The Pathogenesis of Raised Intraocular Pressure in Uveitis

Update on Diagnosis and Treatment of Uveitic Glaucoma

Glaucoma is a common and potentially blinding complication of uveitis. Many mechanisms are involved alone or in combination in the pathogenesis of uveitic glaucoma (UG). In terms of diagnostic evaluation, the effects of inflammatory activity in the retinal nerve fiber layer may be a source of bias in the interpretation of optical coherence tomography measurements. For the successful treatment of UG, the control of intraocular inflammation specific to the cause or anti-inflammatory treatment, combined with IOP management, is mandatory. The early institution of specific treatment improves the prognosis of UG associated with CMV. The young age of UG patients along with increased failure rates of glaucoma surgery in this group of patients warrants a stepwise approach. Conservative and conjunctival sparing surgical approaches should be adopted. Minimally invasive surgical approaches were proved to be effective and are increasingly being used in the management of UG along with the traditionally used techniques of trabeculectomy or tubes. This review aims to summarize the progress that recently occurred in the diagnosis and treatment of UG.

Toxic anterior segment syndrome (TASS): A review and update

Toxic anterior segment syndrome (TASS) is an acute, sterile, postoperative inflammatory reaction of the anterior segment without vitreous involvement, following an uncomplicated and uneventful ocular surgery, having broad and multiple etiologies. The symptoms of decreased visual acuity and ocular discomfort generally occur within the first 12-48 h after intraocular surgery. The clinical signs include prominent limbus-to-limbus corneal edema, anterior chamber cells, aqueous flare, fibrinous inflammation, and/or keratic precipitates. There can be sight-threatening complications of TASS, such as permanent corneal decompensation, intractable glaucoma, and cystoid macular edema. The causes of TASS are emerging and being reported, so are the newer treatment options for managing the inflammation and its complications. Prevention guidelines for TASS are being updated, and a traceability system for surgical instruments and intraocular fluids used during the surgery is being perpetually developed. It is important to recognize TASS and start treatment on an immediate effect. Hereby, we review the literature on TASS, emphasizing its etiology, pathophysiology, management, prognosis, complications, and the importance of prevention as well as prompt recognition.

Incident glaucoma and ocular hypertension after periocular and intravitreal steroid injections: a claims-based analysis

BACKGROUND/AIMS

This study aims to determine the incidence and risk of open-angle glaucoma or ocular hypertension (OHT) following ocular steroid injections using healthcare claims data.

METHODS

We retrospectively reviewed deidentified insurance claims data from the IBM MarketScan Database to identify 19 156 adult patients with no prior history of glaucoma who received ocular steroid injections between 2011 and 2020. Patient demographics and steroid treatment characteristics were collected. Postinjection glaucoma/OHT development was defined as a new diagnosis of glaucoma/OHT, initiation of glaucoma drops, and/or surgical or laser glaucoma treatment. Cox proportional hazards models were used to determine the risk of glaucoma/OHT development within 5 years after first steroid injection.

RESULTS

Overall, 3932 (20.5%) patients were diagnosed with new glaucoma/OHT, 3345 (17.5%) started glaucoma drops and 435 (2.27%) required a laser or surgical glaucoma procedure within 5 years of first steroid injection. Triamcinolone subconjunctival injections were associated with a lower risk of glaucoma/OHT development than retrobulbar or intravitreal steroid injections (p<0.001, HR 0.68, 95% CI 0.59 to 0.79), whereas the 0.59 mg fluocinolone acetonide intravitreal implant had the highest risk of glaucoma/OHT development (p=0.001, HR 2.01, 95% CI 1.34 to 3.02). The risk of glaucoma/OHT development was also higher for patients receiving multiple steroid injections (p<0.001), with the largest increase in risk occurring after three total steroid injections.

CONCLUSION

Patients receiving ocular steroid injections are at risk of developing glaucoma/OHT, even with no prior glaucoma/OHT diagnosis or treatment. Patients should be closely monitored for the development of glaucoma following ocular steroid injections, particularly in the setting of intravitreal and/or repeated steroid administration.

Iris abnormalities may influence the efficacy and filtration strategies of Posner-Schlossman syndrome: a retrospective study involving trabeculectomy, ExPRESS and Ahmed valve implants

PURPOSE

To evaluate and compare the one-year efficacy and influencing factors of different filtration surgeries on Posner-Schlossman syndrome (PSS) patients.

