Secondary Open Angle Glaucoma

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Pseudoexfoliative Glaucoma

  • Most common type of secondary open-angle glaucoma
  • Usually begins after the age of 60
  • Can affect one or both eyes, typically bilateral and asymmetric
  • Pseudoexfoliation syndrome if normal IOP and normal optic nerve (regular follow-up to detect transformation into glaucoma!)
  • Findings: Pseudoexfoliation material (whitish protein) at the pupillary margin, pupillary margin atrophy, on anterior lens surface
  • Gonioscopy: Increased pigmentation of trabecular meshwork (especially inferior), Sampaolesi’s line
  • Intraocular pressure (IOP) often higher than in primary open-angle glaucoma (POAG), more diurnal fluctuations
  • Often poor dilation, phacodonesis, loose zonular fibers (caution during cataract surgery)
  • Treatment similar to POAG, generally responds well to selective laser trabeculoplasty (SLT)

Pigmentary Glaucoma

  • Pigment release from the iris pigment epithelium
  • More common in Caucasian men with myopia, diagnosis usually around 30-50 years
  • Symptoms: sometimes episodes of blurred vision and halos during increased intraocular pressure, often after physical activity or dilated pupils
  • Unilateral or bilateral
  • Findings: deep anterior chamber with backward bowing of the peripheral iris, mid-peripheral iris transillumination (Krukenberg’s spindle , pigment deposits on endothelium), pigment on anterior lens surface
  • Gonioscopy: Heavily pigmented trabecular meshwork, pigment deposition on Schwalbe’s line
  • Increased risk for retinal detachment!
  • Treatment similar to POAG

Other Secondary Open Angle Glaucomas:

  • Steroid-induced Glaucoma (“Steroid response”)
    • Starts about 2-6 weeks after beginning topical steroid therapy
    • Discontinue steroids if possible, switch to milder drops (e.g., Lotemax, FML, Softacort).
    • Pressure-lowering drops, laser trabeculoplasty (SLT)
    • Evaluate glaucoma surgery if high pressure persists
  • Lens Induced Glaucoma:
    • Phacolytic glaucoma (denatured lens proteins in macrophages clog trabecular meshwork)
    • ‘Lens-particle’ glaucoma (lens material post-trauma or cataract surgery clogs trabecular meshwork)
    • Phacoanaphylactic glaucoma (lens proteins cause granulomatous uveitis)
  • Uveitic Glaucoma (e.g., Posner-Schlossman syndrome, Fuchs uveitis, HSV/VZV, UGH syndrome)
  • Glaucoma associated with intraocular hemorrhage:
    • Hemorrhagic glaucoma (erythrocytes clog trabecular meshwork)
    • Ghost cell glaucoma (old erythrocytes clog trabecular meshwork)
  • Glaucoma associated with intraocular tumor (tumor and inflammatory cells clog trabecular meshwork)
  • Glaucoma associated with retinal detachment (Schwartz’s syndrome: photoreceptor outer segments likely clog trabecular meshwork in rhegmatogenous retinal detachment; additionally, drainage obstruction due to pigment release from RPE)
  • Glaucoma associated with trauma (recess)
  • Glaucoma due to elevated episcleral venous pressure (e.g., carotid-cavernous sinus fistula, Sturge-Weber syndrome, thyroid eye disease)

Sources

  • European Glaucoma Society Terminology and Guidelines for Glaucoma, 5th Edition, British Journal of Ophthalmology 2021;105:1-169.
    • Licensed under a Creative Commons License Attribution-NonCommercial 4.0 International CC BY-NC 4.0 DEED
  • Eyewiki Pseudoexfoliation Syndrome
  • Eyewiki Pigmentary Glaucoma
  • The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease; Kalla Gervasio MD, Travis Peck MD et al; Lippincott Williams&Wilkins; 8th Edition (2021)
  • Kanski’s Clinical Ophthalmology: A Systematic Approach; John E Salmon MD; Elsevier; 9th Edition (2019)