Medical Care
In general, treatment is not necessary for patients with the typical low-grade inflammation. Symptomatic flare-ups may require short-term topical corticosteroids; however, long-term therapy is not indicated. Unlike other uveitides, topical steroids should not be used to eliminate cells from the anterior chamber as part of the cells and flare is contributed by the breakdown of the blood-aqueous barrier and leakage of inflammatory infiltrate.
Surgical Care
Surgical decisions are related to the development of cataracts and glaucoma in patients with FHI.
Cataracts associated with Fuchs heterochromic uveitis
Overall, the surgical outcome of patients with FHI is equivalent to patients with age-related cataracts. Patients with FHI tend to have better outcomes following cataract extraction than patients with other forms of uveitis. Preoperative and postoperative control of inflammation with topical steroids is of paramount importance for a successful surgical outcome. Topical prednisolone acetate 1%, 4 times per day, for several days before and after surgery may blunt the inflammation associated with procedure.
A small group of patients with FHI are at a higher risk for complications. Risk factors for complications include the following:
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Rubeosis irides that lead to hyphema
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Glaucoma may be more difficult to control following surgery.
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Severe iris atrophy with transillumination defects tends to have worse postoperative inflammation.
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Dilation of the pupil may be difficult.
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Phacoemulsification tends to have a better outcome in terms of complications when compared to cataracts removed by extracapsular cataract extraction.
In planning for cataract extraction in patients with FHI, small incision surgery is recommended to reduce surgical trauma. Clear corneal incision is preferred to avoid blood vessels in the anterior chamber angle. Slow decompression of intraocular pressure is indicated to reduce the risk of hemorrhage from abnormal iris blood vessels. Peripheral iridectomy is not indicated.
An acrylic intraocular lens implant is preferred over a silicone lens to decrease the amount of pigment adhering to the lens postoperatively and to prevent uveitis relapse. If possible, the lens should be placed within the capsular bag. [29, 33, 26]
Glaucoma associated with Fuchs heterochromic iridocyclitis
The incidence of glaucoma ranges from 15%-59%. Antiglaucoma medications may be required later in the course of the disease, as repeated bouts of inflammation may permanently damage the trabecular meshwork and lead to a slow rise in intraocular pressure over time. Argon laser trabeculoplasty does not appear effective in improving the outflow where trabecular sclerosis and peripheral anterior synechiae are present. [1, 21]
La Hey and colleagues found that medical treatment alone was unsuccessful in effectively lowering the intraocular pressure to acceptable levels in 73% of patients with FHI. Patients with FHI whose intraocular pressure is not effectively controlled with topical medications may require glaucoma filtration surgery. Glaucoma filtering procedures in patients with FHI are less successful than in patients with primary open-angle glaucoma. The intraocular inflammation may lead to bleb failure; therefore, strict control of the inflammation with topical steroids during the perioperative period may improve the surgical outcome. Use of antimetabolites also may improve surgical results. Trabeculectomy with antimetabolites is successful in 60%-70% of patients 2 years postoperatively. [34] Glaucoma drainage implants yield a 90% success rate 1 year postoperatively and a 50% success rate after 4 years. [35]
Management of symptomatic vitreous opacities
Vitrectomy is advisable for visually significant vitreous infiltrates. It successfully eliminates symptoms of floaters and is associated with a better visual outcome when compared to vitrectomy in other uveitides. [2]
