Pseudoexfoliation glaucoma: ‘One of the worst types of glaucoma you can get’
Key takeaways:
- Pseudoexfoliation glaucoma is linked with an increased risk of heart attack and stroke.
- Ophthalmologists must be careful to not confuse signs of pseudoexfoliation with pigmentary glaucoma.
KOLOA, Hawaii — Ophthalmologists must know how to identify and manage pseudoexfoliation glaucoma, one of the most damaging forms of the disease, according to a speaker at Hawaiian Eye 2025.
Pseudoexfoliation is a common cause of secondary open-angle glaucoma and is characterized primarily through extracellular deposition of fibrillar material, Louis B. Cantor, MD, said.
“This is also a systemic disease,” he said. “It's found in skin, lung, heart, liver, and it's actually associated with increased risk of heart attack and stroke. So, this is an important disease to bring to the attention of patients.”
While the cause of pseudoexfoliation glaucoma is unclear, a variant of the lysyl oxidase like 1 gene has been present in nearly all cases, suggesting a possible link, according to Cantor.
When searching for clinical signs of pseudoexfoliation, look for the “bull’s eye” pattern of fibrillar material on the anterior lens capsule, which results in transillumination of the pupillary margin due to pupillary movement and iris contact with the anterior lens.
“Most importantly, when you see this, look for phacodonesis,” Cantor said. “Have the patient look left, right, up, down and back straight ahead quickly, and see if you see any shimmering or any movement of the lens. You want to know that very early on, particularly as these patients are older and often moving into the cataract range.”
When performing gonioscopy on patients with pseudoexfoliation glaucoma, Cantor advised looking for a heavily pigmented trabecular meshwork, pigment deposition anterior to Schwalbe’s line and a narrow angle or angle closure caused by loose zonules. IOP is also typically “higher and more unstable” than in patients with primary open-angle glaucoma (POAG).
“Often, we refer to this as one of the worst types of glaucoma you can get because it's just resistant to everything,” Cantor said. “It seems that these eyes are more susceptible to damage than in POAG.”
While trabeculoplasty is effective, the duration of response is shorter than in POAG, he said, and medical therapy is often more difficult to manage in pseudoexfoliation glaucoma vs. POAG.
“Adjunctive therapy, laser and even [laser peripheral iridotomy] may be indicated with angle closure,” Cantor said. “Don't confuse this with pigmentary; the transillumination and the appearance is very different.”
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Cantor LB. Exfoliation pearls for glaucoma management. Presented at: Hawaiian Eye 2025; Jan. 18-24, 2025; Koloa, Hawaii.
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