Pseudoexfoliation Syndrome and Glaucoma

Treat pseudoexfoliation material as a high-risk ocular finding rather than a diagnosis of glaucoma by itself. Pseudoexfoliation is associated with increased glaucoma risk independent of other recognized glaucoma risk factors, including IOP, while individual clinical trajectories range from no glaucoma to severe vision loss.JAMA+1JAMAThe Relationship Between Glaucoma and PseudoexfoliationScienceDirectA Multitrait Open-Angle Glaucoma Polygenic Risk Score ... Document laterality, IOP in each eye, optic disc appearance, and whether glaucomatous visual field loss or retinal nerve fiber layer injury is present before assigning pseudoexfoliative glaucoma.

Perform gonioscopy rather than presuming a purely open-angle mechanism. Pseudoexfoliation is associated with narrow angles secondary to zonular weakness; cataract or anterior lens movement from zonular laxity can contribute to angle closure and changes management toward lens-based treatment or laser iridoplasty when appropriate.PubMed+1PubMedPseudoexfoliation Syndrome and Glaucoma - StatPearls - NCBI BookshelfPubMedThe Medical and Surgical Management of Pseudoexfoliation ... A painful red eye with sudden visual decline should trigger urgent evaluation for acute angle closure rather than routine chronic-glaucoma follow-up.The LancetThe LancetGlaucoma

Establish a structural-functional baseline with slit-lamp biomicroscopy of the anterior and posterior segments, stereoscopic optic nerve examination, OCT of the optic nerve/RNFL, and standard automated perimetry. OCT, perimetry, and gonioscopy are core glaucoma assessment modalities, and longitudinal visual-field change plus optic nerve examination should drive treatment intensification rather than IOP alone.Oxford Academic+1Oxford AcademicGlaucoma | Training in Ophthalmology - Oxford Academicnice org ukRecommendations | Glaucoma: diagnosis and management | Guidance | NICE

There is no treatment that stops pseudoexfoliation material deposition. In pseudoexfoliative glaucoma, choose therapy according to the pressure reduction required, treatment tolerance, angle anatomy, cataract status, and evidence of structural or field progression.PubMedPubMedPseudoexfoliation Syndrome and Glaucoma - StatPearls - NCBI Bookshelf IOP lowering is the modifiable intervention used to alter glaucoma progression, with topical agents, laser treatment, and drainage surgery constituting the principal options.PubMedPubMedNormal Tension Glaucoma - StatPearls - NCBI Bookshelf

A prostaglandin analog is a common first-line topical approach for open-angle glaucoma. FDA-approved drug classes include prostaglandin analogs, topical carbonic anhydrase inhibitors, beta-blockers, cholinergic agents, and other IOP-lowering therapies; select based on ocular and systemic contraindications rather than class escalation by habit.PubMedPubMedUpdates on the Diagnosis and Management of Glaucoma Avoid nonselective topical beta-blockers in asthma or COPD and also consider heart block, hypotension, and bradycardia.PubMedPubMedOpen Angle Glaucoma - StatPearls - NCBI Bookshelf

When topical treatment is not tolerated, assess preservative-related ocular surface disease and simplify the regimen before abandoning pressure control. Transitioning to preservative-free formulations or formulations with less cytotoxic preservatives can improve ocular surface symptoms; persistent medication intolerance can justify earlier SLT or surgery, depending on pressure and progression risk.PubMedPubMedManaging Ocular Surface Disease in Glaucoma Treatment: A Systematic Review

Consider trabeculectomy after maximal tolerated medical treatment and/or SLT fail to control pseudoexfoliative glaucoma. Reported trabeculectomy outcomes in pseudoexfoliative glaucoma are similar to those in primary open-angle glaucoma without an increased complication rate, but postoperative drops may still be necessary if the achieved target pressure is not low enough.PubMedPubMedPseudoexfoliation Syndrome and Glaucoma - StatPearls - NCBI Bookshelf

Glaucoma drainage devices, canaloplasty, and viscocanalostomy are alternatives in selected eyes. MIGS remains a context-dependent choice: it may reduce medication burden, but its ability to reach very low target pressures is less certain than traditional filtration surgery, and the broader role of MIGS remains controversial.PubMed+2PubMedPseudoexfoliation Syndrome and Glaucoma - StatPearls - NCBI BookshelfPubMedUpdates on the Diagnosis and Management of GlaucomaPubMedNormal Tension Glaucoma - StatPearls - NCBI Bookshelf

Reserve cyclodestructive approaches for appropriate refractory disease; cyclocryotherapy is described as a treatment for painful eyes with vision loss from glaucoma. Procedure choice should be driven by visual potential, target IOP, prior surgery, conjunctival status, and the need to avoid or accept a filtering bleb.PubMedPubMedOpen Angle Glaucoma - StatPearls - NCBI Bookshelf

Before cataract extraction, document dilation quality, phacodonesis, lens subluxation, corneal status, baseline IOP, and glaucoma severity. Pseudoexfoliation affects the anterior segment, including iris, zonules, and cornea, and is associated with increased cataract frequency; zonular detachment can occur through mechanical forces or enzymatic zonulolysis.ScienceDirect+2ScienceDirectPseudoexfoliation and the cataract surgeon: Preoperative, ...ScienceDirectPseudoexfoliation - an overviewPubMedCataract Surgery and Possible Complications in Patients with ...

Anticipate poor mydriasis and zonular instability. Pseudoexfoliation-associated cataract surgery complications include corneal edema, capsular phimosis, inflammation, zonular dialysis, capsular bag rupture, postoperative IOP spikes, and late IOL decentration; lens subluxation and corneal endothelial disease further increase operative complexity.PubMedPubMedPseudoexfoliation Syndrome and Glaucoma - StatPearls - NCBI Bookshelf

If gonioscopy suggests a lens-related angle component, cataract extraction may be beneficial, but it should not be viewed as a substitute for glaucoma surgery when the required target IOP is lower than lens extraction is likely to provide. Coordinate the cataract and glaucoma procedural plan around degree of optic neuropathy, pressure control, and zonular support needs.PubMed+1PubMedPseudoexfoliation Syndrome and Glaucoma - StatPearls - NCBI BookshelfPubMedUpdates on the Diagnosis and Management of Glaucoma

At minimum, eyes with pseudoexfoliation require annual examination to detect ocular hypertension or glaucoma. Increase visit frequency when IOP is elevated, when OCT or visual field testing shows progression, after treatment changes, or when cataract surgery is planned or recently completed.PubMedPubMedPseudoexfoliation Syndrome and Glaucoma - StatPearls - NCBI Bookshelf

Use serial IOP, visual fields, and stereoscopic optic nerve examination to determine whether the current target is adequate. Glaucoma monitoring decisions should incorporate risk factors for conversion and sight loss, coexisting pathology, and detectable changes in visual field or optic nerve status.nice org uknice org ukRecommendations | Glaucoma: diagnosis and management | Guidance | NICE

Counsel that pseudoexfoliation is progressive and that glaucoma risk differs between eyes and over time. Prompt reassessment is warranted for new pain or abrupt visual loss because that presentation is incompatible with routine asymptomatic surveillance and raises concern for acute angle closure.The Lancet+1The LancetGlaucomaScienceDirectCurrent understanding of genetics and epigenetics in ...