First-line treatment is typically prostaglandins, Dr. Yamamoto said. Second-line is usually beta-blockers added to a prostaglandin, and third-line is topical carbonic anhydrase inhibitors added to the first two medications. Patients find putting five drops in their eye a day onerous. Fixed combinations hold advantages in this respect. The number of daily instillations is decreased, leading to improved quality of life and better adherence. Although fixed combinations have become increasingly popular, their introduction raised some controversy.
Arguments were mainly theoretical, Dr. Bron said, based on the assumption that beta-blockers are more active in the morning and prostaglandins are more active in the evening. By not taking into account this relation with time, fixed combinations would decrease the efficacy of individual agents, detractors said. Several studies, however, have shown that the difference is not significant.
Since , Dr. Bacharach has been involved in trials investigating the safety and efficacy of fixed combinations vs. Convenience, improved compliance, cost savings and elimination of potential washout effects are significant advantages. Glaucoma is usually a chronic, progressive condition that requires regular monitoring and continuous adaptation of therapy to disease development.
Yamamoto said that, except for the early months, his normal visit schedule is every 3 to 4 months. Static perimetry is performed to measure the visual field every 6 to 12 months, and imaging technologies, such as optical coherence tomography or Heidelberg Retina Tomograph, are used once a year.
Current Approach in the Diagnosis and Management of Uveitic Glaucoma
Needless to say, in worse conditions, such as severe glaucomatous optic neuropathy or extremely elevated IOP, we need to follow the patient more intensively. Bron said he considers visual field the main parameter for monitoring progression. For any new patient, he takes at least three to four visual fields per year in the first 2 years. I use both trend analysis and event analysis. Event analysis is easier because you need only three visual fields. A higher rate of loss is a big concern. With the many cases of normal-tension glaucoma in Japan, IOP values cannot be a primary parameter to evaluate success, he noted.
Target pressure remains a useful concept in the practical management of glaucoma patients, but international guidelines emphasize the need to adapt this concept to individual cases. There is no single IOP level that is safe for every patient; in addition, target IOP should be constantly updated in patients, following the development of the disease. Bacharach said. Diurnal pressures should also be considered, he said. IOP fluctuates throughout the day, sometimes from 30 mm Hg in the morning to 18 mm Hg in the afternoon, so an IOP assessment in the office might not reflect what is actually happening in the eye.
Yamamoto said he performs repeated IOP measurements during the course of a day in some of his glaucoma patients. His method is an hourly measurement during office hours, from 9 a. In some cases, he measures IOP for longer periods. Several studies have shown that IOP diurnal variation is a marker of the severity and progression of the disease, but there is still some controversy on this issue, Dr. Bron said. He does not perform an IOP curve, as he believes that visits scheduled at different times in the day can give a sufficient idea of fluctuations. Adherence to glaucoma therapy is a well-known issue.
Studies have also investigated the reasons for poor adherence and lack of persistence with medications. According to Dr. Bron, there are three main reasons for this. The first is related to the disease itself: At first, glaucoma is an asymptomatic disease, which raises problems with compliance because patients do not see the need to be treated.
At the last follow-up visit mean follow-up time, years , the complete success rate was The postoperative complications were Prolene suture erosion into the anterior chamber The mean number of steroid drops was in the preoperative period and 6 months postoperatively. Canaloplasty is a promising technique for UG, because it expands the intertrabecular spaces, targeting an important source of outflow resistance in uveitic eyes exposed to glucocorticoids [ 33 ].
These devices often are considered the first choice for UG surgery, especially in etiologies such as JIA [ 47 ]. In patients with extensive peripheral anterior synechiae, the tube should be placed in the sulcus rather in the anterior chamber to avoid endothelial trauma.
Occlusion of the tube by inflammatory materials and corneal decompensation also has been associated with AGV implantation in eyes with UG Figure 7 [ 48 ]. Mata et al. In the postoperative period, oral corticosteroids are taped tapered over 4 weeks [ 50 ]. There was a significantly higher frequency of early complications in the trabeculectomy group compared with the GDD group; however, no significant differences were seen in the frequency of late postoperative complications between groups. The most common postoperative complications after implantation of a Baerveldt GDD were hypotony and CME, but there were no differences between the Baerveldt implant and trabeculectomy.
The authors concluded that implantation of the Baerveldt GDD was more likely to maintain IOP control and avoid reoperation for glaucoma compared with trabeculectomy with antifibrotic therapy in eyes with chronic inflammatory glaucoma [ 13 ]. The Molteno aqueous shunt Molteno Ophthalmic Ltd. The IOP decreased continuously during the first year postoperatively, and the medication was slowly tapered even up to 3 years postoperatively. Therefore, the author suggested postponing further surgical interventions during the first postoperative year after Molteno implantation in UG, even if the IOP is not controlled.
Persistent hypotony was present in 6. In a mixed series of secondary glaucoma cases including four cases with steroid-induced glaucoma, Buchacra et al. Good results were achieved with Glaukos trabecular bypass in one case of IOP elevation induced by steroid treatment after laser in situ keratomileusis [ 53 ]. After preliminary studies, the Glaukos iStent may be an attractive alternative for steroid-induced glaucoma, considering the microinvasive and reversibility characteristics of the procedure, although larger well-designed studies are needed to confirm this conclusion.
