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Dr Richard HartOphthalmologist, Cataract Surgeon
Ophthalmic Plastic Surgeon
Auckland
8:30 - 9:25 WS #213: Glaucoma, Retinal Disease and the Watery Eye
9:35 - 10:30 WS #225: Glaucoma, Retinal Disease and the Watery Eye
(Repeated)
Dr Sonya BennettConsultant Ophthalmologist
Greenlane Clinical Centre Eye Clinic
Dr Clairton De SouzaSenior Lecturer, Optometry
Clinical Senior Lecturer in Ophthalmology
University of Auckland
Best friends:
uveitis and glaucoma
Dr Sonya Bennett
City Eye Specialists
Rotorua GP CME June 2019
Uveitis
• collection of syndromes involving intraocular inflammation which can
lead to pain, ocular tissue scarring and vision loss
• third leading cause of preventable blindness in the developed world
• 20% of uveitis patients develop glaucoma due to the inflammation or
secondary to corticosteroid treatment
Signs and symptoms of uveitis
• ciliary injection
• small pupil
• posterior synechia
• corneal haze
• hypopyon
• tender/painful eye
• photophobia
• blurred vision
Uveitis investigations
• many conditions are clinically obvious such as Fuchs heterochromic
iridocyclitis, Behçet disease, toxoplasmosis, cytomegalovirus (CMV)
retinitis and Vogt-Koyanagi-Harada disease, and require little, if any,
laboratory analysis
• patient presenting with an initial episode of acute non-granulomatous
anterior uveitis and an unremarkable medical history and physical
examination does not require laboratory evaluation
Uveitis investigations
• careful medical history and physical examination are guidance for
choosing appropriate tests
• important to avoid expensive, unnecessary tests and false positive
results
• most important conditions to exclude are syphilis, TB and sarcoidosis
Uveitis investigations
• syphilis serology, Quantiferon gold, serum ACE
• Chest x-ray
• others as indicated after systems review and physical examination
(such as aqueous tap for HSV, VZV or CMV PCR)
Glaucoma
• characteristic, progressive optic neuropathy
• changes to structure and function of optic nerve
• may be associated with elevated IOP
Uveitic glaucoma
• challenging to deal with as OHT/glaucoma usually aggressive and
patients require surgery earlier in the course of disease
• surgical intervention is indicated if medical treatment cannot
adequately control the IOP (selective laser trabeculoplasty is not
effective for long and so is not recommended)
Fuchs’ heterochromic iridocyclitis (FHI)
• 2-7% of anterior uveitis
• mild unilateral anterior uveitis (breakdown of blood-
aqueous barrier not inflammation)
• stellate KP distributed evenly over entire cornea
• iris heterochromia with prominent iris and angle
vessels (Amsler’s sign)
• snowbanking at pars plans and vitreous debris less
common
Fuchs’ heterochromic iridocyclitis (FHI)
• evidence for viral aetiology; Rubella and CMV (40%) on PCR
• viral aetiology would explain poor response to topical corticosteroids
Fuchs’ heterochromic iridocyclitis (FHI)
glaucoma
• retrospective analysis of 88 patients with FHI
• at presentation 52% had cataract and 26% had
ocular hypertension or glaucoma
• 4 years after presentation estimated rates using
Kaplan-Meier curves were 71% for cataract and
39% for glaucoma
• glaucoma risk was associated with patient age >50
years and having a cataract at presentation
Toniolo JT et al Risk Factors for Glaucoma in a Cohort of Patients with Fuchs Heterochromic Iridocyclitis. J Ocul Immunol
Inflamm. 2017
Posner-Schlossman Syndrome
• aka glaucomatocyclitic crisis
• 20-50 years, M>F
• recurrent unilateral attacks of significantly elevated
IOP with minimal conjunctival injection and mild
anterior chamber activity with small KP
• IOP usually normal between attacks
• attacks may last from hours to weeks
Posner-Schlossman Syndrome
• 25-75% of patients found to be CMV positive on PCR of aqueous
(acute attack)
• high seroprevalence of CMV worldwide and the low frequency of
PSS, with specific ethnic distribution, suggests other factors -
genetic or coinfectious (H. pylori)
Posner-Schlossman Syndrome
• approx 25% of patients have glaucoma at any time
• after 10+ years, 2.8x increased risk of glaucoma
• risk to vision in this condition is from glaucoma, not uveitis
Posner-Schlossman Syndrome
• treatment includes:
• topical corticosteroids g.Prednisolone 1% QID
• topical NSAIDS
• topical IOP lowering drugs: timolol, brinzolamide, brimonidine
• oral acetazolamide
Posner-Schlossman Syndrome
• topical and oral valganciclovir have recently been used as a
treatment option in hopes of eliminating CMV in the anterior
chamber, thus removing the infectious drive for uveitis
• a retrospective study compared topical and oral valganciclovir
and found that topical therapy had a higher failure rate;
however, topical therapy yielded a lower recurrence rate
• many studies report that cessation of any form of antiviral
therapy results in a high rate of recurrence, as valganciclovir
is virostatic and not virucidal
Chee SP, Jap A. Cytomegalovirus anterior uveitis: outcome of treatment. Br J Ophthalmol. 2010 Dec. 94 (12):1648-52.
