Risk factors for elevated intraocular pressure in uveitis

Prevalence and clinical characteristics of uveitic glaucoma: multicentric study in Bogotá, Colombia

OBJECTIVES

To describe the clinical features of patients diagnosed with uveitic glaucoma (UG) and ocular hypertension secondary to uveitis (OHT-SU).

METHODS

A multicentric cross-sectional study using medical records of patients with uveitis between 2013 and 2021. Uveitis and glaucoma specialists examined all patients. Variables were analyzed using the chi-square or Fisher's exact test for categorical variables. Additionally, t test, Mann-Whitney, and Kruskal-Wallis variance analysis were used for continuous variables. Finally, a Kaplan-Meier survival analysis for UG and OHT-SU development over time was done.

RESULTS

Of the 660 clinical records reviewed of patients with uveitis, 191 (28.9%) had OHT-SU in at least one visit, and 108 (16.4%) of them developed UG. In all ages, females were more affected than males. Anterior uveitis was the main anatomic localisation, and non-granulomatous, recurrent, and inactive uveitis were the most frequent clinical features. The mean final visual acuity was 0.3 (0.0-1.0) LogMAR. Also, 95.8% of the patients had additional sequelae related to uveitis regardless of UG and OHT-SU. Interestingly, males had earlier affection, with statistical significance in OHT for adults (P = 0.036) and UG for children (P = 0.04). Of all patients, 81.1% received topical hypotensive treatment and 29.8% required a surgical procedure.

CONCLUSIONS

UG and OHT-SU are common complications of uveitis in the Colombian population. These sight-threatening conditions were more common and appeared sooner in men at any age. Our results suggest that earlier and more aggressive treatment with topical hypotensive agents could positively influence the visual outcomes and the requirement of surgical procedures.

The Frequency of Intraocular Pressure Elevation, Incidence of Secondary Glaucoma, and Surgical Treatment With Postoperative Complications in Pediatric and Adult Patients With Uveitis

Purpose To determine the etiology and anatomic localization of uveitis, the frequency of intraocular pressure (IOP) elevation, and the type of secondary glaucoma and to assess the medical, surgical, and postoperative complications in adult and pediatric patients with acute or chronic uveitis. Methods A total of 307 eyes of 186 patients who were followed up in the Uvea-Behçet Unit of the Ophthalmology Department, Erciyes University, Turkey, were included in the study. Demographic, ocular, and systemic data were recorded; ophthalmological examinations were performed; and recurrences and complications of uveitis were identified. The eyes with IOP over 22 mmHg, types of secondary glaucoma, their etiologies, efficiency of medical and surgical treatments, and complications were recorded. Results The mean age was 33 ± 12 years (range: 6-65). Of the 186 patients, diagnoses were as follows: idiopathic uveitis in 84 (45.2%), Behçet disease in 65 (34.9%), ankylosing spondylitis in eight (4.3%), juvenile idiopathic arthritis in five (2.7%), herpetic keratouveitis in three (1.6%), Fuchs iridocyclitis in three (1.6%), Vogt-Koyanagi-Harada syndrome in three (1.6%), tuberculosis uveitis in three (1.6%), Crohn disease in three (1.6%), ocular toxoplasmosis in two (1.1%), multiple sclerosis in two (1.1%), Lyme disease in two (1.1%), rheumatoid arthritis in two (1.1%) and tubulointerstitial nephritis in one patient (0.5%). Secondary glaucoma was detected in 67 (21.9%) of 307 eyes, which developed in 13.7% and 26.8% of the eyes with acute and chronic uveitis, respectively. Of 67 eyes, it was open-angle glaucoma in 58 (86.5%), angle-closure glaucoma in six (9.0%), and neovascular glaucoma in three (4.5%). Control of IOP was achieved by medical therapy in 53 eyes (79.1%) and by surgery in 12 eyes (17.9%), whereas evisceration was required in two eyes (3.0%). Laser iridotomy was performed in four eyes (33.4%), trabeculectomy with mitomycin-C (MMC) in six eyes (50.0%), laser iridotomy plus trabeculectomy with MMC in one eye (8.3%), and express mini shunt implantation in one eye (8.3%). After surgery, IOP was controlled without anti-glaucomatous agents in six eyes (50%) and with anti-glaucomatous agents in the remaining six eyes (50.0%). Conclusion Secondary glaucoma is one of the most important complications of uveitis and may result in severe visual impairment. Early diagnosis and appropriate treatment can prevent these potential complications.

Characteristics of ocular hypertension and uveitic glaucoma among patients with noninfectious uveitis

OBJECTIVE

Ocular hypertension and uveitic glaucoma are important downstream sequela of noninfectious uveitis (NIU). Herein, we describe the clinical outcomes of NIU cases with ocular hypertension and uveitic glaucoma.

DESIGN

Retrospective cohort study.

PARTICIPANTS

All adults (≥18 years) with NIU under the care of uveitis subspecialty tertiary care clinics between 2010 and 2021 were included.

METHODS

The primary outcomes were baseline and final visual acuity.

RESULTS

A total of 216 patients out of 914 (23.6%) cases with NIU had ocular hypertension or uveitic glaucoma over the study period. Of all patients with ocular hypertension or uveitic glaucoma, 46% were corticosteroid responders. Baseline and last median visual acuities were better for the ocular hypertension patients compared with patients with uveitic glaucoma (p < 0.001). A higher proportion of patients with uveitic glaucoma than patients with ocular hypertension required glaucoma surgery (p < 0.001). The regression analyses suggested that baseline visual acuity and anatomical classification are significant predictors of last visual acuity, whereas diagnosis of ocular hypertension versus uveitic glaucoma were significant predictors of requirement for glaucoma surgery (p < 0.001).

CONCLUSION

A quarter of patients with NIU in this study developed ocular hypertension or uveitic glaucoma. Approximately half of the patients with ocular hypertension or uveitic glaucoma were deemed to be corticosteroid responders. Baseline and last visual acuity outcomes are better amongst ocular hypertension patients compared with those with uveitic glaucoma. Poor baseline visual acuity and panuveitis are predictors of worse vision at last follow-up. Additionally, diagnosis of uveitic glaucoma was a significant predictor of requirement for glaucoma surgery.

Surgical Outcomes in Uveitic Glaucoma: Long-Term Evaluation of Trabeculectomy, Non-Penetrating Deep Sclerectomy, Ex-PRESS Shunt and Ahmed Glaucoma Valve. A 3-Year Follow-Up Study

PURPOSE

Uveitis can lead to secondary glaucoma, a condition with challenging management that can carry irreversible visual loss. Filtering surgery has demonstrated a higher failure rate, increased incidence of postoperative complications and reinterventions in uveitic patients. There is no consensus on the optimal surgical approach for uveitic glaucoma (UG) due to limited data comparing various intraocular pressure (IOP)-lowering surgeries. This retrospective cohort aims to assess the clinical outcomes of trabeculectomy (TBT), non-penetrating deep sclerectomy (NPDS), Ex-PRESS shunt and Ahmed glaucoma valve, providing additional insights into the long-term IOP control and safety of filtering surgeries in UG.

METHODS

The filtering surgery was performed on 32 eyes of 27 UG patients. Complete success was defined as IOP ≤ 18 mmHg or a 30% reduction. Qualified success allowed topical hypotensive treatment.