Shimizu et al. The procedure has been suggested for refractory glaucoma associated with chronic childhood uveitis [ 54 — 56 ]. The largest series included 54 goniotomies in 40 eyes, with the predominant diagnosis of juvenile rheumatoid arthritis mean age at surgery, Phakic eyes, fewer peripheral anterior synechiae, age younger than 10 years, and eyes with no previous surgery had significantly better outcomes. Goniosurgery is low risk and effective for refractory glaucoma complicating chronic childhood uveitis.
For some authors, it should be considered the surgical procedure of choice for this condition, although almost half of patients will need glaucoma treatment postoperatively. The surgical outcome is affected adversely by increased age, peripheral anterior synechiae, previous surgeries, and aphakia [ 55 ]. However, goniotomy requires considerable skill and experience and is best avoided by specialists who do not perform it regularly [ 3 ]. Randomized comparative studies are needed to determine the efficacy and safety of goniotomy compared with trabeculectomy or GDD surgery.
Cycloablative techniques can be used to decrease aqueous production by destruction of the ciliary body using transscleral or intraocular diode or Nd:YAG laser cyclophotocoagulation.
Unfortunately, cycloablative procedures can exacerbate inflammation and lead to postoperative hypotony and phthisis bulbi. Schlote et al. The IOP was controlled in The investigators did not observe reactivation of inflammation, persistent hypotony, or phthisis bulbi in any case [ 57 ]. Although preliminary studies have reported encouraging results with TDLC in UG, it should be the last resort for refractory glaucoma in eyes with poor visual potential in which conventional drainage surgery has failed or is impossible because of the ocular anatomic characteristics.
Cataract is very common in patients with uveitis. The optimal sequence of surgery with concomitant cataract and UG is controversial. Cataract surgery can compromise the success of trabeculectomy [ 59 ], but combined glaucoma and cataract surgery increases the risk of postoperative inflammation and may be less successful than isolated filtering procedures [ 3 , 14 ]. If combined glaucoma and cataract surgery is indicated, good control of the inflammation is mandatory preoperatively and postoperatively.
The use of antimetabolites at the time of combined surgery reduces the proliferative response [ 60 ]. A meticulous and minimally invasive surgical procedure also can help increase the surgical success, but the evidence is insufficient to recommend a specific filtering surgery for combined procedures in this kind of patient. It is also essential to be alert for detecting and treating postoperative complications such as hypotony, athalamia, and choroidal detachment.
Stronger and longer postoperative steroid treatment usually is required. Intensification of anti-inflammatory treatment may be necessary in case of recurrent uveitis. Spencer et al. Those investigators recommended multiple at least two or large iridotomies Figure 9 , aggressive treatment with topical steroids and cycloplegics, and close monitoring of patients with frequent early review. If the iridotomy closes, there should be early consideration for a surgical peripheral iridectomy [ 61 ].
Recurrent herpetic keratouveitis has been described after argon laser iridotomy [ 62 ] and after Nd:YAG laser peripheral iridotomy [ 63 ]. The causal relationship is difficult to establish because patients were being treated with topical corticosteroids and in one case with latanoprost, previously related to recurrent keratouveitis. Both cases resolved with oral acyclovir and discontinuation of latanoprost. Preventive treatment with oral acyclovir has been suggested if iridotomy is required in patients with UG associated with herpes virus.
Most studies that have reported the outcomes of trabeculectomy or GDD in uveitic eyes are not specific to uveitis-associated angle closure, and this warrants further investigation in more targeted studies. As in primary angle-closure glaucoma, phacoemulsification combined with goniosynechialysis may be an alternative in patients with uveitis with closed-angle glaucoma, although it is expected to be less successful when chronic peripheral anterior synechiae are present [ 47 ].
Other causes of secondary closed-angle glaucoma such as anterior ciliary body rotation, annular ciliary body detachment, or uveal effusion require specific surgical approaches. The authors declare that there is no conflict of interests regarding the publication of this paper. The funding organization had no role in the design or conduct of this research. BioMed Research International. Indexed in Science Citation Index Expanded. Journal Menu. Special Issues Menu. Subscribe to Table of Contents Alerts.
Table of Contents Alerts. Francisco J. Abstract Uveitic glaucoma UG typically is associated with very high intraocular pressure IOP and more intense optic nerve damage than other glaucoma types. Introduction Patients with uveitis have an increased risk of intraocular pressure IOP elevation not only because of the disease but also as a side effect of corticosteroid use [ 1 ].
Methods We searched the published peer-reviewed medical literature to identify studies that evaluated UG. Physiopathology The mechanisms that determine an IOP increase in UG are diverse and complex; many are often present simultaneously in the same patient. Classification Some authors have proposed differentiating between hypertensive uveitis and UG based on the absence or presence of optic nerve damage, but this distinction usually is not applied to secondary glaucomas [ 3 ].
Figure 3: Fuchs heterochromic uveitis in one patient. The right eye is normal. The left hypochromic eye is affected. Figure 5: Granulomatous uveitis after long-term apraclonidine treatment. Figure 6: PSS. Two small endothelial precipitates are seen. A conjunctival filtering bleb after NPDS is seen. Figure 7: Ahmed valve tube occlusion by fibrin exudation in a patient with UG. Peripheral iris burns after argon laser iridoplasty are seen. References S. Siddique, A. Suelves, U. Baheti, and C.
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Lesson: Controversies in Glaucoma Care
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Normal Tension Glaucoma
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