METHODS

A retrospective study enrolling 91 PSS patients who underwent filtering surgeries and were followed for at least one year. Unilateral PSS was diagnosed as recurrent attacks of mild, unilateral, non-granulomatous anterior uveitis, elevated intraocular pressure (IOP), keratic precipitates (KPs) on the corneal endothelium, open angle, no posterior synechia, and no inflammatory lesions in the posterior segment; the IOP and anterior segment returned to normal between attacks. Medical histories and thorough ocular examination results were collected. Trabeculectomy and ExPRESS were chosen as the first line and AGV was considered for those under high risk of fibrosis. Follow-up data, mainly IOP, best-corrected visual acuity (BCVA), and anterior segment manifestations at the 1st week, 6th month, and 12th month were generated and analyzed. Iris abnormalities were determined by depigmentation or atrophic changes on the anterior segment photograph. Complete surgical success was defined as 5 mmHg < IOP ≤ 21 mmHg without IOP-lowering drug or needle revision; qualified surgical success was defined as 5 mmHg < IOP ≤ 21 mmHg with IOP-lowering drugs or needle revisions. Survival analysis was performed to obtain the success rates.

RESULTS

At the 12th month, the complete surgical success rate of trabeculectomy (N = 54), ExPRESS (N = 23), and AGV group (N = 14) was 58.97% (95%CI 46.91-77.09%), 84.21% (95%CI 68.33-100.87%), and 100%; the qualified success rate was 71.79% (95%CI 62.46-88.34%), 89.47% (95%CI 77.07-103.33%), and 100%, respectively. Patients undergoing trabeculectomy experienced the largest decline of BCVA (from 0.58±0.46 to 1.01±0.51, P < .05); the trabeculectomy group endured the highest IOP (20.84±9.92 mmHg) compared to ExPRESS (14.51±2.86 mmHg, P < .05) and AGV group (13.17±3.32 mmHg, P < .05). At the 12th month, in the ExPRESS group, patients with iris abnormalities had higher IOP than the normal ones (15.65±2.05 mmHg, 12.93±3.17 mmHg, P < .05). ExPRESS helped patients with iris abnormalities maintain lower IOP than trabeculectomy (15.65±2.05 mmHg, 22.52±10.67 mmHg, P < .05). Three patients developed hypotony at the 3rd month (1 in ExPRESS and 2 in trabeculectomy group).

CONCLUSION

AGV and ExPRESS performed better than trabeculectomy in PSS patients in terms of IOP and success rate. Iris abnormalities might influence the postoperative IOP and this may be valuable in guiding filtration strategies.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (No. ChiCTR1800017532, date: 2018/08/02).

"Ab Interno" Surgery of the Schlemm's Canal in Postuveitic Glaucoma Patients

BACKGROUND

Patients with uveitis have a higher risk of developing glaucoma not only because of the disease by itself, but also because of the ongoing corticosteroid therapy. The pathogenesis of uveitic glaucoma is characterized by a complex of biochemical and cellular processes, as well as morphological changes in the trabecular meshwork. Treatment of secondary chronic glaucoma is challenging and often requires different approaches and solutions.

PURPOSE

To present the "ab interno" procedure of the Schlemm's canal (SC) performed with the help of TrabEx+ (MST, Redmond, WA, USA) in postuveitic glaucoma patients.

METHODS

The observed group included patients with postuveitic secondary glaucoma, which consisted of 12 pseudophakic patients (12 eyes). Patients are with intraocular pressure higher than 25 mmHg and on maximal local therapy. Due to insufficient conservative control on IOP, surgical solutions are needed. We describe a new, minimally invasive surgical procedure-the technique of the operation, the postoperative results and complications.

RESULTS

We present the achieved intraocular pressure (on the first day, 2 weeks, 1 month, 6, 8 12 and 18 months). The morphology of the trabecular area was demonstrated by gonioscopy. The effects of the therapy on the glaucoma progression, was evaluated with perimetry and OCT.

DISCUSSION

The following procedure is a minimally invasive procedure and provides good control of intraocular pressure. Aqueous veins in the conjunctiva are significantly preserved compared to conventional filtration trabeculectomy. This potentially modulates the physiological outflow pathways by ablating trabeculum strip the cause of increased outflow resistance-the inner wall of the SC.

CONCLUSION

Removal of the inner wall of the SC, using Trabex+ (MST, Redmond, WA, USA), demonstrates promising results in the selected patients with a minimally invasive nature.

Outcomes of Kahook Dual Blade Goniotomy for Uveitis Associated Open Angle Glaucoma or Ocular Hypertension

PRCIS

Kahook Dual Blade (KDB) goniotomy can successfully lower intraocular pressure in some patients with uveitis-associated ocular hypertension or glaucoma.

PURPOSE

The purpose of this study was to report a case series of patients that underwent KDB goniotomy at a single institution for uveitis-associated ocular hypertension or glaucoma with an open angle.