RESULTS

Complete success was 40.63% (13/32) at 12 months and 36.67% (11/30) at 36 months. Qualified success was 84.38% (27/32) at 12 months and 63.33% (19/30) at 36 months. In the survival analysis, both NPDS and Ex-PRESS demonstrated decreased failure rates compared to TBT (NPDS vs TBT: HR = 0.20, p = 0.049; Ex-PRESS vs TBT: HR = 0.28, p = 0.13). One or more reinterventions were required in 34.38% (11/32) of the eyes. NPDS had the lowest incidence of hypotony. Secondary cataract was a common complication in all groups.

CONCLUSION

Various filtering surgeries are safe and effective procedures for lowering IOP and reducing the requirement of topical antihypertensives in UG at 36 months. However, one-third of the patients will require another IOP-lowering procedure.

Incidence and risk factors for glaucoma development and progression after corneal transplantation

OBJECTIVE

To assess the cumulative incidence and risk factors for glaucoma development and progression within 1-2 years following corneal transplant surgery.

DESIGN

Retrospective cohort study.

METHODS

Patients undergoing penetrating keratoplasty (PK), deep anterior lamellar keratoplasty (DALK), Descemet stripping endothelial keratoplasty (DSEK), Descemet membrane endothelial keratoplasty (DMEK), Boston keratoprosthesis type I (KPro) implantation, or endothelial keratoplasty (DSEK or DMEK) under previous PK (EK under previous PK) at one academic institution with at least 1 year of follow-up were included. Primary outcome measures were cumulative incidence of glaucoma development and progression after corneal transplant, in patients without and with preoperative glaucoma, respectively. Risk factors for glaucoma development and progression were also assessed.

RESULTS

Four hundred and thirty-one eyes of 431 patients undergoing PK (113), DALK (17), DSEK (71), DMEK (168), KPro (35) and EK under previous PK (27) with a mean follow-up of 22.9 months were analyzed. The 1-year cumulative incidence for glaucoma development and progression was 28.0% and 17.8% in patients without and with preoperative glaucoma, respectively. In a Cox proportional hazards analysis, DSEK surgery, KPro implantation, average intraocular pressure (IOP) through follow-up and postoperative IOP spikes of ≥30 mmHg were each independently associated with glaucoma development or progression (p < 0.04 for all).

CONCLUSIONS

A significant proportion of patients developed glaucoma or exhibited glaucoma progression within 1 year after corneal transplantation. Patient selection for DSEK may partly explain the higher risk for glaucoma in these patients. Postoperative IOP spikes should be minimized and may indicate the need for co-management with a glaucoma specialist.

Cataract surgery in patients with uveitis: Data from the Swedish National Cataract Register

PURPOSE

To investigate the surgical and pharmacological management and outcomes of patients with cataract and concurrent uveitis.

METHODS

Data from the Swedish National Cataract Register, 2018-2019, were collected and analysed. Uveitic eyes were identified and eyes without uveitis were used as controls. Generalized estimating equations were used to adjust for intra-individual correlation.

RESULTS

The study included 719 eyes with and 256 360 without uveitis. The mean age was 66.0 ± 13.5 (standard deviation [SD]) years in the uveitis group and 74.3 ± 8.7 years in the control group (p < 0.001). Surgery was associated with more intraoperative difficulties in eyes with uveitis (27.0%) than in control eyes (7.1%; p < 0.001). Posterior capsule rupture/zonular complications were registered in nine eyes with uveitis (1.3%) and in 1464 eyes without uveitis (0.6%; p = 0.02). Hydrophilic acrylic intraocular lenses (uveitis 3.6%, controls 1.2%) and subconjunctival steroids (uveitis 17.4%, controls 6.1%) were more frequently used in eyes with uveitis (p < 0.001). post-operative best-corrected visual acuity (BCVA) was 0.16 ± 0.38 logarithm of the minimum angle of resolution (logMAR, mean ± SD) in eyes with uveitis (n = 52) and 0.08 ± 0.20 in control eyes (n = 14 489; p = 0.008).

CONCLUSION

In this large registry-based Swedish cohort study, the findings demonstrate that cataract surgery in patients with uveitis poses more challenges and requires special surgical precautions. Eyes with concurrent uveitis had worse BCVA prior to and following surgery. Despite the intraoperative challenges, the visual improvement was greater in the uveitic group.

Predictors of glaucoma in patients with uveitis and scleritis

BACKGROUND

To examine risk factors for development of glaucoma in a large cohort of subjects with uveitis and scleritis.

METHODS

Retrospective review of subjects diagnosed with uveitis or scleritis between 2006 and 2019 at Auckland District Health Board. Subjects were excluded if they had glaucoma due to another cause. Main outcome measure was development of glaucoma. Data for local steroid use was not available.

RESULTS

3462 eyes of 2414 subjects were included in the study. Mean follow-up was 5.7 years (total follow-up time 19,897 eye years). Median age was 44.3 years and 1189 (49.3%) were female. Glaucoma developed in 222 eyes (6.3%) during the follow-up. Five-year cumulative risk of glaucoma was 6.2% (CI 5.0-7.5%) for anterior uveitis, 5.4% (CI 3.2-9.0%) for intermediate uveitis, 1.6% (CI 0.4-6.7%) for posterior uveitis, 8.7% (CI 6.5-11.7%) for panuveitis, and 3.2% (CI 1.0-9.5%) for scleritis. Five-year cumulative risk of glaucoma was lowest in HLA-B27 uveitis at 0.9% (CI 0.4-2.1%) and highest in viral uveitis 15.1% (CI 10.1-22.3%), sarcoidosis 9.9% (CI 6.1-15.9%) and tuberculosis 9.7% (CI 5.4-17.0%). On multivariate analysis, risk factors for development of glaucoma were older age at presentation, higher presenting intraocular pressure, chronic inflammation, and cystoid macular oedema.

CONCLUSIONS

Glaucoma is a common complication of uveitis and scleritis and was more frequent in older subjects, high presenting IOP, chronic inflammation and those with cystoid macular oedema. Local steroid therapy contributes to this, but is not quantifiable in this study. Targeted screening is required to avoid irreversible progression of glaucomatous optic neuropathy.

Causal Association between Iritis or Uveitis and Glaucoma: A Two-Sample Mendelian Randomisation Study

Recent studies have suggested an association between iritis or uveitis and glaucoma. This study investigated the causal relationship between glaucoma and iritis and uveitis as exposures in a multi-ethnic population. Single-nucleotide polymorphisms associated with exposures to iritis and uveitis from the genome-wide association study (GWAS) data of Biobank Japan (BBJ) and the meta-analysis data from BBJ and UK Biobank (UKB) were used as instrumental variables (IVs). The GWAS dataset for glaucoma was extracted from the meta-analysis data (n = 240,302) of Genetic Epidemiology Research in Adult Health and Aging and UKB. The casual estimates were assessed with a two-sample Mendelian randomisation (MR) test using the inverse-variance-weighted (IVW) method, weighted median method, MR–Egger method, and MR-Pleiotropy Residual Sum and Outlier test. The IVW method revealed a significant causal association between iritis and glaucoma using IVs (p < 5.0 × 10−8) from the East Asian population (n = 2) (odds ratio [OR] = 1.01, p = 0.017), a significant association between iritis exposures (p < 5.0 × 10−8) in the multi-ethnic population (n = 11) (OR = 1.04, p = 0.001), and a significant causal association between uveitis exposures (n = 10 with p < 5.0 × 10−8) and glaucoma in the multi-ethnic population (OR = 1.04, p = 0.001). Iritis and uveitis had causal effects on glaucoma risk based on IVs from the multi-ethnic population. These findings imply that the current classifications of uveitic glaucoma and open-angle glaucoma overlap, indicating the need for further investigating these complex relationships.

