Uveitis unplugged: glaucoma management in patients with ... · Glaucoma and Uveitis Uveitic...

Uveitis unplugged: glaucoma management in patients with uveitis

Hobart 2017 Peter McCluskey

Save Sight Institute

Sydney Eye Hospital

Sydney Medical School

University of Sydney

Sydney Australia

No financial or proprietary interest in any material discussed

Glaucoma and Uveitis

Uveitic Glaucoma

• responsible for up to 15% vision loss

in patients with uveitis

• difficult to assess and follow

• often ↑ IOP rather than “glaucoma”

• often use arbitrary IOP levels > 25-

30 mmHg

• combined / multiple mechanisms

• steroid induced IOP > 50%

• often requires surgery

2

Frequency of elevated IOP

prevalence: 10 - 20%

acute anterior uveitis 10 %

recurrent AAU 40 %

chronic anterior uveitis 70 %

intermediate 10 %

posterior 10 %

steroid therapy > 50%

3


Closed Angle

• pupil block / iris

bombe

• PAS

• ciliary body rotation /

uveal effusion

• aqueous misdirection

Open Angle

• trabeculitis

• debris → angle blockage

• TM damage - fibrosis

• steroid response

• aqueous hyper-secretion

/ rebound

Mechanisms

NB: Multiple mechanisms common


Principles of Management

• control uveitis

- critical to success of any surgery

- may control the glaucoma

- often requires systemic IMT eg JIA uveitic glaucoma

- no need for additional peri-op steroid therapy


Principles of Management

• determine the mechanism of the glaucoma

- gonioscopy critically important

- consider laser PI if uncertain

- consider secondary mechanism for angle closure – CB rotation

• medical control of IOP

• surgery


Topical

• β blockers

• prostaglandin

analogues

• α agonists

• topical CAIs

Systemic

• oral/IV diamox

• IV mannitol

Avoid: pilocarpine

Medical Control of IOP

Chang JH, McCluskey P, Missotten T, Ferrante P et al.

Use of ocular hypotensive prostaglandin analogues in

patients with uveitis: does their use increase anterior uveitis

and cystoid macular oedema?

Br J Ophthalmol. 2008; 92:916-21.


Indications for Surgery

• ongoing need for systemic diamox

• dangerous IOP level……. > 40mmHg

• IOP > 25 – 30 mm Hg on max topical therapy

• increasing disc cupping

• progressive loss of visual field

NB: no need for peri-operative steroid cover

most

common

less

common


trabeculectomy + anti-

metabolites

- MMC

- 5 FU

glaucoma drainage device

- Baerveldt

- Molteno

cyclodiode

- limited visual potential

consider

- SLT

- NPGS

- MIGS

avoid

- ALT

- phacotrabeculectomy

Glaucoma Surgical Options


Trabeculectomy

• unenhanced surgery poor outcomes

• success at 5 years < 30%

Enhanced Trabeculectomy

• improved outcomes

• intra-operative MMC: 0.4 mg/ml / < 3 mins

• post op sub-conjunctival 5FU: 5mgs


Mitomycin C

• potent, long term effects; inhibits cell growth >> 1month

• standard of care for trabeculectomy surgery

• SEH: single conc: 0.4mg/ml; vary duration: 1-3 minutes

5-Fluorouracil

• short term effects; fibroblasts recover within 7 days

• used post trab, post needling and at time of cataract

surgery post trab

Anti-metabolite use in 2017


MMC Trabeculectomy

• 2017 standard technique

- fornix based conjunctival flap

- widespread deep dissection into fornix

- MMC: 0.4 mg/ml / 1-3 mins; deep in

fornix

- Kelly punch sclerotomy & PI

- releasable sutures flap – 10 o nylon

- tight conjunctival closure - – 10 o nylon


Glaucoma Surgery and Uveitis

……..its all about post op management

•significantly influences final result

•outcome is a good bleb and low IOP

•difficult and time consuming to achieve

•need close, careful follow up & frequent

intervention


Assessing the bleb

• aim to assess

- aqueous flow

- bleb inflammation

• parameters:

IOP

encapsulation

- area

- bleb height

inflammation

- vascularity

Moorfields bleb grading system:

http://www.blebs.net/html/introduction.html


http://www.blebs.net/html/introduction.html

Post-operative management

• 2 critical phases:

1. modulating flow (days 1-10)

• bleb massage

• releasable sutures

• reform flat AC

2. healing response (days 7-21)

