Management Of Uveitic Glaucoma Research Articles

Update on Diagnosis and Treatment of Uveitic Glaucoma.

Glaucoma is a common and potentially blinding complication of uveitis. Many mechanisms are involved alone or in combination in the pathogenesis of uveitic glaucoma (UG). In terms of diagnostic evaluation, the effects of inflammatory activity in the retinal nerve fiber layer may be a source of bias in the interpretation of optical coherence tomography measurements. For the successful treatment of UG, the control of intraocular inflammation specific to the cause or anti-inflammatory treatment, combined with IOP management, is mandatory. The early institution of specific treatment improves the prognosis of UG associated with CMV. The young age of UG patients along with increased failure rates of glaucoma surgery in this group of patients warrants a stepwise approach. Conservative and conjunctival sparing surgical approaches should be adopted. Minimally invasive surgical approaches were proved to be effective and are increasingly being used in the management of UG along with the traditionally used techniques of trabeculectomy or tubes. This review aims to summarize the progress that recently occurred in the diagnosis and treatment of UG.

Childhood Uveitic Glaucoma: Complex Management in a Fragile Population

Uveitic glaucoma (UG) is a potentially blinding complication of intraocular inflammation and is one of the most common causes of secondary glaucoma in pediatric ophthalmology. Overall management of UG is often challenging and requires a multidisciplinary assessment and careful follow-up. The overlap with steroid-induced glaucoma (SIG) is quite common, as well as the failure of medical and surgical therapy; nevertheless, few recent papers have dealt with this topic. We review the features and the clinical approach to UG in childhood, discussing the treatments available in the pediatric population.

Management of Uveitic Glaucoma in Children with Blau syndrome

Pendahuluan: Glaukoma pada anak merupakan kondisi yang berpotensi menyebabkan kebutaan. Penatalaksanaan glaukoma uveitis sulit dan menantang karena banyak mekanisme yang terlibat dalam patogenesisnya. Tujuan: Untuk melaporkan karakteristik klinis dan penatalaksanaan glaukoma uveitis pada anak dengan sindrom Blau. Laporan Kasus: Anak laki-laki berusia 13 tahun datang ke Poliklinik Glaukoma RS Mata Cicendo dengan keluhan kedua mata buram sejak 4 tahun lalu. Pasien telah didiagnosis sebagai sindroma Blau. Keluhan disertai persendian bengkak di lengan dan lutut, kulit hipopigmentasi dan bersisik. Riwayat operasi trabekulektomi mata sebelah kiri. Pemeriksaan oftalmologi menunjukkan visus ODS 1/300, tekanan intraokular OD 34mmHg dan OS 40mmHg. Segmen anterior mata kanan terdapat keratopati pita, sinekia posterior 360o, sinekia anterior perifer, dan katarak. Pada mata kiri terdapat bleb pada konjungtiva bulbar, keratopati pita, sinekia posterior, iridektomi perifer, dan katarak. Pasien didiagnosis sebagai glaukoma uveitis ODS, sindrom Blau, katarak komplikata ODS, keratopati pita ODS. Pasien diterapi dengan tetes mata timolol maleat 0.5%, brinzolamide, metilprednisolon tablet, metotreksat pre operatif. Pasien menjalani trabekulektomi, 5FU, sinekiolisis, retraktor iris, membranektomi mata kanan. Satu tahun pasca operatif tekanan intraokular pasien terkontrol, OD: 19mmHg, OS: 28mmHg dengan pemberian tetes mata timolol maleat 0.5% dan brinzolamide. Kesimpulan: Tatalaksana glaukoma uveitis pada anak membutuhkan terapi multidisiplin yang agresif dalam mengontrol inflamasi, tekanan intraokular, dan terapi ambliopia untuk mempertahankan penglihatan.

Gonioscopy-assisted transluminal trabeculotomy is an effective surgical treatment for uveitic glaucoma

BackgroundTo assess the efficacy and safety of gonioscopy-assisted transluminal trabeculotomy (GATT) in uveitic glaucoma (UG).MethodsA retrospective interventional case series in which 33 eyes of 32 patients with UG underwent GATT...

