Methods for decreasing pigment particles in the anterior chamber in exfoliation syndrome and pigment dispersion syndrome. BY WISAM SHIHADEH, MD, AND ROBERT RITCH, MD

EXFOLIATION SYNDROME Overview Exfoliation syndrome is the most widespread, classifiable cause of open-angle glaucoma worldwide.1 In this age-related disorder, fibrillar extracellular materials are produced by and accumulate in various ocular tissues (Figure 1). Friction between the anterior lens capsule and the iris disrupts the iris pigment epithelium, dispersing pigment throughout the anterior chamber. The result is corneal pigmentation, iris sphincter transillumination defects (Figure 2), and a characteristic increase in the trabecular meshwork’s pigment (Figure 3). Pigment dispersion may occur before the physician even detects exfoliation syndrome with a slitlamp examination.2 The release of pigment into the anterior chamber is common and profuse after pupillary dilation in patients with exfoliation syndrome.3-8 Subsequent increases in IOP can be as high as 30 mm Hg above baseline and may peak as many as 2 or 3 hours after dilation.9 It is particularly important for physicians to measure IOP and assess the degree of pigment release in the anterior chamber after pupillary dilation. If the spread of pigment is extensive, the clinician should continue follow-up until the patient’s IOP is safely under control. Unrecognized pressure spikes may exacerbate glaucomatous damage, particularly in patients whose disease is moderate to severe. We have seen a patient with exfoliative glaucoma who suffered a central retinal vein occlusion and an IOP spike to 55 mm Hg after pupillary dilation.