Exfoliation glaucoma is a condition every treating ophthalmologist approaches with a bit more vigilance than typical primary open-angle glaucoma, since this specific secondary glaucoma has a well-documented reputation for higher pressures, more pronounced diurnal pressure fluctuation, and a generally less predictable, sometimes more treatment-resistant course than its more common counterpart.
From Syndrome to Glaucoma
Pseudoexfoliation syndrome, characterized by the deposition of flaky, dandruff-like white material on the lens capsule, pupillary margin, and other anterior segment structures, is common, particularly in older populations, and a substantial proportion of affected patients eventually develop exfoliation glaucoma, related to progressive obstruction of the trabecular meshwork by this same exfoliative material along with associated pigment.
Why Exfoliation Glaucoma Behaves More Aggressively
Several features distinguish exfoliation glaucoma from typical primary open-angle glaucoma in ways that matter directly for management.
- Intraocular pressure at presentation tends to be higher on average, and more patients present with an acute or subacute pressure spike rather than the more gradual, insidious pressure elevation typical of primary open-angle glaucoma
- Diurnal pressure fluctuation tends to be more pronounced, meaning a single office pressure measurement may not adequately capture a given patient’s true peak pressure burden, similar in concept to the exercise-related fluctuation pattern seen in pigmentary glaucoma, though driven by a different underlying mechanism
- The disease often progresses more rapidly and can be more resistant to standard medical therapy compared with primary open-angle glaucoma
- Asymmetry between the two eyes is common, since pseudoexfoliation syndrome itself, and the resulting glaucoma, frequently affects the two eyes unevenly, sometimes substantially so
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From Choroida — the team behind this siteClinical Features
- Elevated, often markedly elevated, intraocular pressure, sometimes with documented significant diurnal variation
- Visible pseudoexfoliative material on the anterior lens capsule, classically in a target or bullseye pattern with a central disc, a clear zone, and a peripheral granular zone, along with material often visible at the pupillary margin
- Poor pupillary dilation is a commonly associated finding, related to both the exfoliative material itself and associated iris changes, and this has direct practical implications for cataract surgery planning in these patients
- Optic nerve and visual field changes consistent with glaucomatous damage, assessed using standard techniques
Surgical Considerations Beyond the Glaucoma Itself
Pseudoexfoliation syndrome is also associated with zonular weakness, which carries important implications if the patient requires cataract surgery, given the increased risk of intraoperative complications related to inadequate lens support in these eyes (see zonular dehiscence in cataract surgery and capsular tension ring indications for the related surgical planning considerations this association raises).
Diagnostic Evaluation
- Slit-lamp examination identifying the characteristic pseudoexfoliative material on the lens capsule and pupillary margin
- Gonioscopy, often showing increased, sometimes patchy, trabecular meshwork pigmentation
- Intraocular pressure monitoring, with attention to the possibility of significant diurnal fluctuation not captured by a single measurement
- Optic nerve assessment and visual field testing, following standard glaucoma evaluation principles
- Careful assessment of lens stability (checking for phacodonesis) given the associated zonular weakness risk, particularly important if cataract surgery is anticipated
Management
Medical Therapy
Topical aqueous-suppressant medications are used as initial therapy, though given the tendency toward higher and more variable pressure in this condition, closer monitoring of treatment response and a lower threshold for escalating therapy is often appropriate compared with typical primary open-angle glaucoma management.
Laser Trabeculoplasty
Selective laser trabeculoplasty is often notably effective in exfoliation glaucoma, in some reported series showing a particularly robust initial pressure-lowering response compared with primary open-angle glaucoma, making it an appealing treatment option to consider relatively early in the management sequence for this condition.
Surgical Management
Given the tendency toward more aggressive, sometimes treatment-resistant disease, incisional glaucoma surgery is needed more frequently and sometimes earlier in the course of exfoliation glaucoma than in typical primary open-angle glaucoma, with the specific surgical approach chosen based on disease severity and individual patient factors.