Surgical Approach and Outcomes of Uveitic Glaucoma in a Tertiary Hospital.

Aim and objectiveThis study aimed to evaluate the performance of and indication for different surgical techniques in the management of uveitic glaucoma (UG).Materials and methodsA retrospective audit of records of all patients with UG who underwent ≥1 glaucoma surgery, between January 2007 and December 2016. The main outcomes were intraocular pressure (IOP) and the need for antihypertensive medication at each follow-up visit. The total number of surgical interventions needed to control IOP was recorded. Postoperative interventions and complications were analyzed.ResultsForty eyes from 34 patients were assessed. Overall, baseline IOP was 30.7 ± 8.2 mm Hg, and postoperative mean IOP at the last visit was 16.4 ± 2.0 mm Hg, with a mean follow-up of 28 months. Antihypertensive medications were reduced from 2.8 ± 0.8 to 0.8 ± 1.2. During the follow-up, 61.8% of the eyes required only one glaucoma surgery. There was no correlation between the location of uveitis and the total number of glaucoma surgeries required. The greatest IOP reductions were in cases treated with non-penetrating deep sclerectomy (21%), Ahmed valve (23%), and cyclophotocoagulation (CPC) (51%); in cases where an Ahmed implant was the first surgical option, a 43% reduction was achieved.ConclusionFiltering procedures, glaucoma drainage devices, and CPC are all good options for IOP control in UG, but all are prone to failure over time. With respect to IOP reduction, the safety profile, and postoperative care, Ahmed implants and CPC might be the best first surgical option.Clinical significanceThe article highlights the versatility of the surgical techniques required to treat UG, which is one of the most difficult types of glaucoma to manage.How to cite this articleVentura-Abreu N, Mendes-Pereira J, Pazos M, et al. Surgical Approach and Outcomes of Uveitic Glaucoma in a Tertiary Hospital. J Curr Glaucoma Pract 2021;15(2):52–57.

The Management of Uveitic Glaucoma in Children

Children comprise a unique population of patients in regard to the diagnostic and therapeutic approach of uveitic glaucoma. The management of glaucoma secondary to uveitis in children is extremely challenging and presents various difficulties, which are associated both with the underlying uveitis and the young age of the patients. The treatment of uveitic glaucoma calls for a thorough and individualized approach, involving both pharmacotherapeutic and surgical modalities. It appears that the efficient control of inflammatory activity plays a significant role in the final visual outcome of these patients. This study aims to review the current literature about the management of uveitic glaucoma in pediatric patients.

Comparison of surgical outcomes of trabeculectomy, Ahmed shunt, and Baerveldt shunt in uveitic glaucoma

BackgroundUveitis is defined as a collection of syndromes involving intraocular inflammation which can lead to pain, tissue damage, and vision loss. Ophthalmic surgery in uveitis patients can be challenging due to inflammation-induced fibrosis and scarring. Trabeculectomy and implantation of glaucoma drainage devices (aqueous shunts) have been used in surgical management of uveitic glaucoma, however there is a paucity of literature examining the comparative results of these entities in this unique setting. The purpose of this retrospective comparative study is to compare clinical outcomes of trabeculectomy with MMC, Ahmed shunt, and Baerveldt shunt surgery specifically in uveitic glaucoma.ResultsMedian IOP, IOP reduction, glaucoma medication use, and visual acuity at 6- and 12-month follow-up were similar across groups. Postoperative hypotony rate was significantly different across trabeculectomy (53%), Baerveldt (24%), and Ahmed (18%) groups (p = 0.027); other complication rates were similar. Baerveldt eyes had a lower failure rate compared to trabeculectomy (p = 0.0054) and Ahmed (p = 0.0008) eyes.ConclusionsWhile there was no difference in IOP reduction between trabeculectomy, Ahmed, and Baerveldt, Baerveldt eyes had the lowest failure rate.

