoliation was evaluated. In this study, C3a concentration in the aqueous humor of glaucoma patients with pseudoexfoliation was higher than the patients without pseudoexfoliation [12]. The relationship between the complement pathway and pseudoexfoliation can be discussed in light of all these studies. Ovodenko \u003cem\u003eet al\u003c/em\u003e. also discussed the relationship between pseudoexfoliation and the complement system. This study suggested that the presence of C1q and the activation-derived fragments C3c and C4c in pseudoexfoliative material indicates activation of the classical pathway. It is not known whether this activation is triggered by pseudoexfoliative deposits or is related to nongenetic conditions such as viral infections [23].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eShao \u003cem\u003eet al\u003c/em\u003e. compared plasma complement C3 levels in patients with cataract and non-cataract. In patients with cataract, plasma complement C3 concentration was statistically significantly lower than the other group (cataract group: 101 ± 18.2 mg/dL, control group: 123 ± 22.5 mg/dL). Authors interpreted the result of this study as the systemic weakness of the immune pathway, making patients susceptible to infections, and infections contributing to the development and progression of cataracts [3]. In our study, however, plasma complement C3 and C3a were not statistically significantly different among the three groups. However, in Shao \u003cem\u003eet al\u003c/em\u003e.'s study, BMI, diastolic and systolic blood pressures were statistically significantly different between the two groups. The difference in complement C3 values in this study may be related to this [3]. The relationship between BMI and complement has been mentioned before, showing increased complements in obese patients [24].\u003c/p\u003e\n\u003cp\u003eVergroesen \u003cem\u003eet al\u003c/em\u003e. showed that a higher neutrophil-lymphocyte ratio, C3, and systemic immune-inflammation index I are associated with increased cataract risk [25]. Others argue that the immune response is a response to damage in the lens, and plays a role in lens degeneration [26]. These studies have discussed the relationship between immunity and cataracts.\u003c/p\u003e\n\u003cp\u003eIn the present study, we found high serum concentrations of C4 in the pseudoexfoliation group, while there was no statistically significant difference in C3 and C3a levels between groups. Group 1 consists of significantly older patients. It is known that pseudoexfoliation is associated with age [17]. Considering this, no difference was observed when the age effect was corrected between the groups for serum C3, C3a and C4.\u003c/p\u003e\n\u003cp\u003ePseudoexfoliation formation appears to be associated with a proteolytic imbalance of the extracellular matrix, low-level of inflammation, hypoxia, ischemia, and oxidative stress [23]. We cannot consider these processes independently of the complement pathway.\u003c/p\u003e\n\u003cp\u003eAs a matter of fact, although there is no evidence, there are some published articles discussing infection in the etiology of pseudoexfoliation [27]. Evaluation of complement concentrations only in serum in our study may have led us to this conclusion.\u003c/p\u003e\n\u003cp\u003eOur study is the first in the literature to investigate serum complement concentrations among these three groups. The cross-sectional nature and the statistically significant age difference between patient and control groups can be considered limitations of our study. Evaluation of the complement level only in serum can be considered as a limitation. In future studies, complement levels can be evaluated together in aqueous humor and serum samples of patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn our study, the evaluation of complement levels only in serum may be considered a limitation. In future studies, complement levels can be evaluated in aqueous humor and serum. Conducting a power analysis for the number of patients and controls before starting the study, including a gender-matched control group, and using strict exclusion criteria are strengths of the present study.\u003c/p\u003e\n\u003cp\u003eIn conclusion, in our study investigating serum complement C3, C3a and C4 values among three groups, there was no statistically significant difference for these parameters. Serum complement concentrations were not significantly different in patients with cataracts and pseudoexfoliation. According to our study, a relationship between the complement pathway and immune system in these groups could not have been demonstrated. Future studies may clarify the points that need to be made on this subject\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eAL:\u0026nbsp;\u003c/strong\u003eAxial length\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eANCOVA:\u0026nbsp;\u003c/strong\u003eAnalysis of covariance\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBMI:\u003c/strong\u003e Body mass index\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eC1q:\u003c/strong\u003e Component 1q\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eC3:\u003c/strong\u003e Component 3\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eC3a:\u003c/strong\u003e Component 3a\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eC4:\u003c/strong\u003e Component 4\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCV:\u003c/strong\u003e Coefficient of variation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eELISA:\u003c/strong\u003e Enzyme-Linked ImmunoSorbent Assay\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIOP:\u003c/strong\u003e Intraocular pressure\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLOXL1:\u003c/strong\u003e Lysyl Oxidase Like 1\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOCT:\u003c/strong\u003e Optical Coherence Tomography\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003eThis study was approved by the Ethics Committee of Hitit University Medical Faculty (Approval No: 2020-172)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWritten informed consent for participation was obtained from the parents or legal guardians of all participants in accordance with the Declaration of Helsinki.