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Separating glaucoma and cataract surgery in uveitic patients may be preferred.
BY STEVEN D. VOLD, MD
Uveitis in the glaucoma patient presents a unique commonly used agents, but difluprednate (Durezol;
group of challenges to physicians. Inflammation
Alcon Laboratories, Inc.) was recently shown to be an
may affect the selection of topical glaucoma
effective treatment for uveitis as well.1,2
medication, IOP control, cataract development,
When uveitic patients require topical glaucoma thera-
surgical decision making, and medical management after
py, aqueous suppressants are recommended.
glaucoma surgery. This article briefly reviews several of the
Prostaglandins and miotic agents are known to exacer-
issues facing glaucoma patients with uveitis (Figures 1-3)
bate uveitis and are generally avoided in this clinical situa-
and offers some recommendations on management.
tion; beta-blockers, carbonic anhydrase inhibitors, andalpha-agonists are preferred. In patients with uveitis
CHOICE OF MEDICATION
potentially due to a herpetic etiology, oral antiviral agents
Uveitis may either lower or raise patients’ IOP. When
such as acyclovir, valacyclovir, and famciclovir may
the trabecular meshwork is functioning well, anterior seg-
improve intraocular inflammation and IOP control.
ment inflammation commonly lowers IOP by inducing an
Cycloplegic agents may also be useful in preventing angle
aqueous humor shutdown via a cyclitis mechanism. As
closure caused by posterior synechiae.
peripheral anterior synechiae develop, IOP levels mayincrease due to compromised aqueous outflow. The use
SURGICAL DECISION MAKING
of steroids in uveitic patients may also have a variable
When IOP levels remain uncontrolled despite maximal
impact on IOP. In eyes with increased IOP due to trabe-
medical therapy, incisional glaucoma surgery may be indi-
culitis, topical steroids may actually improve pressure con-
cated. Ideally, glaucoma surgery is undertaken after any
trol. Conversely, in patients with both uveitis and glauco-
anterior segment inflammation has resolved. In such
ma, chronic steroid treatment is certainly more likely to
cases, standard filtering surgery in the form of trabeculec-
lead to uncontrolled IOP. The periocular or intravitreal
tomy with an adjunctive antifibrotic agent and with or
application of steroids may also be necessary.
without implantation of the Ex-Press glaucoma mini
Prednisolone acetate and dexamethasone are the most
shunt (Alcon Laboratories, Inc., Fort Worth, TX) is com-
Figure 1. Keratic precipitates and synechial angle closure in
Figure 2. Accumulated pigment in the inferior angle of an
an eye with uveitis.
eye with herpes simplex-induced uveitic glaucoma.
JANUARY/FEBRUARY 2011 ADVANCED OCULAR CARE 29
monly recommended. For mild-to-moderate cases ofopen-angle glaucoma, canaloplasty (iScienceInterventional, Menlo Park, CA) and Trabectome surgery(NeoMedix Corporation, Tustin, CA) may be considered.
In children, goniotomy and trabeculotomy ab externohave provided successful outcomes. Cyclodestructive pro-cedures should be avoided in uveitic children, however,due to the risk of worsening uveitic complications such ascystoid macular edema, choroidal effusion, cataract, andpotentially phthisis bulbi.
In the setting of chronic or recurrent uveitis, filtration
surgery commonly fails or may result in chronic hypotonyand poor vision in eyes with large avascular blebs. In theseclinical scenarios, tube shunt surgery with a patch graftmay be advantageous. Based on my clinical experience, Igenerally prefer to use a valved device such as the AhmedGlaucoma Valve (model FP7; New World Medical, Inc.,
Figure 3. An eye with fibrinous uveitis.
Rancho Cucamonga, CA) or the Baerveldt 250 (not 350)tube shunt (Abbott Medical Optics Inc., Santa Ana, CA).
steroids, Durezol may actually be more effective than pred-
When using a nonvalved device, preventing hypotony with
nisolone acetate in facilitating successful filtration surgery
utilization of a ripcord or tube suture may improve the
outcomes due to its increased potency in reducing ocular
patient’s postoperative course and, ultimately, surgical out-
inflammation. Regarding cycloplegic agents, my patients use
comes. Long-term decreases in aqueous humor production
cyclopentolate, scopolamine, homatropine, or atropine b.i.d.
must be considered in patients with chronic uveitis.
or t.i.d. postoperatively to maintain a deep anterior chamber,
As a general rule, minimizing the amount of surgery in
stabilize the blood-aqueous barrier, and prevent the forma-
these patients is beneficial. For example, separating glau-
tion of posterior synechiae. In patients with chronic uveitis,
coma and cataract surgery in uveitic patients could be
long-term steroid use may be necessary to maintain quiet
advantageous. In a perfect world, clear corneal cataract
eyes, adequate IOP control, and good vision. Periocular and
surgery alone would be performed first when appropriate.
intravitreal steroid drug delivery may benefit some patients.
Incisional glaucoma surgery would follow once the eye
For combined trabeculectomy and cataract surgery, I admin-
ister topical nonsteroidal anti-inflammatory medications toreduce postoperative inflammation and prevent cystoid mac-
PERIOPERATIVE SURGICAL MANAGEMENT
ular edema. Nonsteroidal anti-inflammatory drugs may also
In eyes undergoing incisional glaucoma surgery, the
assist in postoperative pain control.
increased preoperative utilization of topical steroids mayhasten postoperative recovery and enhance long-term
surgical outcomes. More frequent steroid dosing for at
Uveitis can negatively affect the outcome of glaucoma
least 3 to 7 days prior to surgery is often recommended.
surgery. I prefer to manage both glaucoma and uveitis med-
Intraocular (anterior chamber or intravitreal) injections of
ically whenever possible. However, if surgical intervention is
preservative-free triamcinolone (Triesence; Alcon
necessary, proper precautions enhance the possibility of sat-
Laboratories, Inc.) may be given at the time of surgery as
well. Postoperatively, more frequent and longer steroidtreatment is commonly required. The use of tissue glues
Steven D. Vold, MD, is the president and CEO of
or permanent sutures (eg, nylon) may reduce postopera-
Boozman-Hof Eye Clinic, PA, in Rogers, Arkansas,
tive ocular surface inflammation. Removing irritating
and the chief medical editor of
sutures when appropriate may also help decrease postop-
Care’s sister publication
Glaucoma Today. He is a
erative inflammation and improve surgical outcomes.
consultant to Alcon Laboratories, Inc.; iScience
Following trabeculectomy, I prescribe Durezol starting at a
Interventional; and NeoMedix Corporation. Dr. Vold may be
minimum of four times per day but generally dosed every
reached at (479) 246-1700; email@example.com.
2 hours (both preoperatively and postoperatively) in patients
1. Korenfeld MS,Silverstein SM,Cooke DL,et al.Difluprednate ophthalmic emulsion 0.05% for postoperative inflammation and
with concurrent glaucoma and uveitis. Although linked to
pain. J Cataract Refract Surg.2009;35:26-34.
2. Foster CS,Davanzo R,Flynn TE,et al.Durezol (difluprednate ophthalmic emulsion 0.05%) compared to Pred Forte
perioperative IOP spikes possibly more frequently than other
1% ophthalmic solution in the treatment of endogenous anterior uveitis.J Ocul Pharmacol Ther. 2010;26:475-483.
ADVANCED OCULAR CARE JANUARY/FEBRUARY 2011
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