Diagnostic pitfalls of pseudoexfoliation syndrome

ABSTRACT

A 60-year-old Pakistani engineer had a normal eye examination by an American ophthalmologist in 1983. In 1984, I examined his eyes and found intraocular pressures of 26 mm Hg, OD and 21 mm Hg, OS. The cup/disc ratio was higher in OD without any visual field changes. In 1985, a British ophthalmologist diagnosed primary open-angle glaucoma. In 1986, a Pakistani ophthalmologist who agreed with this diagnosis started medical therapy. Later, a Mexican ophthalmologist advised discontinuation of antiglaucoma drops. In 1987, he again consulted me when the ophthalmologist in Pakistan recommended surgery on the right eye. On examination, I discovered the typical changes of pseudoexfoliation syndrome in the right eye. This case illustrates that pseudoexfoliation is easily missed when even highly trained examiners do not have a high index of suspicion, that elevated intraocular pressure may precede the clinical manifestation of pseudoexfoliation, that primary open-angle glaucoma may coexist with pseudoexfoliation, that all cases of unilateral glaucoma should be examined biomicroscopically with dilated pupils on each visit for pseudoexfoliation, and that in addition to the recently reported pigmentary changes in the iris sphincter area, the eyes with unilateral hypertension, more advanced cataract, a poorer pupillary dilation, and a greater pigmentary dispersion during pupillary dilation should be considered pseudoexfoliation syndrome suspects