Surgical Management of Pseudoexfoliation Glaucoma
Surgical Management of Pseudoexfoliation Glaucoma
Despite extensive research to identify the exact chemical composition and pathogenesis of PXF, these remain unknown. However, some studies have emphasized a central role of local and chronic inflammation in the development of PXF, and the presence of an increased ocular inflammatory response following surgery should be taken into consideration. An underlying abnormality of the blood-aqueous barrier can lead to aqueous flare, fibrinoid reaction, posterior synechiae, and macular edema following surgery in PXF patients. The proinflammatory cytokine IL-6, which plays a role in modulating vascular permeability and neovascularization, has been found in higher levels in both the aqueous humor and serum of PXF patients compared with normal and/or POAG patients. In patients undergoing cataract surgery either alone or in combination with glaucoma surgery, it may be prudent to treat PXF patients more aggressively with postoperative steroids and for a longer duration.
Early postoperative IOP spikes are also more common in PXF eyes, particularly in those with PXFG. Shingleton et al reported IOP elevations >30 mm Hg in 4% of PXF and in 17% of PXFG after phacoemulsification alone and in 8.3% of PXFG following combined phacotrabeceulectomy. Given these findings, IOP should be monitored closely and IOP prophylaxis considered in the immediate postoperative period, as early IOP spikes have the potential to further compromise vision, particularly in patients with advanced glaucomatous optic nerve damage.
Postoperative Considerations
Despite extensive research to identify the exact chemical composition and pathogenesis of PXF, these remain unknown. However, some studies have emphasized a central role of local and chronic inflammation in the development of PXF, and the presence of an increased ocular inflammatory response following surgery should be taken into consideration. An underlying abnormality of the blood-aqueous barrier can lead to aqueous flare, fibrinoid reaction, posterior synechiae, and macular edema following surgery in PXF patients. The proinflammatory cytokine IL-6, which plays a role in modulating vascular permeability and neovascularization, has been found in higher levels in both the aqueous humor and serum of PXF patients compared with normal and/or POAG patients. In patients undergoing cataract surgery either alone or in combination with glaucoma surgery, it may be prudent to treat PXF patients more aggressively with postoperative steroids and for a longer duration.
Early postoperative IOP spikes are also more common in PXF eyes, particularly in those with PXFG. Shingleton et al reported IOP elevations >30 mm Hg in 4% of PXF and in 17% of PXFG after phacoemulsification alone and in 8.3% of PXFG following combined phacotrabeceulectomy. Given these findings, IOP should be monitored closely and IOP prophylaxis considered in the immediate postoperative period, as early IOP spikes have the potential to further compromise vision, particularly in patients with advanced glaucomatous optic nerve damage.
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