There are several types of glaucoma, with open-angle and narrow-angle glaucoma being the most common forms. Open-angle is a chronic condition, while narrow-angle is a medical emergency.

Exfoliation glaucoma is mostly associated with open-angle glaucoma, but it can cause narrow-angle glaucoma too. (Learn More) This condition involves abnormal protein accumulation in the trabecular meshwork, or the drainage system in your eye that is behind the sclera and iris. Proteins can include pigmentation from your iris too, which flake off as intraocular pressure increases. (Learn More)

To diagnose exfoliation glaucoma, your eye doctor will use either a slit-lamp test to look at every part of your eye or a gonioscopy, which examines protein buildup in the trabecular meshwork. (Learn More)

Eye drops are not as effective on this type of glaucoma, but laser surgery appears to work well to manage eye pressure. (Learn More)

The only way to know if you have glaucoma is to get regular eye exams, so you can retain your vision. (Learn More)

What Is Exfoliation Glaucoma?

itchy eyes

There are many types of glaucoma, but open-angle glaucoma is the most common. This group of diseases all involve damage to the optic nerve, often associated with high fluid pressure in the eye, called intraocular pressure.

Open-angle glaucoma involves high fluid pressure in the eye’s aqueous solution, which presses on the optic nerve and restricts blood flow. This is a progressive disease with symptoms that are not noticeable until it has reached a critical stage of almost total vision loss. This process takes years. Fortunately, optometrists and ophthalmologists can diagnose glaucoma with fluid pressure tests during your regular eye exam.

In contrast to open-angle glaucoma, narrow-angle or angle-closure glaucoma is considered a medical emergency. This form of glaucoma occurs suddenly. It can cause vision loss, and it is associated with headaches, nausea, and other medical symptoms. While open-angle glaucoma can be treated with prescription eye drops and minimally invasive laser surgeries, narrow-angle glaucoma needs immediate surgery to alleviate intraocular pressure.

As open-angle glaucoma progresses, secondary issues can develop. One of these is exfoliation syndrome, which can lead to exfoliation glaucoma or pseudoexfoliation. This condition can cause chronic glaucoma to progress faster.

How Is Exfoliation Glaucoma Diagnosed?

Although open-angle glaucoma typically progresses slowly, especially when it is treated and monitored, exfoliation glaucoma can cause the disease to move faster. This condition is caused by proteins accumulating in the eye’s drainage systems at an abnormal rate.

Like other types of open-angle glaucoma, exfoliation glaucoma is considered a disease of the elderly. It is a slow-moving, chronic disorder, but there are some instances when exfoliation syndrome moves faster.

Some people can develop exfoliation syndrome without developing glaucoma. They may have higher eye pressure because the drainage systems in their eyes are blocked by abnormal protein accumulation, but there is little to no damage to the optic nerve or associated loss of vision. However, exfoliation syndrome has been found to develop into glaucoma in 15 to 30 percent of cases.

Signs of pseudoexfoliation syndrome include:

  • A white, flakey material at the borders of the pupil and iris.
  • A similar accumulation at the anterior surface of the lens in your eye.
  • A cloudy peripheral ring on the lens of the eye, leading to “three-ring sign.”
  • Loss of iris pigment, which accumulates in the trabecular meshwork, the eye’s drainage system.

You are at a higher risk for exfoliation glaucoma if:

  • You are 50 or older.
  • You already have primary open-angle glaucoma.
  • You are female.
  • You have certain genetic markers.

Tests Used to Diagnose Exfoliation Glaucoma

eye doctor checkup

Although your eye doctor can detect high fluid pressure during a routine, full eye exam, you will need special tests to determine if you have exfoliation syndrome or exfoliation glaucoma. Two tests commonly used include:

  • Slit-lamp exam. This involves a microscope with an attached bright light that your eye doctor will use to look at structures on the front of your eye and inside your eye. To see fully into your eye, your ophthalmologist will dilate your pupils. This can make you sensitive to light after the exam, so you may not be able to drive without special darkened sunglasses.

    The slit-lamp exam will help your eye doctor see different layers of all parts of your eye, to detect if there are any abnormalities in shape, color, or blood flow.

