Exfoliative Syndrome and Glaucoma: Causes, Symptoms, Diagnosis, Treatment

Exfoliative syndrome is a systemic disease that leads to the development of secondary open-angle glaucoma.

A specific flocculent white substance, visible when examining the anterior segment of the eye, can cause obstruction of the trabecular network. Flake-like white matter is also found in other tissues of the body.

[1], [2], [3], [4], [5]

Epidemiology of exfoliative syndrome

The prevalence of exfoliative syndrome varies from almost zero in Eskimos to 30% in Scandinavians. The incidence increases with age and over time. Also the frequency of binocular lesion is increased in comparison with monocular. Patients with ES-related glaucoma may account for only a small proportion of all patients with glaucoma or represent a majority depending on the study population. Despite the increased risk of developing glaucoma in patients with exfoliative syndrome (according to the Blue Mountains Eye Study, 5 times more), most of them do not develop glaucoma.

[6], [7], [8], [9], [10], [11]

Pathophysiology of exfoliative syndrome

The substance forming exfoliation was isolated from the iris, lens, ciliary body, trabecular network, corneal endothelium and endothelial cells of the eye and orbital vessels, as well as from the skin, myocardium, lungs, liver, gall bladder, kidneys and brain membranes. However, its nature is not fully understood. The substance clogs the trabecular network, which leads to the development of secondary open-angle glaucoma. The ischemia of the peripupillary part of the iris also develops, the posterior synechiae form. As a result, the pigment is washed out, the pupillary block and the load on the trabecular network increase, which helps to close the angle of the anterior chamber.

Anamnesis

Despite the rare development of an apparent increase in intraocular pressure, most patients can not identify any significant anamnestic data. Sometimes family cases of the disease are observed, for which the surgical treatment of complicated cataract in the family is characteristic. Precise inheritance mechanisms have not been identified.

Diagnosis of exfoliative syndrome

Biomicroscopy

The symptom of the exfoliative syndrome is a flocculent white substance, which is found most often with the dilatation of the pupil at its edge, in the form of concentric circles on the surface of the anterior capsule of the lens. The same deposits are found on the iris, the structures of the anterior chamber angle, the endothelium, the intraocular lens, and the anterior border membrane of the vitreous with aphakia. When conducting transillumination, peripupillary defects and atrophy of the pigmentary leaf are often detected. The leaching of the pigment from the peripupillary zone is also observed. The pupil on the affected eye is usually smaller and is weaker than the healthy eye, which is associated with siniciasis and ischemia of the iris. The release of pigment, associated with dilatation of the pupil, can cause a jump in intraocular pressure. Cataracts are also often formed in the affected eyes.

Gonioscopy

The angle of the anterior chamber of the eye in exfoliative syndrome is often narrowed, especially in the lower parts. Because of the risk of developing an acute attack of angle-closure glaucoma, constant monitoring of the angle of the anterior chamber is necessary. In gonioscopy, uneven pigmentation of the trabecular network with large dark pigment granules is detected. The deposition of pigment anterior to the Schwalbe line leads to a characteristic waviness of the Sampaolezi line.

Rear Pole

The characteristic glaucoma atrophy of the optic nerve is observed with prolonged ascent or periodic jumps of intraocular pressure.

[12], [13], [14], [15]

Treatment of exfoliative syndrome

In glaucoma associated with exfoliative syndrome, higher intraocular pressure values and more pronounced daily fluctuations are observed. It is possible to prescribe droplets that reduce the vagaryngeal pressure, but it has been shown that this method of treatment is ineffective. Despite the postoperative increase in intraocular pressure with argon laser trabeculoplasty, the method is effective. To affect the intensely pigmented trabecular network, you can use a lower energy laser radiation, which will reduce postoperative intraocular pressure jumps. The results of operations aimed at increasing filtration are the same as for primary open-angle glaucoma. When performing the extraction of cataracts, care should be taken, taking into account the weakness of the capsule and the ligamentous apparatus.