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EW FEATURE 40 Secondary glaucoma challenges May 2015 • Pseudoexfoliation patients respond well to medical and laser treatments, but the effects tend to wear off as exfoliation material accumulates in the trabecular meshwork. • Femtosecond laser-assisted cataract surgery reduces the risk of intraoperative complications in these patients. • MIGS devices and trabeculectomy procedures will broaden the options available to these patients for controlling IOP. by Lauren Lipuma EyeWorld Staff Writer forward," Dr. Moster said. "Ophthal- mologists are really keyed into this— to look for signs on the anterior lens capsule and within the anterior segment so the diagnosis can be properly made." Early recognition allows for early intervention, giving clini- cians better control of the disease as it progresses and broadening the treatment options that are available to patients. Medications Medical treatment is often the first line therapy for pseudoexfoliation glaucoma. When deciding among the available glaucoma medications, it helps to think of the trabecular meshwork as a clogged drain, Dr. Radcliffe said. "If you can imagine that you have a material clogging a drain, one good way to clear the drain in some cases is to flush the drain," he said. "If it is a case where having flow through the trabecular meshwork will help clear the exfoliation mate- rial, then generally you would want to increase the amount of flo ." To that end, it is best to use pilocarpine, which increases flow through the trabecular meshwork, or prostaglandin analogues, which increase flow through the uveoscle - al tract, Dr. Radcliffe said. "It could potentially be harmful to use an aqueous suppressant like timolol because you're reducing the total amount of fluid going through that eye, and that may lead ironi- cally to more exfoliation material collecting in the drain," he said. Patients with pseudoexfoliation glaucoma often respond well to medications initially, but the effect is short-lived—as more material accumulates in the trabecular mesh- work, the IOP creeps upward. "The problem with pseudoex- foliation glaucoma is having higher baseline pressures than primary open angle glaucoma," said Lama Al-Aswad, MD, associate profes- sor of ophthalmology, Columbia University Medical Center, New York. "That means it requires more medication to control it, and the control over time of the medication can wear off. That results in more treatments in the future. So treat- ment is effective, but short-lived, and you might require more than 2 agents to control it early on." Laser trabeculoplasty If increasing flow does not clear the drain, opening new outflow channels with selective laser trabec- uloplasty (SLT) is another option, either as a first-line treatment or early on in the treatment paradigm. SLT is highly effective in lowering IOP in pseudoexfoliation glauco- ma patients, but similar to medical treatment, the effect tends to wear off over time. "One can expect a drop in intra- ocular pressure between 5 and 6 mm Hg in 70% of patients for more than 2 years," Dr. Moster said. "At 5 years, about 50% of patients will still have a response, and selective laser trabec- uloplasty is delicate enough that it can be repeated within 6 months to 1 year if a good effect was noted initially." Repeating the procedure will extend the ability to maintain a treatment goal pressure for a longer period of time, Dr. Moster said, but medications are often needed to bolster this effect. "The patient needs to under- stand that the effect of the medica- tion and the laser treatment wears off, and when it does wear off the pressure can go up quickly," Dr. Al-Aswad said. "You have to monitor those patients continuously. If the disease is very severe, I tend to mon- itor them every 3 months." Surgical intervention If medications and laser treatment have little effect on the progression of the disease, surgery is the next step, Dr. Moster said. "Because this is a disease often seen with co-existing cataracts, the question then becomes 'How do we manage cataracts and pseudoexfoliation simultaneously?'" she said. Top tips for managing pseudoexfoliation glaucoma Experts discuss the best medical, laser, and surgical techniques for treating the disease U nlike other forms of glau- coma, the rise in IOP in pseudoexfoliation glau- coma has a clear etiology —there is an imbalance between matrix metalloproteinases (MMPs) and their tissue inhibitors, which appear to contribute to the progressive accumulation of PXF material. Understanding the mechanism behind the rise in IOP gives physi- cians an edge when choosing among treatment options, but managing the disease remains a challenge be- cause outflow is continually reduced over time. "Exfoliation glaucoma is by definition a progressive pressure control problem," said Nathan Radcliffe, MD, assistant professor of ophthalmology, New York Universi- ty, New York. "The degree to which the pressure is elevated increases as a function of time, presumably because more and more exfoliation material is accumulating in the out- flow pathwa ." Although this type of glaucoma presents unique challenges, clini- cians are recognizing signs of pseu- doexfoliation earlier, said Marlene Moster, MD, glaucoma service, Wills Eye Institute, Philadelphia. "Detection of pseudoexfoliation is becoming much better moving In advanced cases of pseudoexfoliation glaucoma, the exfoliation material may continue to accumulate once the eye is pseudophakic. In this eye, a new scroll of exfoliation material is seen accumulating on the anterior surface of the IOL. Source: Nathan Radcliffe, MD AT A GLANCE continued on page 42