Assessment of conditions affecting surgical success of Ahmed glaucoma valve implants in glaucoma secondary to different uveitis etiologies in adults.

PurposeThere is little known about the long-term efficacy and safety of Ahmed glaucoma valve (AGV) implant and about the conditions affecting surgical success in uveitic glaucoma (UG).Patients and methodsThe charts of adult patients with UG who underwent AGV implantation from 2006 to 2015 were reviewed retrospectively.ResultsData of 46 eyes of 39 patients were evaluated. Mean follow-up was 51.93±23.08 months. Mean preoperative IOP was 37.05±9.62 mm Hg and mean number of preoperative topical anti-glaucomatous medications was 2.98±0.27. One eye (2%) was defined as failure because of implant extraction surgery. In the rest of the eyes, intraocular pressure (IOP) was under control with or without anti-glaucomatous medications during follow-up. The cumulative probability of complete success (IOP control without medications) was 78% at 6 months, 76% at 1 year, 71% at 2 years, 66% at 3 years, and 63% at 4 years (95% confidence interval, 61.24-87.81). The cumulative probability of eyes without complication was 64% at 6 months, 48% at 12 months, 44% at 24 months, 41% at 36 months, and 38% at 48 months (95% confidence interval, 34.64-62.85). Complete success was lower in eyes with previous ocular surgery than the eyes without (P=0.061) and it was lower in eyes with active inflammation at the time of surgery than the eyes without (P=0.011).ConclusionAGV implantation is an effective and safe alternative method in the management of UG, especially when it is performed as a primary surgical option and when no inflammation is present preoperatively.

Short-term to Long-term Results of Ahmed Glaucoma Valve Implantation for Uveitic Glaucoma Secondary to Behçet Disease.

To evaluate short-term to long-term outcomes of Ahmed glaucoma valve (AGV) implantation in the management of uveitic glaucoma (UG) secondary to Behçet disease (BD). A retrospective chart review of 47 eyes of 35 patients with UG secondary to BD who underwent AGV implantation was conducted. Success was defined as having an intraocular pressure (IOP) between 6 and 21 mm Hg with (qualified success) or without (complete success) antiglaucomatous medications and without need for further glaucoma surgery. Mean postoperative follow-up was 57.72±26.13 months. Mean preoperative IOP was 35.40±8.33 mm Hg versus 12.28±2.90 mm Hg at the last follow-up visit (P<0.001). Mean number of preoperative topical antiglaucomatous medications was 2.96±0.29 versus 0.68±1.12 at the last follow-up visit (P<0.001). In all eyes, IOP could be maintained between 6 and 21 mm Hg with or without antiglaucomatous medications during follow-up. The cumulative probability of complete success was 46.8% at 6 months, 40.4% at 12 months, and 35.9% at 36 months, and the cumulative probability of eyes without complication was 53.2% at 6 months, 46.5% at 12 months, and 39.6% at 24 months postoperatively based on Kaplan-Meier survival analysis. No persistent or irreparable complications were observed. This study includes one of the largest series of AGV implantation in the management of UG with the longest follow-up reported. AGV implantation can be considered as a primary surgical option in the management of UG secondary to BD with 100% total success rate (with or without medications).

The Ex-PRESS Glaucoma Filtration Device Implantation in Uveitic Glaucoma

Purpose: To evaluate the outcomes of the Ex-PRESS Filtration Device in patients with uveitic glaucoma.Methods: We reviewed 23 eyes, comparing control simple glaucoma patients (n = 11) to uveitic glaucoma patients (n = 12). Intraocular pressure (IOP) and glaucoma medications at the preoperative examination were compared with those at the 6-month and 10–14-month postoperative examination. Surgical success was defined as ≥25% decrease in intraocular pressure without hypotony, and/or decrease in glaucoma medications at 6 months follow-up.Results: Statistically significant reduction in mean IOP from preoperative levels occurred in both groups at 6 months follow-up (p<0.0001) and 10–14 months follow-up (p = 0.0007) and in the mean number of medications in the uveitic glaucoma (UG) group (p = 0.0313).Conclusions: Surgical success was seen in 10 eyes in the control group (90.9%) and nine eyes (75%) in the UG group (p = 0.314). Ex-PRESS implantation is an effective surgical intervention for the management of uveitic glaucoma.

