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Uveitic glaucoma

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Last updated: February 8th, 2022

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Summary of Evidence

IOP fluctuations

The diurnal variation in IOP was significantly higher in Uveitic glaucoma than in Primary open angle glaucoma patients. {Esen F, Eraslan M, Cerman E, Celiker H, Kazokoglu H. Diurnal Spikes of Intraocular Pressure in Uveitic Glaucoma: A 24-hour Intraocular Pressure Monitoring Study. Semin Ophthalmol. 2020 May 18;35(4):246-251.}

Glaucoma surgery

Ahmed tube vs Baerveldt tube

 

There was higher complete success rate and significantly greater reduction in mean IOP and number of medications in the Baerveldt group vs Ahmed group, but with a higher rate of complications including hypotony. {Sinha S, Ganjei AY, McWatters Z, Lee D, Moster MR, Myers JS, Kolomeyer N, Mantravadi AV, Pro MJ, Razeghinejad R. Ahmed Versus Baerveldt Glaucoma Drainage Device in Uveitic Glaucoma: A Retrospective Comparative Study. J Glaucoma. 2020 Sep;29(9):750-755.}

 

Combined Dexamethasone Intravitreal Implant and Glaucoma Drainage Device Placement

 

In 56 eyes of 37 patients with uveitis that underwent fluocinolone acetonide implantation, concurrent or subsequent glaucoma drainage implant surgery offered excellent long-term control of IOP. Outcomes at mean follow up of 71 months:{Cao JL, Srivastava SK, Lowder CY, Sharma S, Baynes K, Eisengart J. Long-term Outcomes of Glaucoma Drainage Implants in Uveitic Eyes With Fluocinolone Acetonide Implants. J Glaucoma. 2020 Sep;29(9):789-793.}

 

  • IOP was reduced by mean of 52.9%
  • Number of medications decreased by mean of 69.0%
  • Surgical success rate was 71.4% at 10 years

Evidence

1. Background

1.1 Incidence

Clinical trial

2020 Kempen et.al. (MUST)

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2020
Clinical trial

In eyes with intermediate, posterior, and panuveitis managed with fluocinolone acetonide implant, the long-term risk of glaucoma was substantially higher than those managed with systemic therapy.

 

Management of IOP elevation was effective in preventing worsening of glaucoma for the large majority of cases.{Kempen JH, Van Natta ML, Friedman DS, Altaweel MM, Ansari H, Dunn JP, Elner SG, Holbrook JT, Lim LL, Sugar EA, Jabs DA; Multicenter Uveitis Steroid Treatment (MUST) Trial and Follow-up Study Research Group. Incidence and Outcome of Uveitic Glaucoma in Eyes With Intermediate, Posterior, or Panuveitis Followed up to 10 Years After Randomization to Fluocinolone Acetonide Implant or Systemic Therapy. Am J Ophthalmol. 2020 Nov;219:303-316.}

  • Randomized controlled trial of eyes with intermediate, posterior, and panuveitis managed with systemic or fluocinolone acetonide (“implant”) therapy (405 eyes of 232 patients).
  • Findings (10-years)
    • 40% of eyes treated with implant and 8% of eyes treated with systemic therapy developed glaucoma.
    • Adjustment for intraocular pressure elevation during follow-up only partially mitigated the association of implant treatment with glaucoma incidence

Kempen et.al. (MUST)
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1.2 Risk factors

Review

2016 Gregory 2nd et.al.

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2016
Review

Review of the effect of race on the presentation and prevalence of uveitis and the management of uveitic glaucoma.{Gregory AC 2nd, Zhang MM, Rapoport Y, Ling JD, Kuchtey RW. Racial Influences of Uveitic Glaucoma: Consolidation of Current Knowledge of Diagnosis and Treatment. Semin Ophthalmol. 2016;31(4):400-4.}

Gregory 2nd et.al.
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1.3 IOP fluctuations

Case series

2020 Esen et.al.

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2020
Case series

The diurnal variation in IOP was significantly higher in Uveitic glaucoma than in Primary open angle glaucoma patients.{Esen F, Eraslan M, Cerman E, Celiker H, Kazokoglu H. Diurnal Spikes of Intraocular Pressure in Uveitic Glaucoma: A 24-hour Intraocular Pressure Monitoring Study. Semin Ophthalmol. 2020 May 18;35(4):246-251.}

Esen et.al.
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2. Medical treatment

2.1 Ripasudil

Case series

2020 Futakuchi et.al.

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2020
Case series

The mean overall IOP reductions from baseline in a cohort of patients with uveitic glaucoma (UG), exfoliation glaucoma or steroid-induced glaucoma who needed additional IOP reduction and treated with topical 0.4% ripasudil was -7.0mmHg at 6 months.