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eWritten informed consent for publication was obtained from the parents or legal guardians of all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to concerns about patient privacy but are available from the corresponding author on reasonable request.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests Authors\u0026apos; contributions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis work was supported by the Hitit University Coordinatorship of Scientific Projects under Grant [number TIP1901.20.004].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConceptualization:\u003c/strong\u003e GGO and HK; \u003cstrong\u003eresource:\u003c/strong\u003e GGO, HK, ICC and HBC; \u003cstrong\u003emethodology:\u003c/strong\u003e GGO, HBC; \u003cstrong\u003eformal analysis:\u0026nbsp;\u003c/strong\u003eGGO, HK, ICC and HBC; \u003cstrong\u003einvestigation\u003c/strong\u003e: GGO, HK, ICC and HBC; \u003cstrong\u003ewriting\u0026mdash;original draft preparation\u003c/strong\u003e: GGO and HK; \u003cstrong\u003ewriting\u0026mdash;review and\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eediting\u003c/strong\u003e: GGO, HK, ICC.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eBourne RR, Stevens GA, White RA, Smith JL, Flaxman SR, Price H, et al. Vision Loss Expert Group. Causes of vision loss worldwide, 1990-2010: a systematic analysis. Lancet Glob Health. 2013;1(6):e339-49.\u003c/li\u003e\n \u003cli\u003eSuetsugu-Maki R, Maki N, Fox TP, Nakamura K, Cowper Solari R, Tomlinson CR, et al. A complement receptor C5a antagonist regulates epithelial to mesenchymal transition and crystallin expression after lens cataract surgery in mice. Mol Vis. 2011; 17:949-64.\u003c/li\u003e\n \u003cli\u003eShao M, Li D, Teng J, Zhang Y, Li S, Cao W. Association Between Serum Complement C3 Levels and Age-Related Cataract. Invest Ophthalmol Vis Sci. 2017;58(11):4934-39.\u003c/li\u003e\n \u003cli\u003eKliuchnikova AA, Samokhina N I, Ilina IY, Karpov DS, Pyatnitskiy MA, Kuznetsova KG, et al. Human aqueous humor proteome in cataract, glaucoma, and pseudoexfoliation syndrome. PROTEOMICS. 2016; 16(13), 1938\u0026ndash;1946.\u003c/li\u003e\n \u003cli\u003ePuska\u003csup\u003e\u0026nbsp;\u003c/sup\u003eP, Tarkkanen A. Exfoliation syndrome as a risk factor for cataract development: five-year follow-up of lens opacities in exfoliation syndrome. J Cataract Refract Surg. 2001; (12):1992-8.\u003c/li\u003e\n \u003cli\u003eRitch R. Ocular and systemic manifestations of exfoliation syndrome. J Glaucoma. 2014;23: S1-8.\u003c/li\u003e\n \u003cli\u003eSchl\u0026ouml;tzer-Schrehardt U, Naumann GO. Ocular and systemic pseudoexfoliation syndrome. Am J Ophthalmol. 2006; 141:921\u0026ndash;37.\u003c/li\u003e\n \u003cli\u003eErkayhan GE, Dogan S. Cataract Surgery and Possible Complications in Patients with Pseudoexfoliation Syndrome. Eurasian J Med. 2017; 49(1):22-25.\u003c/li\u003e\n \u003cli\u003eAbay RN, Katipoğlu Z. The correlation between pseudoexfoliation syndrome and the Triglyceride-Glucose index. Graefes Arch Clin Exp Ophthalmol. 2022; 260(12):3903-3908.\u003c/li\u003e\n \u003cli\u003eKurtul BE, Kurtul A, Altiaylik Ozer P, Kabatas EU, Ertugrul GT. Serum Lipid Levels in Pseudoexfoliation Syndrome. Semin Ophthalmol. 2017;32(3):281-284.\u003c/li\u003e\n \u003cli\u003eOğurel T, Oğurel R, Topuz M, \u0026Ouml;rnek N, \u0026Ouml;rnek K. Plasma adropin level in patients with pseudoexfoliation. Int Ophthalmol. 2016;36(5):737-42.\u003c/li\u003e\n \u003cli\u003eDoudevski I, Rostagno A, Cowman M, Liebmann J, Ritch R, Ghiso J. Clusterin and complement activation in exfoliation glaucoma. Invest Ophthalmol Vis Sci. 2014;55: 2491\u0026ndash;99.\u003c/li\u003e\n \u003cli\u003eLi S, Chen Y, Shao M, Tang L, Sun X, Cao W. Association of Plasma Complement C3 Levels With Primary Angle-Closure Glaucoma in Older Women. Invest Ophthalmol Vis Sci. 2017;58(1):682-89.\u003c/li\u003e\n \u003cli\u003eZhang L, Bell BA, Li Y, Caspi RR, Lin F. Complement Component C4 Regulates the Development of Experimental Autoimmune Uveitis through a T Cell-Intrinsic Mechanism. Front Immunol. 2017; 8: 1116.\u003c/li\u003e\n \u003cli\u003eChylack LT Jr, Wolfe JK, Singer DM, Leske MC, Bullimore MA, Bailey IL, et al. The Lens Opacities Classification System III. The Longitudinal Study of Cataract Study Group. Arch Ophthalmol. 1993;111(6):831-6.\u003c/li\u003e\n \u003cli\u003eRicklin D, Reis ES, Lambris JD. Complement in disease: a defence system turning offensive. Nat Rev Nephrol. 2016;12(7):383-401.\u003c/li\u003e\n \u003cli\u003eMorris J, Myer C, Cornet T, Junk AK, Lee RK, Bhattacharya SK. Proteomics of pseudoexfoliation materials in the anterior eye segment. Adv Protein Chem Struct Biol. 2021; 127:271-90.\u003c/li\u003e\n \u003cli\u003eBotling Taube A, Konzer A, Alm A, Bergquist J. Proteomic analysis of the aqueous humour in eyes with pseudoexfoliation syndrome. Br J Ophthalmol. 2019;103(8):1190-94.\u003c/li\u003e\n \u003cli\u003eThorleifsson G, Magnusson KP, Sulem P, Walters GB, Gudbjartsson DF, Stefansson H, et al. Common sequence variants in the LOXL1 gene confer susceptibility to exfoliation glaucoma. Science 2007;317: 1397\u0026ndash;1400.