What to Do When Glaucoma Gangs Up on You

What to Do When Glaucoma Gangs Up on You

1) Herpes Simplex. Methods: This study examined a retrospective, nonrandomized comparative interventional case series of 105 UG patients (141 eyes) followed between April 1, 2001 and July 30, 2014 at the outpatient clinic of Tohoku University Hospital. A thoughtful approach toward preoperative planning, intraoperative technique and postoperative management will be most successful. The patients medical history was remarkable for hypercholesterol-emia and migraine headaches. What did you find? One week after the second episode of hypotony, the surgeon revised the trabeculectomy in the patient’s left eye. Most of the patients also had severe secondary glaucoma.

Cataracts and Cataract Surgery: The incidence of cataract development in patients who had a phakic study eye was higher in the OZURDEX® group (68%) compared with Sham (21%). As mentioned earlier, a large number of cases are idiopathic, but infectious causes such as herpes simplex virus can produce inflammation, glaucoma, and other abnormalities. Next, note the size of the precipitates. CMV endotheliitis should be suspected when patients present with corneal endotheliitis involving coin-shaped lesions accompanied by anterior uveitis and ocular hypertension. Is the development of uveitis associated with herpes simplex keratitis, secondary to corneal lesion or associated with a viral invasion of the anterior choroidal currently unknown. However, in this condition, IOP does not decrease when the anterior inflammation is successfully treated because the underlying cause of the angle closure, pupillary seclusion and iris bombé resulting from extensive posterior synechiae or uveal effusion, persists and must be addressed. Tsai’s typical approach to quieting the inflammation in non-infectious cases is topical prednisolone acetate q1h or q2h while awake for one to four days, at which point the patient returns for an exam.

Chee et al found in a cohort study that one-quarter of patients with anterior uveitis tested positive for CMV by aqueous humor PCR testing and that a large majority of these patients had clinical evidence of PSS.11 The likelihood of being positive by PCR testing was greater during an active episode of PSS. He says he’ll increase the steroid to pre-taper levels if the inflammation returns. The acute rise in intraocular pressure (IOP) is related to red blood cells and their byproducts clogging the trabecular meshwork; another cause is direct trauma to the meshwork, which occurs concurrently with the initial trauma. Mr. Other infections associated with IOHS include toxoplasmosis and syphilis. It can also affect the small joints. In addition, they may have loculations within the posterior chamber, effectively isolating any given iridotomy.

Dr. Tsai says that, in patients with secondary angle-closure glaucoma due to their uveitis, posterior synechiae can develop and obstruct the flow of aqueous from the posterior chamber to the anterior chamber, thereby causing pupillary block. If, despite medications, IOP is considered too high for the safety of the optic nerve or it risks blood staining of the cornea, surgery may be required. Several conditions have a predilection for certain age groups. More recent publications have reported a considerable decrease in the incidence of intraoperative and postoperative complications during cataract extraction in uveitis [4–7, 12]. A routine baseline workup comprising complete blood count which includes total and differential count/ hemoglobin/ platelet count, erythrocyte sedimentation rate, purified protein derivative skin test (PPD) and chest X-ray are mandatory. Increased expression of MMP-1, -3, -17, and -24 and TIMP-2, -3, -435 in human trabecular meshwork cell cultures treated with latanoprost acid for 24 hours, and MMP-1, -2, -336 in iris root, ciliary muscle, and adjacent sclera in monkeys may lead to hydrolysis of collagen types I and III (MMP-1), collagen IV and fibronectin (MMP-2), and collagen types III, IV, fibronectin and laminin (MMP-3), resulting in widening of the connective tissue-filled spaces among the ciliary muscle bundles37 and loss of trabecular meshwork (TM) extracellular matrix, hence increased outflow.29,36 Similar anterior segment morphologic changes among the different prostaglandins,38 suggest similar mechanisms of action on uveoscleral or trabecular outflow.31 Studies to elucidate cellular mechanisms associated with PG-induced MMP secretion and alterations in calcium signaling pathways in the trabecular meshwork are ongoing.

However, for a younger patient with good vision in both eyes, he’d opt for a trabeculectomy with antimetabolites. Subsequently, the sponge was removed and it was copiously irrigated with balanced salt solution. Typically, the inflammation resolves rapidly after stopping the alpha-2 adrenergic treatment and with use of topical corticosteroids [31, 32]. Onal has no financial interest in the subject matter. At the time of presentation, her BCVA was 6/6 (OU). Henderer notes that the pseudoexfoliation patient tends to be older, and the condition often presents asymmetrically, though, in general, it’s ultimately a bilateral disease. The patient does demonstrate obvious signs of glaucoma in his left eye both at the level of the optic disc and visual field.

What to Do When Glaucoma Gangs Up on You
Nevertheless, they did not lose faith in their hypothesis and later decided to use a new method that seemed advantageous for the detection of viral DNA: the polymerase chain reaction (PCR). His intraocular pressure was still over 30 mmHg and a repeat trabeculectomy with mitomycin C was planned. “That’s something you don’t see very frequently with open-angle glaucoma, but you see it frequently with pseudoexfoliative glaucoma. The glaucoma can also be more aggressive in these patients.” He adds these patients often don’t dilate well and tend to develop cataract earlier than normal. The most frequently encountered ocular finding was granulomatous KPs, which were present in 82% of eyes. “The liberated pigment deposits on the angle and creates a heavily pigmented trabecular meshwork and slit-like transillumination defects in the mid-periphery of the iris,” describes Dr. Ocular features of all these patients included peripheral multifocal choroiditis with vasculitis (Fig 1).

