October 31, 2016

A failure to diagnose is one of the most common reasons that patients file malpractice cases against optometrists. And, without question, glaucoma is the most frequently missed diagnosis I’ve observed as an expert witness.

Photo Credit: Paul Ajamian, OD

Patients diagnosed with pseudoexfoliative glaucoma (PXG) usually present with advanced vision loss on initial examination and are age 60 or older. Prior to glaucomatous development, the precipitating condition is termed pseudoexfoliation syndrome (PXS). Once PXS is present, the condition can cause a dramatic increase in intraocular pressure (IOP) and lead to glaucoma. Compared to open–angle glaucoma, PXG yields faster rates of visual field loss, is less responsive to topical medications and typically requires surgical intervention.1 Thus, it is imperative to regularly monitor PXS patients for disease progression.

The initial presentation of PXS includes the appearance of grayish–white, flakey protein deposits on the anterior capsule of the crystalline lens—typically located in the periphery or along the pupillary margin. (Because PXS is a systemic condition, such deposits also manifest on other tissues in the body.) Interestingly, the condition also has been associated with a higher incidence of hearing loss and even Alzheimer’s disease.2,3

In most instances, you’ll be able to make a diagnosis of PXS via a dilated pupil examination. Once confirmed, immediately perform a full glaucoma work–up and monitor the patient for rapid IOP elevation. Patients should be seen at least every six months, or sooner if early signs of PXG are present. Ultimately, about 50% of patients with PXS go on to develop PXG—likely due to pseudoexfoliative material build–up in the trabecular meshwork, obstructing aqueous outflow.

1. Miglior S, Bertuzzi F. Exfoliative glaucoma: new evidence in the pathogenesis and treatment. Prog Brain Res. 2015;221:233-41.
2. Roedl JB, Bleich S, Reulbach U, et al. Vitamin deficiency and hyperhomocysteinemia in pseudoexfoliation glaucoma. J Neural Transm (Vienna). 2007;114(5):571-5.
3. Samarai V, Samarei R, Haghighi N, et al. Sensory-neural hearing loss in pseudoexfoliation syndrome. Int J Ophthalmol. 2012;5(3):393-6.

"Even the smallest victory is never to be taken for granted. Each victory must be applauded…"
    –Audre Lord


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