Uveitis unplugged: glaucoma management in patients with uveitis Hobart 2017 Peter McCluskey Save Sight Institute Sydney Eye Hospital Sydney Medical School University of Sydney Sydney Australia No financial or proprietary interest in any material discussed
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Uveitis unplugged: glaucoma management in patients with ... · Glaucoma and Uveitis Uveitic Glaucoma •responsible for up to 15% vision loss in patients with uveitis •difficult
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Uveitis unplugged: glaucoma management in patients with uveitis
Hobart 2017 Peter McCluskey
Save Sight Institute
Sydney Eye Hospital
Sydney Medical School
University of Sydney
Sydney Australia
No financial or proprietary interest in any material discussed
Glaucoma and Uveitis
Uveitic Glaucoma
• responsible for up to 15% vision loss
in patients with uveitis
• difficult to assess and follow
• often ↑ IOP rather than “glaucoma”
• often use arbitrary IOP levels > 25-
30 mmHg
• combined / multiple mechanisms
• steroid induced IOP > 50%
• often requires surgery
2
Frequency of elevated IOP
prevalence: 10 - 20%
acute anterior uveitis 10 %
recurrent AAU 40 %
chronic anterior uveitis 70 %
intermediate 10 %
posterior 10 %
steroid therapy > 50%
3
Glaucoma and Uveitis
Closed Angle
• pupil block / iris
bombe
• PAS
• ciliary body rotation /
uveal effusion
• aqueous misdirection
Open Angle
• trabeculitis
• debris → angle blockage
• TM damage - fibrosis
• steroid response
• aqueous hyper-secretion
/ rebound
Mechanisms
NB: Multiple mechanisms common
Glaucoma and Uveitis
Principles of Management
• control uveitis
- critical to success of any surgery
- may control the glaucoma
- often requires systemic IMT eg JIA uveitic glaucoma
- no need for additional peri-op steroid therapy
Glaucoma and Uveitis
Principles of Management
• determine the mechanism of the glaucoma
- gonioscopy critically important
- consider laser PI if uncertain
- consider secondary mechanism for angle closure – CB rotation
• medical control of IOP
• surgery
Glaucoma and Uveitis
Topical
• β blockers
• prostaglandin
analogues
• α agonists
• topical CAIs
Systemic
• oral/IV diamox
• IV mannitol
Avoid: pilocarpine
Medical Control of IOP
Chang JH, McCluskey P, Missotten T, Ferrante P et al.
Use of ocular hypotensive prostaglandin analogues in
patients with uveitis: does their use increase anterior uveitis
and cystoid macular oedema?
Br J Ophthalmol. 2008; 92:916-21.
Glaucoma and Uveitis
Indications for Surgery
• ongoing need for systemic diamox
• dangerous IOP level……. > 40mmHg
• IOP > 25 – 30 mm Hg on max topical therapy
• increasing disc cupping
• progressive loss of visual field
NB: no need for peri-operative steroid cover
most
common
less
common
Glaucoma and Uveitis
trabeculectomy + anti-
metabolites
- MMC
- 5 FU
glaucoma drainage device
- Baerveldt
- Molteno
cyclodiode
- limited visual potential
consider
- SLT
- NPGS
- MIGS
avoid
- ALT
- phacotrabeculectomy
Glaucoma Surgical Options
Glaucoma and Uveitis
Trabeculectomy
• unenhanced surgery poor outcomes
• success at 5 years < 30%
Enhanced Trabeculectomy
• improved outcomes
• intra-operative MMC: 0.4 mg/ml / < 3 mins
• post op sub-conjunctival 5FU: 5mgs
Glaucoma and Uveitis
Mitomycin C
• potent, long term effects; inhibits cell growth >> 1month
• standard of care for trabeculectomy surgery
• SEH: single conc: 0.4mg/ml; vary duration: 1-3 minutes
5-Fluorouracil
• short term effects; fibroblasts recover within 7 days
• used post trab, post needling and at time of cataract