Pseudoexfoliation syndrome

Common cause of secondary glaucoma: 25% of PXF patients develop glaucoma

More severe and resistant course than POAG

Systemic condition

  • Whitish dandruff-like material is deposited on

    • Eyes
    • Skin
    • Heart
    • Lungs
    • Kidneys
    • Meninges
  • Abnormal elastic microfibrils, basement membrane material, glycosaminoglycans

  • Possibly associated with raised homocysteine

  • 20% of population in Scandinavia

  • Linked to LOXL1 gene on chromosome 15

Risk factors

  • Age >40
  • Female
  • Ethnicity: north european/northern latitudes, mediterranean
  • Higher altitudes

Clinical features

  • Dandruff-material on

    • Pupillary border
    • Lens capsule
    • Stains with Masson Trichrome
  • Peripupillary transillumination defects (cp. Pigment dispersion)

  • Poor mydriasis

  • Iridodonesis

  • Phacodonesis: with risk of zonulodialysis during cataract surgery

  • Pigment in the AC

  • Pigment and pseudoexfoliative material on corneal endothelium

  • Irregular pigment and PXF material deposition in the trabeculum and anterior to Schwalbe’s line (Sampaolesi’s line) on gonioscopy (also seen in PDS, trauma, poorly controlled diabetes and iris melanoma)

    • Open but narrow angle
  • Glaucoma

    • Open angle: PXF deposition in TM
    • Tends to present unilaterally with progression to both eyes in 40%
    • Narrow angle (rare): weak zonules causing anterior lens-iris movement
    • PXF glaucoma tends to be more volatile with faster progression compared to POAG


  • As for POAG
  • More likely to need laser and surgery

Hot Topic

The approach to cataract surgery in a patient with pseudoexfoliation is a hot topic in exams!

  • Anaesthetic considerations
  • Preassessment for phacodonesis
  • Dilation is often poor: intracameral phenylephrine, visco-dilation
  • Vision blue
  • Phaco-chop to reduce stress on zonules
  • Capsular tension ring if less than 4 clock hours of zonulysis
  • Cortical removal with circumferential movements rather than radial traction

Was this page helpful?

Normal Tension Glaucoma