Posner-Schlossman Syndrome
• in NZ we don’t have topical gancyclovir or valgancyclovir available;
oral valgancyclovir is available but only with special authority from
PHARMAC
• I manage my PSS patients who have recurrent episodes and
glaucoma with
• once daily Prednisolone acetate 1%
• topical timolol/brinzolamide/brimonidine (and as a last resort
latanoprost)
• discuss oral valgancyclovir course (no guidelines on length of
course)
CMV Anterior Uveitis
• two case reports of anterior uveitis reactivation
starting after prostaglandin analogue use for IOP
control
• both were immunocompetent; CMV positive on
aqueous tap PCR
• one had a history of FHI (latanoprost) and one had
POAG (travoprost) with no previous uveitis
Babu K, Murthy GJ. CMV anterior uveitis in immunocompetent individuals following topical prostaglandin analogues. J
Ophthalmic Inflamm Infect. 2013
Tuberculous Uveitis
• uncommon, prevalence 5.4/ 1000 subjects J Ophthal Inflam Infect 2018; 8(1); 6
• accounts for 3% of all uveitis cases in our service Auckland NZ (n=2200)
• causes 3-10% of all cases of blindness in the western world• Br J Ophthal 1996, 80(9): 844-48
• 19.2% of patients overall develop vision loss from uveitis, higher risk if retinal involvement or in children
Tuberculous Uveitis
• diagnosis of presumptive TB uveitis requires
• uveitis clinically compatible
• supportive testing demonstrating exposure to TB
• exclusion of other uveitis diagnoses
• diagnosis of definite TB uveitis
• all of the above plus a positive ocular tissue result
Tuberculous Uveitis
• clinical features seen more commonly in TB:
• choroidal granulomas
• occlusive retinal vasculitis
• multifocal serpiginoid choroiditis
Tuberculous Uveitis
• mechanisms for inflammation:
• autoimmune/autoinflammatory 79.5%
• infection 20%
• masquerade eg lymphoma 0.5%
TB uveitic glaucoma
• retrospective cohort study 354 patients with intraocular TB
• most common ocular complications were cystoid macular oedema in
30% and glaucoma in 28%
• in Auckland study 36% had OHT/glaucoma and 15% required
trabeculectomy
Gunasekeran DV, Gupta B, Cardoso J, Pavesio CE, Agrawal R. Visual Morbidity and Ocular Complications in
Presumed Intraocular Tuberculosis: An Analysis of 354 Cases from a Non-Endemic Population.
Ocul Immunol Inflamm. 2018;
Surgery for Uveitic Glaucoma
• not for the faint hearted!
• trabeculectomy and tube drainage surgery are the two most
common surgeries (MIGS - not yet enough evidence)
• the important aspect of success in uveitic glaucoma surgery
is the post-operative care
• higher risk of post-operative hypotony due to ciliary body
impairment from inflammation and from antifibrotic use
• higher rate of surgery failure due to subconjunctival scarring
Surgery for Uveitic Glaucoma
• tricks to improve surgical outcomes:
• oral prednisone starting preoperatively and continuing for approximately
one month
• antifibrotic (mitomycin C) intraoperative application
• subtenon’s/subconjunctival triamcinolone 40mg at completion of surgery
• topical corticosteroid Q1-2hrly post operatively and continue with gradual
taper for at least three months
Grateful thanks to Dr Jo Sims for the TB
uveitis data for this presentation
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