Local versus Systemic Therapy for Noninfectious Uveitis (NIU)

The mainstay of treatment for noninfectious uveitis (NIU) is immunosuppressant therapy. This may come in a localized form that is administered specifically to the eye or a systemic form that penetrates ocular tissues. Over the last twenty years, both local and systemic treatments have undergone advancements in pharmaceutical development. In this review, we will discuss new therapies and analyze the risks and benefits for all existing NIU therapies. Some of these therapies include topical, intravitreal, periocular, and systemic steroids, as well as systemic antimetabolites, tumor necrosis factor-α inhibitors, T-cell inhibitors, anti-CD 20 agents, interleukin-6 inhibitors, alkylating agents, and intravenous immunoglobulin.

Outcomes of Microhook ab Interno Trabeculotomy in Consecutive 36 Eyes with Uveitic Glaucoma

Microhook trabeculotomy (μLOT), recently developed by Tanito belongs to minimally invasive glaucoma surgery and contributes to intraocular pressure (IOP) control in eyes with glaucoma resistant to medical therapy. In this study, we aimed to investigate the effectiveness and safety of μLOT for uveitic glaucoma. The medical records of consecutive 36 eyes from 30 patients who underwent μLOT and were followed up over post-operative 1 year were reviewed. The surgical success (IOP = 5–20 mmHg and ΔIOP ≥ 20% with additional anti-glaucoma drugs) was achieved in 67% of eyes at post-operative 12 months. The median IOP significantly decreased from 30.5 mmHg pre-operatively to 15 mmHg at 12 months post-operatively (p = 0.001), and the median glaucoma drug score changed from 5 pre-operatively to 2.5 at 12 months post-operatively (p = 0.301). Intraocular inflammation scores at post-operative 6 weeks did not show a significant worsening as compared to pre-operatively, and 8 (22%) eyes exhibited exacerbation of inflammation during the 12-month follow-up period. Post-operative complications were confirmed in 58% of eyes, but most of them were mild and transient or successfully managed. With its favorable benefit–risk profile, μLOT would be an option worth considering as the first glaucoma surgery for uveitic glaucoma.

Intermediate Uveitis: A Review

PURPOSE

This review aims to provide an update on the clinical presentation, etiologies, complications, and treatment options in intermediate uveitis (IU).

METHODS

Narrative literature review.

RESULTS

IU affects all age groups with no clear gender predominance and has varied etiologies including systemic illnesses and infectious diseases, or pars planitis. In some instances, IU may be the sole presentation of an underlying associated condition or disease. Management of IU and its complications include administration of corticosteroids, antimetabolites, T-cell inhibitors, and/or biologics, along with surgical interventions, with varying degrees of effectiveness across literature. In particular, increasing evidence of the safety and efficacy of immunomodulatory agents and biologics has seen greater adoption of these therapies in clinical practice.

CONCLUSIONS

IU is an anatomical description of uveitis, involving intraocular inflammation of the vitreous, peripheral retinal vasculature, and pars plana. Various treatment options for intermediate uveitis are currently used in practice.

Long-term Outcomes of Modified 360-degree Suture Trabeculotomy for Uveitic Glaucoma Compared with Primary Open Angle Glaucoma

PRCIS

A Kaplan-Meier survival curve analysis showed no significant differences in success rates between UG and POAG 120 months after modified 360-degree suture trabeculotomy, which was effective for both groups in the long term.

PURPOSE

To examine the outcomes of modified 360-degree suture trabeculotomy in patients with uveitic glaucoma (UG) as compared to those with primary open angle glaucoma (POAG).

METHODS

This was a retrospective, non-randomized, and comparative case series study. Modified 360-degree trabeculotomy using a 5-0 nylon suture (S-LOT) was performed on 51 eyes of 51 patients (54.4±13.4 y) with UG between October 2005 and January 2012 at Hokkaido University Hospital. Age-matched patients with POAG who underwent S-LOT during the same period were enrolled as controls. Written informed consent was obtained from all patients enrolled in the present study. Surgical success was defined as an intraocular pressure (IOP) <18 mmHg with similar or lower doses of antiglaucoma medications. Kaplan-Meier survival curves of surgical failure were analyzed and compared between UG and POAG.

RESULTS

The mean follow-up periods (±SD) for UG and POAG were 104.8±44.0 and 98.1±36.3 months (P=0.23), respectively. Mean pre-operative IOP in UG and POAG were 34.9±11.0 and 25.3±9.4 mmHg (P<0.001), respectively. After surgery, mean IOP in UG and POAG decreased to 12.0±4.1 and 13.8±3.2 mmHg, respectively, at 60 months, and 12.1±5.6 and 12.4±1.8 mmHg (P=0.86), respectively, at 120 months. The Kaplan-Meier survival curve analysis showed no significant differences in success rates between UG and POAG at the end of the follow-up (Log-rank test, P=0.13). Success rates in UG and POAG were 70.0 and 62.5% at 60 months, and 67.5 and 41.2% at 120 months, respectively.

CONCLUSION

These results suggest that S-LOT is effective for UG and POAG alike.

Phacoemulsification after trabeculectomy in uveitis associated with Vogt-Koyanagi-Harada disease: intermediate-term visual outcome, IOP control and trabeculectomy survival

PURPOSE

To evaluate the visual outcome, intraocular pressure control and trabeculectomy survival after phacoemulsification in eyes with prior trabeculectomy in uveitis associated with Vogt-Koyanagi-Harada disease (VKH).

DESIGN

Retrospective comparative study.

METHODS

Eyes with uveitic glaucoma associated with VKH who underwent mitomycin C (MMC)-enhanced trabeculectomy were included. Eyes were divided into two groups: the first study group included eyes that later underwent cataract surgery in the form of phacoemulsification, and the second control group included eyes that did not have cataract surgery. The main outcome measures were changes in the visual acuity, intraocular pressure (IOP), the number of antiglaucoma medications, IOP control and trabeculectomy survival.

RESULTS

There were no significant differences in the final visual acuity (0.78 (±0.9) and 0.92 (±1.1), p = 0.80)) nor IOP (14.21 mmHg (±5.8) and 12.16 mmHg (±6.1), p = 0.29), but there was a difference in the antiglaucoma medications (1.58 (±1.5) and 0.53 (±1.0), p = 0.02) between the study and control group, respectively. There was no difference in the overall trabeculectomy survival (p = 0.381, Log Rank), but more eyes in the study group converted to qualified success after phacoemulsification and required more medications to control the IOP.

CONCLUSION

Phacoemulsification after trabeculectomy seems to be a safe procedure in eyes with combined vision threatening complications of VKH, although the visual improvement was limited. Nevertheless, more medications were required to control the IOP, resulting in less absolute and more qualified trabeculectomy success. Therefore, patient counseling before surgery is essential.

Intraocular pressure fluctuation following intravitreal dexamethasone implant and incidence of secondary ocular hypertension: a Zambian perspective

Introduction

to evaluate the effect of dexamethasone biodegradable implant (DEX-I), on intraocular pressure (IOP), to determine the incidence of secondary ocular hypertension (OHT) and to analyze the IOP changes as per the treatment indication in Zambian cohort.

