Patients with PXG Twice as Likely to Undergo Surgery as Those with POAG

A retrospective analysis of over 800,000 patients in the IRIS Registry found that 13.6% of those with pseudoexfoliative glaucoma underwent glaucoma surgery within four years, compared to 8.6% with primary open-angle glaucoma. PXG patients also experienced higher rates of postoperative IOP spikes (7.5% vs. 5.2%) and repeat surgeries (10.8% vs. 7.9%), underscoring the disease’s more aggressive nature and the need for vigilant management and follow-up. Photo: Henrietta Wang, BOptom, MPH, and Jack Phu, OD, PhD. Click image to enlarge. The pathology and clinical course of pseudoexfoliative glaucoma (PXG) and primary open-angle glaucoma (POAG) are distinctly different, yet their management and treatment strategies are rarely separated. PXG tends to have higher intraocular pressure (IOP) at diagnosis and is more aggressive, meaning the disease progresses more commonly than POAG both with and without treatment. Compared to POAG, PXG occurs in fewer patients, which has made it challenging to research and control for baseline characteristics. Using the American Academy of Ophthalmology Intelligent Research in Sight  (IRIS) registry, researchers were able to compare the incidence of glaucoma surgeries and outcomes between PXG and POAG. Their results were recently published in Ophthalmology.Over 800,000 eligible patients were identified with diagnosis codes for PXG and POAG, and followed from January 2016 through December 2020. Of these, 96.5% were in the POAG group while 3.5% had a PXG diagnosis. Before propensity score matching, the PXG group was a bit older (77.3 vs. 73.0 years old), had more women (65.8% vs. 57.3%), and had higher baseline IOP (19.7mm Hg vs. 18.2mm Hg), worse baseline visual acuity (0.58 logMAR vs. 0.52 logMAR), and lower baseline cup-to-disc ratio (0.62 vs. 0.66) than the POAG group. After propensity score matching, the SMDs for all baseline variables were less than 0.1.According to the results, the cumulative incidence rates of glaucoma surgery at four years were 8.6% in the POAG group and 13.6% in the PXG group. The cumulative incidence rates in the PXG group were 1.8, 1.7, 1.6, and 1.6 times higher than those in the POAG group at one year, two years, three years, and four years, respectively. Filtering surgery accounted for 39% and 51.2% of the first-recorded surgery in POAG and PXG, respectively, while trabecular stents accounted for 44.5% and 31.3%, respectively.Significantly more patients with PXG experienced postoperative IOP spikes than those with POAG (7.5% vs. 5.2%), according to the study, and patients in the PXG group underwent additional glaucoma surgery more frequently that the POAG group (10.8% vs. 7.9%). Factors associated with higher likelihood of undergoing glaucoma surgery in both diagnosis groups were male sex, higher baseline IOP and higher cup-to-disc ratio. Reduced risk was found among those under age 60, patients of Hispanic ethnicity, individuals with visual acuity 20/80 or worse and pseudophakes. The authors wrote in their paper that glaucoma surgery “was nearly twice as likely to be performed” in PXG patients than those with a POAG diagnosis. Furthermore, more than half of the surgeries performed in the PXG group were trabeculectomy or tube shunt surgery, whereas trabecular bypass stent accounted for nearly half of the surgeries performed in the POAG group, “indicating that more aggressive treatments tended to be chosen for patients with PXG than those with POAG even when the baseline characteristics were similar.”Postoperative IOP spikes and additional glaucoma surgery were significantly more frequent in the PXG group compared to the POAG group, underscoring the importance of close postoperative monitoring of patients with PXG, the authors continued. “This higher rate of additional glaucoma surgery in the PXG group may reflect the more aggressive nature of the disease with faster progression, poorly controlled IOP, and greater likelihood of surgical failure as shown in higher incidence rates of postoperative hypotony following trabeculectomy and tube shunt surgery, more frequent IOP spikes and higher preoperative IOP for additional surgeries compared to the POAG group,” they wrote.Basing this study on ICD codes is a limitation noted by the researchers, and some patients with pseudoexfoliative glaucoma may have been miscoded as POAG, potentially leading to an underestimation of the difference between the two groups. They also mention that any glaucoma surgeries these patients received outside of the IRIS registry were not captured, and the study did not have access to visual field and optical coherence tomography data. Despite these, patients with pseudoexfoliative glaucoma were more likely to undergo glaucoma surgery than those with open-angle glaucoma, even when the baseline characteristics were balanced, further reinforcing the disease’s aggressive nature. The authors recommend close monitoring of patients with PXG.Click here for the journal source. Fujita A, Pershing S et al. Comparison of glaucoma surgery incidence and outcomes in pseudoexfoliation and primary open-angle glaucoma: IRIS® Registry analysis. Ophthalmology. September 25, 2025. [Epub ahead of print.] This article was developed by the editorial staff in conjunction with experts in the field. In the process, AI may have been among the editorial tools used to meet the goals of human editors, who approved all content.