This document presents a case study of a 45-year-old female patient with uveitic glaucoma in her left eye. It describes her examination findings and management over time with topical medications, laser peripheral iridotomy, and later cataract surgery with trabeculectomy and mitomycin C to control her intraocular pressure. The document then provides definitions and classifications of uveitic glaucoma and discusses common etiologies including Fuchs' heterochromic uveitis, Posner-Schlossman syndrome, juvenile idiopathic arthritis, herpetic uveitis, and sarcoidosis. It covers pathogenesis, clinical features, investigations and management approaches for these entities.

1. Uveitic glaucoma
Presenter- Dr. Janhvi Mehta
Moderator- Dr. Rita Dhamankar

2. Index
 Case presentation
 Definition
 History
 Epidemiology
 Age at presentation
 Sex preponderance
 Pathogenesis
 Classification
 Clinical features
 Investigations
 Specific diseases
 Differential diagnosis
 Management

3. Case presentation
 Mrs BM, 45yr female
 16th sept 2011
 C/O LE BOV for distance and near since 1 month
 H/O LE trauma with wooden stick in 2006
 H/O glasses since 5 yrs (not using since 1 yr)
 No H/O systemic illness

4. examination
RE LE
BCVA 6/9,N6 BCVA 6/36, N36
AS- cornea clear AS- ep. microcystic edema
PACD =1/2 CT(grade II) VH grade 0, cells ++
Pupil- irregular PAS at 3 o’
clock, and 6-8 o’ clock
Pupil- 360˚ posterior
synechiae, iris bombe
Lens- Early NS Lens- Early NS
Fundus – CDR- 0.7 : 1 Fundus- Hazy view
IOP- 11 mmHg IOP- 39 mmHg

6. Management
 LE YAG peripheral iridotomy done on same day
 LE Gatifloxacin-Dexamethasone combination e/d
QID for 1 week
 LE Timolol maleate 0.5% e/d BD for 1 week

7. After 1 week
 LE – BCVA 6/36, N18
 LE patent PI
 IOP RE- 10mmHg; LE-34mmHg
 Started on brimonidine tartrate+timolol maleate
combination e/d BD
 Gonioscopy- PTM SL
PTM PTM SL SL
PTM SL

8. 1 month follow up
 IOP – RE 8mmHg ; LE 22mmHg
 Impression- secondary glaucoma post uveitis

9. After 2 months
 LE pain
 IOP- LE 32mmHg
 AC shows no cells / Flare , only old KP’s
 Management- added LE Brinzolamide e/d BD

10. After 2 months
 c/o LE redness , pain, watering since 5-7 days
 O/E – RE healed uveitis with posterior synechiae with
complicated cataract
 LE- circumciliary congestion,
old pigmented KPs,
Cells 1+
360˚PAS
PI patent
IOP- 30mmHg
 Management- prednisolone acetate e/d QID
Homatropine e/d BD
Continue antiglaucoma medication

11. Investigations
 Mantoux test – negative
 ESR- normal
 CCT- RE- 460μm
LE- 447μm
 Fundus : normal sized disc with a c/d 0.9
 Diagnosis – active nongranulomatous uveitis with
secondary glaucoma with cataract
 Advised LE cataract surgery with trabeculectomy with
MMC

12. Further management
 Prenisolone acetate 1% e/d in tapering doses
 Injection 5-FU s/c post operatively
 Timolol maleate 0.5% e/d BD

13. Last visit
RE LE
BCVA 6/18,N6 BCVA 6/9, N6
AS- pigmented old KP AS- few pigmented old KP
Post. synechiae Diffuse shallow bleb
Lens- NS2 Lens- PCIOL
Fundus – CDR- 0.7 : 1 Fundus – CDR 0.9 : 1
IOP- 12 mmHg IOP- 12 mmHg

14. Definition
Elevated
IOP
uveitis
Glaucomatous
optic nerve
damage
Visual field
defects

15. History
 1st reported by Joseph Beer 1813
 Priestly Smith 1891- modern classification of UG
 20% of uveitic patients have glaucoma
 More common in chronic cases