• intensive topical steroids

• post op 5 FU

Day 30


Phase I: modulate aqueous flow

• days: 1-10

• day 1: IOP around pre-op IOP

• titrate down IOP with

- bleb massage

- “loosen” sutures

- stepwise suture removal

• watch for inflammatory response

- wound healing

- begins around day 7

one of the many techniques

for releasable sutures


Phase II: Control Bleb Inflammation

• days: 7-21

• try to treat inflammatory response

before IOP

• threshold: grade 2 vascularity

- steroids to 8 times / day

- 5 FU superior or adjacent to the bleb

- maximum 7 doses in 10 days

• bleb encapsulation

- needling with 5-FU

Grade 2:

Moderate increased vascularity

(congestion, numerous vessels -

some corkscrew)

Grade 4:

Severe increased vascularity

(congestion, numerous vessels,

many corkscrews)


MMC Uveitic Glaucoma

• no prospective studies

• multiple retrospective cases

series

• 90% 1 year success rates;

80% at 2 years; 60% at 4

years.

• risk factors for failure

cataract surgery &

granulomatous uveitis

(chronic uveitis)Iwao K, Inatani M, Seto T, Takihari Y et al.

Long term outcomes and prognostic factors for Trabeculectomy

with MMC in eyes with uveitic glaucoma: A retrospective cohort study

J Glaucoma 2012 ePub August 2012


Glaucoma Drainage Devices

• technique modifications have

improved safety & outcome

- vicryl tie around tube

- 3 0 nylon stent in tube (not supramid)

- AC & ciliary sulcus tube placement

- pars plana tube placement

• 25% + need additional treatment

by 5 years

Molteno175 & 230 mm

nasal or temporal quadrant

Baervaldt250 & 350 mm

temporal quadrant only


Glaucoma Drainage Device

• 2017 standard technique

- Baervaldt dominant

- fornix based conjunctival flap

- widespread dissection into fornix +

hyalase & adrenaline LA

- tunnel technique or scleral flap

- 3o nylon stent + 6o vicryl tie

- conjunctival closure - 8 o vicryl


post operative tube management:

• analagous principles to trab:

• arrest flow for 3-5 weeks with stent and suture

• must continue glaucoma therapy post-op to

control IOP

• prevents early hypotony and severely inflamed

bleb

• 80% of patients don’t need stent removal


collagen barrier

capillary

capsule, 11 days

cell migration

capsule, 56 days

death messenger drift

collagen breakdown

equilibrium>6 weeks

MMP-1MMP-2MMP-3(McCluskey 2009)

CD31Välimäki (2015)


Molteno AC, SuterAJ, Fenwick M, Bevin TH, Dempster AG.

Otago glaucoma surgery outcome study IOVS 2006; 47: 1975-81

Leong J et al Br J Ophthalmol. 2006; 90:501-505

Rossiter-Thornton L et al. Br J Ophthalmol. 2010; 94:665-66

54% success at 5 years

40% success at 10 years

Molteno Partial Success – Uveitic Glaucoma


Glaucoma Drainage Devices

• 54% success at 5 years

• 40% success at 10 years

• 25% need additional treatment by 5 years

• 5FU/MMC no change in

success rate


25


MIGS & NPGS

• rapidly growing & changing area

• many devices

- EX-Press shunt – external bypass stent

- iStent – internal trabecular bypass stent

- hydrus stent – internal trabecular bypass stent

- trabectome – internal trabeculectomy

- CyPass – internal bypass to supraciliary space


Is there a role for MIGS or NPGS in uveitic

glaucoma?

• small pilot studies only

year technique eyes/patie

nts

outcome Follow up

2016 canaloplasty 14/12 60% 2.0

2015 deep

sclerectomy

33/21 70% 1.5

2015 trabecutome ?/24 40% 1.0

2014 EX-press shunt 5/5 100% 1.0

…………..too early to tell


Surgical Management Algorithm

• MMC trabeculectomy

• repeat MMC trabeculectomy

OR

• Molteno / Baervaldt GDD

• high risk – primary GDD

- pseudophakic

- chronic anterior uveitis

- children


What’s new in 2017

• post-op follow up & management critical

• MMC trab surgery has changed greatly

• MMC trab much safer with improved outcomes

• tubes increasingly used – Baervaldt appears dominant GDD

• tube surgery has changed significantly

• 5 FU now only used as adjunctive therapy

• tube surgery likely to become dominant


Ocular TB Thank youThank you

Uveitis unplugged: glaucoma management in patients with ... · Glaucoma and Uveitis Uveitic...

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