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