METHODS

We performed a retrospective chart review of all patients with uveitis-associated ocular hypertension or glaucoma who underwent KDB goniotomy with trabecular meshwork excision alone or in combination with phacoemulsification cataract surgery at a single center between August 2017 and February 2020. The case series included 45 eyes of 37 patients. All eyes developed ocular hypertension refractory to maximum-tolerated medical therapy and required surgical intervention. Two eyes were excluded as they were lost to follow-up before 5 months postoperatively. Surgical success was defined as reaching the goal intraocular pressure or lower for each patient, including ongoing medical therapy.

RESULTS

At most recent follow-up, 25 (55.6%) of 45 eyes had an intraocular pressure that was at goal. Mean follow-up time was 15.2±12.1 months ranging from 0.5 to 36 months postoperatively, considering that patients were eliminated from the data analysis once they required a second surgery. The mean number of preoperative medications, including oral carbonic anhydrase inhibitors was 3.7±1.2 medications. The mean number of postoperative medications through the last clinic visit was 2.5±1.9 medications for a mean reduction of 1.2±1.6 medications ( P -value <0.0001*).

CONCLUSIONS

This larger case series shows that some patients with uveitis-associated ocular hypertension or glaucoma with an open angle may have success with KDB goniotomy.

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.

Risk of Elevated Intraocular Pressure With Difluprednate in Patients With Non-Infectious Uveitis

PURPOSE

To evaluate the risk factors associated with clinically important intraocular pressure (IOP) elevation with topical difluprednate treatment in patients with non-infectious uveitis.

DESIGN

Retrospective cohort study.

METHODS

Fifty-four eyes of 54 patients with non-infectious uveitis treated with topical difluprednate at the current institution were included. Demographics and clinical characteristics of uveitis patients were collected. The main outcome measure was development of clinically important IOP elevation defined as IOP ≥21 mmHg and an increase of ≥10 mmHg from baseline.

RESULTS

A clinically important IOP elevation was observed in 17 patients (31.5%). The mean time to clinically important IOP elevation was 7.4±4.8 weeks (range 3-19). Statistically significant risk factors for incident clinically important IOP elevation were being a child (adjusted hazard ratio [aHR] 7.85 [95% CI 1.48-41.56], P = .02) and concurrent use of systemic steroids (aHR 5.31 [95% CI 1.18-24.00], P = .03). Patients with concurrent systemic corticosteroids developed clinically important IOP elevation earlier than those without systemic corticosteroid (mean 5.7±3.4 [range 3-14] vs 10.4±5.7 [range 4-19] weeks, P = .05). Incident IOP ≥30 mmHg occurred in 7 patients (13.0%). All patients responded well to the cessation of difluprednate and/or use of topical antiglaucomatous agents and no eyes required glaucoma surgery.

CONCLUSIONS

This study demonstrated that clinically important IOP elevation is common in uveitis patients with topical difluprednate treatment. Children and patients with concurrent systemic corticosteroids are at substantial risk of developing clinically important IOP elevation.

Methotrexate Effectively Controls Ocular Inflammation in Japanese Patients With Non-infectious Uveitis

This single-center retrospective study investigated the clinical characteristics and efficacy of methotrexate (MTX) for the treatment of non-infectious uveitis for more than 6 months at Hiroshima University, from February 2016 to May 2021. Outcome variables included changes in systemic immunosuppressive treatment and intraocular inflammation. Out of 448 patients with non-infectious uveitis, 35 patients (14 male patients and 21 female patients; 65 eyes) treated with MTX for more than 6 months were analyzed. There were 15 patients with anterior uveitis and 20 with posterior and panuveitis. The mean dose of systemic corticosteroids decreased from 12.1 mg/day at baseline to 1.3 mg/day at 6 months and 0.6 mg at 12 months after starting MTX, and approximately 90% of patients were corticosteroid-free at 12 months. The percentage of eyes with inactive uveitis at 6, 12, and 24 months was 49.2%, 59.6%, and 90.0%, respectively. Mean relapse rate score also significantly decreased from 2.88 at baseline to 0.85 at 12 months (p < 0.001). Inflammatory control was achieved with MTX doses of 8-16 mg/week, with a median dose of 12 mg/week. Adverse effects of MTX were observed in 34.3% of patients, and 11.4% required discontinuation; most commonly hepatotoxicity (58.3%), followed by fatigue (25.0%), and hair loss (16.7%). No significant differences were found between the survival curves of patients with anterior uveitis and posterior/panuveitis (Wilcoxon rank-sum test). The percentage of eyes without IOP-lowering eye drops was significantly higher in patients with posterior/panuveitis at 24 months (p = 0.001). Our study suggests that MTX is effective in controlling ocular inflammation for Japanese patients with non-infectious uveitis. Relatively high incidence of MTX-related adverse effects in the Japanese population indicates that careful monitoring and dose adjustments are crucial for the long-term use of this therapy.

