Eyeworld

106 | EYEWORLD | SPRING 2025 G UCOMA by Liz Hillman Editorial Co-director About the physicians Kevin Halenda, MD Assistant Professor of Ophthalmology West Virginia University Morgantown, West Virginia Michael Krause, MD, PhD Assistant Professor University of Virginia Charlottesville, Virginia P seudoexfoliation syndrome is a sys- temic, age-related disease—with an up to 20% prevalence in the 60+ age group—that most obviously affects the eye, though there is evidence that it has "associations … with cardiovascular and cerebrovascular morbidity" as well. 1 These patients need more frequent monitoring due to an increased risk of developing secondary open angle glaucoma from the condition, and it can impact ocular surgery, such as cataract surgery, as well. Kevin Halenda, MD, and Michael Krause, MD, PhD, provided their perspectives on the condition and advice for its identification, man- agement, and considerations for surgery when pseudoexfoliation syndrome is present. Prevalence and identification Dr. Halenda said that pseudoexfoliation syn- drome in his practice is not rare though not entirely common either. "It's probably under diagnosed. There are a lot of patients who have it, and there are some subtle exam findings," he said. Dr. Krause has found in his diverse patient population that pseudoexfoliation is present in many different ethnic groups. The review by Schlötzer-Schrehardt and Naumann cited variation in prevalence with those of Nordic and Eastern Mediterranean descent being most af- fected. They stated that "variation in prevalence has been proposed to be due to epigenetics, the attitude of inhabitants, UV exposure, climatic conditions, proximity to the equator, dietary factors, oxidative stress mechanisms, genetic predisposition, etc." 1 Identification of pseudoexfoliation is important, Dr. Krause noted, because up to 40–50% of these patients will develop glaucoma as a result. As such, Dr. Halenda said if glauco- ma is not yet present, he thinks patients with pseudoexfoliation should be seen in the clinic every 6 months. What's more, he said glaucoma, if it develops, is often faster progressing and can be more severe. "They tend to require surgery more fre- quently and earlier than in primary open angle glaucoma patients because they tend to present with more severe disease," Dr. Halenda said, noting that he'll often see patients who have been diagnosed with pseudoexfoliation glauco- ma every 4 months until he has an idea of how stable their disease is. There are characteristic exam findings associated with pseudoexfoliation syndrome, Dr. Krause said, noting white fibrillar material on the iris border and white flaky deposits on the anterior capsule of the lens. He also said these patients typically dilate poorly, and there may be iris transillumination defects. On gonioscopy, the trabecular meshwork can be pigmented, and there may be a Sampaolesi line (pigment anterior to Schwalbe line). In addition to these signs, Dr. Halenda said other clues include evidence of zonular insta- bility such as one anterior chamber angle being narrower than the other. If the patient has progressed to pseudo- exfoliation glaucoma, Dr. Halenda said that it tends to be very asymmetric between eyes and presents with higher IOPs than those typically seen with primary open angle glaucoma. "Sometimes the pressure can be very high, even higher than 50. One of the things that rais- es my suspicion for pseudoexfoliation glaucoma is if there is a big difference in the severity of the disease between the two eyes. It doesn't mean that they have it, but it raises a red flag," Dr. Halenda said. Pseudoexfoliation glaucoma: management and considerations for ocular procedures " It's probably under diagnosed. There are a lot of patients who have it, and there are some subtle exam findings." —Kevin Halenda, MD

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