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Uveitic Glaucoma

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By Dr. Howard Kane

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Uveitic Glaucoma

  1. 1. Uveitic GlaucomaUveitic Glaucoma Evaluation and ManagementEvaluation and Management Howard Kane MD,ODHoward Kane MD,OD May 22, 2016May 22, 2016
  2. 2. ObjectivesObjectives • Review the pathophysiology of UveiticReview the pathophysiology of Uveitic GlaucomaGlaucoma • Recognize the signs and symptoms of UveiticRecognize the signs and symptoms of Uveitic GlaucomaGlaucoma • Discuss management options in UveiticDiscuss management options in Uveitic GlaucomaGlaucoma • Detail several specific Uveitic GlaucomaDetail several specific Uveitic Glaucoma SyndromesSyndromes
  3. 3. General PrinciplesGeneral Principles • Uveitis is the most common of theUveitis is the most common of the inflammatory processes which affect the eye.inflammatory processes which affect the eye. • Most of the acute cases (< 3 months duration)Most of the acute cases (< 3 months duration) involve the anterior uvea (iritis or iridocyclitis)involve the anterior uvea (iritis or iridocyclitis) • Chronic forms are seen in the followingChronic forms are seen in the following frequencies: Anterior (45%), intermediate (15%),frequencies: Anterior (45%), intermediate (15%), posterior (14%) and panuveitis (24%)posterior (14%) and panuveitis (24%) • Iridocyclitis most common form causing increasedIridocyclitis most common form causing increased IOPIOP • 10% of pts with uveitis will develop10% of pts with uveitis will develop OHT/OAGOHT/OAG
  4. 4. PathophysiologyPathophysiology Secondary OAGSecondary OAG • Obstruction of TM by inflammatory debris, RBCs,Obstruction of TM by inflammatory debris, RBCs, WBCs, fibrin, viscous inflammatory aqueousWBCs, fibrin, viscous inflammatory aqueous • Direct inflammation and swelling of the TMDirect inflammation and swelling of the TM endothelial cells (trabeculitis)endothelial cells (trabeculitis) • Steroid responsivenessSteroid responsiveness • Formation of vascular or cuticular membranesFormation of vascular or cuticular membranes overlying the TM as a result of chronic recurrentoverlying the TM as a result of chronic recurrent InflammationInflammation
  5. 5. PathophysiologyPathophysiology • Secondary ACGSecondary ACG • Pupillary block secondary to posterior synechiaePupillary block secondary to posterior synechiae • Extensive peripheral anterior synechiaeExtensive peripheral anterior synechiae • Choroidal/ciliary effusions with anterior rotation ofChoroidal/ciliary effusions with anterior rotation of the ciliary body and resultant angle closurethe ciliary body and resultant angle closure • Neovascular glaucomaNeovascular glaucoma
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  7. 7. General PrinciplesGeneral Principles IOP in uveitis depends on a delicateIOP in uveitis depends on a delicate balance between aqueous secretion bybalance between aqueous secretion by the ciliary body and aqueous outflow atthe ciliary body and aqueous outflow at the TM and the effects of the specificthe TM and the effects of the specific inflammatory event on these structures.inflammatory event on these structures. • Basic Principles of glaucoma management inBasic Principles of glaucoma management in uveitis patientsuveitis patients • Elevated IOP often complicates cases of anteriorElevated IOP often complicates cases of anterior segment inflammation, rarely in posterior orsegment inflammation, rarely in posterior or intermediate Uveitisintermediate Uveitis
  8. 8. General PrinciplesGeneral Principles • It is uncommon for acute anterior uveitis of short duration (<It is uncommon for acute anterior uveitis of short duration (< 3 months) to cause persistent IOP elevation3 months) to cause persistent IOP elevation • The etiologic agent for specific cases of uveitis is frequentlyThe etiologic agent for specific cases of uveitis is frequently unknown, therefore treatment is often nonspecific, aimed atunknown, therefore treatment is often nonspecific, aimed at suppressing inflammation.suppressing inflammation. • Full medical workup generally done in bilateral, persistentFull medical workup generally done in bilateral, persistent and recurrent cases. Low yield in initial, mild unilateral cases.and recurrent cases. Low yield in initial, mild unilateral cases. • Focused Hx/ROS should be performedFocused Hx/ROS should be performed • Full physical, CXR, SI joint films, ACE levels, HLA-B27, RPR,Full physical, CXR, SI joint films, ACE levels, HLA-B27, RPR, FTA-ABS, ANA, RF, HIV.FTA-ABS, ANA, RF, HIV. • HLA B27 positive accounts for 50% of cases in Caucasians,HLA B27 positive accounts for 50% of cases in Caucasians, predominantly younger menpredominantly younger men • Due to the delicate balance between alterations in aqueousDue to the delicate balance between alterations in aqueous production and outflow, IOP in uveitic glaucoma mayproduction and outflow, IOP in uveitic glaucoma may fluctuate greatly.fluctuate greatly.
