Long-term follow-up of trabeculectomy without antimetabolites in patients with uveitis

Management of inflammatory glaucomas

PURPOSE OF REVIEW

To review the epidemiology, pathogenesis and management of uveitic glaucoma in the light of significant studies published during the review period (October 2002-2003).

RECENT FINDINGS

The visual prognosis of glaucoma secondary to certain types of uveitis, for example Juvenile Idopathic Arthritis, remains poor because of late presentation and a high rate of corticosteroid responsiveness. Production of Myocilin is intimately linked with outflow resistance and corticosteroid responsiveness. Although Myocilin gene expression is widespread in the eye, corticosteroid-induction is specific for trabecular meshwork. The hypotensive effect of some glaucoma medications such as Latanoprost and Brimonidine may be partially blocked by concurrent administration of NSAIDs, though the risk of redcrudescence of uveitis with Latanoprost appears to be much lower than initially feared. Use of Mitomycin C in uveitic trabeculectomy has not clearly translated into better long-term IOP control, though this may be due to an absence of prospective studies. Glaucoma drainage devices appear to be more successful in uveitic glaucoma than in other recalcitrant types.

SUMMARY

The management of uveitic glaucoma requires a careful balance between adequate anti-inflammatory therapy and appropriate intraocular pressure (IOP)-lowering to prevent long-term visual loss. In the foreseeable future, successful elucidation of the function of Myocilin is most likely to lead to improvements in the management of corticosteroid-induced and hence uveitic glaucoma.

Viscocanalostomy in patients with glaucoma secondary to uveitis

PURPOSE

To assess the efficacy of viscocanalostomy in eyes with uncontrolled glaucoma secondary to uveitis.

SETTING

Immunology and Uveitis Service, Department of Ophthalmology and Visual Sciences, University Hospital San Raffaele, Milan, Italy.

METHODS

All consecutive patients with glaucoma secondary to uveitis and inadequate intraocular pressure (IOP) control (IOP >21 mm Hg) under maximum-tolerated medical therapy had viscocanalostomy. Patients with active uveitis at the time of surgery, peripheral anterior synechias in the upper quadrant, previous ocular surgery, or sight in only 1 eye were excluded. Eleven eyes of 11 patients with a mean age of 52.2 years +/- 19.9 (SD) were operated on. The etiology of the uveitis was recorded. The ocular variables were IOP, best corrected visual acuity, number of antiglaucoma medications, and complications. Success was defined as an IOP between 6 mm Hg and 21 mm Hg (inclusive) without medication (complete success), or with 1 or more antiglaucoma medications and/or goniopuncture (qualified success). The mean follow-up was 45.9 +/- 11.6 months (range 23 to 56 months).

RESULTS

Viscocanalostomy significantly reduced IOP from a mean baseline value of 35.1 +/- 7.0 mm Hg (range 23 to 48 mm Hg) to a mean final value of 18.1 +/- 4.9 mm Hg (range 12 to 30 mm Hg) (P<.0001). Complete success was achieved in 6 eyes (54.5%) and qualified success, in 10 eyes (90.9%). The mean number of preoperative and final antiglaucoma medications was 3.4 +/- 0.8 (range 2 to 4) and 0.7 +/- 1.2 (range 0 to 3), respectively (P =.0004). Complications were minor and included transient hyphema and postoperative IOP spike.

CONCLUSION

This preliminary study suggests that viscocanalostomy is a safe, effective surgical alternative for treating glaucoma in patients with uveitis.

Trabeculectomy with antiproliferative agents in uveitic glaucoma

PURPOSE

To evaluate the outcome of trabeculectomy with antiproliferative agents in patients with uveitic glaucoma

METHODS

A retrospective chart review of 44 eyes of 44 patients with uveitic glaucoma who underwent trabeculectomy with mitomycin C or 5-fluorouracil. The authors defined complete success as an intraocular pressure of 21 mm Hg or lower without pressure-lowering medications, qualified success as an intraocular pressure of 21 mm Hg or lower with medications, and failure as an intraocular pressure of more than 21 mm Hg with medications, loss of light perception, or the need for reoperation.

RESULTS

The cumulative probability of complete or qualified success was 78% at 1 year and 62% at 2 years. At 2 years, success rates were 39% in males and 71% in females (P = 0.02), 74% in white patients and 55% in black patients (P = 0.58), and 45% in patients with idiopathic uveitis and 74% in patients with sarcoid uveitis (P = 0.17). Sixteen of 31 (51.6%) phakic patients developed new cataracts or had progression of existing cataracts and required cataract extraction. Four of 16 eyes (25%) lost intraocular pressure control and needed repeat trabeculectomy after undergoing cataract surgery.

CONCLUSIONS

Patients with uveitic glaucoma can have good outcomes after trabeculectomy with antiproliferative agents. Male gender was the only statistically significant risk factor for trabeculectomy failure. Cataract management in the presence of a filtering bleb poses a treatment dilemma between improvement of visual acuity and loss of intraocular pressure control.