High rate of conversion from ocular hypertension to glaucoma in subjects with uveitis

AIMS

To examine presentation, management and long-term sequelae of ocular hypertension and uveitic glaucoma.

METHODS

Retrospective observational study of all subjects with uveitic glaucoma or ocular hypertension seen in Auckland uveitis clinics over the last 10 years.

RESULTS

A total of 188 eyes of 139 subjects with uveitic glaucoma or ocular hypertension were included for analysis. Total follow-up was 1854.5 eye years (mean 9.9 years). The mean age at uveitis diagnosis was 49.3 years. 52.5% of subjects were male. The most common diagnoses were idiopathic uveitis (29.3%), sarcoidosis (13.3%), herpes zoster (6.9%), HLA-B27 uveitis (6.9%), tuberculosis (5.9%) and Posner-Schlossmann or cytomegalovirus (CMV) uveitis (5.3%). Median intraocular pressure (IOP) at diagnosis was 35 mm Hg (IQR 29-45). 144 eyes (77.0%) developed glaucoma during the follow-up period, of whom 41 lost some central vision due to glaucoma. Oral acetazolamide was required for IOP control in 64.5%, 50 eyes underwent trabeculectomy, 18 eyes required a tube and 6 underwent minimally invasive glaucoma surgery.

CONCLUSION

Rapid progression was observed from ocular hypertension to uveitic glaucoma. Uveitic glaucoma is aggressive, with high likelihood of requiring surgical management and high risk of central vision loss. Close collaboration between uveitis and glaucoma specialists is required to maximise outcomes for these patients.

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.

Reduction of Neuroinflammation by δ-Opioids Via STAT3-Dependent Pathway in Chronic Glaucoma Model

The main objective of this study was to determine the inhibition of pro-inflammatory cytokines and their associated signaling molecules by δ-opioid receptor activation by a selective ligand, SNC-121 in chronic rat glaucoma model. Intraocular pressure was raised in rat eyes by injecting 2 M hypertonic saline into the limbal veins. SNC-121 (1 mg/kg; i. p) or Stattic (5 mg/kg; i. p) was administered in Brown Norway rats daily for 7 days. The mRNA expression of IL-1β, TNF-α, Fas, IL-6, leukemia inhibitory factor, and IFN-γ was increased significantly in the retina of ocular hypertensive animals at day 7, post injury. Administration of SNC-121 (1 mg/kg; i. p. injection) for 7 days (once a day) completely inhibited the increase in the mRNA and protein expression of pro-inflammatory cytokines. Mechanistically, we provide data showing a significant increase in the phosphorylation of STAT3 at tyrosine 705 whereas a moderate but significant increase in the total STAT3 protein expression was also seen in the retina of ocular hypertensive animals. Data illustrated that SNC-121 administration completely abrogated ocular hypertension-induced increase in STAT3^Y705 phosphorylation. Interestingly, acetylation of STAT3 at lysine 685 (AcK685) was reduced in ocular hypertensive animals and subsequently increased significantly by SNC-121 treatment. Stattic, a selective STAT3 inhibitor, administration resulted in a complete attenuation in the production of IL-1β and IL-6 in ocular hypertensive animals. In conclusion, δ-opioid receptor activation suppressed the phosphorylation of STAT3 at tyrosine 705 and increased acetylation at lysine 686 and these posttranslational modifications can regulate the production of some but not all pro-inflammatory cytokines in response to glaucomatous injury.

[The trabecular meshwork: Structure, function and clinical implications. A review of the littérature (French translation of the article)]

Glaucoma is a blinding optic neuropathy, the main risk factor for which is increased intraocular pressure (IOP). The trabecular meshwork, located within the iridocorneal angle, is the main pathway for drainage of aqueous humor (AH) out of the eye, and its dysfunction is responsible for the IOP elevation. The trabecular meshwork is a complex, fenestrated, three-dimensional structure composed of trabecular meshwork cells (TMC) interdigitated into a multilayered organization within the extracellular matrix (ECM). The purpose of this literature review is to provide an overview of current understanding of the trabecular meshwork and its pathophysiology in glaucoma. Thus, we will present the main anatomical and cellular bases for the regulation of aqueous humor outflow resistance, the pathophysiological mechanisms involved in trabecular dysfunction in the various types of glaucoma, as well as current and future therapeutic strategies targeting the trabecular meshwork.