Methods

retrospective consecutive case series of patients receiving one DEX-I between January 2016 and September 2018 with a minimum follow-up of four months in a tertiary care centre in Zambia. The IOP was recorded before the injection and at 1^st week, 1^st, 2^nd, 3^rd and 4^th month after the injection. Ocular hypertension was defined as IOP ≥ 21 mmHg or an increase of ≥ 10 mmHg from baseline.

Results

the effects of 122 injections given to ninety - nine patients (65 male: 65%; mean age 57.3) were included. The main indications for treatment were diabetic macular edema (DME, 52%), retinal vein occlusion (18%), post-surgical macular edema (18%) and non-infectious posterior uveitis (10%). Mean IOP before the injection was was 14.7mmHg and at 1^st week, 1^st, 2^nd, 3^rd and 4^th months after the injection it was 14.4 (p=0.08), 16.1 (p=0.01), 17.5 (p<0.001), 15.7 (p=0.006) and 14.9 (p=0.06) mmHg, respectively. The incidence of secondary OHT was 30.32% in this cohort. Peak incidence of OHT was between 1 - 2 months, with majority of cases in DME group (75%) and 43% diabetic eyes followed by 23% non-infectious posterior uveitis cases developing OHT post injection. OHT was well managed with anti-glaucoma medications only.

Conclusion

DEX-I showed a good pressure tolerance in this cohort. Secondary ocular hypertension developed in one-third of patients receiving injection which was transient and successfully managed with topical anti-glaucoma medications only. Diabetic eyes are more prone to develop ocular hypertension and therefore needs close monitoring following injection.

Long-term outcomes of initial trabeculectomy in glaucoma associated with granulomatous and non-granulomatous uveitis

PURPOSE

To evaluate the outcomes of initial trabeculectomy in granulomatous and non-granulomatous uveitis.

METHODS

Retrospective comparative study of 68 eyes that underwent an initial trabeculectomy.

RESULTS

The mean follow-up was 74.18 and 74.86 months in both groups (p = 0.95). The intraocular pressure decreased from 40.03 mmHg ( ± 7.2) and 36.48 mmHg ( ± 11.3) to 14.00 mmHg ( ± 6.2) and 13.48 mmHg ( ± 5.7), the number of medications decreased from 3.73 ( ± 0.7) and 3.58 ( ± 0.9) to 1.00 ( ± 1.4) and 1.13 ( ± 1.4) on the last follow-up (p < 0.01) in the granulomatous and non-granulomatous groups, respectively. More eyes in the granulomatous uveitis group developed delayed postoperative complications like cataract, transient hypotony and glaucoma progression. Success rates were 64.9 and 71.0%, while failure rates were 35.1 and 29.0% in both groups (p = 0.84).

CONCLUSIONS

Trabeculectomy seems to have comparable IOP control and survival in granulomatous and non-granulomatous uveitis. Nevertheless, more eyes in the granulomatous uveitis group developed late-onset complications.

Surgical Outcomes of Trabeculectomy in Uveitic Glaucoma: A Long-Term, Single-Center, Retrospective Case-Control Study

Purpose

To evaluate the long-term outcomes of trabeculectomy with mitomycin C (MMC-TLE) in patients with uveitic glaucoma (UG). Patients and Methods. This was a retrospective, nonrandomized case series study. MMC-TLE was performed on 50 eyes with UG between February 2001 and January 2015 at Hokkaido University Hospital. Age- and sex-matched patients with primary open angle glaucoma (POAG) who underwent MMC-TLE were matched by age and sex and enrolled as controls. Surgical success was defined as an intraocular pressure (IOP) less than 18 or 15 mmHg. The Kaplan–Meier survival curves for surgical failure were analyzed.

Results

The mean preoperative IOP in UG and POAG was 27.6 ± 10.6 and 18.0 ± 4.5 mmHg, respectively. After the surgery, the mean IOP in UG and POAG was reduced to 11.7 ± 4.2 and 12.2 ± 3.8 mmHg at 12 months, 11.9 ± 7.0 and 12.1 ± 3.1 mmHg at 36 months, and 13.0 ± 5.2 and 10.6 ± 1.2 mmHg at 120 months, respectively. The success rates (IOP <18 mmHg, IOP reduction >20%) in UG and POAG were 91.7% and 88.0% at 12 months, 82.2% and 75.6% at 36 months, and 66.5% and 61.8% at 120 months, respectively. The success rates (IOP <15 mmHg) in UG and POAG were 64.0% and 58.0% at 12 months, 55.1% and 45.5% at 36 months, and 47.9% and 37.8% at 120 months, respectively. There was no significant difference in the success rate between UG and POAG at 120 months after surgery by either definition of surgical success.

Conclusions

MMC-TLE effectively reduced IOP in both UG and POAG. There was no significant difference in the success rate between UG and POAG. Following sufficient inflammation suppression, surgical outcomes of UG may be comparable with those of POAG.

Aetiology and clinical characteristics of uveitic glaucoma in Turkish patients

PURPOSE

To investigate the types, frequency and clinical profiles of uveitic glaucoma seen at a tertiary care center and also to have an idea about the distribution of uveitic glaucoma types in Turkish population.

METHODS

Consecutive case notes of all patients attending a specialized uveitis clinic over a 3-month period were reviewed retrospectively.

RESULTS

One hundred and seven eyes of 96 patients were included. Sixty-five of the eyes had anterior, one intermediate, nine posterior uveitis while 32 of them had panuveitis. Twenty-three eyes had acute, 52 chronic and 32 recurrent uveitis. Herpes virus associated iridocyclitis was the leading cause of anterior uveitis-associated uveitic glaucoma followed by cytomegalovirus (CMV) associated anterior uveitis; while steroid-induced glaucoma accounted for the majority of chronic uveitis with glaucoma followed by Fuchs' uveitis syndrome (FUS). The most common causes of glaucoma among the cases were steroid-induced in 30 eyes (28%), Herpes virus anterior uveitis in 24 eyes (22%), CMV anterior uveitis in 20 eyes (18%), FUS in 15 eyes (14%), ocular toxoplasmosis in 5 eyes (4%). Behçet's uveitis was the most common (n = 11, 36%) cause of steroid-induced glaucoma. The need for surgical intervention was 23.32% (n = 25; 12 of them were FUS, 8 steroid-dependent, 1 HSV and 3 CMV anterior uveitis and 1 angle closure glaucoma with idiopathic uveitis) in our cases.

CONCLUSION

Uveitic glaucoma is a common complication in a tertiary clinic. The most common causes are steroid-induced, FUS, viral anterior uveitis. The most common disease causing steroid induced glaucoma was Behçet's disease. Glaucoma surgery is required in a significant number of cases.

Characteristics of uveitic glaucoma in Turkish patients

PURPOSE

To evaluate the prevalence of uveitic glaucoma (UG) in the Turkish population and investigate the primary underlying diseases.

METHODS

This multicenter, cross-sectional, prospective study included patients who presented to the glaucoma units of 10 tertiary ophthalmology departments in Ankara, Turkey from 15th March to 16th May 2015 and fulfilled the criteria of UG. Patients were inspected for age, sex, medical history, best corrected visual acuity, biomicroscopic findings, intraocular pressure values, and visual field results.

