This document discusses the management of uveitic glaucoma. It begins by noting that approximately 10% of patients with uveitis will develop glaucoma due to complications of the disease. It then covers the typical intraocular pressures seen in uveitis, how uveitic glaucoma is defined, and risk factors associated with higher prevalence. The document also classifies uveitic glaucoma anatomically, pathologically, and clinically. It discusses the multifactorial pathophysiology of elevated intraocular pressure in uveitis and treatments aimed at controlling the underlying disease, inflammation, and high pressure through medical, laser, and surgical means. Key challenges in managing uveitic glaucoma are noted due to
2. Introduction
It has been estimated that
uveitis affects more than
2 million people worldwide
and almost 10% of them will
suffer from irreversible
visual loss due to the
complications of the disease
that include uveitic
glaucoma.
3. What are typical IOPs in uveitis?
LOW Ciliary body shut down +/-
incease uveosclearl outflow
4. Uveitic glaucoma
Is defined as a raised IOP in
a patient with uveitis who is
diagnosed with optic nerve
damage causing typical
progressive visual field
loss.
5. 10 % of uveitic patients
3rd or 4th decade of life
Females > male
Anterior uveitis, older age at
presentation and chronic uveitis are
associated with higher prevalence of
uveitic glaucoma
Certain types like JIA, Sarcoidosis,
FHU, Herpes simplex uveitis are
associated with higher prevalence
Prevelance
10. Elevation of IOP in uveitis is multifactorial.
• Breakdown of the blood-aqueous barrier
• Exudation of proteins , inflammatory cells & mediators resulting
in clogging up of the TM
• Steroid treatment is another potential underlying mechanism for
IOP elevation.
Pathogenesis Open
angle
11. • Formation of posterior synechiae between the iris and lens
• Formation of PAS
• forward rotation of the ciliary body.
Pathogenesis closed
angle
14. Treat underlying disease
• Antiviral treatment should be prescribed in herpes simplex or varicella
zoster uveitis.
• Topical antiviral therapy is indicated in patients with keratouveitis
• Long-term antiviral prophylaxis such as oral acyclovir, valacyclovir, is
required to prevent recurrences.
.
21. Cholinergic Agents (Miotics)
Cholinergic agents or miotics generally are contraindicated for treating UG because of the potential exacerbation of
inflammation via blood-aqueous barrier breakdown.
In addition, miotics promote development of posterior synechiae, and in patients with synechial angle closure these
drugs are generally ineffective given their mechanism of action of increasing trabecular aqueous outflow.
Tips and Tricks in prescribing anti-glaucoma
medication
Cholinergic Agents (Miotics)
Are contraindicated for treating
UG
22. Tips and Tricks in prescribing anti-glaucoma
medication
Beta-Blockers
Metipranolol
Anterior granulomatous uveitis
23. Tips and Tricks in prescribing anti-glaucoma
medication
Prostaglandin receptor agonists
The efficacy of prostaglandin agonists may be partially
inhibited by the simultaneous administration of (NSAIDs)
PGs induce chronic conjunctival inflammation that may
have a negative effect in future filtering surgeries
24. Tips and Tricks in prescribing anti-glaucoma
medication
Carbonic anhydrase inhibitors (CAIs)
In patients with preexisting corneal endothelial
injury, topical CAIs must be avoided.
25. Tips and Tricks in prescribing anti-glaucoma
medication
Alpha-2 Adrenergic Agonists
long-term use of apraclonidine and brimonidine.
Granulomatous anterior uveitis
26. Tips and Tricks in prescribing anti-glaucoma
medication
Mannitol has limited value because
of disrupted blood aqueous barrier
28. Laser iridotomy
In pupillary block glaucoma, laser
peripheral iridotomy (LPI)
is usually the treatment of choice,
however, the LPI may close
secondary to inflammatory
membranes with recurrence of the
pupillary block.
30. Filtration Surgery
The choice of the most appropriate surgery depends on
• Patient age
• Inflammatory activity.
• Previous ocular surgeries.
• Conjunctival scarring.
• Pathophysiology of the IOP elevation.
• Surgeon experience.
• Postoperative IOP goal.
31.
