A Multifaceted Approach to Managing Pseudoexfoliation Glaucoma

By Dan Arreaza Kaufman, MD; Jonathan Eisengart, MD; and Mary Qiu, MD

Pseudoexfoliation glaucoma (PXG) is a common and progressive form of secondary glaucoma.¹ Characterized by the accumulation of abnormal fibrillar material in the anterior segment, PXG leads to elevated intraocular pressure (IOP) and optic nerve damage.²

While treatment typically begins with medication, the disease often advances, requiring surgical intervention. The challenge lies in selecting the right intervention for each patient, given the unique anatomical and pathophysiological changes in PXG.

For many patients, early medical or laser intervention can keep the disease stable for years. However, if IOP becomes difficult to control, surgical treatment, ranging from newer minimally invasive glaucoma surgery (MIGS) to traditional trabeculectomy and tube shunts, may become necessary.

PXG pathophysiology

PXG is caused by the accumulation of pseudoexfoliative material, which can obstruct the trabecular meshwork and impede aqueous outflow.²

The condition is most common in older adults. It can occur in various ethnic groups, most often in people of Scandinavian or Mediterranean descent.³

Treatment options: A stepwise approach

1. Medical management. In the early stages of PXG, IOP control often can be achieved with medication.⁴ While medications can be effective in reducing IOP, they do not address the underlying pathology of the disease. In some patients, as PXG progresses, medications alone may become insufficient.

2. Laser treatment. Selective laser trabeculoplasty (SLT) can be a helpful adjunct for PXG patients who require additional IOP lowering. Although it can provide moderate IOP reduction, SLT may not be as effective for advanced disease, and its effect might last less in patients with PXG.^5,6

3. Traditional glaucoma surgeries. When medical management and laser therapy fail to control IOP, surgical options are required. Trabeculectomy and tube shunt surgeries remain the gold standards for managing advanced PXG.⁴ These procedures provide significant IOP reduction but come with risks. For example, trabeculectomy can lead to complications such as infections, bleb failure or hypotony, while tube shunts may be associated with tube-related corneal decompensation as well as erosion and infection.^4,7

4. MIGS. For mild cases of PXG, MIGS is often the first-line surgical intervention. Goniotomy or a microstent, for example, are less invasive, have a quicker recovery time and carry a favorable safety profile. These MIGS options can help reduce IOP by improving aqueous outflow through microstent placement in the trabecular meshwork.⁸

For moderate to severe PXG, gonioscopy-assisted transluminal trabeculotomy (GATT) is becoming an increasingly important option. GATT offers a more robust approach by targeting the underlying pathology of PXG, removing the blocked trabecular meshwork and allowing for more effective aqueous outflow. It’s a promising procedure for patients who have significant IOP elevation from PXG. GATT has shown encouraging results with lower complication rates than traditional filtering surgeries.^9,10

Tailoring clinical recommendations

For the successful management of PXG, a multimodal approach is essential. Early diagnosis and aggressive medical management often can prevent the need for surgical intervention. For patients who require surgery, it is important to tailor the treatment plan to the patient’s individual needs, taking into consideration their stage of disease and overall health.

MIGS procedures, including GATT, should be considered a viable option for managing PXG. If those surgeries fail, however, traditional surgeries like trabeculectomy or tube shunts may be necessary. By adopting a personalized, stepwise treatment approach, ophthalmologists can more effectively and safely manage PXG and preserve patients’ vision.

Drs. Eisengart and Qiu are glaucoma specialists at Cleveland Clinic Cole Eye Institute. Dr. Arreaza Kaufman is a glaucoma fellow.

References

1. Ritch R. Exfoliation syndrome — The most common identifiable cause of open-angle glaucoma. J Glaucoma. 1994 Summer;3(2):176-7.
2. Melese EK, Shibeshi MA, Sherief ST. Prevalence of pseudoexfoliation among adults and its related ophthalmic variables in southern Ethiopia: A cross-sectional study. Clin Ophthalmol. 2022 Nov 29;16:3951-3958.
3. Tuteja S, Zeppieri M, Chawla H. Pseudoexfoliation syndrome and glaucoma. [Updated 2023 May 31]. In: StatPearls [Internet].
4. Desai MA, Lee RK. The medical and surgical management of pseudoexfoliation glaucoma. Int Ophthalmol Clin. 2008 Fall;48(4):95-113.
5. Gracner T. Intraocular pressure response of capsular glaucoma and primary open-angle glaucoma to selective Nd:YAG laser trabeculoplasty: A prospective, comparative clinical trial. Eur J Ophthalmol. 2002 Jul-Aug;12(4):287-92.
6. Ayala M. Risk factors for visual field progression in newly diagnosed exfoliation glaucoma patients in Sweden. Sci Rep. 2022 Jun 24;12(1):10763.
7. Conway RM, Schlotzer-Schrehardt U, Kuchle M, Naumann GO. Pseudoexfoliation syndrome: Pathological manifestations of relevance to intraocular surgery. Clin Exp Ophthalmol. 2004;32(2):199-210.
8. Samet S, Ong JA, Ahmed IIK. Hydrus microstent implantation for surgical management of glaucoma: A review of design, efficacy and safety. Eye Vis (Lond). 2019 Oct 22;6:32.
9. Aktas Z, Ozdemir Zeydanli E, Uysal BS, Yigiter A. Outcomes of prolene gonioscopy assisted transluminal trabeculotomy in primary open angle glaucoma and pseudoexfoliation glaucoma: A comparative study. J Glaucoma. 2022 Sep 1;31(9):751-756.
10. Sharkawi E, Lindegger DJ, Artes PH, et al. Outcomes of gonioscopy-assisted transluminal trabeculotomy in pseudoexfoliative glaucoma: 24-month follow-up. Br J Ophthalmol. 2021 Jul;105(7):977-982.