Eyeworld

EW GLAUCOMA 36 December 2018 by Stefanie Petrou Binder, MD, EyeWorld Contributing Writer Presentation spotlight cataract surgery in individuals with PXF," Dr. Lazreg explained. Phacoemulsification cataract surgery resulted in a significant IOP reduction (20%) over a 12-month follow-up period in patients with PXF and POAG, including a signif- icant reduction in the amount of medications needed, particularly in the PXF group. 5 "Several studies demonstrated an IOP-lowering effect following cat- aract surgery, particularly in patients with PXF. Cataract surgery provides a better IOP control in the short to medium term and is often useful in order to avoid or at least delay more invasive filtering surgery," she said. Treatment option: EX-PRESS device The EX-PRESS device (Alcon, Fort Worth, Texas) is a good option in PXF, as it avoids iridectomy and sclerotomy, since the implant is placed into the anterior chamber. The advantage of this over standard trabeculectomy is less inflammation due to decreased manipulation. "This may be especially relevant in PXFG, which can be prone to a heightened inflammatory response following surgery," Dr. Lazreg noted. A retrospective review of the re- cords of 100 eyes (100 patients) who underwent trabeculectomy or EX- PRESS device implantation found no differences in IOP reduction or postoperative IOP-lowering medica- tions between the two procedures in POAG and PXFG patients. 6 Treatment option: angle-based procedures "The mechanism underlying ele- vated IOP in PXF appears to be the accumulation of exfoliation material and/or liberated iris pigment imped- ing outflow, primarily at the level of the trabecular meshwork. Suppress- ing obstruction at this junction may be theoretically more advantageous for PXFG over POAG," Dr. Lazreg said. One option, trabecular aspi- ration, was initially developed as a way to increase the trabecular outflow facility in PXFG, either lived, and failure can occur at a fast- er rate than in POAG patients. The 2-year success rate of primary ALT in PXFG was reported as high as 80% compared to 77% in POAG but de- clined to 36% in PXFG versus 67% in POAG after 8 years of follow-up. 3 Laser application methods can influence outcomes. A systematic re- view that analyzed trials comparing SLT with other glaucoma treatment options showed that in 17 random- ized controlled trials that met the inclusion criteria, no difference was observed overall between SLT and ALT laser treatments in glaucoma patients in terms of IOP-lowering effect. Three trials indicated no dif- ference between 360-degree SLT and medical therapy, with one of the tri- als indicating greater IOP reduction with latanoprost over 90-degree and 180-degree SLT. Three trials indicat- ed no difference between 180-de- gree SLT and 360-degree SLT. It was inconclusive whether 90-degree treatments were less efficacious than 180-degree SLT. One trial reported greater IOP reduction with excimer laser trabeculoplasty (ELT) over 180-degree SLT in the long term. 4 Treatment option: trabeculectomy The most widely used surgical procedure in PXFG is by far trab- eculectomy with antimetabolites. According to Dr. Lazreg, given the higher mean IOP in PXFG compared to other types of glaucoma and the larger diurnal fluctuations, filtering surgery is often the best choice. "Non-penetrating surgeries that are less efficient in IOP reduction are not recommended for these pa- tients," she said. Exfoliation syndrome predispos- es to many complications such as capsule rupture, zonular dehiscence, and vitreous loss during cataract ex- traction. PXF is also associated with an increase in cataract formation. Combined cataract and glaucoma surgery was reported to be an effec- tive treatment in PXFG. "Cataract extraction implies a higher degree of technical difficulty and a larger rate of complications in PXF surgeries. It is recommendable not to delay seen among older individuals of Scandinavian and Mediterranean origins," she said. Treatment option: trabeculoplasty Treatment for PXF aims to lower IOP in order to hinder any further glaucomatous optic nerve damage. Medical therapy shows IOP fluctua- tions and often necessitates adjunc- tive therapy with either medications and/or laser treatment. Pseudoexfoliative glaucoma (PXFG) patients frequently require surgical intervention to manage their high IOP. The traditional surgical options for managing PXFG are similar to those for POAG and include laser trabeculoplasty, filtering surgery, and tube shunt implantation. With the advent of microinvasive glaucoma surgery (MIGS) procedures, either alone or in combination with cataract surgery, more options may become available to this patient group. "Usually PXFG responds well to trabeculoplasty, probably due to the increased pigmentation of the angle, which makes the laser treatment more effective," Dr. Lazreg said. "Trabeculoplasty can be performed using selective laser trabeculoplasty (SLT) and argon laser trabeculoplas- ty (ALT), in which the IOP-lowering effect is frequently short lived." SLT and ALT were seen to achieve equivalent levels of efficacy and side effects in a meta-analysis on the outcomes of all randomized controlled trials up until 2013 that compared the two laser techniques in open angle glaucoma patients (482 eyes). No significant difference was noted in IOP-lowering effects between SLT and ALT at all time points from 1 hour after surgery up to 5 years in patients naive to laser. 1 Long-term outcomes of SLT and ALT resulted in similar efficacies and a 50% failure rate after 2 years, although the repeatability of SLT is thought to be one of the advantages over ALT. 2 Historically, PXF patients have responded well to ALT, however, the IOP-lowering effect can be short Glaucoma specialist shares her best strategies to reduce IOP in individuals with PXF P ressure reduction in glaucoma patients with pseudoexfoliation syn- drome requires special considerations. Speaking at the 2018 World Ophthalmology Congress, Sihem Lazreg, MD, Laz- reg Ophthalmology, Algiers, Algeria, shared her expertise on the treat- ment and management of pseudoex- foliative (PXF) glaucoma. "PXF is a very serious type of glaucoma. The successful long-term management of PXF remains the biggest challenge," Dr. Lazreg said in her presentation. "Compared to primary open angle glaucoma (POAG), medical treatment renders lower control. It is associated with a more aggressive evolution that tends toward a rapid progression and a worse prognosis. PXF needs a tailored and more anticipating man- agement strategy, however, there is no consensus in the literature on the treatment and management of this glaucoma," she said. PXF PXF syndrome is an age-related sys- temic condition, with PXF glaucoma seen in up to 50% of eyes with PXF. It is characterized by an abnormal accumulation and deposition of ex- tracellular matrix, protein-like mate- rial throughout the anterior segment of the eye, most noticeably along the pupillary border and on the an- terior lens capsule. Its pathogenesis has both genetic and environmental factors. "PXF syndrome is the most common identifiable cause of sec- ondary open angle glaucoma world- wide. Compared to POAG, it runs a more aggressive clinical course with high IOP at onset, faster rates of pro- gression, poor response to medical therapy, and increased need for sur- gical intervention. The prevalence of the condition shows huge variations among different populations, mostly Optimizing glaucoma surgery in exfoliative glaucoma

• Blank Page
• Blank Page (1)