CURRICULUM VITAE ROBERT ALAN RINGEL, M.D. DEGREES HELD POSITIONS HELD Curriculum Vitae – Robert Alan Ringel, MD ACADEMIC RESPONSIBILITIES AND ENDEAVORS Director, Electroencephalography Laboratory, West Virginia University Hospitals, Inc., 1986 – 1988 CPR Committee, West Virginia University Hospitals, Inc. Neurointensive Care Unit Committee, West Virginia Univ
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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 Advanced Ocular 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 protected] 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.
30 ADVANCED OCULAR CARE JANUARY/FEBRUARY 2011
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