Ocular Comorbidities and the Relationship between Eye Diseases and Systemic Disorders.

Ocular Comorbidities and the Relationship between Eye Diseases and Systemic Disorders.

Current Approach in the Diagnosis and Management of Uveitic Glaucoma.

Uveitic glaucoma (UG) typically is associated with very high intraocular pressure (IOP) and more intense optic nerve damage than other glaucoma types. This secondary glaucoma requires an early diagnosis and adequate management of both uveitis and glaucoma. It is mandatory to identify the mechanisms of IOP elevation that in many eyes have multiple combined mechanisms. Management of these patients commonly requires an interdisciplinary approach that includes a glaucoma specialist and rheumatologist to control the inflammation and IOP. Glaucoma surgery is required early in these patients due to the high IOP usually present and is less successful than in primary open-angle glaucoma. Recurrent uveitic episodes, multiple mechanism, and the complications associated with uveitis make surgical management of UG challenging. In this review, the management and treatment of UG are updated to clarify the pathogenesis and prevent optic nerve damage.

Uveitis and Glaucoma: A Critical Review

Raised intraocular pressure is a frequently encountered complication of uveitis. Intraocular homeostasis, maintained by the impermeable blood-ocular barrier, is important to guarantee optimal visual function. During uveitis breakdown of the blood-ocular barrier occurs, allowing the influx of proteins as well as inflammatory and immunocompetent cells. The combination of action of inflammatory cells and the mediators they release; and the chronic corticosteroid therapy used to treat the uveitis can participate in the pathogenesis of uveitic glaucoma. These factors alter the normal anatomic structure of the anterior chamber and angle. Management of uveitic glaucoma may be difficult because of the numerous mechanisms involved in its pathogenesis and is guided by careful delineation of the pathophysiology involved in each individual case. This article reviews, in detail, the pathogenesis of uveitic glaucoma and its therapies, with emphasis on the recent developments in the subject.

Deep sclerectomy and trabeculectomy in uveitic glaucoma

To compare the results of deep sclerectomy (DS) and trabeculectomy (TRAB) in the management of uveitic glaucoma. A retrospective chart review was carried out of 41 eyes (38 patients) operated on for uncontrolled uveitic glaucoma, 20 by DS with an implant and 21 by TRAB, with antiproliferative agents in both cases. Main outcome criteria were intraocular pressure (IOP), flare values, complications, and need for postoperative adjustments or re-operation. Mean follow-up lasted 21.1+/-11.3 months in the TRAB group and 18.9+/-10.7 months in the DS group (P=0.184). Mean IOP did not differ significantly in the two groups on the day before surgery, at postoperative days 1 and 7, or at months 1, 6, and 12. At postoperative month 12, IOP values in the TRAB and DS groups were 12.4+/-4.3 and 11.7+/-3.3 mm Hg (P=0.688), respectively. The cumulative probability of success at 12 months was 89% for TRAB and 88% for DS (P=0.306). After DS, more postoperative adjustments were necessary to lower IOP than after TRAB (85 vs 9.5%, P<0.001), but 7 days after surgery, intraocular inflammation was higher after TRAB (245.8 vs 38.5 ph/ms, P<0.001). DS and TRAB afforded equivalent IOP control in uveitic glaucoma. TRAB involved deeper invasion of the eye and resulted in more inflammation during the week after surgery, but successful DS required closer postoperative monitoring and more postoperative adjustments.

