Pseudoexfoliation glaucoma: what it is, how it is found and how it is treated

Glaucoma UK explains that eye pressure is controlled by a watery fluid called aqueous humour, made behind the iris by the ciliary body. It flows through the pupil and drains through tiny channels called the trabecular meshwork in the angle between the cornea and the iris. In a healthy eye inflow and outflow are balanced; in glaucoma that balance is disturbed and pressure rises.

Pseudoexfoliation syndrome is one of the conditions that can disturb it. Glaucoma UK describes protein deposits that look like dandruff forming on the front of the lens, the iris, around the pupil edge and in the drainage channels. As the iris moves and the lens and iris touch, deposits flake off into the aqueous fluid and can clog the meshwork. The condition is therefore classed as a secondary glaucoma, meaning it develops because of another process in the eye rather than for no identifiable reason.

Glaucoma UK says the condition is more common in older people and in people of Scandinavian and Southern Mediterranean origin. This fits the general picture the NHS gives for glaucoma, which is most common in adults aged 50 and over, and which tends to be more likely if you have a close relative with the condition, are from a Black African, Caribbean or Asian background, or have conditions such as short-sightedness, long-sightedness or diabetes.

Glaucoma UK draws a distinction for secondary glaucomas generally, between secondary ocular hypertension, where the pressure is raised but there is no detectable nerve damage, and secondary glaucoma, where the damage becomes visible.

Most glaucoma gives no warning. The NHS says it does not usually have symptoms and most people do not realise they have it, developing slowly over many years and usually picked up during routine eye tests. Moorfields adds that it tends to affect the edges of vision (peripheral vision) first, so many people do not notice. RNIB says it can eventually affect contrast, night vision and side vision, and central vision if left untreated.

The NHS says that sudden severe symptoms, such as intense eye pain, a red eye, blurred vision, rainbow-coloured circles around lights, nausea and vomiting or a headache, need 999 or A&E.

Glaucoma UK explains that the signs are usually first spotted by an optometrist at a routine eye test, using a visual field test, an eye pressure test and an examination of the optic nerve. The optometrist does not diagnose glaucoma; if tests show signs you are referred to a specialist glaucoma service, which repeats tests and considers risk factors such as ethnicity and family history before deciding whether you have glaucoma and whether you need treatment.

The NHS says that you should have an eye test at least every 2 years, and more often if you are at higher risk.

Glaucoma UK says treatment of secondary glaucoma depends on what is causing it, with the aim of bringing pressure down into the normal range to slow further damage. The options it lists are eye drops, laser treatment and surgery, selected according to your general health and medical history. The NHS also lists drops, laser and surgery, and says there is currently no cure but treatments can slow damage.

Glaucoma UK describes eye drops as the most common treatment, laser as a way to decrease the amount of fluid in the eye, and surgical options including trabeculectomy, aqueous shunt implants and minimally invasive glaucoma surgery (MIGS). RNIB says that when first diagnosed with open angle glaucoma, laser (SLT) is now usually offered as a first option, and that most people with glaucoma will not need surgery.

Follow-up appointments matter. The NHS says it is important not to miss them, as they monitor your eyes and check treatment is working. Moorfields describes recovery after surgery as taking up to six weeks for blurring to settle, with advice to avoid driving, reading and heavy lifting for at least a week.

Cataracts and glaucoma often occur together in older people. Glaucoma UK says glaucoma itself does not cause cataracts, though glaucoma treatments such as trabeculectomy or drainage tubes can speed cataract formation, and that cataract surgery is the most common operation in hospital eye departments. If you have pseudoexfoliation, tell the surgical team and the optometrist, so that the glaucoma is taken into account in planning, and ask your ophthalmologist about anything specific to your eyes.

Glaucoma UK also says that steroids can raise eye pressure and that it is important to have regular eye pressure checks if you use steroid eye drops for a long time.

RNIB says the most important thing is to keep to the recommended treatment, which for many people means eye drops every day for life, and to attend regular clinic visits. It says most people with glaucoma will retain good vision with the right treatment if it is detected early. Support is available from Glaucoma UK and RNIB, including helplines, buddy schemes and support groups, as the NHS lists.

On the NHS, optometrists refer people with suspected glaucoma to hospital eye services or community glaucoma clinics. Private ophthalmology can provide earlier appointments or a second opinion, and treatments such as drops, SLT, drainage surgery and MIGS are the same procedures. Because glaucoma is lifelong, many people receive monitoring in the NHS and private clinics at different times; keep your pressure readings and field tests together so that decisions are made on the full record.