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

Management of Refractory Glaucoma, a New Surgical Paradigm: Review of the Literature

PURPOSE

To review current therapeutic strategies and innovations in the management of refractory glaucoma, with a focus on recent advancements in implantable surgical devices.

METHODS

A comprehensive literature search across PubMed, Embase, and Cochrane Library, included terms such as "refractory glaucoma," "posterior drainage implants," "cyclodestruction," and "minimally invasive glaucoma surgery." Articles discussing surgical and medical interventions, as well as device innovations, were included.

RESULTS

Therapeutic options include creating new sites for filtering surgery, posterior drainage implants, minimally invasive devices, cyclodestruction, or continuing medical management without surgery.

CONCLUSION

Therapeutic decisions regarding refractory glaucoma should be made on a thoughtful, individualized basis, carefully weighing the expected benefits against the potential risks for the patient. Recent innovations in implantable devices expand the range of surgical possibilities.

Outcomes of Micropulse Transscleral Cyclophotocoagulation in Uveitic Glaucoma

PURPOSE

To report a case series of patients with uveitic glaucoma who were treated with micropulse transscleral cyclophotocoagulation (mpCPC).

METHODS

This retrospective case series consists of patients from the University of Colorado Sue Anschutz-Rodgers Eye Center from 2015 to 2020 who were diagnosed with uveitic glaucoma. Information collected includes demographic data, type of uveitis, glaucoma severity, and prior glaucoma surgeries. Pre- and postoperative best corrected visual acuity, intraocular pressure (IOP), glaucoma medications, degree of inflammation, and uveitis therapies were included up to 36 months postoperatively. Surgical success was defined as an IOP reduction of 30% with achievement of IOP goal using the same number of glaucoma medications or less at 6 months or 1 year. Uveitis success was defined as the absence of persistent anterior uveitis at 3 months.

RESULTS

Six patients and seven eyes with uveitic glaucoma underwent mpCPC. Types of uveitis included idiopathic anterior uveitis, HLA-B27-associated anterior uveitis, varicella zoster virus anterior uveitis, juvenile idiopathic arthritis-associated chronic anterior uveitis, lichen planus-associated intermediate uveitis, and sarcoidosis-associated panuveitis. Two of six eyes (33.3%) at 6 months and three of five eyes (60%) at 1 year achieved surgical success. Around 6 months postoperatively, two out of seven eyes (28.6%) required Ahmed glaucoma valve placement (n = 1) or repeat mpCPC (n = 1). One eye (14.3%) required phacoemulsification with goniotomy followed by an Ahmed glaucoma valve 18 months after mpCPC. There were no cases of persistent anterior uveitis, hypotony, or phthisis after mpCPC in this cohort.

CONCLUSIONS

Micropulse transscleral cyclophotocoagulation may safely reduce intraocular pressure in some patients with uveitic glaucoma without exacerbation of intraocular inflammation. Multiple treatments may be required to achieve longer-term success.

XEN®-45 implantation for refractory uveitic glaucoma

PURPOSE

To evaluate the efficacy of XEN®-45 gel stent ab interno implantation for medically uncontrolled uveitic glaucoma.

METHODS

Retrospective analysis of 25 eyes receiving XEN® gel stent for medically uncontrolled uveitic glaucoma from February 2019 to February 2023 with recording of intraocular pressure (IOP) values, ocular hypotensive medication, requirement for revision or secondary surgery and complications. Prerequisites for XEN® implantation were a clear cornea, an open iridocorneal angle and an unscarred, mobile conjunctiva at the implantation site. Minimum follow-up required for inclusion was 3 months. The primary outcome measure was IOP compared to baseline. Complete and qualified success were defined as final IOP of ≤ 18 mmHg without or with topical antiglaucomatous treatment, respectively. Failure was defined as IOP > 18 mmHg on two consecutive visits, IOP reduction < 20%, persisting complications from hypotony and open conjunctival bleb revision. Further glaucoma surgical intervention was defined as complete failure.

RESULTS

Mean preoperative IOP was 35.3 ± 10.9 mmHg on 2.9 ± 0.9 topical antiglaucomatous agents. 19 of 25 patients (76%) received additional oral acetazolamide. 19 eyes were pseudophakic, 5 eyes phakic and 1 aphakic. Early postoperatively, mean IOP reduced to 7.7 ± 3.0 mmHg (75.8% reduction). At final follow-up (mean 17.7 months) mean IOP was 12.0 ± 3.8 mmHg (62.5% reduction) on 0.2 ± 0.6 medications. Six eyes (24%) required bleb revision at mean 28 weeks and therefore were categorized as failure. One eye failed despite bleb revision and restart of topical ocular hypotensive medication. Three other eyes (12%) had IOP spikes with uveitis flare-ups. Transient hypotony complications occurred in 32%. At final follow-up, 18 eyes (72%) achieved complete success and one eye (4%) qualified success.

CONCLUSION

The XEN® gel stent effectively reduced IOP in uncontrolled uveitic glaucoma, with 72% complete success. Bleb revision was required in 24%. IOP spikes occurred in 12% despite functioning blebs. Further follow-up is needed to determine long-term outcomes.

Ocular surface and glaucoma, a mutual relationship. Practical suggestions for classification and management

The chronic use of glaucoma medications could improve the development of an ocular comorbidity, the glaucoma therapy-related ocular surface disease. This could be related to the exposure of the conjunctiva to preservatives, but also active compounds such as prostaglandin analogues may improve the risk of ocular surface inflammation. Inflammation has a negative impact on tolerability and adherence to eyedrops and to the outcome of filtration surgery as well. A stratification of glaucoma patients based not only on visual field progression but also on glaucoma therapy-related ocular surface disease would be desirable for a strategic management. Early diagnosis, individualized treatment, and safe surgical management should be the hallmarks of glaucoma treatment. One of the main issues for the proper and successful management of patients is the right timing, effectiveness and safety for both medical and surgical treatment options leading to a precision medicine in glaucoma disease as the best modern treatment.

Early Postoperative Effect of Ripasudil Hydrochloride After Trabeculectomy on Secondary Glaucoma: A Randomized Controlled Trial

Purpose:

To evaluate the effect of Rho-associated kinase inhibitor (ripasudil hydrochloride hydrate; ripasudil) eye drops on postoperative intraocular pressure (IOP) after trabeculectomy in eyes with uveitic glaucoma.

