Glaucoma in Uveitic Eyes: Long-Term Clinical Course and Management Measures

BACKGROUND

The management of glaucoma in uveitis is challenging. A meticulous combination of anti-glaucoma and anti-inflammatory agents is often needed to control the intraocular pressure (IOP) and preserve the visual status in an otherwise blinding disease.

AIM

To study the clinical course and management of glaucoma in uveitic eyes.

METHODS

A retrospective study analyzing the case records of patients over 12 years, referred for the management of uveitic glaucoma in the last two decades.

RESULTS

The analysis of 582 uveitic glaucoma eyes of 389 patients was done, and the mean IOP at baseline was 25.89 (±13.1) mmHg. Non-granulomatous uveitis (102 eyes) was the most common diagnosis. Granulomatous uveitis was the most common diagnosis among the treatment failure eyes and in eyes requiring more than one surgical intervention for glaucoma.

CONCLUSION

An appropriate and adequate combination of anti-inflammatory and IOP-lowering therapy will lead to better clinical outcomes.

The spouse as co-therapist in the treatment of agoraphobia

Involving the spouse as a co-therapist made no significant difference to the outcome of treatment in a controlled study of 19 married patients suffering from agoraphobia who were engaged in short-term home-based behavioural treatment. Improvement continued to 6-month follow-up. The marriages of those with some marital difficulties at the start tended to improve, whether or not the spouse was involved. Poor initial marital adjustment was not related to the degree of improvement in agoraphobic symptoms.

Group exposure for agoraphobics: a replication study

A replication study was conducted of the treatment of agoraphobics by exposure in cohesive groups, as described by Hand, Lamantagne and Marks (1974). The continuing improvement during follow-up, with consequent large overall improvement, reported in the original study was not replicated. However, the present study confirmed the usefulness of this procedure as a highly cost-efficient treatment. The assumed equivalence of the Gelder and Marks (1966) phobic rating scale and its modification by Watson and Marks (1971) was examined. Large discrepancies between the scales were obtained for initial assessments and change scores. It is suggested that there is a need for workers in this field to agree on methods of measurement.

Imaginal flooding and exposure to real phobic situations: treatment outcome with agoraphobic patients

Each of thirty-six female agoraphobic out-patients were treated by one of three methods: 8 sessions of imaginal flooding followed by 8 sessions of practice in the real situation; 16 sessions of combined flooding and practice; or 16 sessions of practice alone. Three therapists treated equal numbers of patients in each group, and there was some evidence that patients' response varied according to the therapist seen, irrespective of treatment group. There were no significant differences between treatment groups after 8 sessions, 16 sessions or on six-month follow-up. It is concluded that there are no long-term differences between the effects of treatments involving exposure to either imaginal or real phobic situations or to a combination of both, provided that patients are encouraged to practise between sessions.

Imaginal flooding and exposure to real phobic situations: changes during treatment

This paper reports the results of measures taken during treatment in the study of imaginal flooding and exposure to real phobic situations previously described by Mathews, Johnston, Lancashire, Munby, Shaw and Gelder (1976). On weekly measures of change of similar reduction in phobic behaviour in all treatments was found, confirming the previous findings. Differences in therapist effectiveness were also confirmed. On measures of the immediate effects of treatment, exposure to the phobic situation had consistent positive effects, imaginal flooding had little or no detectable effect. It is proposed that the treatments studied differ in their immediate effects on phobic behaviour but also have the common effect of facilitating counterphobic behaviour outside the treatment situation, and that this is the main agent of therapeutic change.

Specific and non-specific factors in behaviour therapy

Previous investigations have suggested that desensitization is the treatment of choice for simple phobic disorders, but is less effective with agoraphobia, particularly when the phobias are accompanied by much generalized anxiety (Gelder and Marks, 1966). Even the milder agoraphobias usually respond incompletely despite prolonged treatment. An alternative treatment that offers more rapid or effective results, particularly with agoraphobia, would therefore be of value. The technique of flooding or implosion has recently been the subject of a number of studies, and some, but not all, have shown evidence of considerable therapeutic power. The method is also of some theoretical interest since it breaks the rules which are thought to be important in desensitization. Thus, according to early proponents (Stampfl and Levis, 1967) success depends on exposing patients to fantasy material of an extremely intense and anxiety-provoking nature, so that extinction to cues associated with the original traumatic situation may take place. From this theoretical viewpoint desensitization can be only partially successful, since these traumatic origins are neither sought for nor presented to the patient. Even if the necessity of dealing with original anxiety-provoking cues is not accepted, the use of material which evokes maximal anxiety for prolonged periods is contrary to the counter-conditioning theory of desensitization (Wolpe, 1958). Indeed, this theory predicts that flooding would rarely be successful and might make the phobia worse because uncontrolled increases in anxiety may cause reconditioning.

Tics and Gilles de la Tourette's syndrome: a follow-up study and critical review

Tics or habit spasms have been described in various ways, but perhaps the most useful definition is that of Kanner (1937) that they are “quick, sudden and frequently repeated movements of circumscribed groups of muscles, serving no apparent purpose”. Children with this symptom not infrequently present to the paediatrician or child psychiatrist with accompanying symptoms of emotional disturbance, and by the age of seven years approximately five per cent of children have a history of such movements (Kellmer Pringle et al., 1967). Less commonly, adolescents who have suffered with tics from an earlier age develop vocal tics and coprolalia (compulsive swearing) symptomatic of Gilles de la Tourette's syndrome. Tiqueurs are rarely seen for treatment in adult life, except in a few well-documented cases where Gilles de la Tourette's syndrome persists (Fernando 1967).

Forearm blood flow and phobic anxiety

The measurement of muscle blood flow using occlusive plethysmography has recently been proposed as an objective index of anxiety (Harper et al., 1965; Kelly, 1966, 1967). Although the method has been used by physiologists for many years, and its sensitivity to psychological stress has often been mentioned as an incidental finding in physiological studies, its application in psychiatric or psychological research has been slow to develop, perhaps because rather cumbersome apparatus is required. However, promising results were reported by Kelly (1966), who differentiated patients suffering from anxiety states from mixed neurotic patients and normal controls, and who showed changes after leucotomy in anxious patients.

Drug treatment of adolescent tiqueurs. A double-blind trial of Diazepam and Haloperidol

Various forms of treatment have been recommended for multiple tics, including psychotherapy (Zausmer, 1954), behaviour therapy (Yates, 1958) and phenothiazines and other tranquillizers (Lucas, 1964; Kelman, 1965), but there have been no reports of an adequate controlled trial of any particular therapy.