A Foggy Focus

“Dandruff” in your eyes, or pseudoexfolliation glaucoma, can rob your sight

Dandruff or frosted flakes in your eyes? That’s the simplest description of a particular kind of glaucoma. Unlike the dandruff in your hair that is mainly unsightly, this glaucoma poses a danger to your vision. But treatment is available.

Just the name is a mouthful and deserving of an explanation—pseudoexfolliation glaucoma. Glassblowers and furnace workers without eye protection used to get true exfoliation deposits on the lens of the eye from the intense heat and associated infrared radiation of blowing glass or standing in front of a hot furnace, says ophthalmologist Dr. Samuel N. Garrett of Virginia Beach Eye Center. Pseudoexfoliation syndrome and glaucoma are so named because the deposits look like exfoliation but are unassociated with external causes. These deposits form as the outer layer of your eye’s lens shears off in little flakes just like dandruff, Garrett says. (Since glassblowing is not as common a profession as in colonial times and workers exposed to high heat are now protected, true exfoliation now very rarely occurs, so the slightly simpler term exfoliation syndrome and glaucoma is often used now and for this story.)

The mere presence of the so-called frosted flakes on the lens surface is called exfoliation syndrome, says ophthalmologist Dr. Len Rappaport of Tidewater Eye Center with locations in Chesapeake, Portsmouth and Virginia Beach. About 30 percent of people with exfoliation syndrome eventually get exfoliation glaucoma, Rappaport says.

 The danger posed by the flakes is simple: they clog up the drains (called the trabecular meshwork) in your eye, causing fluid from your eyes to build up, which in turn increases the pressure in your eyes and causes glaucoma, Garrett says.

 The material accumulates in the trabecular meshwork and limits outflow,” Rappaport says. “Eventually the fluid in the eye can’t get out and pressure begins to build up,” he says.
 The increased eye pressure kills nerve fibers that send visual information through the optic nerve to the brain, Garrett says. Eventually, a person with glaucoma begins to lose peripheral vision, usually without realizing the loss, and ultimately may lose all their sight, Rappaport says.

With treatment, eye doctors usually can halt the progress of the disease, but can’t reverse it. That’s why it’s important to have an annual complete eye exam, especially as you get older to detect this and other types of glaucoma, Garrett says. A physician can see those flakes especially well when the eye is dilated during a thorough eye exam, Rappaport says.

Particularly at risk for exfoliation glaucoma are people of Scandinavian descent, black patients from South Africa and people from Mongolia, Rappaport says. Those patients have a risk of up to 25 percent. In the general population, the risk rises to 5 percent among those 75 to 85 years old, Rappaport says.

Often patients have exfoliation glaucoma in only one eye initially, but once it occurs, 40 percent will develop it in the other eye, Rappaport says.

Researchers have identified a genetic marker strongly associated with exfoliation syndrome, Rappaport says. In the future, patients may have additional options to be tested to determine their risk, he says. For now, if you have a family member who has been diagnosed, you should let your ophthalmologist know.

Several treatments, from simple to more involved, are available. The first recourse is usually medicated eye drops that cause the eye to produce less fluid, which lowers the eye pressure, Rappaport says. Another medication helps encourage fluid to drain through different pathways in the eyes where the flakes don’t typically accumulate, he says.
If those treatments don’t work or become less effective, an ophthalmologist can use a laser to stimulate the eye’s drain to work better. This is done by encouraging the drain to more quickly repopulate itself with healthy cells and to encourage the recruitment of so-called scavenger cells to clear away the flakes. This unclogs the drain and lowers eye pressure, Rappaport says.

The next option is to lower eye pressure by creating a new pathway for excess fluid to drain from the eye by creating a trapdoor on the surface of the eye, Rappaport says. Although this may be the most effective option, it is last for a reason—it poses the most risk to vision and has potential for other complications such as scarring, hemorrhage and infection, he says.

Finally, exfoliative glaucoma makes performing cataract surgery more problematic and risky, Garrett says. The lens capsule is more fragile and the ligaments (zonules) holding the lens capsule in place are more fragile and easily broken, he says.

As of now, there is no way to prevent exfoliative syndrome or exfoliative glaucoma. But again once diagnosed, treatment can usually stop the progression—one more reason not to delay an appointment with your eye doctor.

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