Design:

This was a prospective, observational, controlled, and randomized study.

Methods:

Sixteen eyes of 16 patients with uveitic glaucoma who underwent trabeculectomy without mitomycin C were randomly treated without ripasudil (8 eyes) and with ripasudil (8 eyes). Postoperative IOP and surgical outcomes 3 months after surgery were compared between the two groups.

Results:

No patient discontinued treatment due to the lack of efficacy or adverse effects of ripasudil during the 3-month study period in the ripasudil group. The mean IOP (mmHg) in the control and ripasudil groups were 42.5 ± 9.8 mmHg /43.9 ± 11.7 mmHg (p = 0.82) at baseline, 14.3 ± 4.9 mmHg /9.0 ± 3.7 mmHg (p = 0.04) at 1 week, 16.3 ± 4.2 mmHg /10.6 ± 3.0 mmHg (p = 0.01) at 1 month, and 16.0 ± 3.4 mmHg /12.5 ± 2.3 mmHg (p = 0.04) at 3 months. The number of laser suture lysis procedures (2.0 ± 0.5 vs 0.4 ± 0.7), the rate of bleb revision by needling (50.0% vs 0.0%), and the mean number of antiglaucoma medications (1.6 ± 1.5 vs. 0.1 ± 0.3) after trabeculectomy were higher in the control group than in the ripasudil group (all p < 0.05). A multivariate analysis showed that the IOP reduction rate at 3 months after surgery was associated with the use of ripasudil and baseline IOP (all p < 0.05).

Conclusion:

This study demonstrated the therapeutic efficacy, safety, and tolerability of ripasudil for 3 months postoperatively. Ripasudil may effectively reduce postoperative IOP and increase the success rate of trabeculectomy in patients with uveitic glaucoma.

A comparison of long-term results after Baerveldt 250 implantation in advanced uveitic vs. other forms of glaucoma

INTRODUCTION

Uveitic glaucoma remains challenging despite medical and surgical advancements and can potentially lead to blindness if left uncontrolled. Conservative alternatives as well as microinvasive surgeries can postpone the necessity of a highly invasive intervention. However, such procedures are still necessary to treat some refractive glaucoma cases. Since previous studies have reported excellent results following the primary implantation of glaucoma drainage devices, it was our study's aim to evaluate long-term results following a Baerveldt 250 implantation in highly complex and surgically burdened uveitic glaucoma eyes (UG) and compare these to a similar population suffering from other forms of glaucoma (OFG).

MATERIAL AND METHODS

We performed a retrospective analysis of all eyes (UG vs. OFG) following a Baerveldt 250 implant between 2013 and 2019. Efficacy parameters as well as post-operative complication data were extracted from our electronic data system for statistical analysis.

RESULTS

A total of 62 eyes were included in our study (24 UG and 38 OFG). UG baseline mean IOP was 35.04 mmHg (± 11.85 mmHg) with 3.08 (± 1.13) topical agents, and OFG was 32.63 mmHg (± 7.74 mmHg) with 2.68 (± 1.28) topical agents. A majority of eyes also required systemic acetazolamide (UG: 79% OFG: 87%) and had undergone at least one glaucoma-related operation prior to the Baerveldt 250 implant ((UG: 1.21 (± 0.66)), OFG: 1.74 (± 1.33)). At the median follow-up period (UG 592, OFG 764 days), 52.5%/32.5% of UG/OFG cases showed qualified success (IOP below 21 mmHg with either topical or/and systemic medication), 15%/30% no longer required topical medication, and 47.5% /47.5% were free of acetazolamide systemically. Moreover, 75%/72.5% of eyes experienced no further pressure-related surgical event. Although sight-threatening complications such as corneal and macular edema were reported in both groups, most either maintained or improved their visual acuity at the last follow-up (58.33%/57.89%).

CONCLUSION

The Baerveldt 250 implant is shown to be both effective and safe for advanced glaucoma cases in uveitis and other forms. No further glaucoma-related surgery is required in the majority of eyes in either group within a follow-up period of almost 2 years. Despite sight-threatening complications such as macular and corneal edema, visual acuity can be either maintained or improved in most eyes.

Inflammatory cytokines levels in aqueous humour and surgical outcomes of trabeculectomy in patients with prior acute primary angle closure

PURPOSE

To quantify the levels of three inflammatory cytokines in the aqueous humour of patients with prior acute primary angle closure (APAC) and investigate their correlation with surgical outcomes of trabeculectomy.

METHODS

In this prospective cohort study, aqueous humour samples were collected from 44 prior APAC eyes. Analyte concentrations of monocyte chemoattractant protein-1 (MCP-1), vascular endothelial growth factor (VEGF) and interleukin-6 (IL-6) were measured using multiplexed immunoassay kits. Intraocular pressure was measured using Goldmann application tonometry.

RESULTS

Forty-four prior APAC eyes were followed up for 24 months after trabeculectomy and divided into success and failure groups according to surgical outcomes. Monocyte chemoattractant protein-1 (MCP-1) levels in the aqueous humour were significantly higher in the failure group (p = 0.0118). Univariate and multivariate analyses showed that MCP-1 level was a significant risk factor for trabeculectomy outcomes (univariate analysis: p = 0.016, odds ratio = 14.538; multivariate analysis: p = 0.023, odds ratio = 13.718). When prior APAC eyes were divided according to MCP-1 levels, the overall success rate was significantly higher in eyes with low MCP-1 levels than eyes with high MCP-1 levels (p = 0.0249).

CONCLUSION

In prior APAC patients, the MCP-1 level in the aqueous humour predicts trabeculectomy results. Therefore, modulation of MCP-1 expression may have potential clinical applications after filtration surgery.

Evaluating the long-term efficacy and effectiveness of Viscocanalostomy and combined phacoemulsification with Viscocanalostomy in the treatment of patients with uveitic glaucoma: 5-year follow up data

BACKGROUND

Uveitic glaucoma commonly leads to a more intense optic nerve damage than other types of glaucoma, causing glaucomatous optic nerves and visual field defects. Anterior uveitis is the most commonly associated risk factor. Surgical intervention is usually indicated when all medical treatment has failed. We report five-year results for 16 eyes of uveitic glaucoma managed with viscocanalostomy (VC)/Phaco viscocanalostomy (PVC).