RESULTS

During the study period, 4604 eyes of 2541 patients with glaucoma were screened and 145 eyes of 104 patients (4.1%) were identified as having UG. One hundred and thirty-four eyes (92.4%) had open-angle glaucoma and 11 eyes (7.6%) had closed-angle glaucoma. The mean patient age was 47 ± 16 (6-90) years. Idiopathic uveitis (54 eyes), Behçet's disease (26 eyes), Fuchs heterochromic cyclitis (21 eyes), Herpes Simplex virus infectious uveitis (14 eyes), and ankylosing spondylitis (six eyes) were the leading types of uveitis associated with glaucoma. Acute anterior uveitis was the most common type of uveitis diagnosed in 72 patients (105 eyes), whereas 21 patients (27 eyes) had panuveitis, eight patients (nine eyes) had intermediate uveitis, and three patients (four eyes) had posterior uveitis. The need for surgical intervention was 37.2% among all cases and the most common surgery was trabeculectomy in 45 eyes.

CONCLUSION

UG is a vision-threatening complication commonly seen in patients with uveitis. This study demonstrates the epidemiological features and underlying etiologies of UG in the Turkish population. The most common primary causes of UG were Behçet's disease and Fuchs heterochromic cyclitis.

Diurnal Spikes of Intraocular Pressure in Uveitic Glaucoma: A 24-hour Intraocular Pressure Monitoring Study

PURPOSE

The aim of this study was to document diurnal changes in intraocular pressure (IOP) in uveitic glaucoma (UG) and compare it with primary open angle glaucoma (POAG) patients.

METHODS

Eight patients with UG and seven patients with POAG were included in this study. The patients were matched for age, gender, and glaucoma medications. None of the patients experienced angle closure, uveitis attack, and ocular surgery, and were not under steroid or immunomodulatory therapy within the last three months. The 24-hour IOP fluctuations were recorded with the help of a contact lens sensor (Sensimed Triggerfish ®, Switzerland). The diurnal IOP fluctuations were modeled with best-fit lines and statistical comparisons between the longitudinal responses of the two groups were determined with nonlinear regression.

RESULTS

The comparison of mean 24-hour contact lens sensor (CLS) amplitudes revealed a significant difference between the fluctuation levels of UG and POAG groups (213 ± 160 millivolt equivalents (mVeq) vs. 162 ± 168 mVeq, respectively p = .003). The top level of the best-fit curves was significantly higher in the UG group (266 ± 143 mVeq) compared to the POAG group (159 ± 162 mVeq, p < .001). Both curves had their top levels between 5:00 PM and 8:00 AM. The longitudinal regression analysis revealed that the amplitudes of the 24-hour fluctuation waves were significantly different (p = .041).

CONCLUSIONS

This study demonstrated for the first time that the diurnal variation in IOP was significantly higher in UG patients. This difference was also more distinct between 5:00 PM and 8:00 AM clock-hours. The uveitis and glaucoma specialists should consider this potential for higher IOP fluctuations, while tailoring the glaucoma treatment in uveitic patients.

Glucocorticoid-Induced Ocular Hypertension: Origins and New Approaches to Minimize

Introduction

Glucocorticoids (GCs) have unique actions in their combined anti-inflammatory and immunosuppressive activities and are among the most commonly-prescribed drugs, particularly for inflammatory conditions. They are often used clinically to treat inflammatory eye diseases like uveitis, optic neuritis, conjunctivitis, keratitis and others, but are often accompanied by side effects, like ocular hypertension that can be vision threatening.

Areas covered

The review will focus on the complex molecular mechanism of action of GCs that involve both transactivation and transrepression and their use therapeutically that can cause significant systemic side effects, particularly ocular hypertension that can lead to glaucoma.

Expert Opinion

While we are still unclear as to all the mechanisms responsible for GC-induced ocular hypertension, however, there are potential novel therapies that are in development that can separate some of the anti-inflammatory therapeutic efficacy from their ocular hypertension side effect. This review provides some insight into these approaches.

Involvement of autotaxin in the pathophysiology of elevated intraocular pressure in Posner-Schlossman syndrome

To examine whether autotaxin (ATX) in the aqueous humor causes elevated intraocular pressure (IOP) in patients with Posner-Schlossman syndrome (PSS). ATX and transforming growth factor beta (TGF-β) in the aqueous humor were quantified in PSS patients. The expression of ATX and TGF-β in cytomegalovirus (CMV)-infected-human trabecular meshwork (hTM) cells was examined. Biological changes in hTM cells and monkey Schlemm’s canal endothelial (SCE) cells cultured in the conditioned medium of CMV-infected hTM cells were analyzed. The expression of ATX and TGF-β1 was upregulated in the aqueous humor of CMV-positive PSS patients, and the level of ATX in the aqueous humor was positively correlated with IOP. CMV infection upregulated ATX and TGF-β1 in hTM cells. The conditioned medium induced fibrotic changes in hTM cells and reduced SCE permeability, which was attenuated by an ATX inhibitor, a lysophosphatidic acid receptor antagonist, and a Rho kinase inhibitor. ATX in the aqueous humor induced by CMV infection may trigger elevated IOP. Modulating ATX activity may be a novel treatment modality for PSS.

Evaluating the Impact of Uveitis on Visual Field Progression Using Large-Scale Real-World Data

PURPOSE

To compare rates of visual field (VF) loss in uveitis patients with glaucoma against patients with primary open-angle glaucoma (POAG) and explore the association between intraocular pressure (IOP) and rate of VF loss.

DESIGN

Retrospective cohort study.

METHODS

Anonymized VFs and IOP measurements extracted from the electronic medical records of 5 regionally different glaucoma clinics in England. A total of 205 eyes with diagnosis of uveitis plus glaucoma were compared with 4600 eyes with POAG only. Minimum inclusion criteria were ≥4 visits within a 4-year window. Relative risk (RR) of being a "rapid progressor" (mean deviation [MD] loss ≥1.5 dB/year) was calculated. A mixed-effects model (MEM) and a pointwise VF progression analysis of pattern deviation were used to confirm differences between the groups. Longitudinal IOP mean, range, and variability were compared with rate of VF progression.

RESULTS

Median (interquartile range) baseline MD in the uveitis and POAG groups was -3.8 (-8.7, -1.5) dB and -3.1 (-6.6, -1.2) dB, respectively. The uveitis and POAG groups had 23 of 205 (11%) and 331 of 4600 (7%) "rapidly progressing" eyes, respectively. Age-adjusted RR for "rapid progression" in uveitic vs POAG eyes was 1.9 (95% confidence interval: 1.8-2.0). The MEM confirmed that uveitic eyes (-0.49 dB/year) showed higher rates of VF progression than the POAG group (-0.37 dB/year; P < .01). IOP range and variability were higher in the "rapidly progressing" uveitic eyes.

CONCLUSIONS

Our analysis suggests that VF loss occurs faster in glaucoma patients with uveitis than those without uveitis. The risk of progressing rapidly in glaucoma with uveitis is almost double than in those without uveitis. Early identification of "rapid progressors" may enable targeted intervention to preserve visual function in this high-risk group.

Clinical results of ab interno trabeculotomy using the trabectome in patients with uveitic glaucoma

IMPORTANCE

To evaluate the safety and efficacy of ab interno trabeculotomy (AIT) (trabecular ablation) with the trabectome in patients with uveitic glaucoma.

BACKGROUND

Traditional glaucoma filtration surgeries in the uveitic patient population come with a higher risk of complications such as failure and hypotony.

DESIGN

Retrospective observational cohort study.

PARTICIPANTS

All patients diagnosed with uveitic glaucoma were included in this study. Patients were excluded if they have less than 12 months of follow-up.

