Eyeworld

FALL 2025 | EYEWORLD | 69 G Relevant disclosures Eisengart: Nova Eye Grover: None Vinod: None Contact Eisengart: EISENGJ@ccf.org Grover: dgrover@glaucomaassociates.com Vinod: kate.vinod@gmail.com effective method for treating PDS/PG, and many glaucoma doctors have moved away from this approach," he said. Dr. Eisengart acknowledged that some glau- coma specialists would perform a laser periph- eral iridotomy, which was intended to eliminate any reverse pupillary block, flatten the iris configuration, and possibly reduce chafing of the iris on the zonules. Dr. Vinod also discussed studies regarding laser iridotomy with the intent to relieve the concave configuration of the iris. She said there is a lack of evidence demonstrat- ing a beneficial effect on visual field progression and the overall disease course. 1 Dr. Eisengart noted that treatment of PG is like POAG with a few caveats. When consider- ing laser trabeculoplasty, Dr. Eisengart said eyes with PG are more likely to experience post-laser pressure spikes, due to excess pigment more effectively absorbing the laser energy. "While I typically perform SLT laser 360 degrees in one sitting for eyes with POAG, I am more likely to treat only 180 degrees at a time in eyes with PG to mitigate this risk," he explained. Dr. Vinod said due to the risk of IOP spikes post-SLT, she also only initially treats a limit- ed part of the angle (90 degrees) with lower energy settings (starting energy of 0.4 mJ vs. 0.8–1.0 mJ) as a test run. "I check the IOP with- in an hour after SLT and follow patients with PDS/PG more frequently after the procedure than I would patients with POAG," she said. In addition to Dr. Grover, Dr. Eisengart and Dr. Vinod also said that eyes with PG respond well to goniotomy or ab interno trabeculotomy, if surgery is needed. Dr. Vinod said anterior seg- ment surgeons should be aware of IOP spikes that can follow certain MIGS procedures and other complications that can occur with inci- sional surgery in the PG patient population. "For example, one retrospective study of patients with OAG undergoing the second-gen- eration iStent inject [Glaukos] found that all 3 patients with PG included in the study devel- oped IOP spikes of 30 mm Hg or higher within the first postoperative month and required subsequent trabeculectomy," 2 she said. "While trabeculectomy remains a good option for those with more advanced PG and refractory IOP elevation, patients with PG who are highly myopic are at higher risk for hypotony-related postoperative complications, such as maculopa- thy. Glaucoma drainage implant surgery is also a reasonable surgical option for advanced PG." PDS long term and final thoughts PDS can "burn out" over time, usually after a decade, likely due to age-related changes in the lens dimension that relieves friction between the iris and zonules, Dr. Vinod said. This burn- out, according to Dr. Eisengart, can also occur because the iris runs out of pigment to release. "The pigment cells on the posterior iris surface do not replace themselves, and once all the cells being chafed are rubbed off, there are simply no more to release," he said. Whether less chaf- ing is due to lens changes or fewer cells left to chafe, Dr. Eisengart said that IOP can stabilize and become easier to control for these patients. "Pigmentary glaucoma should remain in the differential diagnosis for an older patient with what appears to be OAG with IOP within the 'normal' range (especially if asymmetric) with- out characteristic findings of PDS/PG, since the IOP can eventually normalize and the degree of pigment deposition in the angle can diminish over time," Dr. Vinod said. "Classically, older patients with PDS/PG may display the 'pig- ment reversal sign,' whereby the superior angle appears more pigmented due to a decrease in pigmentation in the inferior angle." Widespread iris transillumination defects caused by loss of posterior iris pigment Source: Jonathan Eisengart, MD

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