METHODS

Retrospective analysis on all uveitic glaucoma cases meeting a five-year follow up was completed. All patients were managed surgically with either viscocanalostomy (VC) or phacoviscocanalostomy (PVC). Outcomes evaluated included intraocular pressures measurement pre-listing, on day 1, year 1 to year 5. Complete success rate was defined as achieving an intraocular pressure (IOP) lower than 21 mmHg or reduced by 30% without medications, and qualified success was achieved when IOP was lower than 21 mmHg or a reduction in IOP of 30% with topical medical therapy ± Laser goniopuncture (LGP). If further surgeries were required to reduce IOP due to glaucoma progression then they were classified as a failure.

RESULTS

A total of 16 patients with uveitic glaucoma were reviewed. Complete success was seen in 75% of patients at year 1, 50% of patients at year 3 and 19% of patients in year 5. Conversely qualified success was achieved in 94% of patients at year 1, 86% of patients at year 3 and 75% of patients at year 5. In the group of patients requiring further surgery, 50% of patients had previous surgeries, including cataract surgery, trabeculectomy and viscocanalostomy. There was a mean number of 4 pre-operative drops before their primary surgery and a mean drop in eye medications of 1.1 at 5 years follow-up. Success rates were prognostically linked to lower mean number of interventions and lower percentage of previous surgeries.

CONCLUSION

There remains a significant paucity of information in the utilization of PVC in uveitic glaucoma. The advantage of nonpenetrating glaucoma surgery (NPGS) includes the lack of entry into the anterior chamber and the avoidance of an iridectomy which may reduce intraocular inflammation and postoperative complications. Our study shows that non-penetrating surgery is successful in treating advanced uveitic glaucoma.

Phacotrabeculectomy in Eyes With Uveitic Glaucoma: A Retrospective Case-Control Study

PRECIS

Phacotrabeculectomy with adjunctive mitomycin C is a good option for the management of coexisting cataract and glaucoma. Strict preoperative control of inflammation and close follow-up are essential in the management of eyes with uveitic glaucoma (UG).

PURPOSE

The purpose of this study was to compare the outcomes of phacotrabeculectomy with adjunctive antimetabolites in the management of patients with UG and patients with primary open-angle glaucoma (POAG).

MATERIALS AND METHODS

A retrospective case-control study of 112 patients with UG and 120 patients with POAG who underwent phacotrabeculectomy with mitomycin C and had a follow-up of ≥12 months between January 2000 and June 2015 was performed. Patients who had undergone intraocular surgery or cyclodestructive procedures earlier were excluded. The primary outcome was intraocular pressure (IOP) control; secondary outcomes included visual acuity and complication rates.

RESULTS

IOP control was similar at the final visit in the UG group (14.52±6.74 mm Hg) and the POAG group (14.39±4.18 mm Hg) (P=0.867). Kaplan-Meier survival analysis showed a cumulative probability of survival (IOP: 6 to 18 with or without medications) in 71% and 77% at the end of 5 years (P=0.094) in the UG and POAG groups, respectively. Visual outcomes were worse in the UG group (0.5±0.68 logMAR units), as compared with the POAG group (0.27±0.47 logMAR units) (P=0.002). Complications such as cystoid macular edema (P=0.025) and posterior capsular opacification (P=0.004) were more common in the UG group. Recurrence of inflammation occurred in 34 eyes (30.04%) in the UG group.

CONCLUSION

Meticulous control of perioperative and postoperative inflammation could have contributed to the favorable long-term outcomes of phacotrabeculectomy in UG, as compared with POAG.

A literature review on Fuchs uveitis syndrome: An update

Fuchs uveitis syndrome is a chronic, typically unilateral, ocular condition characterized by an asymptomatic mild inflammatory syndrome that can result in cataract and secondary glaucoma. Diagnosis is largely clinical because the etiology remains obscure. Fuchs uveitis syndrome is most likely the result of different insults or pathogenic mechanisms, including infections, autoimmune diseases, hereditary and sympathetic dysfunction. According to the infectious theory, the infection of herpes simplex virus, ocular toxoplasmosis, cytomegalovirus, rubella virus, and other viruses have been implicated in the pathogenesis of the disease. There is no indication for corticosteroid therapy in Fuchs patients, and treatment should be mostly reserved to cataract and glaucoma. Phacoemulsification with intraocular lens implantation is a safe procedure with good visual outcomes in patients with Fuchs uveitis syndrome. Glaucoma is often unresponsive to treatment and should actively be monitored both preoperatively and postoperatively in these patients. We discuss the current understanding of Fuchs uveitis syndrome from its clinical presentations through recommended management and provide a comprehensive description and the updated knowledge of its pathophysiology.

Fuchs heterochromic iridocyclitis-associated glaucoma: a retrospective comparison of primary Ahmed glaucoma valve implantation and trabeculectomy with mitomycin C

Background: The aim of this study was to compare the safety and efficacy of primary trabeculectomy with mitomycin C and Ahmed glaucoma valve (AGV) implantation in patients with Fuchs heterochromic iridocyclitis (FHIC)-related glaucoma, a rare complication of an uncommon form of uveitis. Methods : In this retrospective comparative case series, 26 FHIC-associated glaucoma patients received trabeculectomy (n=12) or an AGV (n=14). Primary outcome measures were surgical success, defined as intraocular pressure (IOP) ≤21 mmHg, decreasing ≥20% from baseline, and no secondary glaucoma surgery. Secondary outcome measures were the number of glaucoma medications, complications, best corrected visual acuity (BCVA), and IOP. Results: The follow-up was 34.0±17.7 months in patients that received trabeculectomy and 33.4±18.6 months in AGV (P= 0.837). The cumulative probability of success rate was 41.7% for trabeculectomy and 85.7% for AGV, with no significant difference in complications (P>0.05). The IOP in patients that received trabeculectomy dropped from 23.4±3.3 mmHg to 21.6±5.2 mmHg at the final visit (P= 0.041). In patients that received AGV, the IOP decreased from 24±7.8 to 17.1±2.6 mmHg (P= 0.003). The number of glaucoma medications at baseline were 3.3±0.5 in those that received trabeculectomy and 3±0.6 in those that received AGV (P=0.233), and decreased to 2.4±1.0 (P=0.008) and 1.7±0.6 (P=0.002), respectively. BCVA was equal in both groups and did not change (P>0.05). Conclusion: Primary AGV had a higher success rate than trabeculectomy, with patients also needing fewer medications for the management of FHIC-associated glaucoma.

