Pseudoexfoliation Syndrome (Pseudoexfoliation Glaucoma) Treatment & Management

Updated: Oct 23, 2018
  • Author: Mauricio E Pons, MD; Chief Editor: Inci Irak Dersu, MD, MPH  more...
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Treatment

Medical Care

Patients with pseudoexfoliation syndrome should have annual eye examinations for early detection of glaucoma. Glaucoma in pseudoexfoliation is more resistant to medical therapy and has a poorer prognosis than primary open-angle glaucoma.

The treatment of pseudoexfoliation glaucoma is the same as that of primary open-angle glaucoma; however, topical medications tend to be less effective. Miotics lower IOP, but they aggravate the blood-aqueous barrier dysfunction and decrease iris mobility, thereby increasing the risk of posterior synechiae and cataract formation.

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Surgical Care

Argon laser trabeculoplasty is frequently used with excellent initial success. Its hypotensive effect may be facilitated by enhanced heat absorption because of increased trabecular pigmentation.

According to a published study, selective laser trabeculoplasty (SLT) has been shown to be equivalent to argon laser trabeculoplasty in terms of lowering IOP at 1 year. The theoretical advantage of SLT is that SLT is a repeatable procedure because it does not seem to produce thermal damage to the trabecular meshwork.

If medical therapy and laser therapy are unsuccessful to control the glaucoma, trabeculectomy can be performed with similar success rates to that of primary open-angle glaucoma. Because patients with pseudoexfoliation glaucoma have higher IOP, they tend to undergo glaucoma filtering surgery more frequently than patients with primary open-angle glaucoma.

Cataracts occur more commonly in patients with pseudoexfoliation syndrome. The Blue Mountains Eye Study suggest that the presence of pseudoexfoliation syndrome is associated with an increased risk of nuclear cataract and cataract surgery. [46] Weakness of the zonular fibers, spontaneous lens subluxation, and phacodonesis also can be present. Therefore, in these patients, cataract surgery alone or combined cataract surgery and glaucoma filtering surgery in the presence of pseudoexfoliation is associated with a higher incidence of intraoperative complications, most notably zonular dialysis, vitreous loss, and lens dislocation.

The increased intraoperative posterior capsule complication rate appears to correlate with the level of cataract maturity. Modern surgical techniques involving the use of capsulorrhexis, small-incision surgery, and better viscoelastics have improved the surgical outcome. Capsular tension rings have been used to decrease surgical stress on the zonules.

Postoperative cataract surgery complications can occur after uneventful operations due to continued destabilization of the zonules and capsular contraction.

Jacobi et al described a nonfiltering surgical technique consisting of trabecular aspiration with or without cataract removal with encouraging results. [47] The operation attempts to increase the outflow facility along the trabecular meshwork by removing pretrabecular and trabecular debris using an externally applied suction device. Trabecular aspiration can be performed with modern tools such as trabectome as a minimally invasive surgery.

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Diet

The use of supplements with vitamin B-12 and folic acid to decrease hyperhomocysteinemia in patients at risk has been suggested. A randomized clinical trial is needed to prove its benefit.

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