Uveitic Glaucoma Treatment & Management

Treatment of glaucoma in uveitis depends on the underlying disease and on the individual patient. The treatment rationale consists of (1) treating any underlying systemic disease, (2) treating the ocular inflammation, and (3) treating the glaucoma. The ocular inflammation and glaucoma usually can be controlled with eye drops. Often, treatment of the inflammation will control the IOP.

It is a general rule that surgery should be avoided, when possible, in the inflamed eye. However, if surgery is required, the eye should receive maximal preoperative anti-inflammatory therapy to decrease the inflammation as much as possible.

In eyes with active uveitis, preparation for intraocular surgery should include perioperative topical and, occasionally, systemic corticosteroid therapy to avoid exacerbation of uveitis and failure of filtering surgery. If an elective surgical case is to be performed, the uveitis should be as quiet as possible for 3 months prior to surgery. One week prior to surgery, topical prednisolone 1% solution should be given hourly, and oral prednisone 40 mg daily should be considered.

At the conclusion of surgery, a depot of corticosteroid should be injected subconjunctivally. Postoperatively, topical and oral corticosteroids may be tapered according to control of the inflammation. In emergency cases, severe postoperative exacerbation of existing inflammation should be anticipated; therefore, aggressive perioperative topical and systemic corticosteroid therapy is warranted.

More recently, the injection of intraocular corticosteroids such as triamcinolone has been found to be effective in reducing macular edema and improving vision in uveitic eyes that have proved refractory to systemic or periocular corticosteroids. The effect is usually transient but can be repeated, although the adverse effects of cataract and raised intraocular pressure (IOP) are increased in frequency with intraocular versus periocular corticosteroid injections. This has led to the development of new intraocular corticosteroid devices designed to deliver sustained-release drugs and obviate the need for systemic immunosuppressive treatment.

The first such implant was Retisert (0.59 mg fluocinolone acetonide intravitreal implant), which is surgically implanted and is designed to release fluocinolone over a period of about 30 months. Callanan et al reported a reduced recurrence rate of uveitis from 62% to 20% during the 3-year postimplantation period after Retisert implantation. ^[8] Despite successful control of the uveitis, IOP elevation was common, and 40% of implanted eyes required glaucoma surgery. The most common adverse events associated with a sustained delivery fluocinolone acetonide device include eye pain, procedural complications, cataract progression (managed by standard cataract surgery), and elevated IOP (managed with the use of IOP-lowering eye drops or surgery. In one retrospective study, almost 50% of eyes followed over the course of the 8-year study period required glaucoma surgical intervention following Retisert implantation. ^[9]

Ozurdex, a bioerodible dexamethasone implant (0.7 mg intravitreal dexamethasone) that can be inserted in an office setting, has gained approval for the treatment of macular edema and noninfectious posterior uveitis. This implant lasts approximately 6 months and has been found to be effective with a much better adverse effect profile than Retisert or intravitreal triamcinolone injection, at least for one injection. ^[10] Lowder et al studied the safety and efficacy of two doses of dexamethasone intravitreal implant for the treatment of noninfectious intermediate or posterior uveitis. The proportion of eyes with a vitreous haze score of 0 at week 8 was 47% with the 0.8-mg dexamethasone implant, 36% with the 0.35-mg dexamethasone implant, and 12% with the sham treatment. The percentage of eyes with IOP of 25 mm Hg or more peaked at 7.1% for the 0.7-mg dexamethasone implant, 8.7% for the 0.35-mg dexamethasone implant, and 4.2% for the sham treatment. ^[11]

Yutiq (0.18-mg intravitreal fluocinolone acetonide implant) has been studied extensively for the management of chronic noninfectious uveitis affecting the posterior segment of the eye. Jaffe et al randomized 129 patients to Yutiq injection or sham treatment. The 6-month and 12-month uveitis recurrence rates were significantly lower in the Yutiq group versus the sham group. IOP lowering treatment use was equal between both groups. ^[12]

Laser iridotomy

Extensive posterior synechiae formation can lead to pupillary block glaucoma, so it is important to reestablish communication between the posterior and anterior chambers before a full-blown attack of pupillary block occurs. Performing laser iridotomy prophylactically is preferable to performing this procedure during an attack of acute angle-closure glaucoma because visualization of the iris may be difficult due to corneal edema caused by high IOP.

An argon laser or an Nd:YAG laser may be used to perform the iridotomy. In patients with uveitis, the Nd:YAG laser may have the advantage of inducing less postoperative inflammation and requiring less energy compared with the argon laser. Combined Nd:YAG laser and argon laser is preferable in eyes with thick brown irides. Also, combined laser may allow for a larger iridotomy, which may be less prone to close.

