7 common mistakes in managing uveitic glaucoma
Glaucoma is a relatively common complication of uveitis, occurring in about 20% of affected eyes and arising through several different mechanisms.
Emmett T Cunningham Jr., MD, PhD, MPH, reviewed seven common mistakes clinicians make in evaluating and managing elevated intraocular pressure (IOP) in eyes with uveitis during the Glaucoma Symposium CME at the 2016 Glaucoma 360 meeting.
Dr. Cunningham is director, Uveitis Service, California Pacific Medical Center, San Francisco; adjunct clinical professor of ophthalmology, Stanford University, Stanford, CA; research associate at The Francis I. Proctor Foundation, University of California-San Francisco; and a partner at West Coast Retina Medical Group, San Francisco.
Mistake #1: Failure to recognize masquerades
Dr. Cunningham described two issues—failure to distinguish leukocytes from pigment and failure to recognize acute angle closure. As an aid in distinguishing leukocytes from pigment, he reminded ophthalmologists to look for hallmark signs of inflammation.
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“If there is pigment release, you should not see keratic precipitates or posterior synechiae,” he said.
Dr. Cunningham noted that acute angle closure is typically not too difficult to distinguish. Although there can be cells, corneal edema and elevated IOP are the predominant findings and the fellow eye will show the narrow angle.
Mistake #2: Failure to recognize inflammatory ocular hypertension syndrome (IOHS)
IOHS is a strong predictor of infectious uveitis, and when the infection is treated appropriately, the IOP will go down. “When you see an acute elevation of IOP in eyes with uveitis, think about and look for infection,” Dr. Cunningham said.
The most common cause of IOHS is herpes virus infection. “About 30% to 40% of herpetic eyes have IOHS, and the dictum is, IOHS is herpetic until proven otherwise,” Dr. Cunningham said.
Presence of cutaneous manifestations of herpetic infection can provide a diagnostic clue to herpes related-IOHS, as will sectoral iris atrophy, which is virtually pathognomic for herpes zoster or herpes simplex infection, Dr. Cunningham said.
Other infections associated with IOHS include toxoplasmosis and syphilis. Ocular hypertension can also occur with sarcoidosis, which has not been linked definitively to infection, but suspicion for an infective cause remains, and with Posner-Schlossman syndrome, which is widely thought to be form fruste herpetic anterior uveitis.