Practical points
Eyes with exfoliation syndrome may have large pressure swings, so a single normal reading does not exclude trouble. Home or diurnal measurements may help. Laser trabeculoplasty is often effective early, although the effect may fade sooner than in other types. Patients should be told that the condition is lifelong, that the other eye may follow, and that cataract surgery needs extra care.
Prognosis
Exfoliation glaucoma generally requires more vigilant, sometimes more aggressive, management than primary open-angle glaucoma, given its tendency toward higher pressure, greater fluctuation, and a less predictable overall course.
With appropriately close monitoring, a lower threshold for treatment escalation, and attention to the specific surgical considerations this condition raises should cataract surgery become necessary, many patients still achieve good long-term pressure control and stable vision, though the more vigilant approach this condition warrants is genuinely important to its favorable management.
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From Choroida — the team behind this siteReferences
- Ritch R, Schlotzer-Schrehardt U. Exfoliation syndrome. Surv Ophthalmol. 2001;45:265-315.
- Konstas AG, Mantziris DA, Stewart WC. Diurnal intraocular pressure in untreated exfoliation and primary open-angle glaucoma. Arch Ophthalmol. 1997;115:182-185.
- Damji KF, Konstas AG, Liebmann JM, et al. Intraocular pressure following selective laser trabeculoplasty in exfoliation versus primary open angle glaucoma. Br J Ophthalmol. 2006;90:1529-1532.
- Schlotzer-Schrehardt U, Naumann GO. Ocular and systemic pseudoexfoliation syndrome. Am J Ophthalmol. 2006;141:921-937.
Test yourself
A few questions straight from this article.
-
What mechanism raises intraocular pressure in exfoliation glaucoma?
Exfoliation glaucoma develops through progressive obstruction of the trabecular meshwork by exfoliative material together with associated pigment. The same material is deposited on the lens capsule and pupillary margin. -
What is the classic appearance of pseudoexfoliative material on the anterior lens capsule?
The material classically forms a target or bullseye pattern comprising a central disc, an intervening clear zone and a peripheral granular zone. Material is often visible at the pupillary margin as well. -
How does intraocular pressure in exfoliation glaucoma typically compare with primary open-angle glaucoma?
Pressure at presentation tends to be higher on average and diurnal fluctuation is more pronounced than in primary open-angle glaucoma. More patients also present with an acute or subacute pressure spike rather than gradual elevation. -
What does pronounced diurnal fluctuation in exfoliation glaucoma mean for pressure monitoring?
Because fluctuation is wide, one office measurement may not capture a patient's true peak pressure burden, so a single normal reading does not exclude trouble. Diurnal or home measurement can help. -
Which pattern of eye involvement is common in exfoliation glaucoma?
Pseudoexfoliation syndrome, and the glaucoma that follows it, frequently affects the two eyes unevenly, sometimes substantially so. Patients should be told the fellow eye may follow. -
Which associated iris finding complicates cataract surgery planning in exfoliation glaucoma?
Poor dilation is commonly associated, arising from both the exfoliative material and related iris changes. It has direct practical implications for planning cataract surgery in these patients. -
Which lens-related association raises intraoperative risk during cataract surgery in pseudoexfoliation?
Pseudoexfoliation syndrome is associated with zonular weakness, which increases the risk of intraoperative complications from inadequate lens support. This shapes surgical planning whenever cataract surgery is required. -
Which examination finding should be sought to assess lens stability in pseudoexfoliation?
Careful assessment of lens stability by checking for phacodonesis is advised because of the associated zonular weakness. It is particularly important when cataract surgery is anticipated. -
Which laser treatment is often notably effective early in exfoliation glaucoma?
Selective laser trabeculoplasty is often notably effective in exfoliation glaucoma, with some series showing a particularly robust initial pressure-lowering response compared with primary open-angle glaucoma. This makes it appealing relatively early in the treatment sequence. -
How often is incisional glaucoma surgery required in exfoliation glaucoma relative to primary open-angle glaucoma?
Because the disease tends to be more aggressive and sometimes treatment-resistant, incisional surgery is needed more often and sometimes sooner than in primary open-angle glaucoma. The specific operation is chosen on disease severity and individual patient factors.
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