  • Gonioscopy: This procedure involves wearing a special contact lens so your ophthalmologist can see the drainage system in your eye. Under normal circumstances, even during other parts of your eye exam, this system cannot be seen. This exam allows your eye doctor to look at this part of your eye and understand if you have glaucoma.

    During the exam, you will receive numbing drops in your eye. Then, a special contact lens will be placed on your eye and the slit lamp will illuminate this organ. Looking at the “angle” of your drainage system helps to determine if it is “open” or “closed.” The test can also detect if there are abnormal blood vessels, adhesions, or damage from trauma to the eye.

Both these exams can show where proteins or flaked pigment from your iris accumulate, leading to drainage problems in your eye. Since this is often a slow process, it is associated with open-angle glaucoma. There is some correlation between exfoliation syndrome and narrow-angle glaucoma, which is a medical emergency.

Treating Exfoliation Glaucoma Likely Means Surgery

Unlike progressive open-angle glaucoma (POAG), exfoliation glaucoma benefits the most from surgery. Often, eye drops are used to treat glaucoma, allowing for lower eye pressure in the aqueous humor, which reduces pressure on the optic nerve. However, the ongoing buildup of proteins and pigment in your eye’s drainage system from exfoliation glaucoma may mean that eye drops are far less effective, since they do not address the problem of buildup in the trabecular meshwork.

There are no strategies to prevent exfoliation syndrome, and about 50 percent of people with this condition will ultimately develop glaucoma. This form of glaucoma responds well to laser surgery. Other types of surgery may help if the disease has progressed or is an emergency.

Some approaches may include surgeries like:

  • Laser trabeculoplasty. This treatment helps fluid drain from the eye by creating small incisions in the meshwork using a laser. You will likely need multiple laser treatments to manage fluid pressure in your eyes. Although this procedure wears off in five years or less, it is one of the most effective current treatments for exfoliation glaucoma.
  • Trabeculectomy: If medications and lasers fail to manage eye pressure, your doctor may turn to more conventional and invasive forms of surgery, which need to be performed in a hospital setting. Your eye surgeon will numb your eyes and remove a small portion of your trabecular meshwork, creating a different set of drainage holes.There are many more risks, including cataracts, infection, and excessively low eye pressure. However, it is 60 to 80 percent effective at treating glaucoma symptoms.

Regular Eye Exams Help You Keep Your Vision for Longer

Exfoliation glaucoma requires a series of exams to diagnose, and unfortunately, you may lose some vision before you begin a treatment plan. While there is no cure, the condition can be managed and its progression can be slowed.

Laser surgery and eye drops can be used in tandem to ease glaucoma symptoms by lowering eye pressure, so the disease moves much slower. Although there is no way to stop pigment or proteins from building up in the drainage system of your eyes, there are ways to help your eyes drain, depending on whether your glaucoma is a medical emergency or not.

The best way to retain as much of your sight as possible is to get regular eye exams, and report any vision problems you experience to your eye doctor. They can help you to best manage the disease and preserve as much of your eyesight as possible.

 

References

What Is Glaucoma? (August 2019). American Academy of Ophthalmology (AAO).

Exfoliative Glaucoma. (September 2019). Glaucoma Research Foundation. Management of Exfoliative Glaucoma: Challenges and Solutions. (May 2015). Clinical Ophthalmology.

Diagnosis and Management of Pseudoexfoliation Glaucoma. (June 2006). American Academy of Ophthalmology (AAO).

Pseudoexfoliation (PXE) Syndrome and Pseudoexfoliation Glaucoma. (March 2017). Bright Focus.

Exfoliation Syndrome. (November/December 2013). Glaucoma Today.

What Is a Slit Lamp? (April 23, 2018). American Academy of Ophthalmology (AAO).

Gonioscopy: What Is It and Why Is It Needed? (October 2017). Glaucoma Research Foundation.

Pseudoexfoliative Glaucoma. (September 2019). EyeWiki, American Academy of Ophthalmology (AAO).

Pseudoexfoliation: Treatment. Shiley Eye Institute, UC San Diego Health.