Eyeworld

JULY 2023 | EYEWORLD | 71 G by Ellen Stodola Editorial Co-Director About the physicians Jonathan Eisengart, MD Glaucoma Service Director Cole Eye Institute Cleveland Clinic Cleveland, Ohio Ninani Kombo, MD Assistant Professor of Ophthalmology and Visual Science Yale School of Medicine New Haven, Connecticut Aubrey Tirpack, MD Cincinnati Eye Institute Cincinnati, Ohio 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, or fibrin membranes that lead to elevated intraocular pressure. These compli- cations need to be treated promptly, often with laser or incisional surgery. Eyes with uveitis can have a profound inflammatory response to sur- gery, so surgical planning must be done careful- ly 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 popu- lation. "The literature says that up to 20% of uveitis patients will present with elevated intra- ocular pressure, which can result in optic nerve damage and irreversible vision loss," she said. C reating an effective treatment plan for a patient with uveitic glaucoma re- quires the ophthalmologist to consider and balance evolving, multiple, and sometimes competing disease process- es. 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 rap- idly. "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 peo- ple 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 intra- ocular pressure, Dr. Eisengart said, and that is achieved most commonly with topical medica- tions. 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 ste- roid treatment may help lower the eye pressure, that can cause the uveitis to flare. Steroids need to be carefully titrated to the lowest effective How to handle uveitic glaucoma continued on page 72 About 6 weeks after Baerveldt (Johnson & Johnson Vision) implantation with phaco and synechiolysis, this young male with anterior uveitis and glaucoma developed a severe fibrinoid inflammatory reaction upon tube ligature release. High dose steroids quieted the inflammation, but he was left with a small, bound down pupil and a pupillary membrane across his IOL. The possibility of recurrent synechiae was anticipated during that 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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