Medical Care

Complete medical care for patients presenting with glaucomatocyclitic crisis includes a reasonably thorough history of present illness, a review of drug allergies and sensitivities, a targeted past medical history and review of systems, a complete eye examination, a careful explanation of the disorder in accordance with the patient's level of understanding, and a commitment to long-term follow-up care of the patient.^[39]

Medical therapy should be individualized to meet the patient's needs. The favored initial treatment is a combined regimen of a topical NSAID to control the anterior uveitis and an antiglaucoma drug for the elevated IOP.

Treatment recommendations include the following:

Topical NSAIDs - Diclofenac 0.1% 1 gtt TID/QID or equivalent plus
Topical antiglaucoma drops - Timolol 0.25-0.5% 1 gtt BID, brimonidine 0.2% 1 gtt BID/TID, or dorzolamide 2% 1 gtt BID/TID

The following can be considered:

Topical steroids - Prednisolone acetate 1% 1 gtt QID
Systemic carbonic anhydrase inhibitors - Acetazolamide 250 mg PO QID
Oral NSAIDs - Indomethacin 75-150 mg/d PO

Miotics and mydriatic agents are seldom used because they may have further deleterious effects on the blood-aqueous barrier and there is low risk for posterior synechiae formation. Long-acting periocular steroids are typically not recommended because of lingering IOP effects.

In the absence of underlying chronic glaucoma, antiglaucoma agents do not prevent recurrences of glaucomatocyclitic crisis; therefore, they are not necessary between episodes.

Topical and oral valganciclovir has recently been added as a treatment option in hopes of eliminating CMV in the anterior chamber, thus removing the infectious drive for uveitis. A 2010 retrospective study compared topical and oral valganciclovir and found that topical therapy had a higher failure rate; however, topical therapy yielded a lower recurrence rate. Multiple studies report that cessation of any form of antiviral therapy results in a high rate of recurrence, as valganciclovir is virostatic and not virucidal.^[40]Long-term antiviral treatment is still being studied.

Surgical Care

An occasional patient may require a filtering procedure, which is not effective in preventing recurrences of the episodes of iritis but may be useful in the management of high IOP seen with these episodes.^{[5, 41, 42]}

Filtering surgery is generally not as effective in lowering IOP in uveitic glaucoma. During trabeculectomies in this population, higher levels of fibroblasts, lymphocytes, and macrophages are found in the conjunctiva, increasing the scarring of the bleb and decreasing the effectiveness of postoperative 5-FU subconjunctival injections.^[43]

Laser trabeculoplasty likely provides no benefit in this population.

Consultations

An ophthalmologist should be consulted to treat the elevated IOP and to provide long-term follow-up care for patients with POAG.

Activity

No restrictions on activity are required.

Long-Term Monitoring

Patients with elevated IOP should be monitored carefully and frequently until the IOP normalizes and the medications are tapered off appropriately.

Annual visual field assessment is indicated in patients with ongoing optic nerve compromise or pressure irregularities. This assessment also helps in identifying those patients who are at risk of developing POAG.^[35]

Long-term follow-up care of patients by an ophthalmologist is important.

Medication

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Author

Leonard K Seibold, MD Assistant Professor, Co-Director, Glaucoma Fellowship, Department of Ophthalmology, University of Colorado School of Medicine

Leonard K Seibold, MD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, Association for Research in Vision and Ophthalmology, Chandler Grant Glaucoma Society, Colorado Society of Eye Physicians and Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Erin G Sieck, MD Resident Physician, Department of Ophthalmology, University of Colorado School of Medicine

Erin G Sieck, MD is a member of the following medical societies: American Academy of Ophthalmology

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Martin B Wax, MD Professor, Department of Ophthalmology, University of Texas Southwestern Medical School; Vice President, Research and Development, Head, Ophthalmology Discovery Research and Preclinical Sciences, Alcon Laboratories, Inc

Martin B Wax, MD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, Society for Neuroscience

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy, Sr, MD † Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

Andrew I Rabinowitz, MD Director of Glaucoma Service, Barnet Dulaney Perkins Eye Center

Andrew I Rabinowitz, MD is a member of the following medical societies: Aerospace Medical Association, American Academy of Ophthalmology, American Society for Laser Medicine and Surgery, American Academy of Ophthalmology, American Medical Association

Disclosure: Nothing to disclose.

James H Oakman, Jr, MD Partner, Southern Eye Center, Augusta, Georgia

James H Oakman, Jr, MD is a member of the following medical societies: Association of American Physicians and Surgeons, Georgia Medical Society, Georgia Society of Ophthalmology, Georgia Society of the American College of Surgeons, American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery

Disclosure: Nothing to disclose.