  9. 9. • Signs andSigns and symptomssymptoms • Wide rangeWide range • Pain, photophobia,Pain, photophobia, tearing, decreased VAtearing, decreased VA • Ciliary flush, miosis, cellCiliary flush, miosis, cell & flare, KPs, AC,& flare, KPs, AC, vitreous cells,vitreous cells, • Ant/post synechiae, irisAnt/post synechiae, iris atrophy, Bandatrophy, Band keratopathy, cornealkeratopathy, corneal edema and IOPedema and IOP changes.changes.
  10. 10. • Signs and symptomsSigns and symptoms • Wide rangeWide range • Pain, photophobia, tearing, decreased VAPain, photophobia, tearing, decreased VA • Ciliary flush, miosis, cell & flare, KPs, ant vitreousCiliary flush, miosis, cell & flare, KPs, ant vitreous cells, hypopioncells, hypopion • Ant/post synechiae, iris atrophy, Band keratopathy,Ant/post synechiae, iris atrophy, Band keratopathy, corneal edema and IOP changes.corneal edema and IOP changes.
  11. 11. Treatment Principles for UveiticTreatment Principles for Uveitic GlaucomaGlaucoma • Treatment is aimed at reducing the acuteTreatment is aimed at reducing the acute inflammation and controlling the IOP.inflammation and controlling the IOP. • A further long term treatment goal is to preventA further long term treatment goal is to prevent any permanent structural damage that couldany permanent structural damage that could predispose the eye to secondary conditionspredispose the eye to secondary conditions such as cataract, corneal decompensation andsuch as cataract, corneal decompensation and glaucoma.glaucoma. • Specific Tx required in certain casesSpecific Tx required in certain cases – eg: ABx for STD, TB, Toxoplasmosiseg: ABx for STD, TB, Toxoplasmosis
  12. 12. Treatment Principles for UveiticTreatment Principles for Uveitic GlaucomaGlaucoma • Prompt identification of the mechanism of IOP elevation andPrompt identification of the mechanism of IOP elevation and treatment of the underlying cause.treatment of the underlying cause. • Cycloplegics and corticosteroids are the mainstays of treatment toCycloplegics and corticosteroids are the mainstays of treatment to control inflammation and prevent synechiae.control inflammation and prevent synechiae. – IOP must be closely monitored while on steroidsIOP must be closely monitored while on steroids – Steroid potency:Steroid potency: Difluprednate(Durezol)>Dexamethasone>Prednisolone>Difluprednate(Durezol)>Dexamethasone>Prednisolone> Loteprednol (Lotemax)>FML>AlrexLoteprednol (Lotemax)>FML>Alrex – Route of administrationRoute of administration – Steroids must be tapered.Steroids must be tapered. • Topical NSAIDS may be used adjunctively in patients who areTopical NSAIDS may be used adjunctively in patients who are known steroid responders.known steroid responders. • Systemic immunosuppresive Tx successful in 70% of patientsSystemic immunosuppresive Tx successful in 70% of patients unresponsive to other Txunresponsive to other Tx
  13. 13. Treatment Principles for UveiticTreatment Principles for Uveitic GlaucomaGlaucoma • Select target IOP based on level and duration of IOP elevation,Select target IOP based on level and duration of IOP elevation, presence and degree of optic nerve damage, central cornealpresence and degree of optic nerve damage, central corneal thickness.thickness. • Elevated IOP initially treated with B blockers and CAIs, both topicalElevated IOP initially treated with B blockers and CAIs, both topical and systemic.and systemic. • Alpha agonists also effective in these patients, although there haveAlpha