Differential diagnosis of acute ocular pain: Teleophthalmology during COVID-19 pandemic - A perspective

Ocular pain is a common complaint which forces the patient to seek immediate medical attention. It is the primeval first response of the body to any severe condition of the eye such as trauma, infections and inflammation. The pain can be due to conditions directly affecting the eye and ocular adnexa; or indirect which would manifest as referred pain from other organ structures such as the central nervous system. Paradoxically, there are several minor and non-sight threatening conditions, which also leads to ocular pain and does not merit urgent hospital visits. In this perspective, we intend to provide guidelines to the practising ophthalmologist for teleconsultation when a patient complains of pain with focus on how to differentiate the various diagnoses that can be managed over teleconsultation and those requiring emergency care in the clinic. These guidelines can decrease unnecessary hospital visits, which is the need of the hour in the pandemic era and also beyond. Patients who are under quarantine and those who are unable to travel would be benefitted, and at the same time, the burden of increased patient load in busy hospital systems can be reduced.

[Uveitic glaucoma in Behçet's disease: When everything gets complicated]

INTRODUCTION

Behçet's disease is a systemic disease of unknown etiology. Its ocular manifestations are multiple and polymorphic, with uveitis at the top of the list. Classically, uveitis in Behçet's disease does not cause elevation of intraocular pressure. However, this may be found in 10 to 20% of cases, secondary to trabeculitis, trabecular obstruction by inflammatory cells, anterior or posterior synechiae, or induced by prolonged use of corticosteroids. Its occurrence is a major complication, the management of which is especially delicate when glaucoma occurs. The purpose of this study was to study the factors predictive of glaucoma in Behçet's disease.

MATERIALS AND METHODS

This is a retrospective study of all the charts of patients consecutively hospitalized for Behçet's disease over a period of 8years in the ophthalmology A department of the specialty hospital of Rabat university medical center.

RESULTS

Fifty patients were treated for Behçet's disease during the study period. There were 41 men (82%), and 9 women (18%). Glaucoma was diagnosed in 11 patients (22%). The mean age of this subgroup was 31years, with a gender ratio of 6 women/5 men. The glaucoma was associated with anterior synechiae in 4 cases, primary open-angle glaucoma in 5 cases, neovascular glaucoma in 1 case and seclusio pupillae in 1 case. Therapeutically, all patients were on glaucoma eye drops, and five underwent filtering surgery. Statistically, on univariate analysis, ocular hypertension was observed particularly in patients with low initial visual acuity (less than 1/10) (P=0.001), with severe posterior segment involvement, especially retinal vasculitis (29% vs. 6%, P=0.04), macular edema (40% vs. 4%, P=0.001), and optic disc edema (50% vs. 15%, P=0.02). A high number of recurrences was also associated with glaucoma (1.0 vs. 3.0, P<0.0001). On multivariate analysis, low baseline visual acuity, presence of retinal vasculitis, and high number of recurrences were independent risk factors for ocular hypertension in our patients followed for Behçet's disease.

CONCLUSION

Glaucoma can complicate the management of Behçet's disease. This glaucoma will be more difficult to manage in this delicate pathological context. It requires special vigilance in patients with severe posterior segment inflammation, to institute effective management to avoid its potentially blinding complications.

Surgical management of uveitis-glaucoma-hyphema syndrome

AIM

To report outcomes of patients after intraocular lens (IOL) repositioning or exchange for the version of the uveitis-glaucoma-hyphema (UGH) syndrome that does not include closed loop anterior chamber IOL (nUGH).

METHODS

Chart review of patients with nUGH who underwent IOL repositioning or exchange by one surgeon were reviewed. The main outcome measures were best corrected visual acuity (BCVA) as a decimal fraction preoperatively and postoperatively after IOL repositioning or exchange. Clinical findings evaluated included the presence of uveitis, hyphema, elevated intraocular pressure (IOP), and other complications such as pigment dispersion or vitreous hemorrhage. The number of anti-inflammatory and glaucoma medications were assessed before and after IOL repositioning or exchange.

RESULTS

The study included 14 pseudophakic eyes. The median time at the onset of contemporary UGH after cataract extraction and IOL implantation (CE/IOL) was 7.5y. IOL repositioning or exchange was performed at a mean duration of 8.1±4.7mo (median: 4mo) after onset of UGH. The mean BCVA was improved from 0.45±0.26 preoperatively after onset of UGH syndrome to 0.76±0.22 (P=0.016) after IOL repositioning or exchange. Among the 14 eyes, uveitis, elevated IOP, and hyphema were present preoperatively in 13, 13, and 6 eyes, respectively. Uveitis and hyphema resolved in all cases after IOL surgery. The mean IOP was reduced from 26.4±4.5 mm Hg preoperatively to 14.7±4.9 postoperatively (P=0.01). The mean number of glaucoma medications used was reduced from 1.7±1.1 medications preoperatively to 0.8±1.08 (P=0.04) postoperatively.