\u003c/li\u003e\n \u003cli\u003eRoy Chowdhury U, Hann CR, Stamer WD, Fautsch MP. Aqueous humor outflow: dynamics and disease. Invest Ophthalmol Vis Sci. 2015;56(5):2993-3003\u003c/li\u003e\n \u003cli\u003eHardenborg E, Botling-Taube A, Hanrieder J, Andersson M, Alm A, Bergquist J, et al. Protein content in aqueous humor from patients with pseudoexfoliation (PEX) investigated by capillary LC MALDI-TOF/TOF MS. Proteomics Clin Appl. 2009;3(3):299-306.\u003c/li\u003e\n \u003cli\u003eSharma S, Chataway T, Burdon KP, Jonavicius L, Klebe S, Hewitt AW, et al. Identification of LOXL1 protein and Apolipoprotein E as components of surgically isolated pseudoexfoliation material by direct mass spectrometry. Exp Eye Res. 2009;89(4):479-85.\u003c/li\u003e\n \u003cli\u003eOvodenko B, Rostagno A, Neubert TA, Shetty V, Thomas S, Yang A, et al. Proteomic analysis of exfoliation deposits. Invest Ophthalmol Vis Sci. 2007;48(4):1447-57.\u003c/li\u003e\n \u003cli\u003eLynch AM, Eckel RH, Murphy JR, Gibbs RS, West NA, Giclas PC, et al. Prepregnancy obesity and complement system activation in early pregnancy and the subsequent development of preeclampsia. Am J Obstet Gynecol. 2012; 206(5): 428.e1\u0026ndash;428.e8.\u003c/li\u003e\n \u003cli\u003eVergroesen JE, Thee EF, de Crom TOE, Kiefte-de Jong JC, Meester-Smoor MA, Voortman T, et al. The inflammatory potential of diet is associated with the risk of age-related eye diseases. Clin Nutr. 2023;42(12):2404-2413.\u003c/li\u003e\n \u003cli\u003eStepp MA, Menko AS. Immune responses to injury and their links to eye disease. Transl Res. 2021;236:52-71.\u003c/li\u003e\n \u003cli\u003eMastronikolis S, Kagkelaris K, Pagkalou M, Tsiambas E, Plotas P, Georgakopoulos CD. Antioxidant Defense and Pseudoexfoliation Syndrome: An Updated Review. Med Sci (Basel). 2022;10(4):68.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1. Clinical characteristics of all patients in the study\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44.9519%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eParameters\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55.0481%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian (Minimum - Maximum)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44.9519%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (year)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55.0481%;\"\u003e\n \u003cp\u003e67 (54 - 83)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44.9519%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55.0481%;\"\u003e\n \u003cp\u003e28 (20 - 44)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44.9519%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRight AL (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55.0481%;\"\u003e\n \u003cp\u003e23 (21 - 26)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44.9519%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLeft AL (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55.0481%;\"\u003e\n \u003cp\u003e23 (20 - 26)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44.9519%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRight IOP (mmHg)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55.0481%;\"\u003e\n \u003cp\u003e15 (10 - 22)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44.9519%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLeft IOP (mmHg)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55.0481%;\"\u003e\n \u003cp\u003e15 (9 - 22)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44.9519%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eC3 (mg/L)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55.0481%;\"\u003e\n \u003cp\u003e2860 (970 - 8380)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44.9519%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eC3a (ng/L)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55.0481%;\"\u003e\n \u003cp\u003e1170 (394 - 4919)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44.9519%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eC4 (mg/L)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55.0481%;\"\u003e\n \u003cp\u003e80 (31 - 606)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eBMI:\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;Body Mass Index; \u003cstrong\u003eAL:\u003c/strong\u003e axial length; \u003cstrong\u003eIOP:\u003c/strong\u003e Intraocular Pressure; \u003cstrong\u003eC3:\u003c/strong\u003e complement component 3; \u003cstrong\u003eC3a:\u003c/strong\u003e complement component 3a; \u003cstrong\u003eC4:\u003c/strong\u003e complement component 4\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Comparison of the measurements between groups.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"641\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6562%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.2188%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 1\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMedian\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(min-max)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.3125%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 2\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMedian\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(min-max)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.9688%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 3\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMedian\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(min-max)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.84375%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; P\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6562%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (year)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.2188%;\"\u003e\n \u003cp\u003e73 (61\u0026minus;83)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.3125%;\"\u003e\n \u003cp\u003e70 (54\u0026minus;81)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.9688%;\"\u003e\n \u003cp\u003e61 (56\u0026minus;79)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.84375%;\"\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6562%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.2188%;\"\u003e\n \u003cp\u003e27.6 (19.5\u0026minus;34.