Eyeworld

EW GLAUCOMA 68 May 2016 by Tony Realini, MD, MPH postoperative observation. "Eyes with pseudoexfoliation have more postoperative inflammation, poste- rior synechiae, and macular edema than eyes with POAG, and warrant more aggressive steroid use," she said. What is the role of cataract surgery in eyes with pseudoexfolia- tion glaucoma? Certainly the risk of complications is higher in these eyes than in eyes with POAG, owing to laxity of the zonules and the risk of vitreous loss. But when approached carefully, there is benefit. "Cataract surgery alone effec- tively lowers IOP in some eyes with pseudoexfoliation glaucoma," said Beth Edmunds, MD, Portland, Oregon. "Also, hypothetically, lens removal may reduce the risk of developing glaucoma in eyes with pseudoexfoliation." Glaucoma specialists often en- counter pseudoexfoliation patients who've been told by other doctors to avoid having cataract surgery until it is absolutely necessary. "On the contrary," Dr. Edmunds said, "getting the lens out sooner rather than later may be a good idea to reduce complications associated with hard lenses." EW Editors' note: The physicians have no financial interests related to their comments. Contact information Damji: kdamji@ualberta.ca Edmunds: edmundsb@ohsu.edu Kornmann: hkornmann@med.miami.edu Lee: rlee@med.miami.edu glaucoma are mixed. "Early studies suggested lower postoperative IOP after trabeculectomy in pseudoex- foliation eyes compared to POAG eyes," said Helen Kornmann, MD, Miami, "but more recent studies have found similar results or even reduced efficacy of trabeculectomy in pseudoexfoliation eyes." "Combined phaco-trabeculec- tomy lowers IOP more than phaco alone in pseudoexfoliation eyes," she said. One study demonstrated a mean 30% reduction with combined surgery versus 20% with cataract sur- gery alone. Likewise, Dr. Kornmann said, "EX-PRESS glaucoma filtration device [Alcon, Fort Worth, Texas] implantation in pseudoexfoliation eyes provides comparable surgical success, need for medications, and complication rates as in eyes with POAG." Tube shunt implantation pro- vides comparable IOP outcomes in pseudoexfoliation and POAG eyes, she added, but pseudoexfoliation eyes may be at higher risk of tube erosion through the conjunctiva. What about angle-based procedures? "These target the tissue where the problem is," Dr. Kornmann said. "Trabectome [NeoMedix, Tustin, California] as a standalone procedure has a higher success rate in pseudoexfoliation eyes compared to POAG eyes, but when combined with cataract surgery, outcomes become compa- rable." She cautioned that eyes with pseudoexfoliation require careful Choosing the right medication Do some medications work better than others? "Prostaglandin analogues lower IOP better than aqueous suppres- sants in eyes with pseudoexfoliation glaucoma," Dr. Damji said. Further, he said, "Evening dosing of fixed combinations of a prostaglandin and a beta blocker may provide better IOP reduction than morning dosing." Almost a decade ago, the International Collaborative Exfo- liation Syndrome Treatment study compared 2 treatment regimens—a combination of both latanoprost and pilocarpine versus aqueous suppression with timolol with or without dorzolamide as needed—to assess 2-year effects on IOP, aqueous outflow facility, and angle pigmen- tation. The hypothesis was that the addition of pilocarpine might reduce dispersion of the pseudoexfoliation material and thus render the glauco- ma less severe over time. In 2009, the study group report- ed significantly lower IOP, better outflow facility, and reduced angle pigmentation in the latanoprost/ pilocarpine group compared to the aqueous outflow suppression group at the 2-year time point. Despite the results of this ran- domized clinical trial, the use of a prostaglandin analogue combined with pilocarpine for pseudoexfoli- ation glaucoma has not become a standard therapy for the disease. "The best initial medical thera- py for pseudoexfoliation glaucoma is a prostaglandin analogue," Dr. Damji said. "This can be augment- ed with an aqueous suppressant, pilocarpine 2%, or another agent as deemed appropriate for adequate IOP control." Laser and surgery Laser trabeculoplasty is often uti- lized in both open-angle glaucoma and in pseudoexfoliation glaucoma. According to Dr. Damji, "Se- lective laser trabeculoplasty is as effective in pseudoexfoliation glau- coma as it is in primary open-angle glaucoma." Risks in these eyes in- clude post-treatment IOP spikes and corneal decompensation, both of which are uncommon but can occur on occasion. The literature on surgical outcomes for pseudoexfoliation Experts weigh in on treating this aggressive form of glaucoma P seudoexfoliation—first described by Lindberg in 1917—will next year mark a century as a dis- tinct entity from primary open-angle glaucoma (POAG). Its findings are classic: flaky exfoliative material on the anterior lens capsule in a bull's eye pattern, peripupillary transillumination defects, and often pigment on Schwalbe's line in the angle. Eyes with pseudoexfoliation are at high risk for glaucoma. Compared to POAG, pseudoexfoliation glauco- ma tends to be more aggressive. The disease is aggressive in part due to both high IOP and dramat- ic IOP fluctuations, said Karim Damji, MD, Alberta, Canada. "In the Early Manifest Glaucoma Trial, approximately 93% of untreated eyes with pseudoexfoliation glau- coma progressed over the 6-year study," he said. This is in contrast to progression rates of 56% and 74% in normal tension and high tension open-angle glaucoma, respectively. "We need to treat this aggressive disease aggressively," he said. There are several ways to opti- mize visual outcomes in eyes with pseudoexfoliation. Make the diagnosis The first step is to recognize the disease. "Pseudoexfoliation is the most common identifiable cause of glau- coma," said Richard Lee, MD, PhD, Miami. "It's a slit lamp glaucoma—if you don't detect it with the slit lamp, you will miss the diagnosis." One key to avoid missing the diagnosis is to examine the anterior lens capsule after dilation. It has been estimated that up to 20% of cases will be missed if the lens is only examined predilation. In some eyes, the findings can be subtle. Pseudoexfoliation should be suspected in any patient with high IOP (above 35 mm Hg) and/or with marked IOP variability. Short- term IOP fluctuations of 15–20 mm Hg are not uncommon. Pseudoexfoliation glaucoma: Which treatments work best? Exfoliation syndrome on the anterior hyaloid face following cataract surgery Source: Karim Damji, MD

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