42 EyeWorld Asia-Pacific | June 2025 GLAUCOMA 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 instability such as one anterior chamber angle being narrower than the other. If the patient has progressed to pseudoexfoliation 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 raises 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 confirm the diagnosis, but it definitely raises a red flag,” Dr. Halenda said. Management Dr. Krause said management with drops or SLT are both reasonable initial treatment strategies. Though, he noted, the effect of SLT wane more quickly in patients with pseudoexfoliation glaucoma. “Since these patients often present with advanced damage, a surgical procedure is often necessary,” Dr. Krause added. “If possible, this should be combined with cataract surgery. Angle-based procedures like a goniotomy, Hydrus Microstent [Alcon], Omni [Sight Sciences], or iTrack Advance [Nova Eye Medical] are good minimally invasive options. However, filtration surgery with a XEN 45 Gel Stent [AbbVie], trabeculectomy, or glaucoma drainage implant may be required.” Dr. Krause said that someday suprachoroidal shunts would be a welcome option to treat pseudoexfoliation glaucoma patients. Dr. Halenda said he prefers excisional procedures such as trabeculotomy or goniotomy when selecting MIGS for these patients. Dr. Halenda said for all surgeries with this condition, patients can have more prolonged and profound inflammation. As such, they may require more longer and more potent steroid tapers than typical. Considerations For Cataract Surgery There is a higher rate of complications for cataract surgery in patients with pseudoexfoliation syndrome, according to Dr. Halenda, primarily due to the effect of the condition on the zonules, which compromises lens stability. He said it’s important to create a large enough capsulorhexis for these patients because they’re at higher risk for capsular phimosis later on, which could contribute to lens dislocation. He also said it’s important to minimize lens rotation, making sure there is adequate hydrodissection and potentially utilizing phaco-chop techniques. Dr. Halenda said there is an increased risk of vitreous loss and zonular damage during cataract surgery in patients with pseudoexfoliation. In addition, the exfoliative material affecting the iris might necessitate use of a pupillary expansion ring or iris hooks. For lens instability, a capsular tension segment or capsular hooks might be needed. “Some surgeons advocate for placing a 3-piece IOL in the capsule because it exerts a little more tension, which can increase stability,” he said. “Also, the exfoliative material does compromise the corneal endothelium, so they’re at greater risk for corneal decompensation after cataract surgery or any other intraocular surgery.” Finally, Dr. Halenda said that these patients have a higher risk of IOP spikes after cataract surgery, especially if a MIGS procedure wasn’t performed. Thus, he said “it’s important to thoroughly irrigate out the viscoelastic from the eye at the end of surgery.” About the Physicians Kevin Halenda, MD | Assistant Professor of Ophthalmology, West Virginia University, Morgantown, West Virginia | evin.halenda1@hsc.wvu.edu Michael Krause, MD, PhD | Assistant Professor, University of Virginia, Charlottesville, Virginia | xdb3me@uvahealth.org Relevant Disclosures Halenda: None Krause: None Reference 1. Schlötzer-Schrehardt U, Naumann G. Ocular and systemic pseudoexfoliation syndrome. Am J Ophthalmol. 2006;141:921–937. This article originally appeared in the March 2025 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. “It’s probably underdiagnosed. There are a lot of patients who have it, and some subtle exam findings can be overlooked.” Kevin Halenda, MD
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