Exfoliation glaucoma is the most common recognizable cause of open angle glaucoma worldwide and is perhaps the most aggressive form of open angle glaucoma. The exfoliation syndrome is highly asymmetric between eyes, may be difficult to detect in its early stages and more difficult to treat in its later stages, and is associated with cataract1, the management of which is more complex. It is a serious enough issue that there are over 1700 articles on the topic in PubMed, and The Glaucoma Foundation has recently decided to dedicate its resources to fighting exfoliation glaucoma.
Co-management of cataract with exfoliation glaucoma is a critical aspect of this disease, particularly given that 18% of patients with exfoliation glaucoma will have some component of angle closure as well.2 Additionally, the sometimes rapidly forming cataract can obscure visual field test results and interfere with optic nerve assessment, examination and imaging. In eyes with poor media, progression can be more difficult to detect, an issue that can become serious given the volatile nature of exfoliation glaucoma. Therefore, timely cataract extraction in patients with exfoliation glaucoma and cataracts may benefit the patient’s functional vision, glaucoma status, and quality of life. Cataract extraction is associated with intraocular pressure lowering, even in eyes with the exfoliation syndrome, though careful assessment for temporary IOP elevation in the short-term postoperative period is important.3 Improving patients visual quality and media clarity can have benefits for both structural and functional assessment of progression. Cataract extraction can also provide the opportunity to perform safer, micro invasive glaucoma surgery (MIGS) at the same sitting.
So what does the patient with exfoliation syndrome need to know? To begin with, the patient needs to know that this syndrome causes cataract and glaucoma and that both of them need to be monitored a little more frequently than normal. While this syndrome does have some systemic manifestations, the presence of exfoliation syndrome does not decrease longevity – and a recent long-term study suggested that higher folate intake may be associated with a lower risk of exfoliation glaucoma, a mechanism that is potentially mediated through the homocysteine pathway.4,5
While this type of cataract and glaucoma can be more difficult to treat, there are some positive sides to that story: laser therapy works well in eyes with the exfoliation syndrome,6 and cataract surgery, and particularly cataract surgery combined with micro invasive glaucoma surgery, also has been shown to have better-than-average IOP lowering success.7
In summary, exfoliation glaucoma offers challenges to the patient and physician, but with a customized approach and comanagement of cataract and glaucoma, patients with exfoliation glaucoma can do well. At the end of the day, patients with exfoliation glaucoma respond well to IOP lowering just like other patients with glaucoma.8
1. Kanthan GL, Mitchell P, Burlutsky G, Rochtchina E, Wang JJ. Pseudoexfoliation syndrome and the long-term incidence of cataract and cataract surgery: the blue mountains eye study. Am J Ophthalmol 2013 Jan;155(1):83-88.
2. Wishart PK, Spaeth GL, Poryzees EM. Anterior chamber angle in the exfoliation syndrome. Br J Ophthalmol.1985;69:103-107.
3. Shingleton BJ, Laul A, Nagao K, Wolff B, O'Donoghue M, Eagan E, Flattem N, Desai-Bartoli S. Effect of phacoemulsification on intraocular pressure in eyes with pseudoexfoliation: single-surgeon series. J Cataract Refract Surg. 2008 Nov;34(11):1834-41.
4. Kang JH, Loomis SJ, Wiggs JL, Willett WC, Pasquale LR. A Prospective Study of Folate, Vitamin B6, and Vitamin B12 Intake in Relation to Exfoliation Glaucoma or Suspected Exfoliation Glaucoma. JAMA Ophthalmol. 2014 Apr 3.
5. Svensson R1, Ekström C. Pseudoexfoliation and mortality: a population-based 30-year follow-up study. Acta Ophthalmol. 2014 Mar 26.
6. Kara N, Altan C, Yuksel K, Tetikoglu M. Comparison of the efficacy and safety of selective laser trabeculoplasty in cases with primary open-angle glaucoma and pseudoexfoliative glaucoma. Kaohsiung J Med Sci. 2013 Sep;29(9):500-4.
7. Ting JL, Damji KF, Stiles MC; Trabectome Study Group. Ab interno trabeculectomy: outcomes in exfoliation versus primary open-angle glaucoma. J Cataract Refract Surg. 2012 Feb;38(2):315-23.
8. De Moraes CG, Juthani VJ, Liebmann JM, Teng CC, Tello C, Susanna R Jr, Ritch R. Risk factors for visual field progression in treated glaucoma. Arch Ophthalmol. 2011 May;129(5):562-8.
Nathan Radcliffe, MD, a glaucoma specialist, is an assistant professor of ophthalmology and director of the Glaucoma Service at Weill Cornell Medical College and New York-Presbyterian Hospital in New York.