agonists also effective in these patients, although there have been reports of a granulomatous anterior uveitis in patients takingbeen reports of a granulomatous anterior uveitis in patients taking brominidine 0.2%brominidine 0.2% • Miotics are contraindicated.Miotics are contraindicated. • PGAs are probably effective. Anecdotal reports of CME, ant uveitis.PGAs are probably effective. Anecdotal reports of CME, ant uveitis. • Laser trabeculoplasty generally ineffective in uveitic glaucoma andLaser trabeculoplasty generally ineffective in uveitic glaucoma and may result in IOP spikes.may result in IOP spikes. • Laser PI is the treatment of choice for RPB although associatedLaser PI is the treatment of choice for RPB although associated with a higher rate of secondary closure.with a higher rate of secondary closure.
  14. 14. Treatment Principles for UveiticTreatment Principles for Uveitic GlaucomaGlaucoma • Goniosynechiolysis, both laser and surgical, may beGoniosynechiolysis, both laser and surgical, may be effective in reversing PAS that have been present foreffective in reversing PAS that have been present for under a year.under a year. • Trabeculectomy with antimetabolite is effective butTrabeculectomy with antimetabolite is effective but should be done in a setting of as little inflammation asshould be done in a setting of as little inflammation as possible. 60-65% 5 yr success rate.possible. 60-65% 5 yr success rate. • Tube shunt surgery may also be effective in these eyes.Tube shunt surgery may also be effective in these eyes. Slightly higher success rate than Trabeculectomy butSlightly higher success rate than Trabeculectomy but often need medications.often need medications. • Cyclodestructive surgery an option in eyes with poorCyclodestructive surgery an option in eyes with poor visual potential.visual potential.
  15. 15. Treatment Principles forTreatment Principles for Uveitic GlaucomaUveitic Glaucoma Ahmed Glaucoma ValveAhmed Glaucoma Valve
  16. 16. Common Uveitic EntitiesCommon Uveitic Entities Associated with GlaucomaAssociated with Glaucoma • Fuchs Heterochromic Iridocyclitis (FHI)Fuchs Heterochromic Iridocyclitis (FHI) • Chronic low grade inflammatory conditionChronic low grade inflammatory condition characterized by heterochromia, KPs, vitreouscharacterized by heterochromia, KPs, vitreous opacities, cataract and glaucoma.opacities, cataract and glaucoma. • There is no gender or ethnic predisposition.There is no gender or ethnic predisposition. • Unilateral in 95% of cases.Unilateral in 95% of cases. • Patients usually present with a white, quiet eyePatients usually present with a white, quiet eye complaining of decreased VA due to cataract.complaining of decreased VA due to cataract. • Minimal flare and cell present and fine stellate KPsMinimal flare and cell present and fine stellate KPs • Stromal iris atrophy present with iris TI defects.Stromal iris atrophy present with iris TI defects.
  17. 17. Fuchs Hetereochromic IridocyclitisFuchs Hetereochromic Iridocyclitis • Development of OAG in 20-40% of patients.Development of OAG in 20-40% of patients. • Most commonly misdiagnosed form of uveitis.Most commonly misdiagnosed form of uveitis. • Accounts for 2-5% of all uveitis cases.Accounts for 2-5% of all uveitis cases. • Heterochromia may be missed in AA patientsHeterochromia may be missed in AA patients • Glaucoma develops gradually and often late in theGlaucoma develops gradually and often late in the course of the disease.course of the disease.