Fuchs heterochromic iridocyclitis-associated glaucoma: a retrospective comparison of primary Ahmed glaucoma valve implantation and trabeculectomy with mitomycin C

Background: The aim of this study was to compare the safety and efficacy of primary trabeculectomy with mitomycin C and Ahmed glaucoma valve (AGV) implantation in patients with Fuchs heterochromic iridocyclitis (FHIC)-related glaucoma, a rare complication of an uncommon form of uveitis. Methods : In this retrospective comparative case series, 26 FHIC-associated glaucoma patients received trabeculectomy (n=12) or an AGV (n=14). Primary outcome measures were surgical success, defined as intraocular pressure (IOP) ≤21 mmHg, decreasing ≥20% from baseline, and no secondary glaucoma surgery. Secondary outcome measures were the number of glaucoma medications, complications, best corrected visual acuity (BCVA), and IOP. Results: The follow-up was 34.0±17.7 months in patients that received trabeculectomy and 33.4±18.6 months in AGV (P= 0.837). The cumulative probability of success rate was 41.7% for trabeculectomy and 85.7% for AGV, with no significant difference in complications (P>0.05). The IOP in patients that received trabeculectomy dropped from 23.4±3.3 mmHg to 21.6±5.2 mmHg at the final visit (P= 0.041). In patients that received AGV, the IOP decreased from 24±7.8 to 17.1±2.6 mmHg (P= 0.003). The number of glaucoma medications at baseline were 3.3±0.5 in those that received trabeculectomy and 3±0.6 in those that received AGV (P=0.233), and decreased to 2.4±1.0 (P=0.008) and 1.7±0.6 (P=0.002), respectively. BCVA was equal in both groups and did not change (P>0.05). Conclusion: Primary AGV had a higher success rate than trabeculectomy, with patients also needing fewer medications for the management of FHIC-associated 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.

Deep sclerectomy for uveitic glaucoma: long-term outcomes

PurposeTo report long-term outcomes of deep sclerectomy (DS) in eyes with raised intraocular pressure (IOP) and glaucoma secondary to uveitis.Patients and methodsRetrospective consecutive case series of 43 eyes of 43 patients with uveitic glaucoma. Mitomycin C (MMC) 0.2-0.4 mg/ml was applied sub-conjunctivally prior to scleral flap dissection for 2-3 min in 35 eyes (81%). Combined phacoemulsification and DS was done in 4 cases (9%).ResultsMean follow-up was 68.5±33.5 months. In total, 23 eyes (53.5%) had previous intraocular surgery. Pre-operative IOP was 33.6±12.0 mm Hg. Mean IOP at one, three and five years after surgery was 15.5±5.0 mm Hg, 16.9±6.7 mm Hg and 16.4±5.2 mm Hg, respectively.The probability of IOP <22 and <19 mm Hg was 69 and 62% at 3 years and 60 and 51% at 5 years, respectively. This included eyes that had undergone needle revision and/or laser goniopuncture within that period but had not needed glaucoma medication or further glaucoma procedures. The overall number of glaucoma medications decreased from 3.0±1.2 to 0.8±1.2 by last follow-up (P<0.001). Serious complications included hypotony with macular folds in two eyes and occlusion of the trabeculo-Descemet's membrane (TDM) by iris in two eyes. Recurrence of uveitis was observed in 16 eyes. Seven eyes (16.3%) had subsequent procedures including trabeculectomy with MMC in one eye, DS with MMC in two eyes and Baerveldt tube implantation in five eyes.ConclusionsDS is a safe and effective procedure to lower IOP in uveitic glaucoma. However, as with other glaucoma procedures, a significant proportion of patients will require another IOP-lowering procedure in the long-term.

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.

Treatment of Juvenile Idiopathic Arthritis-Associated Uveitis

Pediatric uveitis may be a serious health problem because of the lifetime burden of vision loss due to severe complications if the problem is not adequately treated. Juvenile idiopathic arthritis (JIA)-associated uveitis is characterized by insidious onset and potentially blinding chronic anterior uveitis. Periodic ophthalmologic screening is of utmost importance for early diagnosis of uveitis. Early diagnosis and proper immunomodulatory treatment are essential for good visual prognosis. The goal of treatment is to achieve enduring drug-free remission. The choice of therapeutic regimen needs to be tailored to each individual case. One must keep in mind that patients under immunomodulatory treatment should be monitored closely due to possible side effects. Local and systemic corticosteroids have long been the mainstay of therapy; however, long-term corticosteroid therapy should be avoided due to serious side effects. Steroid-sparing agents in the treatment of JIA-associated uveitis include antimetabolites and biologic agents in refractory cases. Among the various immunomodulatory agents, methotrexate is generally the first choice, as it has a well-established safety and efficacy profile in pediatric cases and does not appear to increase the risk of cancer. Other classic immunomodulators that may also be used in combination with methotrexate include azathioprine, mycophenolate mofetil, and cyclosporin A. Biologic agents, primarily tumor necrosis factor alpha inhibitors including infliximab or adalimumab, should be considered in cases of treatment failure with classic immunomodulatory agents.

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.

The Pathogenesis of Raised Intraocular Pressure in Uveitis

AIM

To analyze current understanding of the factors that contribute to raised intraocular pressure (IOP) in patients with uveitis.

METHODS

A pubmed literature review was carried out using words including "uveitic glaucoma", "IOP AND uveitis", "ocular hypertension AND uveitis", "inflammation AND glaucoma", "aqueous dynamics" AND "glaucoma/uveitis".

