GLAUCOMA EWAP SEPTEMBER 2023 45 or fibrin membranes that lead to elevated intraocular pressure. These complications need to be treated promptly, often with laser or incisional surgery. Eyes with uveitis can have a profound inflammatory response to surgery, so surgical planning must be done carefully and often requires a surge in steroid dosing around the time of laser or incisional surgery. While uveitic glaucoma is less common than primary open angle glaucoma, Aubrey Tirpack, MD, said it is an important cause of morbidity and vision loss in this patient population. “The literature says that up to 20% of uveitis patients will present with elevated intraocular pressure, which can result in optic nerve damage and irreversible vision loss,” she said. The underlying causes for intraocular pressure rise can vary, with both open and closed angle mechanisms. Open angle mechanisms include inflammation causing trabecular meshwork dysfunction or obstruction and steroid-induced pressure rise. Closed angle mechanisms include a slow, progressive synechial closure of the angle or a secondary angle closure from posterior synechiae of the iris to the lens. Treatment of uveitic glaucoma necessitates control of both intraocular inflammation and pressure, Dr. Tirpack said. Because the intraocular pressure rise is often driven by inflammatory mechanisms, aggressive treatment of the inflammation is required. “I manage these patients with my uveitis partners, who use steroids to treat the inflammation, and often involve a rheumatologist for initiation of systemic therapy,” she said. When to involve a uveitis/ rheumatology specialist “Involving rheumatology is often necessary to complete a workup for underlying systemic disease and initiate systemic immunosuppression, if appropriate,” Dr. Tirpack said. “Since steroids often drive intraocular pressure rise, finding steroid - sparing, long - term options for these patients is often necessary.” Dr. Kombo said that it’s important to have a team-based approach. You want to know the cause of the uveitis. Is it an infection? Is it autoimmune? Is it associated with a systemic condition? Some glaucoma specialists are comfortable doing the investigative work to get to the bottom of the cause. If not, referral to a uveitis specialist is appropriate. When uveitis becomes chronic, and you can’t get the patient off steroids, that’s the time to refer to a uveitis specialist and a rheumatologist. Dr. Eisengart said that this will vary depending on the glaucoma specialist’s access to other subspecialties and comfort in managing uveitis. “I would recommend a glaucoma doctor involve a uveitis specialist when the etiology of the uveitis is uncertain, when there are posterior segment complications, such as chronic macula edema, or when the disease is progressing despite treatment,” he said. “Rheumatology should be consulted when there are signs or symptoms suggestive of systemic involvement or if immunosuppressive drugs are required to control the uveitis.” Treatment and management Dr. Tirpack said that first-line treatment for intraocular pressure control is typically initiation of topical glaucoma medications. “I tend to avoid the use of prostaglandin analogs in uveitic patients given the increased risk of worsening inflammation and cystoid macular edema,” she said. “I also caution against the use of miotics in these patients given the risk of posterior synechiae formation and further disruption of the blood-aqueous barrier.” She added that beta blockers, carbonic anhydrase inhibitors, and alpha agonists can be used based on patient-specific comorbidities and tolerances. In cases of open angle uveitic glaucoma, selective laser trabeculoplasty can be considered for intraocular pressure control. Since this laser is pro-inflammatory, Dr. Tirpack said she will coordinate with her uveitis colleague to ensure adequate uveitis control prior to using it. “Uveitic glaucoma refractory to medications and selective laser trabeculoplasty will require incisional surgery to control the intraocular pressure,” she said, adding that angle-based surgery is a great option for patients without synechial closure and has the benefit of sparing the conjunctiva for future surgery, if needed. Goniotomy and gonioscopy - assisted transluminal trabeculotomy are effective angle-based surgeries in these patients. For patients with synechial closure or extremely elevated IOP, filtering surgery should be done, she said. Trabeculectomy is traditionally avoided in uveitic patients given the high risk of failure secondary to inflammation. Tube shunt remains the most common filtering surgery for uveitic patients, and Dr. Tirpack said that both valved and non- valved tubes can be considered. “Uveitic patients are at higher risk for postoperative hypotony, and therefore, I will often choose a valved tube shunt to help mitigate this risk,” she said. In young, well-controlled uveitics, an unvalved tube shunt can be a good option. Regardless of the surgical procedure, these patients need good control of the inflammation pre-, intra-, and postoperatively.
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