CONCLUSION

IOL repositioning or exchange is an effective treatment in many cases for medically resistant contemporary UGH syndrome.

The trabecular meshwork: Structure, function and clinical implications. A review of the literature

Glaucoma is a blinding optic neuropathy, the main risk factor for which is increased intraocular pressure (IOP). The trabecular meshwork, located within the iridocorneal angle, is the main pathway for drainage of aqueous humor (AH) out of the eye, and its dysfunction is responsible for the IOP elevation. The trabecular meshwork is a complex, fenestrated, three-dimensional structure composed of trabecular meshwork cells (TMC) interdigitated into a multilayered organization within the extracellular matrix (ECM). The purpose of this literature review is to provide an overview of current understanding of the trabecular meshwork and its pathophysiology in glaucoma. Thus, we will present the main anatomical and cellular bases for the regulation of aqueous humor outflow resistance, the pathophysiological mechanisms involved in trabecular dysfunction in the various types of glaucoma, as well as current and future therapeutic strategies targeting the trabecular meshwork.

Changes in intraocular pressure and aqueous flare in eyes with multiple evanescent white dot syndrome

PURPOSE

To study the changes in intraocular pressure (IOP) and aqueous flare in eyes with multiple evanescent white dot syndrome (MEWDS) during the disease course.

STUDY DESIGN

Retrospective observational study.

METHODS

Twenty-one patients with unilateral MEWDS were retrospectively evaluated. IOP values were compared between the affected and fellow eyes 2 weeks, 1 month, and 3 months following disease onset in 17 patients, and within 7 days from disease onset in 11 patients. Aqueous flare values measured using a laser flare-cell meter in ten eyes between 1 weeks and 1 month from disease onset were compared between the affected and fellow eyes.

RESULTS

IOP values were significantly lower in the affected eyes than in the fellow eyes at both 2 weeks (P=0.002) and 1 month from disease onset (P=0.02). However, IOP values of affected eyes did not show significant differences from the fellow eyes within 7 days ((P=0.11) and 3 months of onset (P=0.30). Aqueous flare values were significantly increased in the affected eyes compared to those in the fellow eyes (P=0.010) and significantly correlated with IOP values (r=-0.67, P=0.035).

CONCLUSION

IOP values mildly decreased in association with aqueous flare values in the acute phase in eyes with MEWDS.

A Review of the Differential Diagnosis of Acute Infectious Conjunctivitis: Implications for Treatment and Management

The diagnosis of acute infectious conjunctivitis can be difficult. Clinical ambiguity exists between the acute viral and bacterial as well as the allergic forms, which can confound diagnosis. Also, discrimination between viral or bacterial origins of infectious conjunctivitis based on historical, nonspecific, clinical signs and symptoms contributes to a high rate of misdiagnosis and overuse of antibiotic treatment. Therefore, in order to effectively treat acute infectious conjunctivitis, physicians must be aware of the clinical signs and symptoms and available diagnostic tests that can provide a more accurate differential diagnosis.

Steroid-induced glaucoma: Epidemiology, pathophysiology, and clinical management

Glucocorticoids are a class of anti-inflammatory drugs commonly used to treat various ocular and systemic conditions. Although the role of glucocorticoids in the treatment of numerous serious inflammatory diseases is pivotal, their prolonged use may increase intraocular pressure resulting in steroid-induced glaucoma. We provide a detailed update on steroid-induced glaucoma as a preventable cause of blindness in the adult and pediatric population and describe its epidemiology, social impact, and risk factors. Furthermore, we explore the propensity of different steroids to increase the intraocular pressure, the role of different routes of steroid administration, dosage and duration of treatment, as well as the clinical features, genetics, and management of steroid-induced glaucoma.

[Pharmacological treatment strategies and surgical options for uveitis]

BACKGROUND

Modern treatment of uveitis aims at a complete control of inflammatory activity, preservation of visual function and the prevention of secondary organ damage as a consequence of the underlying inflammatory disease and its treatment.

OBJECTIVE

This article gives an update about the strategies of pharmacological and surgical options for uveitis.

MATERIAL AND METHODS

The outcomes reported here are based on a PubMed search using the terms <"uveitis" AND "therapy"> and <"uveitis" AND "surgery" OR "surgical treatment">. All prospective studies and case series with more than 20 cases as well as review articles from the last 5 years along with cited cross-references were evaluated.