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.3125%;\"\u003e\n \u003cp\u003e28.2 (21.9\u0026minus;43.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.9688%;\"\u003e\n \u003cp\u003e29.6 (22.7\u0026minus;41.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.84375%;\"\u003e\n \u003cp\u003e0.071\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6562%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRight AL (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.2188%;\"\u003e\n \u003cp\u003e23.2 (21.6\u0026minus;26.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.3125%;\"\u003e\n \u003cp\u003e23.4 (21.3\u0026minus;25.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.9688%;\"\u003e\n \u003cp\u003e23.0 (21.7\u0026minus;25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.84375%;\"\u003e\n \u003cp\u003e0.118\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6562%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLeft AL (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.2188%;\"\u003e\n \u003cp\u003e23.2 (21.6\u0026minus;25.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.3125%;\"\u003e\n \u003cp\u003e23.4 (20.2\u0026minus;26.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.9688%;\"\u003e\n \u003cp\u003e23.0 (21.7\u0026minus;25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.84375%;\"\u003e\n \u003cp\u003e0.085\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6562%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRight IOP (mmHg)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.2188%;\"\u003e\n \u003cp\u003e15 (10\u0026minus;20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.3125%;\"\u003e\n \u003cp\u003e15 (10\u0026minus;22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.9688%;\"\u003e\n \u003cp\u003e15 (11\u0026minus;21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.84375%;\"\u003e\n \u003cp\u003e0.234\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6562%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLeft IOP (mmHg)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.2188%;\"\u003e\n \u003cp\u003e16 (10\u0026minus;22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.3125%;\"\u003e\n \u003cp\u003e15 (9\u0026minus;22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.9688%;\"\u003e\n \u003cp\u003e15 (10\u0026minus;21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.84375%;\"\u003e\n \u003cp\u003e0.468\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eData are presented as median (minimum-maximum). Kruskal-Wallis H test was used. P\u0026lt;0.05 was accepted as the significance level.\u0026nbsp;Different groups were shown with different asterisks(\u003csup\u003ea\u003c/sup\u003e,\u003csup\u003eb\u003c/sup\u003e)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eBMI:\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;Body Mass Index; \u003cstrong\u003eAL:\u003c/strong\u003e axial length; \u003cstrong\u003eIOP:\u003c/strong\u003e Intraocular Pressure; \u003cstrong\u003emin:\u003c/strong\u003e minimum; \u003cstrong\u003emax\u003c/strong\u003e: maximum *The significant difference was between group 3 and others.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Results of Covariance Analysis of Measurement Values Between Groups, Controlling for Age.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"643\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.084%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4837%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 1\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eEstimated Mean \u0026plusmn; SE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4837%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 2\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eEstimated Mean \u0026plusmn; SE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4837%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 3\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eEstimated Mean \u0026plusmn; SE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.46501%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.084%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4837%;\"\u003e\n \u003cp\u003e28.0\u0026plusmn;0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4837%;\"\u003e\n \u003cp\u003e28.4\u0026plusmn;0.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4837%;\"\u003e\n \u003cp\u003e29.1\u0026plusmn;0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.46501%;\"\u003e\n \u003cp\u003e0.607\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.084%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRight AL (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4837%;\"\u003e\n \u003cp\u003e23.3\u0026plusmn;0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4837%;\"\u003e\n \u003cp\u003e23.4\u0026plusmn;0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4837%;\"\u003e\n \u003cp\u003e23.0\u0026plusmn;0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.46501%;\"\u003e\n \u003cp\u003e0.116\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.084%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLeft AL (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4837%;\"\u003e\n \u003cp\u003e23.2\u0026plusmn;0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4837%;\"\u003e\n \u003cp\u003e23.4\u0026plusmn;0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4837%;\"\u003e\n \u003cp\u003e22.9\u0026plusmn;0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.46501%;\"\u003e\n \u003cp\u003e0.083\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.084%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRight IOP (mmHg)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4837%;\"\u003e\n \u003cp\u003e15.7\u0026plusmn;0.