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

1. Management of Uveitic
Glaucoma;
The hard equation
By
Amgad Mahmoud El Nokrashy
Lecturer of ophthalmology
Mansoura university
2022

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

6. Classification
 Anatomical
 Pathological
 Clinical

7. Classification
Anatomical
Anterior​ Intermediate posterior​ panuveitis
Posnar
sclossman
syndrome​
Sacoidosis Toxoplamosis Behcet disease​
FHU​ T.B​ ARN​ VKH​
Infectious uveitis​ Lyme disease​ Sacoidosis
Artheitis
Associated​
uveitis​
T.B​
Classification
•Anatomical

8. Classification
•Pathological
Granulomatous
Non
Granulomatous

9. Classification
•Clinical
Inflammatory ocular
HTN Syndromes
Acute uveitic angle
closure
Corticosteroid
induced ocular HTN/
Glaucoma
Chronic or mixed
mechanisms
Uveitic
glaucoma

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

12. Incidence of uveitic glaucoma
• Fuchs’ Heterochromic Iridocyclitis : 27%.
• Posner-Schlossman Syndrome : 25%
• Herpetic Uveitis : 10–54%
• Juvenile Idiopathic Arthritis : 14–27%
• Sarcoidodid : 34%

13. Treatment
of uveitic
glaucoma
• Aims:
Treat underlying
disease.
Control of intraocular
inflammation.
Control High IOP.

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.
.

15. Control of intraocular inflammation

16. Steroid induced glaucoma

17. Control High IOP
Medical Laser Surgery

18. Medical

19. Medical

20. Medical

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

27. Laser

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.

29. Surgery

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.

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

36. 4. Visco-Trabeculotomy

37. Visco-Trabeculotomy

38. Visco-Trabeculotomy

39. 5. Minimally invasive glaucoma
surgery (MIGS)
Limited studies revealed the
efficacy of MIGS in cases of uveitic
glaucoma

40. 6. Glaucoma Drainage Surgery

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

43. Thank you