Glaucoma Quiz 1

Yichieh Shiuey, MD | Massachusetts Eye and Ear Infirmary, Harvard Medical School

March 26, 1997
Figure 1
Figures 1-2. The photograph on the left is the eye of a 70 year old man with an intraocular pressure of 30 on the left and an intraocular pressure of 20 on the right. The photograph on the right shows gonioscopy of the left eye of the same patient.
Figure 2
Questions and Answers
1. What is your diagnosis?
Answer: Pseudoexfoliation syndrome. This patient had a layer of fibrillar material deposited on the anterior lens capsule in a target pattern, which is characteristic of pseudoexfoliation. Pseudoexfoliation syndrome is often associated with elevated intraocular pressures and glaucoma.

2. What is the epidemiology of this condition?
Answer: This condition may be unilateral, as was the case in this patient, or bilateral. Pseudoexfolation syndrome with glaucoma is more commonly unilateral. The condition is more common in older patients and the incidence increases dramatically after age 70. In Scandinavia, this condition represents greater than 50% of all cases of open angle glaucoma.

3. What are the gonioscopic findings of this condition?
Answer: The angle is open, but may be shallow. Irregular hyperpigmentation of the trabecular meswork is common. A hyperpigmented band of pigment may also be seen anterior to Schwalbe's line (Sampaolesi's line)

4. What is the pathophysiology of this condition?
Answer: The underlying pathogenesis is uncertain, but pseudoexfoliation syndrome is believed to be part of a systemic basement membrane disorder. Histochemically, the fibrillar material is similar to amyloid. Glaucoma is believed to caused by mechanical obstruction of the meshwork by the fibrillar material.

5. How would you treat glaucoma in a patient with this condition?
Answer: Glaucoma in pseudoexfoliation syndrome is more refractory to medical therapy than primary open angle glaucoma, but medical treatment should probably be tried first. Laser trabeculoplasty is often very effective in pseudoexfoliation. If both medical and laser treatment fails, trabeculectomy is often successful.

6. If this patient developed visually significant cataract, what would you need to be concerned about?
Answer: Pseudoexfoliation syndrome is associated with weak lens zonules and increased risk of complications during cataract surgery including capsular rupture and vitreous loss.