RESULTS

Local and systemic corticosteroids form the foundation of treatment after exclusion of an infectious etiology. If uveitis activity is not controlled within 6 weeks or if the daily corticosteroid dosage is unacceptably high, a treatment escalation using immunomodulatory drugs is required. If a complete control of inflammatory activity is not achieved, in a third phase treatment is supplemented by antibody-based treatment or cytokines, so-called biologics, with the aim of complete long-term freedom from disease without local or systemic steroid treatment. This target is achieved in 65-80% and guarantees long-term functional stability and anatomical integrity. Early treatment escalation in cases of persisting or recurrent activity as a rule prevents new secondary organ damage. Surgical options are utilized for diagnostic purposes, the administration of intravitreal drugs and for treatment of secondary complications.

CONCLUSION

Just like the majority of immunological diseases, uveitis is a chronic disease requiring long-term and possibly lifelong treatment and remission (absence of inflammation without treatment) is achieved in only <20%. Surgical interventions can be performed with a good prognosis, if the optic nerve head and macula are not involved. They have a substantially lower complication rate when freedom from symptoms exists preoperatively for at least 3 months.

Toxic anterior segment syndrome: A review

Toxic anterior segment syndrome is a surgical complication characterized by a noninfectious anterior chamber inflammatory reaction having multiple etiologies. The clinical signs (prominent limbus-to-limbus corneal edema, anterior chamber inflammation) and symptoms (decreased visual acuity, discomfort) generally occur within the first 12-48 hours after intraocular surgery. Most patients achieve good clinical and visual outcomes when there is a prompt clinical diagnosis and adequate treatment. We review the literature on toxic anterior segment syndrome, emphasizing its etiology, pathophysiology, and clinical and surgical management, as well as prognosis and sequelae. Our goal is to reduce the frequency of toxic anterior segment syndrome by highlighting the importance of prevention, early recognition, and distinguishing toxic anterior segment syndrome from infectious endophthalmitis.

Long-term outcomes of uveitic glaucoma treated with Ahmed valve implant in a series of Chinese patients

AIM

To report long-term outcomes of secondary glaucoma due to uveitis treated with Ahmed glaucoma valve (AGV) implantation in a series of Chinese patients.

METHODS

The retrospective study included 67 eyes from 56 patients with uveitic glaucoma who underwent AGV implantation. Success of the treatment was defined as patients achieving intraocular pressure (IOP) levels between 6 and 21 mm Hg with or without additional anti-glaucoma medications and/or a minimum of 20% reduction from baseline IOP. The main outcome measurements included IOP, the number of glaucoma medications at 1, 3, 6, 12, 24, 36, 48 and 60mo after surgery, surgical complications, final best-corrected vision acuity (BCVA), visual field (VF) and retinal nerve fiber layer (RNFL).

RESULTS

The mean follow-up was 53.3±8.5 (range 48 to 60)mo. The cumulative probability of success rate was 98.5%, 95.5%, 89.6%, 83.6%, 76.1%, 70.1%, 65.7% and 61.2% at 1, 3, 6, 12, 24, 36, 48 and 60mo, respectively. IOP was reduced from a baseline of 30.8±6.8 to 9.9±4.1, 10.1±4.2, 10.9±3.7, 12.9±4.6, 13.8±3.9, 13.2±4.6, 12.3±3.5 and 13.1±3.7 mm Hg at 1, 3, 6, 12, 24, 36, 48 and 60mo, respectively (P<0.01). The number of postoperative glaucoma medications was significantly decreased compared with baseline at all time points during the study period (P<0.05). There was no significant difference between preoperative and postoperative BCVA. Remarkable surgical complications were not found after surgery. The VF and RNFL of the patients were stable after the surgery.

CONCLUSION

AGV implantation is safe and effect in terms of reducing IOP, decreasing the number of glaucoma medications, and preserving vision for patients with uveitic glaucoma.

Outcomes of severe uveitic glaucoma treated with Baerveldt implant: can blindness be prevented?

PURPOSE

To evaluate long-term outcomes on efficacy and safety of severe uveitic glaucoma treated with a Baerveldt glaucoma implant (BGI).

METHODS

A retrospective study of 47 eyes of 47 patients with uveitic glaucoma treated by a BGI between September 2002 and September 2015. Main outcome measures were intraocular pressure (IOP), number of glaucoma medications, course of the uveitis, visual acuity (VA) and complications.