32. Quiescent Disease
Preoperative At Surgery Postoperative
• Continue pre-op meds
(topical, systemic)
• Topical NSAIDs t.d.s
→ 4 days before surgery
• Prednisone 70mg daily
→ 2 days before surgery
IV Solumedrol
250mg
• Systemic Prednisone 1 mg/kg
→ Gradual Tapering
• Topical Prednisolone/2 hours
→not taper until quiet
• Topical NSAID & Cycloplegic
→ several weeks
33. Trabeculectomy for glaucoma associated with uveitis (UG) carries one of the highest failure rates for glaucoma
filtration surgery
1. Trabeculectomy
Trabeculectomy for Uveitic glaucoma carries
one of the highest failure rates for glaucoma
filtration surgery
34. Trabeculectomy for glaucoma associated with uveitis (UG) carries one of the highest failure rates for glaucoma
filtration surgery
2. Augmented Trabeculectomy
Mitomycin C (MMC)
5-Fluorouracil (5-FU)
Ologen implant
35. 3. Deep sclerectomy
The non-opening of the anterior chamber and the
avoidance of a peripheral iridectomy may lower the
incidence of complications while retaining the efficacy of
trabeculectomy
41. 7. Cyclodestructive Procedures
There is no role for cyclophotocoagulation in
the management of uveitic glaucoma since
these procedures are pro-inflammatory.
42. Conclusions
Uveitic glaucoma is considered one of refractory glaucoma
Different challenges should be considered in management of
uveitic glaucoma as a result of limitations in our weapons to
control IOP in a uveitic eye
Control of inflammation is the first line in lowering IOP. But
you should be wise in steroid use
Topical antiviral therapy is indicated in patients with keratouveitis to prevent viral replication during treatment with topical steroids, but it is considered ineffective in herpetic uveitis.
Acyclovir 800 mg twice daily or valacyclovir prophylactically for patients with herpes simplex disease and double the dose for varicella zoster disease have been recommended
The first step in UG management is controlling the inflammation, which minimizes the adverse effects of the inflammatory process. In some cases, controlling the uveitis may help reduce the IOP.
Corticosteroids are the preferred anti-inflammatory drug used to treat uveitis. It is advisable to start with strong topical corticosteroids such as prednisolone acetate.
In corticosteroid responders, immunosuppression with drugs such as cyclosporine, azathioprine, methotrexate, or anti-tumor necrosis factor-alpha antibody therapy may be necessary.
Topical rimexolone 1% has less tendency to increase IOP in comparison to other commonly used topical steroids like prednisolone acetate 1% and dexamethasone sodiumm phosphate 0.1%
difluprednate ophthalmic emulsion) 0.05%
Are contraindicated for treating UG because of the potential exacerbation of inflammation via blood-aqueous barrier breakdown.
Miotics promote development of posterior synechiae
Metipranolol should be avoided because of its association with anterior granulomatous uveitis.
Dorzolamide significantly inhibits CAI activity. Irreversible corneal decompensation has been described after topical administration of dorzolamide in patients with underlying corneal endothelial compromise.
Most cases developed it about 1 year after treatment .
Typically, the inflammation resolves rapidly after stopping the alpha-2 adrenergic treatment and with use of topical corticosteroids .
ALT currently is not recommended for treating UG.
Selective laser trabeculoplasty (SLT) has been suggested as an alternative treatment for UG. Siddique et al. Reported a significant IOP reduction after SLT in na¨ıve eyes with UG (19.8% after a 1-year follow-up).
SLT was less effective in eyes that underwent a previous glaucoma surgery. However, the complete results and complications have not been published, and currently there is insufficient clinical evidence to recommend SLT to treat UG.
Pre-operative inflammatory control
• Achieve remission by any means
• At least 3 months of quiescence
• No anterior chamber cells
• Less than 1+ flare
• No retinitis
• No CME
• Infectious cause completely eradicated.
• Sometimes greater than 3 months is recommended
• If risk of amblyopia, less than 3 months
Trabeculectomy with or without antimetabolites
has well-documented complications,as a result of anterior chamber opening including hyphema, anterior chamber inflammation, shallow or flat anterior chamber, hypotony, cataract formation, and choroidal detachment
Different glaucoma implants can be used in cases with low long term success rate after repeated surgeries