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    Tips to best manage exfoliative glaucoma

    Why a tailored and more proactive management strategy is needed to prevent visual loss in exfoliative glaucoma patients

    Take-home message: Exfoliative glaucoma can prove to be a particularly difficult disease for opthalmologists to manage. In this article, aspects of IOP-lowering therapy specific to this type of glaucoma are considered, as well as the range of treatments available and the potential advantages and challenges associated with each therapy. 


    Exfoliative glaucoma (XFG) typically presents in patients older than 60 years with glaucomatous optic nerve head damage and elevated IOP. In the majority of these patients significant optic nerve head and visual field damage is already present at diagnosis. Conversion from exfoliative syndrome (XFS) to XFG is considered to happen as a result of environmental factors increasing oxidative stress in the anterior chamber.

    Did you know these 7 men were ophthalmologists?

    To provide long-term disease stability in XFG patients, a low mean IOP (<17 mmHg) and a narrow 24-hour IOP fluctuation should be acheived. Careful follow-up of XFS patients is essential to assess IOP levels and monitor for early glaucomatous structural and functional changes; this will help detect transition to XFG.

    Specific aspects of IOP-lowering therapy in exfoliative glaucoma

    The following aspects need to be considered for successful long-term XFG management:

    • A greater reduction of mean IOP will need to be achieved, combined with adequate 24-hour IOP control.
    • There is a greater risk of IOP elevation after pharmacological pupil dilation due to iris pigment release.
    • There is an age-related decline in beta blocker tolerability.
    • Fixed-dose combinations may support patient adherence.
    • Dry eye syndrome and ocular surface disease treated with preserved topical medications should be considered.
    • The actual value of IOP reduction achieved by removing exfoliation material and pigment from the trabecular meshwork should be determined, as the effect from the procedure is usually temporary.
    • A gradual or sudden IOP elevation in XFG eyes may occur despite employing a previously successful IOP-lowering therapy, laser, or surgery, due to disease-related progression.
    • Consultation with other specialists may be required for comanagement of XFG-related systemic vascular disease.

    Next: Medical management of ZFG

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