16. Epidemiology
 INDIAN SCENARIO
 2650 glaucomatous eyes
 579 eyes (21.84%) – secondary glaucoma
 47 eyes (8%) uveitic glaucoma
 90% of cases followed anterior uveitis
Ritu Gadia, Ramanjit Sihota,Tanuj Dada,Viney Gupta. Current profile of
secondary glaucoma. Indian J Ophthalmol. 2008 Jul-Aug; 56(4): 285–289

17. Ritu Gadia, Ramanjit Sihota,Tanuj Dada,Viney Gupta. Current profile of
secondary glaucoma. Indian J Ophthalmol. 2008 Jul-Aug; 56(4): 285–289

18. Study Anterior Intermediate Posterior panuveitis
Merayo
Lloves J
et al
67% 5% 14% 14%
Merayo Lloves J, Power WJ, Rodriguez A et al. secondary
glaucoma in patients with uveitis. Ophthalmologica 1999;
213(5): 300-04

19. Age at presentation
 3rd to 4th decade
 With increasing age there is imbalance in trabecular
meshwork function and inflammatory load
 Mean age – 41.1 yrs
 10%- 41-60yrs; 9%- 21-40yrs
 Prevalence in children- 5% - 13.5%
Ritu Gadia, Ramanjit Sihota,Tanuj Dada,Viney Gupta. Current profile of
secondary glaucoma. Indian J Ophthalmol. 2008 Jul-Aug; 56(4): 285–289
Kanski JJ , Shun Shin GA. Systemic uveitis syndrome in childhood: an
analysis of 340 cases. Ophthalmology 1984:91:1247-52

20. Sex preponderance
 Females more affected
Ritu Gadia, Ramanjit Sihota,Tanuj Dada,Viney Gupta. Current profile of
secondary glaucoma. Indian J Ophthalmol. 2008 Jul-Aug; 56(4): 285–289

21. Pathogenesis
 Various mechanisms
 Imbalance between aqueous production and
resistance to aqueous outflow from inflammation
Cellular and
biochemical changes
Morphological changes in
angle

22. Cellular and Biochemical changes
 Inflammatory cells-
 PMNs and macrophages increase IOP by:-
 Mechanical obliteration
 Cytotoxic
 Proinflammatory cells
 Proteins:-
 Increased permeability of blood aqueous barrier leads to
nonspecific transudation of protein
 Increased aqueous viscosity
 Reduced outflow
 Chronic flare

23. Cellular and Biochemical changes
 Inflammatory mediators and toxic agents:-
 Cytokines-
 Secreted by macrophages and lymphocytes
 Promote neovascularization
 Oxygen free radicals might damage outflow pathway

24. Morphological changes
 Usually open angle glaucoma
 Mechanical obstruction
 Increased viscosity
 Mediators causing constriction of trabecular
endothelium
 Trabeculitis
 Chronic cases
 Prolonged use of corticosteroids

25. Morphological changes
 Angle closure glaucoma- secondary
 Posterior synechiae and iris bombe
 Peripheral anterior synechiae
 Ciliary body rotates forward

26. Classification
 Anatomical
 Pathological
 Etiological

27. Anterior Intermediate Posterior Panuveitis
Fuchs’
heterochromic
uveitis
Sarcoidosis Toxoplasmosis Tuberculosis
Posner
Schlossman
syndrome
Tuberculosis Acute retinal
necrosis
Sarcoidosis
Infective uveitis Lyme’s disease Behcet’s disease
Arthritis
associated
uveitis
Vogt-Koyanagi-
Harada
DeepankurMahajan, Pradeep Venkatesh, S.P. Garg ; Uveitis and
glaucoma: a critical review : Journal of Current Glaucoma Practise,
September December 2011; 5(3): 14-30

28. Pathological classification
Non
granulomatous
uveitis
Granulomatous
Uveitis

29. Etiological classification
 Infectious
 Herpes
 Varicella zoster
 Rubella
 Autoimmune
 JIA
 Sarcoidosis
 Systemic
 Sarcoidosis
 Tuberculosis
 Idiopathic