  18. 18. • FuchsFuchs HeterochromicHeterochromic IridocyclitisIridocyclitis • PAS, posterior synechiae arePAS, posterior synechiae are unusualunusual • Light NV of the iris and ACLight NV of the iris and AC angleangle • Fine iris nodules occur inFine iris nodules occur in 20% of patients20% of patients • FA shows delayed filling,FA shows delayed filling, sector ischemia and NV ofsector ischemia and NV of the iris.the iris. • Iris transillumination mayIris transillumination may be present.be present.
  19. 19. • Management of FHIManagement of FHI • Cataract surgery in these patients is relatively routineCataract surgery in these patients is relatively routine and is generally associated with good visualand is generally associated with good visual outcomes. Higher incidence of post op CME, IOPoutcomes. Higher incidence of post op CME, IOP spikes, hyphema and PO uveitis.spikes, hyphema and PO uveitis. • GlaucomaGlaucoma • Incidence is greater with longer term follow upIncidence is greater with longer term follow up • Does not respond to aggressive steroid therapy and may, inDoes not respond to aggressive steroid therapy and may, in fact, develop steroid induced glaucoma if usedfact, develop steroid induced glaucoma if used inappropriately.inappropriately. • Laser trabeculoplasty is ineffective in FHILaser trabeculoplasty is ineffective in FHI • Standard glaucoma medications are useful but oftenStandard glaucoma medications are useful but often ineffective but often ineffective in the long term.ineffective but often ineffective in the long term. • Avoid pilocarpine.Avoid pilocarpine.
  20. 20. • Management of FHI (cont)Management of FHI (cont) • GlaucomaGlaucoma • Trabeculectomy c MMC as well as tube shuntTrabeculectomy c MMC as well as tube shunt procedures have good success rates in a majorityprocedures have good success rates in a majority of these patients if medical treatment fail.of these patients if medical treatment fail.
  21. 21. Common Uveitis EntitiesCommon Uveitis Entities Associated with GlaucomaAssociated with Glaucoma • Glaucomatocyclitic Crisis (Posner-SchlossmanGlaucomatocyclitic Crisis (Posner-Schlossman Syndrome)Syndrome) • Characterized by recurrent unilateral attacks of mildCharacterized by recurrent unilateral attacks of mild anterior uveitis with marked elevations of IOPanterior uveitis with marked elevations of IOP • Young to middle aged adults, age 20-50 yo.Young to middle aged adults, age 20-50 yo. • Symptoms, slight in relation to the level of IOP,Symptoms, slight in relation to the level of IOP, include slight ocular discomfort, blurred vision andinclude slight ocular discomfort, blurred vision and halos lasting several hours to weeks. Recurrenceshalos lasting several hours to weeks. Recurrences monthly to yearly.monthly to yearly. • Mild ciliary flush, epithelial edema, faint flare andMild ciliary flush, epithelial edema, faint flare and scant KPs. Angle is open. Absence of synechiae.scant KPs. Angle is open. Absence of synechiae. • There is an association with subsequent POAG.There is an association with subsequent POAG. • Etiology unknownEtiology unknown
  22. 22. • Glaucomatocyclitic CrisisGlaucomatocyclitic Crisis • GlaucomaGlaucoma • IOP typically elevated into the 40-60 mmHg range.IOP typically elevated into the 40-60 mmHg range. • IOP and facility of outflow return to normal between attacks.IOP and facility of outflow return to normal between attacks. • Typically normal appearing ONH and visual fields, early on.Typically normal appearing ONH and visual fields, early on. • GCC is a self limiting condition.GCC is a self limiting condition. • Corticosteroids are beneficial in controlling the inflammatoryCorticosteroids are beneficial in controlling the inflammatory process (Unlike FHI)process (Unlike FHI) • CAIs, B-blockers and Alpha agonists are all effective inCAIs, B-blockers and Alpha agonists are all effective in controlling IOP during acute attacks. Prophylacticcontrolling IOP during acute attacks. Prophylactic antiglaucoma meds and corticosteroids are not necessaryantiglaucoma meds and corticosteroids are not necessary between attacks.between attacks.
