Management

Medical management of uveitic glaucoma requires aggressive control of both intraocular inflammation and IOP as well as prevention of glaucomatous optic nerve damage and visual field loss (see BCSC Section 10, Glaucoma). Aqueous suppressants are generally the first-line agents. Prostaglandin analogues may be used to treat uveitic glaucoma and generally do not exacerbate intraocular inflammation, especially when used concomitantly with IMT and corticosteroids. However, caution should be used in eyes with herpetic uveitis. Use of pilocarpine should be avoided in uveitis, as the smaller fixed pupil may be at risk for worsening of posterior synechiae, and pilocarpine causes breakdown of the blood–aqueous barrier.

When medical management fails, glaucoma filtering surgery is indicated. Standard trabeculectomy has a greater risk of failure in these eyes. Results may be improved by using mitomycin C with intensive topical corticosteroids. However, intense and recurrent postoperative inflammation can often lead to failure of filtering surgery in uveitic eyes. Up to 90% of patients 1 year after surgery and approximately 62% 5 years after surgery achieve IOP control with 1 or 0 medications. Surgical complications include cataract formation, bleb leakage (early and late) that could lead to endophthalmitis, and choroidal effusions.

Alternatives to classic trabeculectomy are numerous and have been used with some short-term success in uveitic glaucoma. Nonpenetrating deep sclerectomy with or without a drainage implant has been shown effective in controlling IOP in up to 90% of uveitic eyes for 1 year after surgery. Viscocanalostomy has shown higher success rates in a limited number of studies. Among pediatric uveitis patients, goniotomy has up to a 75% chance of reducing IOP to 21 mm Hg or less after 2 surgeries. This procedure may be complicated by transient hyphema and worsening of the preexisting cataract. Trabeculodialysis and laser sclerostomy have high rates of failure because of recurrent postoperative inflammation. The role of minimally invasive glaucoma surgery remains unclear in uveitis.

Most cases of uveitic glaucoma, especially in pseudophakic or aphakic eyes, require aqueous drainage devices. These devices may be tunneled into the anterior chamber or placed through the pars plana directly into the vitreous cavity after vitrectomy. A unidirectional valve design (valve implant) can prevent postoperative hypotony. These implants are more likely than trabeculectomy to successfully control IOP in the long term; results indicate up to a 75% reduction of IOP from preoperative levels and that nearly 75% of patients achieve target IOP levels with use of 0 or 1 topical antiglaucoma medication after 4 years. Complications of glaucoma-drainage-device surgery (10%/patient-year) include shallow anterior chamber, hypotony, suprachoroidal hemorrhage, and blockage of the drainage device by blood, fibrin, or iris. Long-term complications include device erosion through the conjunctiva, valve migration, corneal decompensation, drainage device–cornea touch, and retinal detachment. Unlike trabeculectomy, these drainage devices have proven to be robust and continue to function despite chronic, recurrent inflammation; they provide excellent long-term IOP control in eyes with uveitic glaucoma.

Cyclodestructive procedures may worsen ocular inflammation and lead to hypotony and phthisis bulbi. Laser trabeculoplasty is generally considered ineffective in eyes with uveitis.

As with all surgeries in uveitic eyes, tight and meticulous control of perioperative inflammation—including the use of preoperative regimens similar to those used before cataract surgery as well as of immunomodulators and corticosteroids—not only improves the success of glaucoma surgery but also improves visual acuity outcomes by limiting sight-threatening complications such as UME and hypotony. Additional details and information on surgical procedures for uveitic glaucoma are described in BCSC Section 10, Glaucoma.

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Excerpted from BCSC 2020-2021 series: Section 9 - Uveitis and Ocular Inflammation. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.