METHODS

All patients who received AIT alone or combined with phacoemulsification.

MAIN OUTCOME MEASURES

Major outcomes include intraocular pressure (IOP), number of glaucoma medications and secondary glaucoma surgery, if any. Kaplan-Meier method was used for survival analysis and success was defined as IOP ≤21 mmHg, at least 20% IOP reduction from baseline for any two consecutive visits after 3 months, no additional glaucoma medications, and no secondary glaucoma surgery.

RESULTS

A total of 45 eyes, 45 patients, with an average age of 52 years were included in the study. The majority were Japanese (40%) and underwent AIT alone (71%). IOP was reduced from 29.2 ± 8.0 to 16.7 ± 4.6 mmHg at 12 months (P < .01*), while the number of glaucoma medications was reduced from 4.0 ± 1.0 to 2.5 ± 1.6 (P < .01*). Survival rate at 12 months was 91%. Six cases required secondary glaucoma surgery and no other serious complication were reported.

CONCLUSIONS AND RELEVANCE

The trabectome AIT procedure appears to be effective in reducing IOP in uveitic glaucoma patients. Although no statistically significant difference was found in the number of glaucoma medications, a decreasing trend was found.

Chronic and recurrent non-infectious paediatric-onset uveitis: a French cohort

Objective

To evaluate the demographics, aetiologies, complications, treatments and visual prognoses of chronic and recurrent non-infectious paediatric-onset uveitis in France.

Methods

Descriptive, retrospective and bicentric study in patients whose disease started before 17 and who were followed up in two centres from January 2010 to May 2017.

Results

We included 147 patients with 268 affected eyes. Eighty-two had juvenile idiopathic arthritis-associated chronic uveitis, 58 were antinuclear antibody (ANA) positive and 24 were ANA negative, 36 had idiopathic uveitis, 9 had enthesitis-related arthritis-associated uveitis, 9 had sarcoidosis-associated uveitis and 11 had other inflammatory aetiologies. These patients cumulated 161 complications: ocular hypertension, cataract, band keratopathy, macular oedema, optic disk oedema and decreased visual acuity, including permanent visual loss for 31 patients. The most used treatments were corticosteroid (CS) eye drops (82%), systemic CSs (34%), methotrexate (58%) and biologics (38%). At the latest follow-up, 45 patients had achieved remission of uveitis without any treatment, 56 had inactive uveitis on topical steroids and 48 still had active uveitis.

Conclusion

Paediatric-onset uveitis are associated with a high rate of complications. However, following the introduction of biologics and particularly antitumour necrosis factor alpha antibodies, a significant proportion of uveitis became inactive on or even off treatment.

Assessing the biomechanical properties of the porcine crystalline lens as a function of intraocular pressure with optical coherence elastography

In this study, we investigated the relationship between the biomechanical properties of the crystalline lens and intraocular pressure (IOP) using a confocal acoustic radiation force (ARF) and phase-sensitive optical coherence elastography (OCE) system. ARF induced a small displacement at the apex of porcine lenses in situ at various artificially controlled IOPs. Maximum displacement, relaxation rate, and Young's modulus were utilized to assess the stiffness of the crystalline lens. The results showed that the stiffness of the crystalline increased as IOP increased, but the lens stiffening was not as significant as the stiffening of other ocular tissues such as the cornea and the sclera. A mechanical hysteresis in the lens was also observed while cycling IOP, indicating that the viscoelastic response of the lens is crucial to fully understanding its biomechanical properties.

SAFETY OF INTRAVITREAL DEXAMETHASONE IMPLANT (OZURDEX): The SAFODEX study. Incidence and Risk Factors of Ocular Hypertension

PURPOSE

To analyze the incidence, risk factors, and time course of intraocular pressure elevation after intravitreal dexamethasone implant (Ozurdex).

METHODS

The medical charts of 421 consecutive eyes (361 patients) receiving one or more Ozurdex implant between October 2010 and February 2015 were reviewed retrospectively. Ocular hypertension was defined as intraocular pressure of at least 25 mmHg or an increase of at least 10 mmHg from baseline. The main indications for treatment were retinal vein occlusion (34%), diabetic macular edema (30%), postsurgical macular edema (17%), uveitis (14%), and other etiologies (5%).

RESULTS

Among 1,000 intravitreal injections, ocular hypertension was recorded for 28.5% of injected eyes over a mean follow-up period of 16.8 months (3-55). Intraocular pressure-lowering medication was required for 31% of eyes. Only three eyes with preexisting glaucoma required filtering surgery to manage postinjection intraocular pressure elevation. Early retreatment between the third and fourth month does not increase the risk of intraocular pressure elevation. Younger age, male sex, Type 1 diabetes, preexisting glaucoma treated with dual or triple therapy, and a history of retinal vein occlusion or uveitis were significant risk factors for ocular hypertension after dexamethasone implant injection (P < 0.05 for all the above).

CONCLUSION

Episodes of ocular hypertension after Ozurdex implant were generally transient and successfully managed with topical treatment. An analysis of the risk factors may help to determine the risk-benefit ratio for individual patients treated with dexamethasone implants.

A retrospective study on the outcomes of Ahmed valve versus Ahmed valve combined with fluocinolone implant in uveitic glaucoma

Purpose

To compare the intraocular pressure (IOP) outcomes of Ahmed glaucoma valve (AGV) surgery alone versus AGV with fluocinolone implant in uveitic glaucoma patients.

Methods

We identified uveitic glaucoma patients with AGV surgery alone and AGV surgery combined with fluocinolone implant from the Massachusetts Eye and Ear Ocular Inflammation Database. Demographic information, visual acuity, and IOP were recorded at preoperative visits and 1, 6, and 12 months after surgery. Incidence of hypertensive phase, defined as an IOP of >21 mm Hg or use of additional treatment to lower IOP occurring any time between 7 days to 6 months postoperatively, was investigated. Multilevel mixed effects models were performed to compare the outcomes between groups.

Results

Eighteen eyes of 13 uveitic glaucoma patients with 1-year follow-up data were included. There were 11 eyes of 9 patients (mean age, 56.5 years; 63.6% male) in the AGV group and 7 eyes of 4 patients (mean age, 61.3 years; 71.4% male) in the AGV + fluocinolone group. There was no significant difference in visual acuity change at 1 year after surgery between groups (P = 0.25), although visual acuity improvement was significant in the AGV group (P = 0.01). The hypertensive phase occurred in 91% of AGV patients and 43% of AGV + fluocinolone patients (P = 0.30), with onset of 8-40 days (mean, 18 days) after surgery. IOP and number of glaucoma medications decreased at the 1-year postoperative visits in both the AGV group (P < 0.0001, P < 0.0001) and the AGV + fluocinolone group (P = 0.001, P < 0.0001). Compared to the AGV group, the AGV + fluocinolone group used fewer glaucoma medications (0.28 vs 1.30 [P = 0.01]) and had better inflammation control (P = 0.02). The surgical complication rates were similar between groups.

Conclusions

In uveitic glaucoma, AGV with fluocinolone achieves a similar, desired IOP control but with fewer glaucoma medications than AGV alone.

Complications of Uveitis: The Northern California Epidemiology of Uveitis Study

PURPOSE

To describe the uveitis complications in a large, community-based cohort.

METHODS

Retrospective, community-based, cross-sectional cohort study analyzing complications and associations with complications.

