The stepwise
approach to the management of the patient with exfoliation syndrome (XFS) is
similar to that of primary open-angle glaucoma (POAG), and includes
beta-adrenergic antagonists, alpha-adrenergic agonists, miotics, carbonic
anhydrase inhibitors, prostaglandin analogs, and laser and intraocular surgery.
Response to these interventions however, differs when compared to patients with
POAG.
Glaucoma associated
with XFS tends to respond less well to medical therapy than does POAG, to be
more difficult to treat, to require surgical intervention more commonly, and to
have a worse prognosis. Miotics have multiple beneficial actions in eyes with
XFS. Not only do they lower IOP, but by increasing aqueous outflow, they should
enable the trabecular meshwork to clear more rapidly, and by limiting pupillary
movement, should slow the progression of the disease.
Argon laser
trabeculoplasty (ALT) is particularly effective, at least early on, in eyes
with XFS. The baseline IOP is usually higher than in eyes with POAG undergoing
ALT and the initial drop in IOP is greater. There is a gradual reduction in
success over time, with long-term success dropping to approximately 35-55% at
3-6 years. Laser iridotomy is the procedure of choice for angle-closure
glaucoma. Angle-closure glaucoma caused by anterior lens movement or
subluxation may not be cured by iridotomy alone and may require argon laser
peripheral iridoplasty to mechanically pull the iris away from the trabecular
meshwork.
The results of
trabeculectomy are comparable to those in POAG. Trabeculotomy, performed with
the rationale that it may bypass mechanical blockage of the trabecular
meshwork, has been reported to be successful. Jacobi and Krieglstein have reported
success with trabecular aspiration, a procedure designed to improve outflow
facility.