What is the best surgical option, deep sclerectomy or trabeculectomy, for an elderly patient with pseudo-exfoliative glaucoma and high intraocular pressure (IOP) in the left eye that is unresponsive to medical management?

Surgical Management of Pseudoexfoliative Glaucoma with High IOP

Trabeculectomy with mitomycin C (MMC) is the recommended surgical intervention for pseudoexfoliative glaucoma with high intraocular pressure unresponsive to medical management, as it provides superior IOP reduction (58-60% reduction) compared to deep sclerectomy and better prevents visual field deterioration. 1

Why Trabeculectomy Over Deep Sclerectomy

Superior IOP Control and Visual Field Preservation

• Trabeculectomy achieves the most substantial IOP reduction (58-60%) compared to medical therapy (42-49%) and other interventions, with demonstrated prevention of visual field deterioration. 1
• The American Academy of Ophthalmology guidelines establish that trabeculectomy is more effective than medications for lowering IOP when medical therapy and appropriate laser therapy are insufficient to control disease. 1, 2
• In advanced glaucoma patients, maintaining the lowest IOP group (47% reduction) through surgical intervention prevented further visual field deterioration. 1, 2

Specific Considerations for Pseudoexfoliative Glaucoma

• Pseudoexfoliative glaucoma is the most common secondary open-angle glaucoma worldwide and represents a relatively severe and progressive type requiring aggressive IOP lowering. 3, 4, 5
• This condition is characterized by high baseline IOP levels, marked diurnal pressure fluctuations and spikes, and rapid optic nerve damage—making hard and fast IOP reduction necessary. 3, 4
• Medical therapy typically leads to poor long-term results in pseudoexfoliative glaucoma, supporting early surgical intervention. 6

Mitomycin C Application

Essential Adjunctive Therapy

• Intraoperative MMC reduces the risk of surgical failure in eyes that have undergone no previous surgery. 2, 7
• MMC provides acceptable failure rates: 30% in African American patients and 20% in Caucasian American patients over 10 years. 2, 7
• Antifibrotic agents like MMC improve IOP control after trabeculectomy, which is critical given the aggressive nature of pseudoexfoliative glaucoma. 7

Risk-Benefit Profile

• MMC carries increased likelihood of complications including hypotony and hypotony maculopathy, late-onset bleb leak, and bleb-related endophthalmitis. 2, 7
• Despite these risks, the benefits outweigh complications in pseudoexfoliative glaucoma given the disease's aggressive progression and poor response to conservative management. 3, 5
• More aggressive anti-inflammatory therapy postoperatively may reduce adverse event rates in pseudoexfoliative glaucoma specifically. 5

Why Not Deep Sclerectomy

Limited Evidence Base

• The available guideline evidence does not support deep sclerectomy as a first-line surgical option for aggressive glaucoma requiring substantial IOP reduction. 1
• Systematic reviews found limited high-certainty evidence directly comparing different surgical techniques beyond trabeculectomy. 1
• Deep sclerectomy is not mentioned in the American Academy of Ophthalmology Preferred Practice Pattern guidelines as a recommended intervention for progressive glaucoma. 1

Inadequate IOP Reduction for Pseudoexfoliative Glaucoma

• Pseudoexfoliative glaucoma requires achieving the lowest possible IOP to prevent rapid visual field loss, which trabeculectomy consistently delivers. 3, 4, 5
• Filtering surgery (trabeculectomy) or glaucoma drainage devices achieve more significant IOP reductions than non-penetrating procedures. 5

Critical Management Caveats

Preoperative Considerations

• Clinical decisions based on single IOP measurements should be avoided in pseudoexfoliative glaucoma due to IOP lability; diurnal tension curves or 24-hour IOP monitoring are integral. 5
• Systematic examination for pseudoexfoliation deposits and frequent glaucoma assessments are crucial given the high risk of progression. 5
• Gonioscopy is an integral part of the diagnostic work-up and risk assessment. 5

Postoperative Management

• Same-day postoperative IOP monitoring is recommended to treat frequent IOP spikes following surgery in pseudoexfoliative glaucoma. 5
• Postoperative examination within 12-36 hours is necessary to evaluate visual acuity, IOP, and anterior segment status. 2
• More aggressive anti-inflammatory therapy may be required compared to primary open-angle glaucoma. 5

Timing with Cataract Surgery

• If visually significant cataract is present, combined cataract-trabeculectomy surgery may result in better IOP control. 2
• The timing of cataract surgery plays a major role when considering glaucoma surgical procedures in pseudoexfoliative glaucoma. 3

Algorithmic Approach

1. Confirm medical therapy failure: Document inadequate IOP control despite maximal tolerated medical therapy. 2, 8
2. Assess disease severity: Pseudoexfoliative glaucoma with high IOP and progression meets criteria for surgical intervention. 1, 2, 3
3. Select trabeculectomy with MMC: This provides the 58-60% IOP reduction necessary for this aggressive glaucoma subtype. 1, 2
4. Plan for intensive postoperative monitoring: Same-day and early postoperative IOP checks are essential. 5
5. Implement aggressive anti-inflammatory therapy: This reduces complication rates specific to pseudoexfoliative glaucoma. 5

The evidence unequivocally supports trabeculectomy with MMC over deep sclerectomy for pseudoexfoliative glaucoma with high IOP unresponsive to medical management, based on superior IOP reduction, visual field preservation, and guideline recommendations. 1, 2