Surgical Management of Pseudo-Exfoliative Glaucoma with High IOP
Trabeculectomy with mitomycin C (MMC) is the recommended surgical approach for your pseudo-exfoliative glaucoma with high intraocular pressure in the left eye. 1
Why Trabeculectomy Over Deep Sclerectomy
Trabeculectomy achieves superior IOP reduction (58-60% reduction) compared to all other interventions and demonstrates the most robust protection against visual field deterioration. 2 This is particularly critical in pseudo-exfoliative glaucoma, which is characterized by:
- Higher baseline IOP levels than primary open-angle glaucoma 3
- Marked diurnal pressure fluctuations and dangerous IOP spikes 3, 4
- Rapid optic nerve damage and accelerated visual field loss 3
- More aggressive disease progression requiring lower target IOP 5, 3
The American Academy of Ophthalmology establishes that trabeculectomy is indicated when medications and appropriate laser therapy are insufficient to control disease progression. 1
Critical Role of Mitomycin C
Intraoperative MMC reduces the risk of surgical failure in eyes that have undergone no previous surgery. 1 The data shows:
- 30% failure rate in African American patients over 10 years 1
- 20% failure rate in Caucasian American patients over 10 years 1
However, you must counsel the patient that MMC carries increased likelihood of complications including hypotony and hypotony maculopathy, late-onset bleb leak, and late-onset bleb-related endophthalmitis. 1
Why Deep Sclerectomy Is Not Preferred
While deep sclerectomy is mentioned as an option for pseudo-exfoliative glaucoma management 5, 6, the evidence base is substantially weaker. The landmark studies demonstrating that the lowest IOP group (47% IOP reduction) had no further visual field deterioration in advanced glaucoma were achieved with trabeculectomy, not deep sclerectomy. 2, 1
Pseudo-exfoliative glaucoma requires aggressive IOP lowering due to its severe and progressive nature—trabeculectomy consistently delivers the most substantial IOP reduction. 3
Target IOP Considerations
Given the aggressive nature of pseudo-exfoliative glaucoma, your target IOP should be:
- 10-12 mmHg if severe glaucomatous damage is present 7
- 12-15 mmHg if moderate damage 7
- 15-17 mmHg if mild damage 7
The Advanced Glaucoma Intervention Study demonstrated that maintaining the lowest IOP group (47% reduction) protected against further visual field deterioration. 1
Postoperative Management Requirements
You must perform postoperative examination within 12-36 hours to evaluate visual acuity, IOP, and anterior segment status. 8 Pseudo-exfoliative glaucoma patients experience frequent IOP spikes following surgery, making same-day postoperative IOP monitoring essential. 4
Additional critical follow-up includes:
- At least one visit during the first 1-2 weeks postoperatively 8
- More aggressive anti-inflammatory therapy than standard glaucoma surgery to reduce postoperative adverse events specific to pseudo-exfoliative glaucoma 4
- Topical corticosteroids prescribed and tapered appropriately 8
- More frequent visits if complications develop (flat anterior chamber, early bleb failure, increased inflammation, Tenon's cyst formation) 8
Common Pitfalls to Avoid
Never base clinical decisions on single IOP measurements in pseudo-exfoliative glaucoma due to the marked lability of IOP. 4 Diurnal tension curves or 24-hour IOP monitoring are integral to proper risk assessment. 4
Systematic examination for PEX deposits is crucial as the compromised blood-aqueous barrier results in leakage of inflammatory cytokines and extracellular matrix material into the anterior chamber. 4