  23. 23. • Glaucomatocyclitic CrisisGlaucomatocyclitic Crisis • NSAIDS ? Study showed benefits of IndomethacinNSAIDS ? Study showed benefits of Indomethacin • Glaucoma surgical procedures may be indicated if severe orGlaucoma surgical procedures may be indicated if severe or prolonged attacks lead to progressive ON damage.prolonged attacks lead to progressive ON damage.
  24. 24. Common Uveitis EntitiesCommon Uveitis Entities Associated with GlaucomaAssociated with Glaucoma • SarcoidosisSarcoidosis • A multi system inflammatory disorder with aA multi system inflammatory disorder with a predilection for young adults and African Americans.predilection for young adults and African Americans. • Pathology consists of noncaseating granulomasPathology consists of noncaseating granulomas involving the lungs, liver, spleen, skin, eyes andinvolving the lungs, liver, spleen, skin, eyes and CNS.CNS. • Glaucoma occurred in 10% of pts c Sarcoid relatedGlaucoma occurred in 10% of pts c Sarcoid related iridocyclititisiridocyclititis
  25. 25. Common Uveitis EntitiesCommon Uveitis Entities Associated with GlaucomaAssociated with Glaucoma • SarcoidosisSarcoidosis.. • Ocular manifestations occur inOcular manifestations occur in 38-50% of sarcoidosis patients38-50% of sarcoidosis patients and include anterior uveitisand include anterior uveitis (most common), chorioretinitis,(most common), chorioretinitis, retinal periphlebitis, opticretinal periphlebitis, optic neuritis and lacrimal glandneuritis and lacrimal gland involvement.involvement. • Diagnosis is made by Chest X-Diagnosis is made by Chest X- ray (hilar lymphadenopathy),ray (hilar lymphadenopathy), ACE levels and lymph node orACE levels and lymph node or skin biopsyskin biopsy
  26. 26. • Sarcoid UveitisSarcoid Uveitis • Both an acute form andBoth an acute form and chronic relapsing form.chronic relapsing form. • Initially unilateral with anInitially unilateral with an insidious onset it frequentlyinsidious onset it frequently develops into a chronicdevelops into a chronic phase often becomingphase often becoming bilateral.bilateral. • Characterized by muttonCharacterized by mutton fat KPs, iris nodulesfat KPs, iris nodules (Busacca and Koeppe),(Busacca and Koeppe), nodules in the AC anglenodules in the AC angle and synechiae.and synechiae.
  27. 27. • Sarcoid GlaucomaSarcoid Glaucoma • Glaucoma is more commonly associated with theGlaucoma is more commonly associated with the chronic relapsing form of sarcoid anterior uveitischronic relapsing form of sarcoid anterior uveitis which has a worse visual prognosis.which has a worse visual prognosis. • Corticosteroids are generally effective in the treatmentCorticosteroids are generally effective in the treatment of systemic and ocular sarcoidosis.of systemic and ocular sarcoidosis. • CycloplegicsCycloplegics • CAIs, B-Blockers and Alpha agonists effective toCAIs, B-Blockers and Alpha agonists effective to control IOP. As always avoid miotics. PGAs possible.control IOP. As always avoid miotics. PGAs possible. • Trabeculectomy c MMC, tube surgery. ExpectTrabeculectomy c MMC, tube surgery. Expect prolonged course and taper of corticosteroids in theseprolonged course and taper of corticosteroids in these cases. Treatment can include lower potency steroidscases. Treatment can include lower potency steroids and NSAIDS.and NSAIDS.

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