RESULTS

Of the two studies looking at the aqueous dynamics in experimentally induced uveitis, both found aqueous flow decreased acutely, and one found that uveoscleral outflow increased. This is likely to reflect the types of uveitis that present acutely with hypotony. A study examining patients with Fuch's heterochromic cyclitis found no difference in aqueous flow or uveoscleral outflow. No studies have examined aqueous dynamics in types of uveitis that present with acutely raised IOP. Levels of prostaglandins rise in acute uveitis, which has been shown to increase uveoscleral and trabecular outflow, without affecting aqueous flow. Studies have demonstrated that raised levels of trabecular protein reduce trabecular outflow. Steroid treatment, inflammatory cells, free radicals and enzymes are also likely to contribute to the development of raised pressure. When considering the impact of the pathogenesis of raised pressure in uveitis on its treatment, prostaglandins may provide good intraocular pressure control, but there are concerns regarding their theoretical ability to worsen the inflammatory response in uveitis. Studies have not conclusively proven this to be the case. Surgical success rates vary, but trabeculectomy plus an antimetabolite, deep sclerectomy plus an antimetabolite, and Ahmed valve surgery have been used.

CONCLUSIONS

Uveitic glaucoma is caused by a number of different diseases, some of which present with acute hypotony, others with acutely raised IOP, and others which demonstrate an increase in IOP over time. Further studies should be carried out to examine the differing pathogenesis in these types of diseases, and to establish the best treatment options.

Two-year outcome of repeat trabeculectomy with mitomycin C in primary open-angle and PEX glaucoma

PURPOSE

To evaluate the effectiveness of repeat trabeculectomy with risk factor-adjusted mitomycin C (MMC) application in primary open-angle glaucoma (POAG) and pseudoexfoliation glaucoma (PEXG) over 2 years.

METHODS

A total of 58 patients (43 with POAG, 15 with PEXG) who had undergone repeat trabeculectomy with MMC were included in this retrospective study. Exposure time of MMC 0.3 mg/mL was adjusted according to a standardized protocol. Main outcome measures were best-corrected visual acuity (BCVA), intraocular pressure (IOP) reduction, surgical success rate (criteria were defined as A: IOP ≤21 mm Hg and a reduction of IOP ≥20%; B: IOP ≤18 mm Hg and a reduction of IOP of ≥30%; C: IOP ≤15 mm Hg and a reduction of IOP of ≥40% from baseline), and number of medications at baseline, 3 months, and 2 years postoperatively.

RESULTS

The BCVA remained stable for 2 years after surgery (0.47 ± 0.47 at baseline, 0.49 ± 0.64 logMAR units after 2 years, respectively). Mean IOP decreased from 22.2 ± 7.0 mm Hg at baseline to 12.7 ± 3.1 mm Hg at 3 months and 12.9 ± 4.3 mm Hg 2 years after surgery. The qualified success rate for criterion A was 75.4%, for criterion B 66.6%, and for criterion C45.6%. Complete success rates were 42.9%, 37.5%, and 32.1%, respectively. Two years after repeat trabeculectomy, the mean IOP was reduced by 38.8%, and the number of medications was reduced significantly.

CONCLUSIONS

Repeat trabeculectomy with MMC is successful at lowering IOP in POAG and PEXG and permits a significant and safe reduction of antiglaucomatous medication for at least 2 years after surgery.

Outcomes of trabeculectomy in microspherophakia

PURPOSE

To report the outcomes of trabeculectomy in eyes with glaucoma in microspherophakia.

MATERIALS AND METHODS

In a retrospective non-comparative case series, we analyzed 29 eyes of 18 patients with glaucoma in microspherophakia, who underwent primary trabeculectomy between 1998 and 2012. Success was defined as complete if the intraocular pressure (IOP) was ≤ 21 and > 5 mm Hg without any antiglaucoma medication and qualified if IOP ≤ 21 and >5 mm Hg with or without antiglaucoma medications. Eyes not falling into qualified success criteria were labeled as failure.

RESULTS

The median age at the time of trabeculectomy was 23 years (inter quartile range: 12, 28). The mean IOP reduced from 31.1 ± 8.6 mm Hg to 14.6 ± 4.4 mm Hg after trabeculectomy over a median follow up of 77 months (P < 0.001). The probability of complete success was 96% (95% CI: 77-99%) at one year, 88% (95% CI: 67-96%) at 2 years, which was maintained till 7 years and decreased to 79% (95% CI: 50-92%) at 8 years. The probability of qualified success was 100% till 7 years and decreased to 90% (95% CI: 47-98%) at 8 years. The median number of postoperative medications reduced from 2 to 0 postoperatively (P < 0.001) . Five eyes (21%) developed post-operative shallow anterior chamber (AC) requiring anterior chamber reformation, with 2 of these eyes needing lensectomy for resolution of this complication.

CONCLUSION

Primary trabeculectomy had good success rate in glaucoma associated with microspherophakia. Post-operative shallow AC was a frequent complication needing additional intervention.

Monocyte chemotactic protein-1 level in the aqueous humour as a prognostic factor for the outcome of trabeculectomy

BACKGROUND

The aim of this study was to elucidate the effects of the aqueous humour monocyte chemotactic protein-1 level on the surgical outcome of trabeculectomy in cases of phakic glaucoma.

DESIGN

Retrospective study.

PARTICIPANTS

Fifty-three cases of open-angle glaucoma.

METHODS

At the time of trabeculectomy, aqueous humour samples were collected before any incisions were made. The monocyte chemotactic protein-1 level was then determined by immunoassay. The Cox proportional hazards test was used to analyse the clinical factors related to failure of trabeculectomy. Subsequently, the success probability was calculated by Kaplan-Meier analysis and cumulative success probabilities were analysed by the log-rank test.

MAIN OUTCOME MEASURES

Probability of success.

RESULTS

In 30 phakic glaucoma and 23 pseudophakic glaucoma cases, the mean monocyte chemotactic protein-1 levels in aqueous humour were 1165.2 and 2152.9 pg/mL, respectively; the difference was statistically significant (P < 0.0001). Univariate analysis showed that the outcomes of surgery were correlated with the monocyte chemotactic protein-1 level, but not with age, gender, diagnosis of exfoliation glaucoma, pseudophakic status or pretrabeculectomy intraocular pressure. Subsequent multivariate analysis revealed that only the aqueous humour monocyte chemotactic protein-1 level was significantly correlated with the outcomes of trabeculectomy (P = 0.043). Among the 30 phakic glaucoma eyes, the success probabilities after trabeculectomy were significantly different between the high and low monocyte chemotactic protein-1 groups (P = 0.018).

CONCLUSION

In open-angle glaucoma patients, the monocyte chemotactic protein-1 level is a prognostic factor for the results of trabeculectomy.