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4837%;\"\u003e\n \u003cp\u003e14.8\u0026plusmn;0.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4837%;\"\u003e\n \u003cp\u003e15.6\u0026plusmn;0.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.46501%;\"\u003e\n \u003cp\u003e0.212\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.084%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLeft IOP (mmHg)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4837%;\"\u003e\n \u003cp\u003e16.1\u0026plusmn;0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4837%;\"\u003e\n \u003cp\u003e15.3\u0026plusmn;0.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4837%;\"\u003e\n \u003cp\u003e15.9\u0026plusmn;0.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.46501%;\"\u003e\n \u003cp\u003e0.403\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eEstimated marginal means (mean \u0026plusmn; standard error). It was calculated by Analysis of Covariance (ANCOVA) by controlling the age effect. Differences between groups were evaluated by multiple comparisons with Bonferroni correction. p\u0026lt;0.05 level was considered statistically significant.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eBMI:\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;Body Mass Index; \u003cstrong\u003eAL:\u003c/strong\u003e axial length; \u003cstrong\u003eIOP:\u003c/strong\u003e Intraocular Pressure; \u003cstrong\u003emin:\u003c/strong\u003e minimum; \u003cstrong\u003emax\u003c/strong\u003e: maximum\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4.\u0026nbsp;\u003c/strong\u003eComparison of the C3, C3a, and C4 values between groups with the Kruskal-Wallis H test.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"614\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24.5928%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComplement\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.4984%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 1\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMedian\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(min-max)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.127%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 2\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMedian\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(min-max)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.127%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 3\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMedian\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(min-max)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.65472%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp;p\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24.5928%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eC3 (mg/L)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.4984%;\"\u003e\n \u003cp\u003e2860 (970\u0026minus;8380)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.127%;\"\u003e\n \u003cp\u003e2980 (1030\u0026minus;6250)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.127%;\"\u003e\n \u003cp\u003e2720 (1010\u0026minus;7910)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.65472%;\"\u003e\n \u003cp\u003e0.181\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24.5928%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eC3a (ng/L)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.4984%;\"\u003e\n \u003cp\u003e1170 (390\u0026minus;4920)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.127%;\"\u003e\n \u003cp\u003e1220 (470\u0026minus;3950)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.127%;\"\u003e\n \u003cp\u003e1150 (400\u0026minus;4190)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.65472%;\"\u003e\n \u003cp\u003e0.827\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24.5928%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eC4 (mg/L)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.4984%;\"\u003e\n \u003cp\u003e90 (30\u0026minus;610)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.127%;\"\u003e\n \u003cp\u003e70 (30\u0026minus;220)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.127%;\"\u003e\n \u003cp\u003e80 (30\u0026minus;190)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.65472%;\"\u003e\n \u003cp\u003e0.028*\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eData are presented as median (minimum-maximum). Comparisons between groups were made with the Kruskal-Wallis test. p\u0026lt;0.05 was accepted as the significance level. P values marked * are statistically significant.