Ahmed glaucoma valve implantation in uveitic glaucoma versus open-angle glaucoma patients

Background: The poor long-term success rate of repeat trabeculectomies in refractory uveitic glaucoma (UG) patients has led to the use of glaucoma drainage devices (GDDs). However, the success and complication rates of GDDs in UG patients utilizing a control group with standard demographic data, design, and surgical technique have never been evaluated. Methods: Fifteen patients (15 eyes) with chronic uveitis and 53 patients (53 eyes) with uncontrolled openangle glaucoma (OAG) who underwent Ahmed glaucoma valve (AGV) implantation were included in a retrospective, comparative, case-controlled study. Postoperative intraocular pressure (IOP), number of antiglaucoma medications, visual acuity, and complications were compared. Results: There was a significant difference between the UG versus the OAG group with respect to age only (59.3 years vs 68.4 years, p = 0.006). Regression analysis of the postoperative IOP controlled for age and glaucoma type, and preoperative IOP revealed significantly lower IOP in the UG group at 1 month ( p = 0.04; 95% confidence interval [CI] −5.9 to 0.15) and 2 months ( p = 0.008; 95% CI −6.0 to 0.97). No significant differences were found at 3, 6, 12, 24, and 30 months.The cumulative success rates at 3 to 30 months for the UG and OAG groups were 80% to 66.6% versus 84.9% to 57% ( p = 0.713), respectively. The only complication between the 2 groups that was significantly different was tube removal, which occurred more often in the UG group ( p = 0.018). Interpretation: AGV implantation is an effective and safe procedure in the management of UG, similar to primary OAG.

Resultados de la esclerectomia profunda no perforante en el tratamiento del glaucoma inflamatoria al año de seguimiento

To assess the efficacy and safety of nonpenetrating deep sclerectomy in uveitic glaucoma. In this observational retrospective trial, 6 eyes with inflammatory glaucoma underwent a nonpenetrating deep sclerectomy and a reticulated hyaluronic acid implant. The minimal follow-up period was 12 months. At 12 months, the complete success rate (defined as an IOP higher than 5 and lower than 21 mmHg without medication) was 66.67% and the qualified success rate was 100%. The mean postoperative IOP at 12 months was 16.67 mmHg (SD: 3.26), and the mean IOP reduction was 23.00 mmHg (SD:13.75) (p= 0.027). The mean number of antiglaucoma medications required was reduced from 2.67 (SD: 0.52) before surgery to 0.50 (SD: 0.84) one year after surgery (p= 0.038). No change on visual acuity was observed. Complications included one case of hyphema and one case of bleb encapsulation. Nonpenetrating deep sclerectomy in this preliminary study, deep sclerectomy was efficacious and had few postoperative complications, so it can be an alternative in the management of uveitic glaucoma.

Outcome of Baerveldt glaucoma drainage implants for the treatment of uveitic glaucoma

Objective To evaluate the efficacy and safety of Baerveldt glaucoma drainage devices in the management of uveitic glaucoma. Design Retrospective, noncomparative case series. Participants Twenty-four eyes of 24 patients who underwent implantation of Baerveldt glaucoma drainage devices between 1996 and 2000 for the treatment of uveitic glaucoma refractory to medical therapy. Intervention Implantation of Baerveldt glaucoma drainage device. Main outcome measures Control of intraocular pressure (IOP), number of glaucoma medications needed for adequate IOP control, visual acuity, complications associated with the surgery, and the effect of subsequent surgery on the ability of the device to control IOP. Success was defined as IOP ≥5 and ≤21 mmHg with or without antiglaucoma medications and without need for further glaucoma surgery, loss of light perception, or phthisis. Results Cumulative life-table success rates were 95.8% at 3 months and 91.7% at 6 months, 12 months, and 24 months. The mean postoperative follow-up was 20.8 months. The IOP was reduced from a preoperative mean of 30.5 ± 8.96 mmHg with 3.1 ± 0.99 antiglaucoma medications to a postoperative mean at 6 months or 1 year of 13.0 ± 4.6 mmHg ( P < 0.001) with 0.8 ± 0.8 antiglaucoma medications ( P < 0.001). At last follow-up 14 of 24 eyes (58.3%) required no antiglaucoma medications. Best-corrected visual acuity improved or remained within 2 lines of preoperative visual acuity in 19 (79.2%) eyes. The most common complications were choroidal effusions in four (16.7%), hypotony in three (12.5%) eyes, cystoid macular edema in three (12.5%) eyes, and failure of corneal grafts in two (8.3%). Seven of 22 eyes (31.8%) in which successful control of IOP with the Baerveldt implant was achieved underwent subsequent nonglaucoma-related incisional surgery. None of these eyes (0%) lost IOP control after the subsequent procedure. Conclusions The Baerveldt glaucoma drainage device offers reasonable safety and effectiveness for the control of IOP in eyes with uveitis and refractory glaucoma.