Glaucoma and uveitis

Despite its relative rarity, uveitis is the third leading cause of preventable blindness worldwide. Glaucoma associated with uveitis is one of the most serious complications of intraocular inflammation. We review in detail the epidemiology and pathogenesis of uveitic glaucoma and the safety and efficacy of the current medical and surgical treatment modalities.

Combined Baerveldt glaucoma implant and scleral buckling surgery for patients with retinal detachment and coexisting glaucoma

PURPOSE

To report on the usefulness of combined Baerveldt glaucoma implantation (BGI) and scleral buckling surgery for patients with glaucoma requiring a scleral buckle for retinal detachment repair.

METHODS

Retrospective, consecutive, noncomparative, and interventional case series of 30 eyes (30 patients) that underwent simultaneous scleral buckle and BGI surgery, using a staged (group 1, n=21 patients) or nonstaged (group 2, n=9 patients) approach to BGI implantation. Successful intraocular pressure (IOP) control was defined as 6 mm Hg≤IOP≤18 mm Hg.

RESULTS

Although not statistically significant, mean best corrected visual acuity (LogMAR) improved from 2.0 before surgery to 1.7 after surgery (P=0.13) with a mean follow-up of 27.7 months. Of the 21 patients in group 1, only 13 (62%) required second-stage tube insertion at a mean of 7.0±8.0 months (range, 1 to 24 mo) postoperatively. For these eyes combined with group 2 eyes, mean IOP was reduced from 31.1±10.8 to 12.7±6.0 mm Hg (P<0.0001), and the mean number of glaucoma medications was reduced from 2.9±1.4 to 1.2±1.3 (P<0.001). Life table rates of successful IOP control were 90% and 80% at 12 and 24 months, respectively.

CONCLUSIONS

Combined scleral buckle and BGI is an effective technique for managing coexisting glaucoma and retinal detachment and provides the clinician with a useful surgical option while minimizing surgical risk.

Deep Sclerectomy with Mitomycin C for Glaucoma Secondary to Uveitis

Purpose.

To report outcomes of deep sclerectomy augmented with mitomycin C (MMC) in eyes with raised intraocular pressure (IOP) secondary to uveitis.

Methods.

This was a retrospective case series of 26 eyes of 26 patients with uveitic glaucoma. Mitomycin C 0.2–0.4 mg/mL was applied subconjunctivally prior to scleral flap dissection for 2–3 minutes.

Results.

Mean follow-up was 46.5±22 months (range 12–83). Fifteen eyes (58%) had previous intraocular surgery. Preoperative IOP was 33±12 mmHg. Intraocular pressure at 1, 2, and 3 years after surgery was 13±4 mmHg, 13±4 mmHg, and 14±4 mmHg, respectively. The probability of IOP <21 and 18 mmHg with needle revision and laser goniopuncture but without medications or further glaucoma procedure was 89% and 84%, respectively, at 3 years. The cumulative probability for performing laser goniopuncture was 42% at 1 year, 50% at 2 years, and 64% at 3 years. Needle revision was performed in 6 eyes (23%). Three (12%) patients required further glaucoma surgery. The number of glaucoma medications decreased from 3.3±1.2 to 0.3±0.8 by last follow-up (p<0.001). Four eyes (15%) were on medications to control IOP Intraoperative perforation of trabeculo-Descemetic membrane occurred in 3 eyes (12%) and late iris entrapment in perforation or goniopuncture in 4 eyes (15%). Recurrence of uveitis was seen in 11 eyes (42%) with no loss in IOP control.

Conclusions.

Deep sclerectomy with MMC appears to be a safe and effective procedure to lower IOP in uveitic glaucoma with a low rate of complications.

Surgical outcomes of uveitic glaucoma

PURPOSE

Secondary glaucoma is a difficult and frequent complication of uveitis. The aim of this study is to describe the results of surgery in uveitic glaucoma and to identify situations linked to a high risk of failure of the surgery.

METHODS

Retrospective observational study. Clinical and surgical data from 27 cases of uveitic glaucoma that underwent glaucoma surgery over a period of 9 years were collected.

RESULTS

The main diagnosis and aetiology were anterior uveitis (61.90%) and herpes (38.10%) respectively. Trabeculectomy with mitomycin C was performed in 51.9% of the cases. An intraocular pressure lower than 16 mmHg and managed with less than two drugs was achieved in 48.15% of the cases. Higher risks of surgical failure were associated with intermediate uveitis, idiopathic uveitis, Fuchs' cyclitis, combined surgery with phacoemulsification, omission of mitomycin C, intraocular inflammation at surgery and relapse of the uveitis.

CONCLUSIONS

There are some situations linked to a high risk of failure of surgery in uveitic glaucoma, which should be avoided when possible, mainly the association of higher risk with combined approaches.

Nonpenetrating glaucoma surgery

Nonpenetrating glaucoma surgeries have been developed in recent years in order to improve the safety of conventional filtering procedures. The goal of nonpenetrating filtering procedures is to reduce intraocular pressure by enhancing the natural aqueous outflow channels, while reducing outflow resistance located in the inner wall of the Schlemm's canal and the juxtacanalicular trabecular meshwork. In the last few years viscocanalostomy and deep sclerectomy with external trabeculectomy have become the most popular nonpenetrating filtering procedures. Both involve removal of a deep scleral flap, the external wall of Schlemm's canal and corneal stroma behind the anterior trabeculum and Descemet's membrane, thus creating an intrascleral space. The aqueous humour leaves the anterior chamber through the intact trabeculo-Descemet's membrane into the scleral space, from where it will egress into different pathways. The technique is associated with a long learning curve. Published clinical trials comparing nonpenetrating glaucoma surgery to full-thickness trabeculectomy have a consensus on the superior safety profile of nonpenetrating glaucoma surgery but are not in agreement when it comes to efficacy, where conflicting results have been found. This article reviews the nonpenetrating surgical techniques, mechanisms of action, indications, contraindications, complications, and results.

[Efficacy and complications of a mini-trabeculectomy technique]

OBJECTIVE

To assess the outcome and the complication rate of an adjustable mini-trabeculectomy in medically uncontrolled glaucoma.

