GLAUCOMA 44 EWAP SEPTEMBER 2023 Creating an effective treatment plan for a patient with uveitic glaucoma requires the ophthalmologist to consider and balance evolving, multiple, and sometimes competing disease processes. Several physicians discussed what to look for and how to manage these patients. In uveitis, uveitic glaucoma is common, according to Ninani Kombo, MD. In most cases, the pressure increases very slowly, so patients may be asymptomatic. “What helps is frequent follow-ups and monitoring so you can catch problems early,” she said. However, some cases may have a rapid onset, with a dramatic rise in pressure; for example, a patient can have angle closure where the pressure goes up very rapidly. “Those patients will come in immediately because the acute increase in pressure can cause brow ache, nausea, vomiting, pain, redness, light sensitivity, and blurry vision. They come in much earlier because of the dramatic symptoms they experience,” she said. A literature review demonstrates a wide variety of estimates as to the prevalence of glaucoma in uveitis, said Jonathan Eisengart, MD, but it is reasonable to say 10–20% of people with uveitis develop glaucoma. With severe uveitis or with certain sustained-release steroid implants used to treat uveitis, the prevalence can reach nearly 50%. Most often, patients with glaucoma experience no symptoms until the late stages of the disease, Dr. Eisengart said, adding that this is true for glaucoma in uveitis as well. However, patients with uveitis are more likely to have complications resulting in rapid rises in intraocular pressure that can cause pain, blurred vision, red eye, nausea, and vomiting. The goal of treatment is to lower the intraocular pressure, Dr. Eisengart said, and that is achieved most commonly with topical medications. However, there are important additional considerations when treating glaucoma in uveitis. “First, one needs to balance the need to lower the intraocular pressure with the need to treat the uveitis,” he said. “In particular, most uveitis patients are on steroids, which can raise the intraocular pressure. While decreasing steroid treatment may help lower the eye pressure, that can cause the uveitis to flare. Steroids need to be carefully titrated to the lowest effective dose, but many times steroid dosing cannot be safely reduced. In these cases, it is important to treat the glaucoma aggressively. Earlier surgical intervention may be needed.” Dr. Eisengart added that uveitis patients are also more likely to have complications such as peripheral anterior synechiae, pupillary block with iris bombe, How to handle uveitic glaucoma by Ellen Stodola EyeWorld (US) Editorial Co-Director Contact information Eisengart: eisengj@ccf.org Kombo: ninani.kombo@yale.edu Tirpack: atirpack@cvphealth.com This article originally appeared in the July 2023 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. About 6 weeks after Baerveldt (Johnson & Johnson Vision) implantation with phaco and synechiolysis, this patient with anterior uveitis and glaucoma developed a severe fibrinoid inflammatory reaction upon tube ligature release. High dose steroids quieted the inflammation but the patient was left with a small, bound down pupil and a pupillary membrane across the IOL. The possibility of recurrent synechiae was anticipated during the tube insertion surgery, and a peripheral iridotomy was created at the 10:30 limbus, preventing iris bombe. Source: Jonathan Eisengart, MD
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