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Ophthalmology

Pseudoexfoliation Syndrome and Glaucoma

Pseudoexfoliation syndrome is a chronic, age-related disorder of the extracellular matrix that results in the deposition of abnormal fibrillary (pseudoexfoliative) material within various body tissues. This condition manifests primarily in the anterior segment of the eye. Individuals with this condition can develop pseudoexfoliation glaucoma in the presence of chronic elevated intraocular pressure, glaucomatous optic neuropathy, and visual field damage. This activity reviews the evaluation and t

v1 · Reviewed Nov 7, 2026 by Automated Clinical Reviewer (Strict Verbatim v1)
  • PEX can lead to secondary glaucoma, known as pseudoexfoliative glaucoma (PEG), which is a major cause of blindness worldwide.
  • PEX is strongly associated with raised intraocular pressures (IOP) in up to 44% of patients and subsequent development of pseudoexfoliation glaucoma (PEG)
  • Signs of this type of secondary glaucoma include irreversible optic nerve head and retinal nerve fiber layer damage and/or visual field defects
  • Untreated glaucoma may lead to severe peripheral vision loss, followed by central visual loss.
  • This systemic disorder is typically clinically diagnosed during routine ophthalmic examination with slit-lamp visualization of white, flaky fibrillar (pseudoexfoliative) material on the pupillary margin of the iris and the anterior lens capsule.
  • The diagnosis is made clinically via characteristic slit-lamp biomicroscopy and gonioscopic findings:
  • Gonioscopy is fundamental and should be performed in all patients with PEX during slit-lamp examination.
  • Baseline IOP must be measured at the time of diagnosis and periodically due to the high risk of developing ocular hypertension and PEG.
  • Visual examination of optic nerve head : This is evaluated using a slit lamp and condensing lens of sufficient magnification.
  • IOP measurement : Glaucomatous damage in pseudoexfoliation is associated with raised IOP and shows marked variation in diurnal IOP levels.
  • Visual Field Analysis : Static computer automated perimetry is useful for a baseline investigation of glaucoma suspects and monitoring progression in those with confirmed glaucoma.
  • Optical coherence tomography (OCT) : Peripapillary retinal nerve fiber layer (RNFL) thinning is associated with glaucomatous damage.
  • The first-line treatment of PEG is medical.
  • IOP-lowering topical medications that are effective in PEG include prostaglandin analogs, beta-blockers, carbonic anhydrase inhibitors, or a combination of these.
  • Selective laser trabeculoplasty (SLT) : Laser treatment may be used as a first-line treatment or to avoid more invasive surgery.
  • Argon laser trabeculoplasty (ALT), which induces a greater histopathological effect on the trabecular meshwork due to the stronger energy laser applied for a longer time, has also been reported to be useful as a temporary regulation treatment of IOP in PEG.
  • Trabeculectomy in PEG patients has shown similar outcomes as with POAG patients, without an increased risk of complications.
  • Glaucoma drainage devices and alternative methods like canaloplasty and viscocanalostomy may also be considered, although target pressures after surgery do not tend to be low, thus local eyedrops may still be needed in some patients.
  • If there is a component of angle closure secondary to cataract or anterior lens movement secondary to zonular laxity, laser iridoplasty or cataract extraction may be beneficial.
  • Pilocarpine is not recommended due to the risk of worsening angle-closure glaucoma and posterior synechiae formation.
  • Management of this condition is primarily aimed at regular (at least annual) eye examinations for early detection and treatment of glaucoma.
  • PEX eyes have higher IOPs with an increased diurnal variation.
  • There is a rapid progression of nerve damage, and subsequent field loss may be worse than POAG.
  • PEX eyes may be complicated by progression to ocular hypertension or glaucoma (PEG).
  • Cataract surgery may be challenging in these eyes because of corneal endotheliopathy, poor mydriasis, lens subluxation, and zonular instability.
  • Cataract surgical complications include corneal edema, compromised blood-aqueous barrier, capsular opacification, spikes in IOP, capsular phimosis, increased inflammation, zonular dialysis, capsular bag rupture, iris vascular leaks, and late intra-ocular lens (IOL) decentration.
  • PEX and PEG patients tend to require more frequent follow-ups and aggressive therapies in the presence of elevated IOP and signs of glaucomatous functional and anatomical progression.
  • Patients should be advised to seek annual eye screening to develop ocular hypertension and/or glaucoma.
  • review
    Pseudoexfoliation Syndrome and Glaucoma. StatPearls [Internet] — Sahib Tuteja, Marco Zeppieri, Harshika Chawla — StatPearls Publishing, 2023

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