|PSEUDOEXFOLIATION SYNDROME AND PSEUDOEXFOLIATIVE GLAUCOMA
SIGNS AND SYMPTOMS
Patients with pseudoexfoliation syndrome remain asymptomatic until an
advanced glaucoma develops. The condition is most common in the sixth to eighth decade,
with actual glaucoma developing later in this age range. There is no racial, sexual or
geographic predilection. Typically, pseudoexfoliation syndrome begins unilaterally, but
becomes bilateral within about seven years.
The patient presents with a fine, flaky material on the anterior lens
capsule at the pupillary margin. Over time, this coalesces into a characteristic
"bulls-eye" pattern seen in pseudoexfoliation. There is often increased
transillumination of the iris at the pupillary margin and there may be pigment granules on
the endothelium and iris surface. Within the angle, there may be observable pigment or
clear flaky material. Initially, intraocular pressure is unaffected; however, elevated IOP
develops in up to 80 percent of patients. In these cases, glaucomatous cupping and visual
field loss may ensue.
Due to accumulation of abnormal basement membrane material at the
pupillary margin, there is increased apposition with the iris and subsequent erosion of
iris pigment as the pupil dilates and constricts. This leads to increased iris
transillumination and deposition of pigment granules on the endothelium, iris surface and
trabecular meshwork similar to pigment dispersion syndrome. Because this condition
involves deposition of material on the anterior lens capsule, and not flaking-off of the
lens capsule, lensectomy is not a remedy. In fact, some have observed exfoliative material
deposits on intraocular lens implants.
The development of glaucoma typically occurs due to a buildup within the
trabecular meshwork of pigment granules and pseudoexfoliative material. Patients develop a
secondary open angle glaucoma. However, studies have identified patients with increased
IOP but no decrease in aqueous outflow. In these cases, the glaucomatous mechanism is
Pseudoexfoliation syndrome without a pressure rise requires only
periodic monitoring of IOPs, discs and visual fields. When first diagnosing
pseudoexfoliation syndrome, perform automated visual fields to look for preexisting field
loss since pseudoexfoliative glaucoma undergoes periods of exacerbation and remission.
Treat pseudoexfoliative glaucoma in the same manner as primary open
angle glaucoma. Use topical beta-blockers, topical carbonic anhydrase inhibitors,
prostaglandin analogs and alpha adrenergic agonists if not systemically contraindicated.
However, the IOP level in pseudoexfoliative glaucoma is typically higher than in POAG and
is more difficult to temporize. Laser trabeculoplasty and filtration surgery are often
employed earlier than in POAG.
An initially normal IOP measurement does not preclude
prior IOP elevation with subsequent field loss and disc damage. Remember that
pseudoexfoliative glaucoma undergoes periods of exacerbation and remission. Serial
photographs and automated visual fields are more appropriate for managing this condition
than IOP measurements, since the patient may experience progression yet manifest normal
IOP if measured during remission.
Argon laser trabeculoplasty and filtration surgery are
more effective in controlling IOP in cases of pseudoexfoliative syndrome than in POAG.
Other Reports in This Section
Primary Open Angle Glaucoma
Uveitic Glaucoma & Glaucomatocyclitic Crisis
Pigment Dispersion Syndrome & Pigmentary
Acute Angle Closure Glaucoma
Angle Recession Glaucoma
Lens Induced Glaucoma
Pseudoexfoliation Syndrome and Pseudoexfoliative Glaucoma