PATIENTS AND METHODS

This study retrospectively evaluated the medical records of 40 patients undergoing primary mini-trabeculectomy. All patients were followed at least 24 months, with a mean follow-up of 60.85 +/- 37.7 months. Visual acuity, intraocular pressure (IOP), visual field (MD, Humphrey), number of antiglaucoma medications, intra- and postoperative complications, postoperative procedures (laser suture lysis, 5-fluorouracil subconjunctival injections, or a new trabeculectomy) were analyzed.

RESULTS

Preoperative IOP was 23.2 +/- 6.48 mmHg (range, 13-53 mmHg) with 2.42 +/- 0.74 (range, 1-4) antiglaucoma medications. At last examination, after 60.85 +/- 37.7 months (mean +/- standard deviation; minimum 24 months) of postoperative follow-up, IOP was 12.55 +/- 2.12 mmHg with 0.42 +/- 0.78 antiglaucoma medications (p<0.001 compared to preoperative IOP and p<0.001 compared to the number of medications); 85% and 92.5% of patients had IOP reduced by 30% or more and a final IOP less than 16 mmHg with or without antiglaucoma medications, respectively, and 52.5% had one or more scleral flap sutures released by laser. Postoperative complications were infrequent: flat anterior chamber with choroidal detachment (2.5%) and iris incarceration in the trabeculectomy site (2.5%). Seven patients had an encapsulation of the filtering bleb (17.5%) after a mean follow-up of 34.33 +/- 33 days after surgery. Four patients (10%) had cataract surgery during the 2 years following trabeculectomy. A significant decrease in visual acuity was observed after surgery (p=0.018); nevertheless, there was no statistically significant difference between preoperative and postoperative MD (-10.46+/-9.37 dB and -10.65+/-4.36 dB, respectively; p=0.971, for 23 patients).

CONCLUSION

Adjustable mini-trabeculectomy controlled postoperative filtration. Easy to perform, this surgical technique seemed to be safe and effective, and it reduced the rate of early postoperative complications in the surgical management of patients with glaucoma.

[Wound healing modulation in glaucoma surgery]

The wound healing response is one of the major determinants of filtering surgery success. Over the last two decades, antifibrotic agents, 5-fluorouracil (5-FU) and mitomycin C (MMC), have modified the prognosis of filtering surgery, particularly in patients at high risk for failure. Nevertheless, these agents are associated with severe complications. In order to maximize their benefits and minimize the rate of complications, the use of these powerful treatments has to be carefully evaluated in relation to patient risk factors for scarring. The choice of an antifibrotic agent, mode, dose and duration of application should be made with complete knowledge of the different effects of these treatments and adapted for each patient after an exhaustive preoperative evaluation.

Long-term results of Ahmed glaucoma valve implantation for uveitic glaucoma

PURPOSE

To present long-term outcomes of Ahmed glaucoma valve implantation for uveitic glaucoma.

DESIGN

Interventional case series.

METHODS

Retrospective chart review of 60 patients (60 eyes) with uveitic glaucoma who underwent Ahmed valve implantation over a four-year period at a tertiary uveitis referral center. Success definition 1 included patients with an intraocular pressure (IOP) between 5 and 21 mm Hg, reduced by 25% from that before implantation. Success definition 2 (qualified success) excluded those patients in whom serious complications occurred.

RESULTS

Mean follow-up time was 30 months (range, six to 87 months; four-year results relate to a cohort of 15 patients). Success rates were 77% and 50% and qualified success rates were 57% and 39% at one and four years, respectively. At four years, 74% of the patients required glaucoma medication to maintain IOP control. The overall complication rate was 12%/person-years. The rate of visual acuity loss was 4%/person-years; that was most commonly attributed to corneal complications that were more likely to occur in patients with preoperative corneal disease (P = .01, Fisher exact test).

CONCLUSIONS

Ahmed glaucoma valve implantation is a safe yet moderately successful procedure for uveitic glaucoma. Long-term success rates are enhanced with the use of glaucoma medications, and corneal complications are the most common of all potential serious complications.

Trabeculectomy With Mitomycin C in Secondary Glaucoma Associated With Behçet Disease

PURPOSE

To determine the outcome of initial trabeculectomy with mitomycin C (MMC) in the management of secondary glaucoma associated with Behçet disease (BD) in a 1-year follow-up period.

METHODS

Twenty-three eyes of 13 cases with secondary glaucoma associated with BD, were evaluated prospectively. They underwent primary trabeculectomy with MMC. The operative success was defined as an intraocular pressure (IOP) < or =20 mm Hg (+/- medical therapy) in the absence of phthisis and without the necessity of further surgery for glaucoma and success rates at the postoperative first day, first month, sixth month, and first year were determined.

RESULTS

Success was achieved in all of the eyes (100%) at the postoperative first day and month, in 21 eyes (91.3%) at the postoperative sixth month and in 19 eyes (82.6%) at the postoperative first year. The mean preoperative IOP was 30.9+/-5.3 mm Hg under the mean 3.3+/-0.7 antiglaucoma medications but it reduced to 16.8+/-3.1 mm Hg under the mean 1.7+/-0.8 medications at the postoperative sixth month and 18.5+/-3.2 mm Hg under the mean 2.6+/-1.1 medications at the postoperative first year.

CONCLUSIONS

Trabeculectomy with MMC provides reduction of IOP and the number of antiglaucoma medications in cases with secondary glaucoma associated with BD in a 1-year follow-up period.

Update on Fuchs' uveitis syndrome

PURPOSE OF REVIEW

This update aims to summarize the current knowledge on Fuchs' uveitis syndrome and review publications in the last 10 years. Theories on the pathogenesis and etiology of Fuchs' uveitis syndrome are revisited and the management of cataract and glaucoma is updated to reflect recent surgical change.

RECENT FINDINGS

Retrospective reviews have highlighted that patients with Fuchs' uveitis syndrome are often initially misdiagnosed. Studies comparing local inflammatory mediators and cell types have found differences in Fuchs' uveitis syndrome, but the differences in steroid response and degree of inflammation remain poorly understood. Local production of antibodies to rubella has been recently reported in the aqueous of all patients with Fuchs' uveitis syndrome and no controls. Excellent visual outcomes from phacoemulsification have been reported with reduced complications compared with extracapsular cataract extraction.