RESULTS

A total of 844 cases of uveitis were found; 342 were new-onset, and 462 were prior-onset. In total, 29.5% of patients were affected by one or more complications associated with age, gender, course, and anatomic location of uveitis. Visual loss was experienced by 19.1% of patients and was associated with age, course of disease, and anatomic location of uveitis. Of the patients who developed glaucoma or elevated intraocular pressure over 30 mmHg, 3.9% (n = 33) were related solely to uveitis; 5.2% (n = 44) had an unclear or combined mechanism; and 1.8% (n = 15) were related solely to steroid response. Cystoid macular edema was associated with course of disease and anatomic location of uveitis.

CONCLUSIONS

Complications affect a significant portion of uveitis patients, and are often associated with demographic and clinical factors.

Pathogenesis of Uveitic Glaucoma

Uveitic glaucoma consists one of the most serious complications of intraocular inflammation and, despite its rarity, is considered as one of the leading causes of preventable loss of vision worldwide. It has been associated with a wide spectrum of inflammatory diseases, but its pathogenesis is still not fully comprehended. It appears that the type of inflammation, the steroid-response and the anatomical alterations of the anterior chamber play a pivotal role. To our knowledge, the mechanisms may be both acute and chronic. The main targets of the treatment are to control the inflammation and reduce the intraocular pressure (IOP). The management of glaucoma associated with uveitis remains an extremely challenging condition for ophthalmologists. The successful treatment of uveitic glaucoma is inextricably correlated with prompt and immediate therapeutic decisions. Very often a solid collaboration between clinicians from different specialties may be required for treating the underlying disease.

Further understanding of its pathogenesis can indicate therapeutic targets and may lead to the development of new and more efficient therapeutic approaches. New glaucoma surgical modalities may ameliorate the prognosis after surgical intervention, but this calls for further evaluation. This study aims to highlight the complexity of uveitic glaucoma analyzing the main pathogenetic mechanisms and the correlations with the inflammatory response.

Prevalence and Visual Outcome of Glaucoma With Uveitis in a Thai Population

OBJECTIVE

The aim of this study was to report on the prevalence of uveitic secondary glaucoma (USG) and ocular hypertension in patients with uveitis in Thailand, and to identify factors associated with the development of USG and its visual outcome.

DESIGN

This is a retrospective cohort study.

METHODS

We included 174 consecutive uveitis patients (237 affected eyes) visiting the Ophthalmology Department of Chiang Mai University Hospital, Thailand, from January 2013 to March 2013.

RESULTS

The prevalence of USG was 29% (51/174) and that of ocular hypertension was 18% (32/174). The follow-up period ranged from 3 to 96 months (mean±SD=33±21 mo). Characteristics associated with the development of USG were as follows: age at onset of uveitis above 60 years and longer duration of uveitis (P=0.001). No association between location of uveitis and development of USG was observed. Clinical entities associated with the highest prevalence of USG consisted of Posner-Schlossman syndrome and herpetic uveitis. Within the anterior uveitis group, viral etiology was strongly associated with the development of USG, whereas human leukocyte antigen-B27 (HLA-B27)-associated anterior uveitis had lower prevalence of USG than did their HLA-B27-negative counterparts. The prevalence of patients with at least 1 blind eye was significantly higher in those who developed USG (21/51; 41%) than in uveitis patients without glaucoma (22/123; 18%, P=0.001). Characteristics associated with visual loss in USG included poor visual acuity at presentation (P<0.001), and undergoing glaucoma surgery (P<0.05).

CONCLUSIONS

The prevalence of secondary glaucoma among Southeast Asian patients with uveitis was 29%. Blindness in at least 1 eye developed more commonly in patients with USG than in uveitis patients without USG.

Glucocorticoid therapy and ocular hypertension

The projected number of people who will develop age-related macular degeneration in estimated at 2020 is 196 million and is expected to reach 288 million in 2040. Also, the number of people with Diabetic retinopathy will grow from 126.6 million in 2010 to 191.0 million by 2030. In addition, it is estimated that there are 2.3 million people suffering from uveitis worldwide. Because of the anti-inflammatory properties of glucocorticoids (GCs), they are often used topically and/or intravitreally to treat ocular inflammation conditions or edema associated with macular degeneration and diabetic retinopathy. Unfortunately, ocular GC therapy can lead to severe side effects. Serious and sometimes irreversible eye damage can occur as a result of the development of GC-induced ocular hypertension causing secondary open-angle glaucoma. According to the world health organization, glaucoma is the second leading cause of blindness in the world and it is estimated that 80 million will suffer from glaucoma by 2020. In the current review, mechanisms of GC-induced damage in ocular tissue, GC-resistance, and enhancing GC therapy will be discussed.

Canaloplasty in patients with uveitic glaucoma: a pilot study

PURPOSE

Glaucoma is a common vision-threatening complication of uveitis. We investigated the outcome of canaloplasty in patients with chronic uveitis and uncontrolled secondary glaucoma.

METHODS

This was a retrospective study of 12 patients with medically uncontrolled secondary glaucoma who underwent canaloplasty (14 treated eyes), with follow-up of ≥ 24 months. The primary outcome measure was complete and qualified (requirement for anti-glaucomatous medication) surgical success rates, as determined by a reduction in intraocular pressure (IOP) and the need for anti-glaucomatous medication. Secondary outcome measures were uveitis activity, best-corrected visual acuity (BCVA), vision-threatening complications, and secondary glaucoma surgery.

RESULTS

Canaloplasty resulted in a significant IOP reduction, from a mean preoperative baseline level of 27.1 ± 12.3 mmHg to a mean of 14.5 ± 4.3 mmHg (p = 0.01) at 24 months. Complete success (limit of 15 mmHg) was achieved in six patients and qualified success in one patient. However, failure was noted in five patients, two of whom required additional glaucoma surgery. Topical anti-glaucomatous medications were reduced from 2.7 ± 1.2 (mean ± SD) at baseline to 0.6 ± 1.2 at 24 months (p = 0.007). Uveitis activity did not increase after surgery. BCVA was not reduced; cataract progressed in two patients.

CONCLUSION

At 2-year follow-up, overall success rate was 58 % (IOP ≤ 15 with or without medication), and surgery failed in 5 eyes, 2 eyes requiring additional glaucoma surgery. No harmful complications or worsening of uveitis activity were noted.

Raised Intraocular Pressure in Nonjuvenile Idiopathic Arthritis-Uveitis Children: Risk Factors and Effect on Retinal Nerve Fiber Layer

PURPOSE

To determine risk factors for intraocular pressure (IOP) elevation and glaucoma in children with nonjuvenile idiopathic arthritis-related uveitis and any IOP-related changes in the retinal nerve fiber layer (RNFL) thickness.

PATIENTS AND METHODS

Clinical data were collected from children attending a tertiary referral uveitis clinic between May 2010 and October 2012. We assigned 206 eyes of 103 children into 32 normal eyes, 108 normotensive uveitics (NU), 41 hypertensive uveitics (HU: raised IOP without glaucomatous disc), and 25 glaucomatous uveitics (GU: raised IOP with glaucomatous disc). Risk factors for raised IOP, glaucoma and steroid response (SR) were evaluated and RNFL thickness across groups was compared with determine changes related to raised IOP.