30. Signs and symptoms
 Blurring Of Vision
 Pain
 Redness
 IOP elevation
 Corneal edema
 Photophobia and coloured halos

31. Investigations
 Noninvasive
 Serology- ESR, ACE, Lysozyme, electrolytes,
quantiferon gold
 Skin tests
 Xray, MRI, CT scan, Gallium scan
 Invasive
 Biopsy- conjunctival, vitreous, chorioretinal
 Anterior chamber paracentesis

32. Investigations
 Scanning laser ophthalmoscopy-
Optic nerve head
 Ultrasound biomicroscopy-angle
and ciliary body
 Laser flare photometry

33. Uveitis associated glaucoma
 Fuchs’ heterochromic uveitis
 Posner Schlossman syndrome
 Juvenile idiopathic arthritis
 Herpetic uveitis
 Sarcoidosis
 Syphilis

34. Fuchs’ Heterochromic Uveitis
 Ernst Fuchs, 1906
 Anterior uveitis , heterochromia, cataract
 90% U/L
 3rd-4th decade, both sexes equally
 Chronic

35. Clinical features
 Low grade iridocyclitis
 Without synechiae
 Small stellate KPs
 Fine filaments on endothelium
 Iris- patchy loss of endothelium,
hypochromia, grey-white nodules
 PSC
 Increased IOP - 13–59%
Liesegang TJ: Clinical features and prognosis in Fuchs’ uveitis
syndrome, Arch Ophthalmol 100:1622, 1982.
Velilla S, et al: Fuchs’ heterochromic iridocyclitis: a review of 26
cases, Ocul Immunol Inflamm 9:169, 2001.

36. Associations
 Rubella virus
 Virus and antibodies found in aqueous of FHU patients
 Incidence in the United States has significantly
declined since the advent of rubella vaccination
program.
 Toxocariasis and Toxoplasmosis antibodies also found
Birnbaum AD, et al: Epidemiologic relationship
between Fuchs’ heterochromic iridocyclitis and the
United States rubella vaccination program, Am J
Ophthalmol 144:424, 2007

37. Investigations
 Gonioscopy
 Vessels in angles
 Fluorescein angiography of the iris
 demonstrates ischemia, leakage, neovascularization,
and delayed filling of the vessels.
Areas of non
perfusion
leakage

38. Management
 Poorly responsive to corticosteroid therapy
 Aqueous suppressants
 Surgery- filtration surgery with anti metabolites

39. Posner- Schlossman syndrome
 Glaucomatocyclitic crisis
 1948, Posner and Schlossman
 20-60yrs, U/L
 Mild anterior uveitis with very high IOP
 Discomfort, blurring of vision, haloes
 PG level in aqueous

40. Clinical features
 mild ciliary flush
 a dilated or sluggishly
reactive pupil
 There may be Post syn
 corneal epithelial edema
 IOP - 40–60 mmHg
 open angles
 faint flare
 fine keratic precipitates

41. Pathogenesis
 Immunogenetic- HLA-Bw54
 Viral infection- herpes simplex and cytomegalovirus
 GI disease like ulcerative colitis
 Allergy
 Vascular cause
 PGI, oral indomethacin, s.c. polyphloretin

42. Investigations
 Fluoroscein angiography of iris
leakage
Areas of
non
perfusion

43. Management
 Topical NSAID
 Topical steroid
 Oral NSAID or CAI

44. Juvenile Idiopathic Arthritis
 Prevalence- 14-27%
 Persistent low grade intraocular
inflammation
 Young girls
 Mono/Pauciarticular involvement
 Glaucoma – posterior synechiae/
pupillary block or trabeculitis
Kanski JJ, Shun-Shin GA. Systemic uveitis syndromes in childhood: an
analysis of 340 cases. Ophthalmology. 1984; 91:1247—52
Key SN 3rd, Kimura SJ. Iridocyclitis associated with juvenile
rheumatoid arthritis. Am J Ophthalmol. 1975;80:425--9

