Management of exfoliative glaucoma: challenges and solutions

Figures & data

Figure 1 Fully developed (“classic”) pattern of distribution of exfoliation material on the anterior lens capsule.

Notes: (A) Central disc of exfoliation material with pigment granules released from the pupillary ruff (B), clear intermediate zone, and (C) a granular, layered peripheral zone.

Table 1 Intraocular pressure decrease in exfoliative glaucoma achieved with monotherapies and fixed dose combinations, based on diurnal average values

Topical therapy	Instillation time	Untreated baseline IOP (mmHg)	Mean IOP decrease (mmHg)	Mean IOP decrease (%)	Comment	Reference
Prostaglandin analogs
Latanoprost 0.005%	Evening	31.2	−12.5	−40.2	14 hours after instillation	^Citation27
Latanoprost 0.005%	Evening	24.9	−7.5	−30.1		^Citation22
Latanoprost 0.005%	Evening	23.8	−8.2	−34.4		^Citation23
Latanoprost 0.005%	Evening	25.1	−7.3	−30.8		^Citation24
Latanoprost 0.005%	Evening	26.9	−8.3	−30.8		^Citation25
Travoprost 0.004%	Evening	25.4	−9.3	−36.6		^Citation23
Travoprost 0.004%	Evening	25.1	−7.8	−31.1		^Citation24
Bimatoprost 0.03%	Evening	26.9	−9.3	−34.6		^Citation25
Beta-blocker
Timolol 0.5%	Twice daily	24.7	−6.4	−25.9		^Citation22
Prostaglandin analog/timolol fixed combination
Latanoprost/timolol	Evening	28.5	−8.9	−31.2		^Citation28
Travoprost/timolol	Evening	28.5	−9.8	−34.4		^Citation28
Travoprost/timolol	Morning	27.7	−8.6	−31.0	Mixed XFG/POAG population	^Citation29
Bimatoprost/timolol	Morning	29.03	−9.84	−33.9		^Citation30
Bimatoprost/timolol	Evening	29.03	−10.2	−35.3		^Citation30
Tafluprost/timolol	Morning	26.5 to 28.1	−8.62 to −10.25	−31.8 to −36.7	Mean time-wise IOP and IOP decrease	^Citation31
Topical carbonic anhydrase inhibitor/timolol fixed combination
Dorzolamide/timolol	Twice daily	31.2	−13.3	−42.8	Peak effect	^Citation27
Dorzolamide/timolol	Twice daily	25.7	−11.5	−44.7	Peak effect	^Citation23

Abbreviations: IOP, intraocular pressure; POAG, primary open-angle glaucoma; XFG, exfoliative glaucoma.

Table 2 Results for argon laser trabeculoplasty and selective laser trabeculoplasty in exfoliative glaucoma and primary open-angle glaucoma

Type of laser surgery	Patient population	Length of follow-up (mean ± SD, months)	Baseline IOP (mean ± SD, mmHg)	IOP decrease in mmHg (%)	Comment	Reference
Primary ALT	POAG (n=93); XFG (n=75)	POAG 50.4±28.8; XFG 46.8±27.6	POAG 27.6±3.4; XFG 30.1±6.1	POAG 9.3 (33.7%) XFG 12.2 (40.5%)	Evaluated after second ALT treatment	^Citation35
Adjunctive ALT	POAG (n=66); XFG (n=29)	POAG 27±22; XFG 23±20	POAG 23.2±6.1; XFG 25.8±5.9	POAG n/a (23%) XFG n/a (35%)	16–18 months follow-up	^Citation36
Adjunctive ALT	POAG (n=28); XFG (n=26)	14.7	POAG 22.4±3.8 XFG 25.5±7.8	POAG 6.3 (28.1%) XFG 7.0 (27.4%)	At 4–6 weeks after second ALT treatment	^Citation39
Adjunctive ALT	XFG (55 eyes, 44 patients)	15	25.2	7.3 (29%)	At 6 months	^Citation37
Adjunctive SLT	POAG (n=10); XFG (n=10)	POAG 13.5±4.3; XFG 12.0±5.5	POAG 22.8±2.4; XFG 23.6±5.7	POAG 7.2±1.8 (30.6%) XFG 5.8±3.6 (22.0%)	At 12 months	^Citation38
ALT versus SLT (primary or adjunctive)	XFG/XFS (76 eyes, 60 patients) treated with ALT (n=31) or SLT (n=45)	6	ALT 25.2 SLT 23.1	ALT 7.7 (30.5%) SLT 6.8 (29.4%)		^Citation43
Primary SLT	POAG (19 eyes of 13 patients) XFG (18 eyes, 13 patients)	49	POAG 23.2±3.0; XFG 25.5±3.4	POAG 5.7±2.1 (24.6%) XFG 5.3±3.0 (20.8%)	At 30 months	^Citation46
Adjunctive SLT	XFG (n=57)	12	26.1±2.5	8.3 (31.8%)		^Citation44
Adjunctive SLT	POAG (n=30) XFG (n=30)	1	POAG 23.52±4.6; XFG 24.8±3.0	POAG 6.87 (29.2%) XFG 6.19 (25%)		^Citation45

