Appendix
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Ophthalmology

Pigment Dispersion Glaucoma

This activity describes the evaluations, diagnosis, and management of pigment dispersion syndrome (PDS) and pigmentary glaucoma (PG). It describes the important clinical signs and symptoms in patients at risk and how to follow patients over time. To avoid irreversible glaucomatous optic neuropathy and visual field progression, periodic examinations are of utmost importance for patients with this condition. Management and early diagnosis should include slit-lamp examinations, tonometry, gonioscop

v1 · Reviewed Nov 7, 2026 by Automated Clinical Reviewer (Strict Verbatim v1)
  • Liberation of pigment in PDS/PG can be associated with IOP spikes and corneal edema, which may cause episodic symptoms of short-lasting blurred vision, eye pain, redness, photophobia, colored halos, and headaches
  • The IOP in the acute episode is usually in the twenties or thirties, but it may rarely rise to 50 mm Hg or more.
  • Undiagnosed PG can lead to irreversible functional visual field loss, glaucomatous optic neuropathy, and progressive retinal nerve layer thinning, with possible central visual loss arising in the late stages of the disease.
  • Management and early diagnosis should include slit-lamp examinations, tonometry, gonioscopy, visual field assessment, and optical coherence tomography.
  • The slit-lamp examination must include tonometry, preferably with the gold standard Goldmann applanation tonometry.
  • IOP needs to be measured at baseline and every follow-up examination.
  • Gonioscopy is needed to confirm open angles and intense pigmentation.
  • Fundus examination is of utmost importance to assess optic nerve cupping and notching typically seen in glaucoma.
  • Baseline and follow-up visual field testing are needed for the initial diagnosis of PG and the management of the disease over time.
  • Optical coherence tomography (OCT) can provide structural information regarding peripapillary retinal nerve fiber layer (RNFL) thinning indicative of glaucomatous damage.
  • The central corneal thickness should be performed as it affects the measurement of IOP.
  • Ultrasound biomicroscopy (UBM) and anterior segment OCT (AS-OCT) are used to document the concavity of the peripheral iris and the open angle of the anterior chamber.
  • Phenylephrine provocative test has been used to detect high risk for developing high IOP.
  • The classical triad of clinical signs for PG evident with slit-lamp examination and gonioscopy consists of corneal endothelial pigment deposits (Krukenberg spindle), slit-like mid-peripheral radial iris transillumination defects, and homogenous heavy pigment deposition in TM.
  • Medical therapy, which ranges from beta-blockers, carbonic anhydrase inhibitors, prostaglandin analogs, or a combination of these, are the first-line treatment option in PG.
  • Eye drop of pilocarpine is theoretically an ideal option for these patients considering that it reduces pupil movement, induces miosis, and limits posterior iris bowing.
  • A randomized study found that latanoprost once daily was more effective in reducing IOP at one year and well-tolerated in patients with PG compared to timolol twice daily.
  • Argon laser trabeculoplasty (ALT) has been shown to be useful in PG.
  • Selective laser trabeculoplasty (SLT) , which has greater absorption and effectiveness in pigmented tissues, induces less damage to TM and can be repeated over time.
latanoprost
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Adult
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Renal
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Duration
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timolol
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Adult
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Renal
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Duration
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pilocarpine
Eye drop
Adult
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Renal
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Duration
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  • Laser peripheral iridotomy (LPI) has been proposed in several studies performed in the 90s, with the aim of reducing physical contact and friction between AC structures by inducing iris flattening, reducing iris concavity, limiting posterior bowing of the iris, creating an equilibrium of the pressure in the anterior chamber and the posterior chamber; and preventing reverse pupillary block.
  • LPI may be an option in individuals younger than 40 years, with irido-zonular contact seen on UBM and normal IOP.
  • Surgery can be considered in patients with failure of maximal medical therapy or laser.
  • Trabeculectomy has been shown to be effective in patients with PG, showing comparative outcomes to POAG patients.
  • Alternative methods like deep sclerectomy, canaloplasty, and other surgical techniques with less sight-threatening operative risks can be considered for patients with uncontrolled and progressive PG.
  • Similar to other forms of open-angle glaucoma, modern surgical devices (including minimally invasive glaucoma surgery with Trabectome, iStent, Kahook dual blade) and techniques can be considered to address the decreased outflow mechanisms in PG.
  • To avoid irreversible glaucomatous optic neuropathy and visual field progression, periodic examinations are of utmost importance for patients with this condition.
  • PDS patients at risk of converting to PG are advised to undergo periodic ophthalmologic examinations to monitor IOP and optic disc cupping.
  • Similar to other forms of open-angle glaucoma, treatment is indicated for elevated IOP in the presence of functional and structural glaucomatous damage.
  • The eyes with PG on multiple glaucoma medications, severely pigmented TM, and a previous history of ALT may be at higher risk of IOP rise after SLT.
  • Young myopic males may be at higher risk of hypotony maculopathy and suprachoroidal hemorrhage after filtration surgery.
  • The diagnosis of PG occurs more frequently in male Caucasians with myopia aged 20-50 years.
  • Patients with PG may be more likely to be steroid responders.
  • All patients should undergo routine eye examinations, which is particularly important in patients with risk factors for developing ocular hypertension and glaucoma.
  • Patients with an initial diagnosis of PDS and PG need a more stringent follow-up to monitor and control IOP.
  • In patients on therapy for PG, primary and secondary care is necessary to ensure periodic assessments to control and limit glaucoma progression.
  • review
    Pigment Dispersion Glaucoma. StatPearls [Internet] — Marco Zeppieri, Koushik Tripathy — StatPearls Publishing, 2023

Decision support only. Verify against local protocols and current labeling. Source: www.ncbi.nlm.nih.gov