RESULTS

IOP elevation occurred in 40 patients (38.8%) or 66/174 eyes with uveitis (37.9%); and SR occurred in 35.1% of all corticosteroid-treated eyes. Chronic uveitis was a significant risk factor for raised IOP [odds ratio (OR)=9.28, P=0.001], glaucoma, and SR (OR=8.4, P<0.001). Higher peak IOP was also a risk factor for glaucoma (OR=1.4, P=0.003). About 70% of SR eyes were high responders (IOP increase >15 mm Hg from baseline), associated with younger age and corticosteroid injections. Although no significant RNFL thinning was detected between HU and NU eyes, significant thinning was detected in the inferior quadrant of GU (121.3±28.9 μm) compared with NU eyes (142.1±32.0 μm, P=0.043).

CONCLUSIONS

Children with chronic uveitis are at higher risk of raised IOP and glaucoma. Thinning of the inferior RNFL quadrant may suggest glaucomatous changes in uveitic children with raised IOP.

Combined ab interno trabeculotomy and lens extraction: a novel management option for combined uveitic and chronic narrow angle raised intraocular pressure

Minimally invasive glaucoma surgery is a developing area that has the potential to replace traditional glaucoma surgery, with its known risk profile, but at present there are no randomised controlled data to validate its use. We report on a case where sequential bilateral combined ab interno trabeculotomy and lens extraction surgery was performed on a 45-year-old woman with combined uveitic and chronic narrow angle raised intraocular pressure. Maximal medical management alone could not control the intraocular pressure. At 12-month follow-up, the patient had achieved stable intraocular pressure in both eyes on a combination of topical ocular antiglaucomatous and steroid therapies. This case demonstrates the effectiveness of trabecular meshwork ablation via ab interno trabeculotomy in a case of complex mixed mechanism glaucoma.

Evaluation of Efficacy and Safety of Latanoprost/Timolol versus Travoprost/Timolol Fixed Combinations for Ocular Hypertension Associated with Uveitis

PURPOSE

To compare latanoprost/timolol (LT) versus travoprost/timolol (TT) fixed combinations for ocular hypertension (OHT) associated with uveitis.

METHODS

Thirty-six patients (55 eyes) who were treated with LT (28 eyes) or TT (27 eyes) for OHT associated with uveitis were reviewed retrospectively. Intraocular pressure (IOP) and inflammation scores at the initiation of treatment and at the last visit during therapy were analyzed.

RESULTS

Although IOP was reduced significantly in both LT and TT groups, the reduction rate was significantly greater with TT group than with LT. The differences in the reduction of IOP between the groups remained significant when the cases were classified into inflammation-induced OHT and steroid-induced OHT. Inflammation score was not exacerbated by LT or TT treatment.

CONCLUSIONS

Both LT and TT are safe and effective for the treatment of OHT associated with uveitis and greater IOP reduction may be achieved by TT than by LT treatment.

Ocular hypertension and hypotony as determinates of outcomes in uveitis

Purpose

To assess ocular hypertension (OHT) and hypotony as outcomes of uveitis in patients managed in a mid-Atlantic tertiary care center.

Methods

Retrospective, observational study of uveitis patients seen at the University of Virginia from 1984 to 2014.

Results

A total of 442 patients (582 eyes) with uveitis were identified and included in the study. The patient population was 57.0% female. Overall, 61.9% were Caucasian and 26.6% were African American. Mean age was 46.8 years. Overall, 11.5% of the eyes had OHT at initial visit, and 7.9% had OHT at final visit (P=0.035). For each additional decade of life, the odds that an eye had OHT were elevated by a factor of 1.15 (95% confidence interval [CI]: [1.02, 1.30], P=0.027) at initial visit and by a factor of 1.15 (95% CI: [1.00, 1.32], P=0.055) at final visit. The odds that an anterior uveitis eye had OHT were greater by a factor of 2.50 (95% CI: [1.22, 5.14], P=0.013) than the odds for a nonanterior uveitis eye at initial visit and greater by a factor of 2.61 (95% CI: [1.24, 5.50], P=0.011) at final visit. For each additional 0.5 logarithm of the minimum angle of resolution increase in initial visual acuity, the odds that an affected eye had OHT were elevated by a factor of 1.18 (95% CI: [1.00, 1.39], P=0.047) at initial visit and 1.23 (95% CI: [0.99, 1.54], P=0.065) at final visit. Overall, 21 of 582 eyes (3.6%) were hypotonous initially, while 24 of 582 eyes (4.1%) were hypotonous at final follow-up (P=0.631).

Conclusion

OHT was associated with increasing age, anterior uveitis, and poor presenting visual acuity. Ocular hypotony was more common in anterior uveitis than in nonanterior uveitis. Fluctuations in intraocular pressure are an important cause of visual impairment in patients with uveitis. Careful monitoring of all uveitis patients, and especially those most at risk for fluctuations in intraocular pressure, can preserve vision and improve patient outcomes.

Improved Surgical Success of Combined Glaucoma Tube Shunt and Retisert(®) Implantation in Uveitic Eyes: A Retrospective Study

Introduction

The purpose of this study was to determine whether the outcomes following placement of a fluocinolone acetonide implant (Retisert^®; Bausch & Lomb, Inc.) combined with an Ahmed™ glaucoma valve (New World Medical, Inc.) in eyes with uveitic glaucoma (UG Retisert) were different when compared to an Ahmed valve alone in eyes with uveitic glaucoma or primary open angle glaucoma (UG non-Retisert and POAG, respectively).

Methods

Retrospective, interventional study of consecutive uveitic and OAG eyes undergoing Ahmed valve (AV) implantation with or without combined Retisert insertion at a single academic center between 2009 and 2012. Surgical success was defined as intraocular pressure (IOP) between 5 and 18 mmHg and greater than 20% reduction of IOP at two consecutive visits without need for additional IOP-lowering medications or surgical procedures. Secondary outcome measures included IOP and number of glaucoma medications.

Results

Sixty eyes of 60 patients (22 UG Retisert, 16 UG non-Retisert, 22 POAG) were included. Mean ± standard deviation surgical success duration was significantly greater in UG Retisert eyes, 629 ± 53 days, compared to those with UG non-Retisert, 361 ± 37 days, and POAG, 472 ± 65 days (P = 0.034). At 24 months, the mean IOP was 11.7, 12.1, and 15.0 mmHg and the average patient was on 1.45, 0.71, and 2.00 medications in the UG Retisert, UG non-Retisert, and POAG valve groups, respectively.

Conclusion

Retisert implants when combined with AV in uveitic glaucoma had a longer duration of surgical success than uveitic or POAG treated with AV insertion alone.

Electronic supplementary material

The online version of this article (doi:10.1007/s40123-015-0041-3) contains supplementary material, which is available to authorized users.

Uveitis and glaucoma: new insights in the pathogenesis and treatment

Glaucoma is a potentially blinding complication of uveitis, where intraocular inflammation, secondary corticosteroid response, and varying types and degrees of angle abnormalities contribute to its pathogenesis. Management of uveitic glaucoma remains challenging. Treatment is targeted at reducing the inflammation and lowering the intraocular pressure. Recent studies have highlighted the role of viruses, such as cytomegalovirus, herpes simplex virus, and more recently Ebola virus, in the pathogenesis of uveitic glaucoma. Antiviral therapy may be beneficial in eyes with detectable viral DNA. The success of glaucoma surgery is decreased in eyes with uveitic glaucoma, and surgical interventions are associated with a higher incidence of postoperative complications. Novel glaucoma surgical and laser treatments may improve the predictability of surgery for uveitic glaucoma, but these require further evaluation.