Abbreviations: n/a, not available; SLT, selective laser trabeculoplasty; XFG, exfoliative glaucoma; POAG, primary open-angle glaucoma; ALT, argon laser trabeculoplasty; XFS, exfoliation syndrome; IOP, intraocular pressure; SD, standard deviation.

Table 3 Results of different surgical modalities in exfoliative glaucoma and primary open-angle glaucoma

Type of surgery	Patient population	Length of follow-up (mean ± SD, months)	Baseline IOP (mean ± SD, mmHg)	IOP decrease, mmHg (%)	Comment	Reference
TRB	XFG (n=26) POAG (n=74)	6	XFG 34.2±12.5 POAG 24.6±6.1	XFG 22.4 (65.5) POAG 9.6 (39)		^Citation48
TRB	XFG (n=12) POAG (n=15)	46.2	XFG 29.0±7.3 POAG 29.3±4.7	XFG 10.3 (35.5) POAG 10.0 (34.1)	Patient data requiring postoperative medication	^Citation49
DS	XFG (n=28) POAG (n=29)	XFG 19.9±10.9 POAG 16.2±10.0	XFG 28.3±7.2 POAG 26.8±6.1	XFG 16.3±9.4 (54.6) POAG 10.4±8.9 (40.3)	A similar proportion of Aquaflow or T-flux implants were used in both groups	^Citation55
VC	XFG (n=14) POAG (n=40) PG (n=3)	34.1	24.6	10.7 (43.5)	Data not available for subgroups	^Citation56
Combined VC/phaco	XFG (30 eyes, 22 patients)	18.6±6.2	25.3±5.2	13.0 (51.4)		^Citation57
Combined VC/phaco	XFG (n=30) POAG (n=30)	XFG 19.6±6.6 POAG 19.8±7.5	XFG 24.5±6.7 POAG 21.7±7.0	XFG 12.2 (49.7) POAG 6.7 (30.9)		^Citation58
Trabectome™	XFG (n=67) POAG (n=450)	12	XFG 29.0±7.5 POAG 25.5±7.9	XFG 12.3±8.0 (42.4) POAG 7.5±7.4 (29.4)		^Citation59
Trabectome™ and cataract extraction	XFG (n=45) POAG (n=263)	12	XFG 21.7±8.4 POAG 19.9±5.4	XFG: 7.2±7.7 (33.2) POAG 4.1±4.6 (20.6)	Cataract extraction was presumably made with phacoemulsification	^Citation59
TA versus TRB	XFG (TA, 22 eyes of 19 patients; TRB, 22 eyes of 18 patients)	TA 18 TRAB 22	TA 31.3±7.1 TRB 31.7±6.1	TA 12.3 (39.3) TRB 15.5 (48.9)		^Citation60
TA + cataract extraction versus TRB	XFG (TA + cataract extraction 42 eyes, 36 patients; TRB 22 eyes, 18 patients)	TA + cataract extraction 24 TRAB 22	TA + cataract extraction 32.4±7.2 TRB 31.7±6.1	TA + cataract extraction 13.7 (42.3) TRB 15.5 (48.9)	Phaco or extracapsular extraction as clinically indicated	^Citation60
Phaco versus phaco + TA versus phaco + TRB	XFG (phaco 22 eyes; phaco + TA 26 eyes; phaco + TRB, 26 eyes)	24	Phaco 32.0±7.7 phaco + TA 31.9±8.1 phaco + TRB 32.5±7.3	Phaco 14 (43.7) phaco + TA 13.5 (42.3) phaco + TRB 13.5 (41.5)		^Citation61

Abbreviations: DS, deep sclerectomy; MMC, mitomycin C; Phaco, phacoemulsification; PG, pigmentary glaucoma; TA, trabecular aspiration; TRB, trabeculectomy; VC, viscocanalostomy; POAG, primary open-angle glaucoma; XFG, exfoliative glaucoma; IOP, intraocular pressure; SD, standard deviation.

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