Pseudoexfoliation Glaucoma
Chat Highlights
June 2, 2004

On Wednesday, June 2, 2004, Dr. Rick Wilson, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Pseudoexfoliation Glaucoma."

Moderator:  Tonight's topic is pseudoexfoliative glaucoma.  First of all, Dr. Wilson, what is pseudoexfoliative material?

Dr. Rick Wilson:  Pseudoexfoliative material is a white, fluffy material at the pupil border, on the lens, the endothelium, and zonules in the inferior angle.  Exfoliative material is found in and on the lens capsule, ciliary body, iris, blood vessels, and subconjunctival tissue.  In addition, exfoliative material has been found in skin, heart, lungs, liver, kidney, and cerebral meninges; histochemically, the material resembles amyloid.

Moderator:  Why is it called "pseudo" exfoliative instead of just "exfoliative"?

Dr. Rick Wilson:  Because there is another entity called exfoliation. This occurs when the front capsule of the lens splits, due to high heat or other kind of injury, and the floating piece is seen in front of the lens. This is often seen in glass blowers and forge workers.

P:  The fluffy white material is described to look like dandruff.  How would you describe the composition?  

Dr. Rick Wilson:  It does look like minute dandruff.  Since it is in water, I cannot make out the composition.

P:  If you have this white, fluffy material, does that mean you have pseudoexfoliative glaucoma?

Dr. Rick Wilson:  If you also have glaucoma, there is a high likelihood that you have PSXF glaucoma.

P:  I am a little confused.  Does that mean most glaucoma patients have this flaking, or that if you have this flaking AND have glaucoma, then you probably have PSXF?

Dr. Rick Wilson:  What I meant was, if you have PSXF and glaucoma, it is likely the glaucoma is from the PSXF.  

P:  It is my understanding that pseudoexfoliation is considered to be a disease of people over 60 years of age.  Have you seen it in younger patients with normal-tension glaucoma (NTG)?

Dr. Rick Wilson:  I cannot remember seeing a patient under 60 years of age with PSXF; patients under 60 years with NTG are also unusual.

P:  Are the angles usually narrow or closed with PSXF?

Dr. Rick Wilson:  There is a higher proportion of patients with PSXF who have narrow angles, but not near 50%.

P:  Is the mechanism of IOP dysfunction the same as in pigmentary glaucoma; that is, damage to the trabecular meshwork from an overload of pseudoexfoliative material?

Dr. Rick Wilson:  Yes, that does seem to be the mechanism.

P:  How does this dandruff-like material form?  Is it normal, and people with PSXF just produce more?  Can the production be stopped somehow? 

Dr. Rick Wilson:  We don't know how or why the substance forms. It is not normal, but we don't know how to stop it.

P:  How does PSXF affect vision?

Dr. Rick Wilson:  It does not affect vision, but the pieces that get rubbed off the anterior surface of the lens are carried by the flow of fluid in the eye into the drain, where the debris blocks the outflow, and glaucoma results.

P:  How hard is PSXF to diagnose?  One specialist thought I was a "suspect" for it, based on pigment released upon dilation.  Another doctor thought it was unlikely.  The "fluffy" stuff wasn't there. 

Dr. Rick Wilson:  It is hard to diagnose in the very earliest stage, but easy to diagnose later.

P:  What is the normal course of treatment?  Is laser effective in this case, as it is with pigmentary glaucoma?

Dr. Rick Wilson:  Yes.  Since the effect of laser trabeculoplasty is directly proportionate to the amount of pigment in the drain, patients with pigmentary glaucoma and pseudoexfoliative glaucoma do better than most at their age.

P:  If laser is effective in pigmentary and PSXF, which have drain- clogging problems, why isn't it used in uveitic glaucoma as well, especially if the uveitis is quiet and stable.  Isn't the drain thought to be clogged in that form of glaucoma, too?

Dr. Rick Wilson:  Yes, it is thought that the drain is clogged in that form of glaucoma.  But there are other problems besides inflammatory debris getting caught in the drain.  The inflammation makes the beams in the drain swell and the fluid in the eye thick, so there are other reasons for the intraocular pressure to rise, which the laser does not help.

P:  I understand that some specialists suggest that meds that suppress the aqueous, like the betas (beta blockers) and the 'zopts (Azopt, Cosopt, Trusopt) may actually contribute to the problems of PSXF because the drain doesn't get flushed as well. What do you think?

Dr. Rick Wilson:  That is a theoretical concern.  The best medications that don't suppress aqueous humor are ;the prostaglandins.  But prostaglandins can exacerbate inflammation in the eye.  Patients with PSXF have an iris that rubs over the lens, which is rough with pseudo-exfoliative deposits.  It is like sandpapering the back of the iris, and results in a slight amount of inflammation.  Prostaglandins theoretically can  exacerbate the inflammation from the PSXF.

P:  Why doesn't everything you've said here (about exacerbating inflammation from the rubbing of the posterior iris in PSXF) pertain for the same reasons to pigmentary glaucoma, where the pigment is liberated from the posterior iris?  Wouldn't that contraindicate prostaglandin analogues for pigmentary glaucoma as well as PSXF?  Why would it exacerbate inflammation in PSXF and not pigmentary?  

Dr. Rick Wilson:  Because the PSXF scrapes and traumatizes the back of the iris.  If there is a low level of inflammation, the prostaglandin can augment (intensify) it.

P:  If prostaglandins and aqueous suppressants may cause problems, what do you most often suggest as meds for PSXF patients? Perhaps you just wait and see?

Dr. Rick Wilson:  No.  Usually prostaglandins are prescribed first, unless they cause too much inflammation.

P:  In cataract surgery on a patient with PSXF, is there a good reason to use retrobular anesthesia rather than topical anesthesia?

Dr. Rick Wilson:  Since the ligaments that hold the lens in place attach to the capsule of the lens, and the PSXF material forms on the surface of the lens, the ligaments may find themselves attached to PSXF material, and the lens is not held in place very well.  For this reason, retrobulbar anesthesia may be safer in case the lens dislocates during surgery and a more extensive surgery is needed.

P:  In an earlier chat you mentioned a special vacuum used by the Germans to help with this type of glaucoma.  Has there been any progress with that?  Any plans to test it in the U.S.?

Dr. Rick Wilson:  I haven't heard any more about vacuuming up the pseudoexfoliative material since that original article by the Germans.

P:  We've mentioned before that some research associated high homocysteine with PSXF.   Anything new on that front? 

Dr. Rick Wilson:  There still seems to be a strong connection.  I haven't seen anything lately.

End of highlights for June 2, 2004.

On June 9, Dr. Wilson discussed "Race and Glaucoma" in the Chat room. Click here for highlights of that meeting.

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