RESULTS

Mean IOP dropped from 30.6 ± 8.1 mmHg with 3.6 ± 1.1 glaucoma medications at baseline to 10.6 ± 4.3 mmHg with 1.0 ± 1.3 glaucoma medications after a mean follow-up of 63.6 ± 43.1 months. In the majority of cases, IOP remained stable during follow-up. However, especially in several patients with viral uveitis, episodes with IOP peaks were observed during a flare-up despite a functioning implant. These peaks remained below preoperative levels. During follow-up, 16 patients (34%) experienced a clinically significant VA loss, mainly because of late-stage glaucoma or hypotony maculopathy. Early postoperative complications were transient choroidal effusion (n = 5), shallow/flat anterior chamber (n = 4), hyphaema (n = 2) and suprachoroidal haemorrhage (n = 1). The most important late postoperative complication was hypotony maculopathy (n = 5), three of these in juvenile idiopathic arthritis (JIA) patients.

CONCLUSION

The BGI is an effective and safe treatment for patients with refractive secondary glaucoma due to uveitis. In a majority of patients, VA remains stable and a low and stable IOP is maintained over time with an acceptable number of complications. In particular, patients with viral uveitis and glaucoma should be closely monitored for IOP peaks that may occur during episodes of a flare-up of uveitis, whereas at the other end of the spectrum, patients with JIA seem much more prone to hypotony maculopathy.

Short- to long-term results of Ahmed glaucoma valve in the management of elevated intraocular pressure in patients with pediatric uveitis

OBJECTIVE

The aim of this study was to evaluate the long-term outcome of Ahmed glaucoma valve (AGV) implant for elevated intraocular pressure (IOP) in pediatric patients with uveitis.

DESIGN

This was a retrospective chart review.

PARTICIPANTS

The study included 16 eyes (11 children) with uveitis.

METHODS

Success was defined as having IOP between 6 and 21 mm Hg with (qualified success) or without (complete success) antiglaucoma medications and without the need for further glaucoma or tube extraction surgery.

RESULTS

Mean age of patients at the time of AGV implantation was 14.19 ± 3.25 years. AGV implantation was the first glaucoma surgical procedure in 12 eyes (75%). Average postoperative follow-up period was 64.46 ± 33.56 months. Mean preoperative IOP was 33.50 ± 7.30 mm Hg versus 12.69 ± 3.20 mm Hg at the last follow-up visit (p < 0.001). Three eyes (18.7%) were determined as cases of "failure" because of tube removal in 2 eyes and a second AGV implantation in 1 eye. The cumulative probability of complete success was 68.8% at 6 months, 56.3% at 12 months, 49.2% at 36 months, 42.2% at 48 months, and 35.2% at 84 months, and the cumulative probability of eyes without complication was 75.0% at 6 months, 66.7% at 24 months, 58.3% at 36 months, 48.6% at 48 months and 24.3% at 108 months based on Kaplan-Meier survival analysis.

CONCLUSIONS

Although AGV implant is an effective choice in the management of elevated IOP in pediatric uveitis, antiglaucoma medications are frequently needed for control of IOP. Tube exposure is an important complication in the long term. Differential diagnosis between relapse of uveitis and endophthalmitis is important in patients who received AGV implantation.

Assessment of conditions affecting surgical success of Ahmed glaucoma valve implants in glaucoma secondary to different uveitis etiologies in adults

PurposeThere is little known about the long-term efficacy and safety of Ahmed glaucoma valve (AGV) implant and about the conditions affecting surgical success in uveitic glaucoma (UG).Patients and methodsThe charts of adult patients with UG who underwent AGV implantation from 2006 to 2015 were reviewed retrospectively.ResultsData of 46 eyes of 39 patients were evaluated. Mean follow-up was 51.93±23.08 months. Mean preoperative IOP was 37.05±9.62 mm Hg and mean number of preoperative topical anti-glaucomatous medications was 2.98±0.27. One eye (2%) was defined as failure because of implant extraction surgery. In the rest of the eyes, intraocular pressure (IOP) was under control with or without anti-glaucomatous medications during follow-up. The cumulative probability of complete success (IOP control without medications) was 78% at 6 months, 76% at 1 year, 71% at 2 years, 66% at 3 years, and 63% at 4 years (95% confidence interval, 61.24-87.81). The cumulative probability of eyes without complication was 64% at 6 months, 48% at 12 months, 44% at 24 months, 41% at 36 months, and 38% at 48 months (95% confidence interval, 34.64-62.85). Complete success was lower in eyes with previous ocular surgery than the eyes without (P=0.061) and it was lower in eyes with active inflammation at the time of surgery than the eyes without (P=0.011).ConclusionAGV implantation is an effective and safe alternative method in the management of UG, especially when it is performed as a primary surgical option and when no inflammation is present preoperatively.

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.