Eyeworld

68 | EYEWORLD | FALL 2025 G UCOMA References 1. Michelessi M, Lindsley K. Peripheral iridotomy for pigmen- tary glaucoma. Cochrane Data- base Syst Rev. 2016;2:CD005655. 2. Klamann MK, et al. iStent inject in phakic open angle glaucoma. Graefes Arch Clin Exp Ophthalmol. 2015;253:941–947. "Interestingly, depending on the study, usually around 20–30% of patients with PDS go on to develop pigmentary glaucoma," he said in an email to EyeWorld. He also said that while the most common patient is a young, white, myopic male, this condition can be seen in all ages and races. "Usually, as the patient ages and their cat- aracts develop, the lens/zonular complex moves away from the iris and the chance of pigment liberation decreases. However, despite inactive 'liberation' of pigment, if a patient has PDS, they have a slightly increased lifelong risk of devel- oping glaucoma, usually 2–4 fold higher than their normal baseline risk." Dr. Eisengart said it's important to distin- guish between primary pigment dispersion, which is the focus of this article, and secondary pigment dispersion. The latter occurs post- surgically, often from a sulcus-placed IOL, Dr. Eisengart said, but "anything else that chafes the posterior iris surface, such as a large Soem- mering's ring, can do the same thing." "Second- ary PDS and PG have many of the same findings as primary disease, but it typically occurs in only one eye, and the iris transillumination defects are restricted to areas over the lens implant or other mass in the ciliary sulcus," Dr. Eisengart said. Treating and monitoring Dr. Grover said younger patients are at higher risk for pressure spikes, so he educates them about what to look for and what a spike looks like. Once he establishes a baseline, he thinks following PDS or PG is appropriate. Dr. Eisengart said if a patient presents with PDS, normal pressure, and a healthy optic nerve, he thinks it's reasonable to monitor the patient with annual visits, watching for the first signs of glaucoma. Patients with PDS and untreated ocular hypertension or patients with treated and well-controlled PG should be seen every 6 months. Dr. Eisengart also thinks pro- phylactic treatment for the potential of PG can be prescribed for patients with PDS and ocular hypertension, but he noted that, unfortunately, some eyes aren't diagnosed with PDS until after glaucomatous damage has occurred. Dr. Vinod said that the presence or absence of active pigment dispersion, stability of IOP, and OCT RNFL and visual field results influence her monitoring of these patients. "I might follow patients with PDS with normal IOP (or those with ocular hypertension or mild PG that is well controlled on medication) every 6 months, whereas I'll see patients with active pigment dispersion and refractory IOP elevation far more frequently until we get the IOP under control. Ultimately, the decision of how often to monitor and whether, and how, to treat PDS/PG must be individualized to each patient," she said. Dr. Vinod mentioned that patients should be counseled about the potential for pigment liberation associated with physical exertion, which can cause IOP spikes presenting as blurry vision and pain. She said that retinal detach- ment is more common in patients with PDS/ PG, so they should be counseled about these symptoms as well. "For patients whose OCT RNFL or visual fields appear to be progressing despite seem- ingly well-controlled IOP measurements during office visits, home tonometry is a useful tool to identify IOP spikes related to exercise-induced pigment liberation," Dr. Vinod added. As for treatment, Dr. Grover called SLT a "tremendous option." If that doesn't safely control IOP, he said IOP-lowering medications are appropriate, as are goniotomy and GATT, if surgery is required. "Some used to advocate for performing a laser peripheral iridotomy in an attempt to resolve the 'reverse' pupil block that can sometimes be seen, however, no studies have definitively demonstrated this to be an continued from page 67 Scheie stripe, pigment deposition at zonular insertion onto lens capsule Source: Jonathan Eisengart, MD

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