Transient anterior chamber inflammation occurs in all eyes after this procedure, so topical corticosteroids should be used as warranted postoperatively. When laser iridotomies are unsuccessful or when the use of a laser is not possible, a surgical iridectomy should be performed in cases of inflammatory angle-closure glaucoma. Since this procedure can lead to increased postoperative inflammation, topical and, sometimes, systemic corticosteroids are required in the perioperative period.

Trabeculectomy

Trabeculectomy surgery is indicated for eyes with closed-angle, open-angle, or combined mechanism glaucoma when IOP is believed to be too high, despite maximum tolerated medical and laser therapy. Due to an accelerated wound healing response in uveitis, the results of trabeculectomy generally are poor, particularly in young patients.

Antimetabolite therapy in association with trabeculectomy has been shown to improve the success rate of trabeculectomy in patients with a high risk of failure. Intraoperative application of mitomycin-C is used widely to supplement standard trabeculectomy. The mitomycin can be applied to the eye for a variable duration prior to or after dissection of the scleral flap. Irrigation of the subconjunctival tissues should be carried out to prevent intraocular exposure.

A 2017 retrospective study evaluated intermediate and long-term outcomes of mitomycin C–enhanced trabeculectomy as a first glaucoma procedure in uveitic glaucoma. ^[13] Seventy eyes were studied for a mean follow-up period of 77 months, with the probability of success at only 35.7% at 60 months. Hypotony was a common complication, seen in 30% of eyes.

Dhanireddy et al studied the outcomes of the Ex-Press filtration device in patients with uveitic glaucoma. Surgical success was seen in 90.9% of the eyes in the simple glaucoma group, compared to 75% of eyes in the uveitic glaucoma group. ^[14]

Drainage implantation

Drainage implants are designed to route aqueous from the anterior chamber to a posterior reservoir. They are particularly useful in cases with significant conjunctival scarring due to previous surgery. Drainage valves, such as the Ahmed valve, may be safer than trabeculectomy, as less risk of hypotony exists, which can be seen in postoperative uveitic eyes due to decreased aqueous production.

In eyes with chronic uveitis, long-term corticosteroid therapy may induce glaucoma or glaucoma may occur secondary to the ocular inflammation. In these eyes, it would be beneficial to simultaneously control inflammation and IOP. To this end, a retrospective case series described 7 eyes of 5 patients in which a fluocinolone acetonide implantation was inserted and a glaucoma tube shunt was placed in a single surgical session. ^[15] This procedure was well tolerated and was associated with reduced inflammation, decreased concurrent systemic immunosuppressive therapy, and good IOP control.

Zivneyet al conducted a study to determine whether patients who underwent combined Ahmed tube shunt and Retisert implantation had superior outcomes than did patients with Ahmed implants only in the setting of uveitic glaucoma. ^[16] At 6 months, no significant differences in terms of mean IOP, mean number of IOP-lowering medications, visual acuity, surgical success, or adverse events were noted between Ahmed implantation alone or combined Ahmed and Retisert implantation in patients with uveitic glaucoma. However, Hennein et al found that patients who received Retisert implantation had lower IOP and used fewer glaucoma eye drops compared with control eyes at 1-year following Ahmed valve surgery. ^[17]

Chow et al conducted a retrospective comparative study to compare clinical outcomes of trabeculectomy with mitomycin-C, Ahmed shunt, and Baerveldt shunt surgery specifically in uveitic glaucoma. The postoperative hypotony rate differed significantly 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. ^[18]

Cycloablation

As a last resort, cycloablative techniques can be employed. Diode or Nd:YAG laser cyclophotocoagulation can be used to destroy the secretory ciliary epithelium, leading to decreased aqueous production. Unfortunately, cycloablative procedures often exacerbate the inflammation. These methods are reserved for eyes with poor visual potential due to the relatively high risk of further vision loss and phthisis bulbi.

See the list below:

• Uveitis specialist

• Rheumatologist

• Glaucoma specialist

No special diet is required.

Avoid strenuous exercise and heavy lifting in the early postoperative period.

Postoperative complications include the following:

• Postoperative complications (eg, choroidal effusion, choroidal hemorrhage, shallow anterior chamber, hypotony) may be higher in eyes with uveitic glaucoma than with primary open-angle glaucoma after trabeculectomy with wound modulation.

• Postoperative inflammation is fairly common in eyes with uveitic glaucoma, although this incidence can be lowered by treating the patients with preoperative and postoperative corticosteroids.

• The combination of postoperative inflammation and shallow anterior chamber can lead to the formation of PAS, which may interfere with the function of the glaucoma filter. Cataract formation also is very common with this scenario; therefore, prolonged periods of postoperative shallowing of the anterior chamber should be avoided.

• Phthisis bulbi may occur after any surgical procedure for uveitic glaucoma but is particularly common after cycloablative therapy. Eyes that may be at high risk of developing phthisis include those with a totally occluded angle and a relatively low preoperative IOP.

Patients should receive follow-up care as needed.