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eC3:\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;complement component 3; \u003cstrong\u003eC3a:\u003c/strong\u003e complement component 3a; \u003cstrong\u003eC4:\u003c/strong\u003e complement component 4;\u003cstrong\u003e\u0026nbsp;min:\u003c/strong\u003e minimum; \u003cstrong\u003emax\u003c/strong\u003e: maximum\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp; *The significant difference between group 1 and group 2. \u0026nbsp;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5: Comparison of Complement Values Between Groups, Controlling for Age (Covariance Analysis Results)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eComplement\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 1\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Mean \u0026plusmn; SE)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 2\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Mean\u0026plusmn; SE)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 3\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Mean \u0026plusmn; SE)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eC3 (mg/L)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3170\u0026plusmn;180\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3250\u0026plusmn;160\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2820\u0026plusmn;190\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.233\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eC3a (ng/L)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1420\u0026plusmn;100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1310\u0026plusmn;90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1320\u0026plusmn;110\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.713\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eC4 (mg/L)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e90\u0026plusmn;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e70\u0026plusmn;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e80\u0026plusmn;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.346\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eEstimated marginal means (mean \u0026plusmn; standard error) were calculated by Analysis of Covariance (ANCOVA), controlling for the effect of age. Differences between groups were evaluated by multiple comparisons with Bonferroni correction. p\u0026lt;0.05 level was considered statistically significant.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eC3:\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;complement component 3; \u003cstrong\u003eC3a:\u003c/strong\u003e complement component 3a; \u003cstrong\u003eC4:\u003c/strong\u003e complement component 4\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"boph","sideBox":"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/boph","title":"BMC Ophthalmology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"C3, C3a, C4, cataract, complement pathway, pseudoexfoliation","lastPublishedDoi":"10.21203/rs.3.rs-9452519/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9452519/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackgrounds:\u003c/strong\u003e We aimed to compare serum complement C3, C3a, and C4 levels between cataract patients with and without pseudoexfoliation syndrome, and to compare these groups with the control group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e There were three different groups in the study. The total of 150 patients, 50 in each group, were included. \u0026nbsp;Group 1 consisted of cataract patients with pseudoexfoliation, Group 2 consisted of cataract patients without pseudoexfoliation, and Group 3 consisted of healthy individuals. After centrifugation of the blood samples, the serum portion was stored at –80°C until the analysis. Complement C3, C3a, and C4 levels were evaluated in these three groups using commercially available sandwich ELISA kits.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e There was a statistically significant difference just between Group 1 and Group 2 regarding C4 values. However, after the age correction, this significance was disappeared.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e According to this study, there may not be a relationship between the complement pathway and the immune system in cataract patients with and without pseudoexfoliation syndrome.\u003c/p\u003e","manuscriptTitle":"Comparison of Serum C3, C3a, C4 Levels Between Cataract Patients with and without Pseudoexfoliation and Normal Individuals","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-06 12:04:21","doi":"10.21203/rs.3.rs-9452519/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-17T09:39:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"145736386880631544273555494369865506884","date":"2026-05-13T09:27:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"290715322357952447213657592331755923019","date":"2026-04-28T07:25:21+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-27T16:11:47+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-27T16:10:12+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-27T05:29:40+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-26T21:40:24+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Ophthalmology","date":"2026-04-26T21:36:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"boph","sideBox":"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/boph","title":"BMC Ophthalmology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4d6f641f-1449-4fb8-aa04-ae49293b9c71","owner":[],"postedDate":"May 6th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-17T09:39:27+00:00","index":41,"fulltext":""},{"type":"reviewerAgreed","content":"145736386880631544273555494369865506884","date":"2026-05-13T09:27:24+00:00","index":40,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-06T12:04:21+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-06 12:04:21","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9452519","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9452519","identity":"rs-9452519","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}