Clinical Pathways in Glaucoma

Thom J. Zimmerman and Kranjit S. Kooner (ed.) Clinical Pathways in Glaucoma 565 pages Georg Thieme Verlag, Stuttgart, New York, 2001. GTV ISBN 3–13–125971-X, US$ 99 This is an unusual, almost unique addition to the glaucoma literature. Clinical Pathways in Glaucoma is certainly not a standard textbook on glaucoma that can be read by the novice to learn about the basics of the disease. Thus, it has little information on issues like basic diagnostics, epidemiology or on disease mechanisms for the most common forms of glaucoma. The words tonometry or perimetry are not even present in the book’s index. Instead, this volume has a wealth of information on management and different forms of treatment, also of the most unusual forms of glaucoma. There are, e.g., chapters not only on glaucoma associated with primary disorders of the corneal endothelium, but also on drug-induced glaucoma and management of glaucoma in pregnancy. To facilitate reading the discussion follows a question and answer format with most of the headlines in the form of questions, e.g.: “How is a patient with newly diagnosed CRVO prevented from progressing to neovascular glaucoma?” or “How is a blind painful eye from glaucoma managed?” Flow diagrams are also frequently used to suggest or define clinical management. There are such diagrams in almost every chapter, e.g. “Management of uveitic glaucoma” or “Management of a patient with elevated IOP after first week of filtration surgery“. The book contains a wealth of references, particularly on management. It is a valuable addition to the libraries of all eye departments, but it can also definitely be helpful to glaucoma specialists in unusual clinical situations.

Management of uveitic glaucoma with Ahmed glaucoma valve implantation

Objective To evaluate the safety and efficacy of Ahmed glaucoma valve implantation for the management of glaucoma associated with chronic uveitis. Design Retrospective, noncomparative case series. Participants Nineteen patients (21 eyes) with chronic uveitis underwent Ahmed glaucoma valve implantation for uncontrolled glaucoma between 1995 and 1998. Intervention All patients had their uveitis controlled before surgery via immunomodulatory therapy. Ahmed glaucoma valve implantation was performed. Immunosuppression was continued in the early postoperative period for strict control of inflammation. Main outcome measures Control of intraocular pressure (IOP). A secondary outcome measure was the number of antiglaucoma medications required to achieve the desired IOP. Visual acuity and complications associated with the surgery were monitored. Results The postoperative follow-up averaged 24.5 months. At the most recent visit, all 21 eyes had IOPs between 5 and 18 mmHg. The average pressure reduction after Ahmed glaucoma valve implantation was 23.7 mmHg. The average number of antiglaucoma medicines required to achieve the desired IOP was reduced from 3.5 before surgery to 0.6 after surgery. No eye lost even a single line of Snellen acuity at the most recent postoperative visit. Two eyes developed hypotony in the course of follow-up. One resolved without specific intervention, and the other eye required two autologous blood injections and tube ligature to correct the hypotony. One eye underwent Ahmed glaucoma valve replacement for abrupt valve failure. Two eyes underwent penetrating keratoplasty for reasons believed to be unrelated to the glaucoma surgery. Kaplan-Meier life-table analysis showed a cumulative probability of success after Ahmed glaucoma valve implantation of 94% at 1 year. Conclusions Ahmed glaucoma valve implantation can be an effective and safe method in the management of uveitic glaucoma. The authors hypothesize that control of the patients’ uveitis, through preoperative and long-term postoperative immunomodulatory therapy, may have contributed to the success rate reported herein.