 

UG patients exhibited significant decreases in mean cell score of the anterior segment after ripasudil treatment.{Futakuchi A, Morimoto T, Ikeda Y, Tanihara H, Inoue T; ROCK-S study group collaborators. Intraocular pressure-lowering effects of ripasudil in uveitic glaucoma, exfoliation glaucoma, and steroid-induced glaucoma patients: ROCK-S, a multicentre historical cohort study. Sci Rep. 2020 Jun 25;10(1):10308.}

Futakuchi et.al.
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3. Surgical treatment

3.1 Phacotrabeculectomy

case series

2019 Wadke et.al.

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2019
case series

In a retrospective case-control study of 112 patients with uveitic glaucoma and 120 patients with POAG who underwent phacotrabeculectomy with mitomycin C

 

  • IOP control was similar at final visit.
  • Cumulative probability of survival (IOP: 6 to 18 with or without medications) was 71% and 77% in the UG and
  • POAG groups at 5 years
  • Visual outcomes were worse in the UG group
  • Complications such as CME and PCO were more common in the UG group {Wadke V, Lingam V, George R, George AE, Ganesh SK, Biswas J, Balekudaru S. Phacotrabeculectomy in Eyes With Uveitic Glaucoma: A Retrospective Case-Control Study. J Glaucoma. 2019 Jul;28(7):606-612.}

Wadke et.al.
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3.2 Glaucoma drainage device

case series

2020 Randas et.al.

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2020
case series

Glaucoma drainage devices surgery in patients with uveitis has a similar effect on IOP as in patients without uveitis. The risks of developing macular edema and hypotony were slightly higher in patients with uveitis, but the results were not statistically significant.{Ramdas WD, Pals J, Rothova A, Wolfs RCW. Efficacy of glaucoma drainage devices in uveitic glaucoma and a meta-analysis of the literature. Graefes Arch Clin Exp Ophthalmol. 2019 Jan;257(1):143-151.}

Randas et.al.
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3.2.1 Ahmed vs Baerveldt glaucoma drainage device

case series

2020 Sinha et.al.

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2020
case series

There was higher complete success rate and significantly greater reduction in mean IOP and number of medications in the Baerveldt group vs Ahmed group, but with a higher rate of complications including hypotony. {Sinha S, Ganjei AY, McWatters Z, Lee D, Moster MR, Myers JS, Kolomeyer N, Mantravadi AV, Pro MJ, Razeghinejad R. Ahmed Versus Baerveldt Glaucoma Drainage Device in Uveitic Glaucoma: A Retrospective Comparative Study. J Glaucoma. 2020 Sep;29(9):750-755.}

  • Retrospective comparative study of Ahmed vs Baerveldt glaucoma drainage device in uveitic glaucoma (137 eyes of 122 patients).
  • Outcome definitions:
    • Complete success: IOP ≥6 and ≤21 mm Hg and >20% reduction on 2 consecutive visits after the third month without medications
    • Qualified success: As above, with medications
  • Findings
Baerveldt Ahmed
IOP reduction from baseline 60.3% 44.5%
Complete success rate 30% 9%
Complication rate 51.4% 20.9%
Reoperation rate 4% 19%
Hypotony resulting in failure 10% 0

Sinha et.al.
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3.2.1 Combined Dexamethasone Intravitreal Implant and Glaucoma Drainage Device Placement

case series

2020 Nguyen et.al.

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2020
case series

Concurrent placement of a dexamethasone intravitreal implant and glaucoma drainage device effectively controlled intraocular pressure and inflammation in 8 eyes of 6 patients with uveitic glaucoma.{Nguyen T, Kim H, Mielke C, Momont AC, Brandt JD, Liu Y. Combined Dexamethasone Intravitreal Implant and Glaucoma Drainage Device Placement for Uveitic Glaucoma. J Glaucoma. 2020 Apr;29(4):252-257.}

Nguyen et.al.
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case series

2020 Cao et.al.

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2020
case series

In 56 eyes of 37 patients with uveitis that underwent fluocinolone acetonide implantation, concurrent or subsequent glaucoma drainage implant surgery offered excellent long-term control of IOP. Outcomes at mean follow up of 71 months:{Cao JL, Srivastava SK, Lowder CY, Sharma S, Baynes K, Eisengart J. Long-term Outcomes of Glaucoma Drainage Implants in Uveitic Eyes With Fluocinolone Acetonide Implants. J Glaucoma. 2020 Sep;29(9):789-793.}

 

  • IOP was reduced by mean of 52.9%
  • Number of medications decreased by mean of 69.0%
  • Surgical success rate was 71.4% at 10 years

Cao et.al.
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3.3 Ab interno trabeculotomy

case series

2020 Swamy et.al.

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2020
case series

In 45 eyes of 45 patients with uveitic glaucoma, the trabectome AIT procedure reduced IOP from 29.2mmHg to 16.7mmHg at 12 months. Survival rate was 91%. 6 cases required secondary glaucoma surgery and no other serious complications were reported.{Swamy R, Francis BA, Akil H, Yelenskiy A, Francis BA, Chopra V, Huang A. Clinical results of ab interno trabeculotomy using the trabectome in patients with uveitic glaucoma. Clin Exp Ophthalmol. 2020 Jan;48(1):31-36.}

Swamy et.al.
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3.4 EX-PRESS Glaucoma filtration device

case series

2017 Dhanireddy et.al.

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2017
case series

Surgical success was seen in nine eyes (75%) in the uveitic glaucoma patients who underwent Ex-PRESS Filtration Device.

 

Dhanireddy et.al.
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3.5 Deep Sclerectomy

case series

2017 Merceicayet.al.

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2017
case series

In 43 eyes of 43 patients who underwent deep sclerectomy for uveitic glaucoma, the probability of IOP <22 and <19 mm Hg was 60% and 51% at 5 years, respectively. Seven eyes (16.3%) had subsequent IOP-lowering procedures.{Mercieca K, Steeples L, Anand N; Medscape. Deep sclerectomy for uveitic glaucoma: long-term outcomes. Eye (Lond). 2017 Jul;31(7):1008-1019.}

Merceicayet.al.
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References

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