45. Investigations
 Antinuclear- antibody test
 Rheumatoid factor- usually negative
 Systemic investigations

46. Management
 Topical steroids and cycloplegics
 Regional injection steroids
 Systemic steroids
 Oral NSAIDs
 Immunomodulatory therapy- Methotrexate
 Glaucoma- BB/ Sympathomimetics, CAI, MMC Trab
 Modified goniotomy- Trabeculodialysis Not done any
more

47. Herpetic uveitis
 Secondary glaucoma 10%-54%
 Acute rise in IOP, active iridocyclitis
 U/L
 Herpes simplex, Herpes Zoster, Varicella Zoster
Karbassi M, Raizman MB, Schuman JS. Herpes zoster
ophthalmicus. Surv Ophthalmol. 1992;36:395--410

48. Clinical features
 Synechiae formation
 Disciform keratitis, ulcer
 Hypopyon / hyphaema / fibrin deposition
 Diffuse / sectoral iris atrophy

49. Management
 Systemic antivirals
 Topical steroids and cycloplegics
 IOP- aqueous humour suppressants
 Trabeculectomy with anti metabolites
 Tube shunt surgery- active inflammation

50. Sarcoidosis
 Multisystem granulomatous disease
 Lungs , skin, eyes
 10% develop raised IOP
 Pathogenesis
 Swelling of trabecular meshwork
 Mechanical obstruction
 PAS
 Posterior synechiae
 Neovascular glaucoma
Mutton fat
KP’s

51. Signs
 Conjunctival granuloma
 Anterior uveitis – 22%
 Posterior- vitritis,
intermediate/ panuveitis,
choroidal nodules, CME
 ‘Candle wax dripping’ and
‘punched out lesions’

52. Investigations
 Serum ACE levels- elevated
 Lysozyme levels- elevated
 Hypercalcaemia
 Chest X-ray
 Gallium scan
 PFT

53. Management
 Tube shunt procedures with anti metabolites

54. Syphilis
 Congenital/ Acquired
 Secondary open angle glaucoma in active
inflammatory phases
 Gonioscopy- peripheral anterior synechiae, irregular
pigmentation of TM, presence of endothelial
membrane
 Poor response to medication
 Filtration surgery with drainage valve implantation/
anti metabolites

55. Differential diagnosis
Inflammatory ocular hypertension syndrome(IOHS)
 Elevated IOP for a short duration in uveitis
 More common
 No optic nerve damage or visual field defects
 Raised IOP due to inflammation
 IOP falls after treatment with topical steroids

56. Differential diagnosis
Steroid induced glaucoma
 Instillation of steroids in greater frequency, higher
dose, over a longer period
 Emulate picture of POAG
 Transient raised IOP after instillation- steroid
responders
 Discontinue drug/ weaker alternative

57. Differential diagnosis
Uveitis-glaucoma-hyphaema syndrome
 Presence of iris supported and AC IOLS
 Recurrent raised IOP, uveitis and hyphaema after
cataract surgery
 Extreme blurring, iris chaffing due to IOL haptic

58. Principle of Management
 Manage inflammation first
 Steroids and antiglaucoma help
 Removal of IOL

59. Need to treat primary cause
 Uveitis is to be treated first
 Primary reason for increased IOP
 Relieve associated pain and synechiae

60. Management of inflammation
 Topical / systemic NSAIDs
 Topical / periocular/ systemic corticosteroids
 Systemic immunosuppresants
 Mydriatics/ cycloplegics
 Antimicrobials

61. Challenges of treating uveitic
glaucoma
 Pilocarpine avoided due to increase in spasm and
inflammation
 Prostaglandin analogs would further exacerbate
inflammation in cases where mechanism involves PG
 Fibrinous membrane formation –further clogs the
meshwork, hastens drainage
 Trabeculectomy surgery- production of secondary
aqueous, release of more inflammatory mediators,
increase inflammation