SUMMARY

Although a single etiological agent and a sensitive laboratory test for the diagnosis of Fuchs' uveitis syndrome is alluring, the diagnosis of Fuchs' uveitis syndrome remains clinical, at least for now. Phacoemulsification has increased the safety of cataract extraction, and the use of intraocular lens is generally safe. The ideal lens material and design are not yet known, but silicone lenses may be best avoided. Glaucoma is often resistant to treatment and should actively be screened for in patients with Fuchs' uveitis syndrome. Medical and surgical treatment for reducing intraocular pressure should be especially aggressive in these patients. Vitrectomy appears to be safe in patients with visually significant vitreous opacification.

La trabéculectomie dans la prise en charge du glaucome uvéitique

PURPOSE

To report middle-term results of trabeculectomy in patients with uveitic glaucoma resistant to medical therapy.

PATIENTS AND METHODS

Seventeen eyes of 14 patients with uveitic glaucoma resistant to medical therapy were treated by trabeculectomy without antimetabolites from 1994 to 2001. The patients'mean age was 48.1 years (range, 23-63 years). All had their uveitis controlled for at least 3 months before surgery by an anti-inflammatory therapy.

RESULTS

Mean follow-up was 52.1 months. Success was obtained in 11 eyes (64.7%). It was complete in five eyes (45.5%) and relative in six eyes (54.5%). Failure was noted in six eyes (35.3%), which were treated with a second filtering surgery. Intraocular pressure was reduced from a mean preoperative value of 34.2 mmHg to a mean postoperative value of 18.6 (45.6% reduction). Antiglaucomatous medication was reduced from a mean of 2.8 medications preoperatively to 1.1 medications (60.7% reduction). Postoperative complications included three cases of lens opacity, two cases of hyphema, two cases of transitory hypotony, one case of flat anterior chamber, and one case of inflammation relapse.

CONCLUSION

In the absence of failure risk factors except inflammation, trabeculectomy without antimetabolites can be successful in uveitic glaucoma not controlled by medical therapy, with good results even at the middle term.

Management of chronic pediatric uveitis

PURPOSE OF REVIEW

The diagnosis and management of chronic pediatric uveitis can be particularly challenging, with an estimated 25-33% of childhood uveitis cases resulting in severe, life-long visual disability. This paper reviews the recent literature on the management of chronic pediatric uveitis.

RECENT FINDINGS

This review highlights recent advances in the diagnosis and medical and surgical management of pediatric uveitis. Several systemic diseases associated with chronic uveitis in children are highlighted, including juvenile idiopathic arthritis, sarcoidosis and Behçet's disease. The treatment of primary ocular diseases associated with chronic pediatric uveitis such as intermediate uveitis and Fuchs' heterochromic iridocyclitis is discussed. The management of infectious causes of pediatric uveitis is not covered in this review.

SUMMARY

Knowledge of the ocular complications of chronic pediatric uveitis can help to customize efficacious therapeutic regimens for each patient, maximize the visual potential and minimize complications of these diseases. In addition a close relation should be fostered between pediatricians, pediatric rheumatologists and ophthalmologists to effectively monitor these patients who have multiple medical, surgical and refractive needs. Finally, surgical intervention must be appropriately timed with expert perioperative management of immunosuppressive medications with pediatric concerns in mind.

Ahmed valve implantation in glaucoma secondary to chronic uveitis

PURPOSE

To evaluate the efficacy of Ahmed valve (AV) implantation in patients with uveitic glaucoma.

METHODS

In total, 18 patients (19 eyes) with glaucoma secondary to chronic uveitis, who underwent AV implantation were retrospectively reviewed. Visual acuity, intraocular pressure (IOP), and glaucoma medications at the most recent examination prior to surgery, were compared with those of last postoperative examination. The surgical success was defined as IOP less than 21 mmHg and greater than 4 mmHg without loss of light perception and visually devastating complications at the last postoperative examination. Decrease in the number of glaucoma medications was also a criterion for surgical success.

RESULTS

The mean follow-up period was 26+/-9.7 months. The mean preoperative and postoperative IOPs were 33.3+/-9.7 (range, 20-57) mmHg and 17.3+/-10.8 (range, 6-40) mmHg respectively (P<0.0001). The mean number of antiglaucoma medications was 3.5+/-0.8 (range, 2-5) preoperatively and 1.4+/-1.3 (range, 0-4) postoperatively (P<0.0001). Valve occlusion (five eyes, 26.3%) was the most commonly observed complication. Surgical success was achieved in 13 eyes (68.4%). The cumulative probability of success was 94.4% at 1 year and 60% at 2 years. Five eyes (26.3%) with IOP greater than 21 mmHg and one (5.3%) with corneal decompensation requiring penetrating keratoplasty were considered as failures.

CONCLUSIONS

The implantation of AV is an effective surgical procedure for the management of uveitic glaucoma. The inflammatory background might contribute to the occurrence of valve occlusion, which is the most common complication. Prevention of this complication is an essential factor for improving the surgical outcome.

Incidence of glaucoma in patients with uveitis

PURPOSE

To evaluate the incidence of glaucoma and elevation of intraocular pressure (IOP) in patients with inflammatory eye disease.

METHODS

Retrospective review of medical records of 391 consecutive patients with uveitis attending a uveitis clinic of an academic Department of Ophthalmology from January 1999 to August 2002. Demographic, ocular and systemic variables were recorded. The diagnosis and treatment of uveitis were recorded. Uveitis was classified according to standard anatomic, etiological and clinical criteria. "Glaucoma" was defined as elevated IOP (>21 mm Hg) or glaucomatous optic nerve damage requiring medical and/or surgical anti-glaucoma treatment. Kaplan-Maier analysis and log-rank tests were used to evaluate and compare the incidence of glaucoma.

RESULTS

The incidence of glaucoma as defined above at 3 and 12 months after acute uveitis was 7.6%. In patients with chronic uveitis (n = 337), the incidence of glaucoma at 1 and 5 years was 6.5% and 11.1%, respectively. There was no statistically significant difference in the incidence of glaucoma between different types of uveitis, idiopathic versus non-idiopathic, and among anterior, intermediate, posterior and panuveitis. Visual loss occurred more frequently in patients with glaucoma than in patients without glaucoma.

CONCLUSION

In patients with chronic inflammatory eye disease, the presence of glaucoma was associated with an increasing risk of visual loss. The incidence of glaucoma increased with time and was similar among the different types of uveitis.