62. Management of UG
 Medical
 Beta blockers
 Carbonic anhydrase inhibitors
 Systemic CAI
 i.v hyperosmotic agents
 PG analogs

63. Beta blockers
 1st drug of choice
 Reduce aqueous humour production
 Doesn’t alter pupil size
 Timolol- no systemic contraindication
 Metipranolol- avoided not available

64. Carbonic anhydrase inhibitors
 Reduce aqueous production
 Oral, intravenous, topical
 Dorzolamide- prolonged corneal edema
 Systemic- short term in acute high IOP

65. Hyperosmotic agents
 Intravenous route
 Acute rise in IOP
 Secondary angle closure glaucoma with pupillary
block
 Reduce vitreous volume

66. Prostaglandin analogs
 Initially thought to increase CME and exacerbation of
inflammation
 Used with caution
 Bimoprost, latanoprost, travoprost

67. Rho-kinase inhibitors
 Relaxes trabecular meshwork :-
 Increasing aqueous outflow
 Increasing blood flow to optic disc
 Protecting health of ganglion cells
 Antifibrotic agent post glaucoma surgery
 These drugs are in the pipeline & will be available in
future
Jamie Lynne Metzinger, Olga Ceron, C. Stephen Foster Recent
Advances in Uveitic Glaucoma; Glaucoma Now – Issue No 3, 2013
Challa P, Arnold JJ. Rho-kinase inhibitors offer a new approach in the
treatment of glaucoma. Expert Opinion in Investigational Drugs, 2013

68. Surgical
 Trabeculoplasty
 Laser iridotomy
 Trabeculectomy
 Non penetrating glaucoma surgery
 Drainage devices
 Cycloablation

69. Trabeculoplasty
 ALT/ SLT
 Argon laser trabeculoplasty not preferred – IOP not
under control due to angle alterations
 SLT- 532nm Q switched Nd- YAG laser
 Target pigmented cells in TM
 Low power
 Ultra short duration
 Minimal collateral thermal damage
 Maintain structural integrity
Realini T. Selective laser trabeculoplasty: a review.
J Glaucoma. 2008;17:497--502

70. Laser Iridotomy
 Argon / Nd YAG laser
 Iris bombe or angle closure due to pupillary block
 Generally- 3 bursts of 3-6 mJ

71. Trabeculectomy
 In phakic uveitic glaucoma patients
 After maximal medical and laser therapy has failed
 Maximal success with antimetabolites

72. DeepankurMahajan, Pradeep Venkatesh, S.P. Garg ; Uveitis and
glaucoma: a critical review : Journal of Current Glaucoma Practise,
September December 2011; 5(3): 14-30

73. Trabeculodialysis/ Goniotomy
 Children and young adults
 Success rate- 56% to 75 % over 2.5-8 years
 Goniotomy – children with refractory glaucoma in
chronic uveitis
 Now used less frequently

74. Drainage devices
 Developed due to low long term
success rate and repeated
trabeculectomies
 AGV-
 cumulative success rate (3-
30months)- 80% and 66%
 Short term success-68% - 95%
 Long term success – 50%-87%

75. DeepankurMahajan, Pradeep Venkatesh, S.P. Garg ; Uveitis and
glaucoma: a critical review : Journal of Current Glaucoma Practise,
September December 2011; 5(3): 14-30

76. Non penetrating glaucoma
surgery
 Indication- Mechanical obstruction of trabecular
meshwork with significant PAS
 Success rate- 66.7%-90%
 Complications- hypotony, choroidal effusion,
hyphaema, cataract
 Close post operative monitoring required

77. Cycloablation
 Nd- YAG laser cyclophotocoagulation,
cyclocryotherapy and ultrasonic cycloablation
 Destroys ciliary epithelium
 Induces uveitis
 May result in pthisis in an already compromised
ciliary body

78. Future direction
 Drug delivery implants- Flucinolone acetonide
implant
 4 fold greater risk of raised IOP
 Vs systemic- 23% vs 6% (2 yrs follow up)
 Implantable devices with radiofrequency transceiver:
in vivo model study

79. Thank you