[23] Children with iridocyclitis rarely have a positive serology for a rheumatoid factor, but they frequently have antinuclear antibody [23],[24] and HLA-B27 antigen, and some eventually are found to have typical ankylosing spondylitis. “These findings can be easy to miss if you don’t look for them,” he continues. We speculate that CMV remains latent in the anterior chamber in some individuals, and this may reactivate when the local milieu is altered, such as with the administration of prostaglandin analogues. Pigmentation in the meshwork can be hard to appreciate unless you look at the fellow eye on gonioscopy to assess the difference between the two eyes. And the slit-like defects are tough to see unless you transilluminate the iris. The transillumination defects, if present, can be really difficult to see in eyes with dark irides.” He says the eyes are typically myopic, have a deep anterior chamber with a concave iris configuration and that the disease is usually symmetrical on presentation. Gastrointestinal prophylaxis with a histamine 2 blocker or proton pump inhibitor should also be considered.

1. The recent case of virus-induced inflammation in the central nervous system several months after recovery from Ebola in Pauline Cafferkey, the Scottish nurse, prompts further questions about the inflammatory response in the eye. The chance of developing severe hypotony with an Ahmed Glaucoma Valve is low but possible (1.3% per person/years).6 Given the poor visual prognosis associated with glaucoma secondary to juvenile idiopathic arthritis-associated uveitis, however, the potential benefits of surgical treatment must be weighed against the risk of postoperative complications. Though it can arise from a number of disease states, physicians report that the conditions most often behind the anterior neovascularization are central retinal vein occlusion, proliferative diabetic retinopathy, ocular ischemic syndrome and central retinal artery occlusion. If the patient isn’t diabetic or has no history of CRVO, surgeons say it’s a good idea to order a carotid ultrasound, a carotid flow study, a computed tomography angiogram or magnetic resonance angiogram and possibly a carotid endarterectomy to rule out ocular ischemic syndrome. Managing the patient is a two-person job, surgeons say, with you collaborating with a retina colleague, who will usually be the one administering the anti-VEGF treatment, performing the PRP and otherwise managing the retinal condition, while you handle the glaucoma. When considering surgery, Dr.

In Japan, ganciclovir is available for the treatment of intravenous infusion, and valganciclovir hydrochloride tablets for CMV infection. “I’ve had patients who had a vein occlusion, were treated and then had that eye become their ‘bad’ eye,” he recalls. “But then they developed a vein occlusion in the fellow eye, and it had a worse outcome—their previous ‘bad’ eye had become their good eye. So, I wouldn’t be too quick to write off a 20/400 eye due to a vein occlusion, because the patient may have underlying vascular disease that will make the other eye the worse eye in the end.” He recommends avoiding non-steroidal anti-inflammatories for pain control, to avoid affecting platelet aggregation should the patient need surgery. Am J Ophthalmol. “Both neovascular and uveitic glaucoma aren’t considered to be ideal for long-term trabeculectomy survival,” says Dr. Watching television from a distance of greater than 10 feet is acceptable because of the minimal eye movement that occurs with viewing a fixed screen at this distance.

Brown’s uveitis has been stable, without subsequent flare-ups since June 2012. Neovascular glaucoma can be challenging because when you actually enter the eye you can cause some hemorrhage by cutting the vessels in the angle and causing a hyphema. “Also, both uveitic and neovascular glaucoma can occasionally have a problem with the iris wrapping around the tube of an implant and blocking it,” Dr. Henderer says. “Fortunately, in my experience, that’s pretty rare. Also, if you perform surgery in the setting of very high pressure, too rapid of a postop pressure drop runs the risk of choroidal detachment or suprachoroidal hemorrhage. However, at first a cleft can be blocked by blood or other tissues, and hypotony may only become apparent later.

Hetero-chromia of iris can be either hypochromic (abnormal eye is lighter than fellow eye) as seen in Fuch’s heterochromic iridocyclitis or hyperchromic (abnormal eye is darker than fellow eye) as seen in melanosis of iris. Recently published study by Ganesh and colleagues analysed ten eyes of 7 patients who had phacoemulsification with IOL implantation done by a single surgeon. “I put in permanent sutures that adjust the pressure for what I’d eventually like the long-term pressure to be, but I temporarily tighten the trabeculectomy flap with releasable sutures so the pressure is at an intermediate point between the preop pressure and the long-term postop goal pressure. So, if the IOP was 45 mmHg preop and I’d like the eventual pressure to be 15, I’d set the permanent sutures for 15 and the releasable suture for an intermediate pressure of 25 to 30. That way, after a week, I can pull the releasable sutures and minimize the trauma to the eye as the pressure goes down, stepping it down in a way that I hope will be safer. There were two cases each of hyphema and diffuse bleb. The integrity of the trabeculodescemetic window allows controlled outflow of aqueous humor, which reduces the risk of profound and long-term hypotony, and it also has been postulated to prevent egress of cytokines and inflammatory mediators from the anterior chamber into the subconjunctival space, which reduces the risk of inflammation, scarring, and failure of filtering surgery [39–41].

This doesn’t open the tube completely, so it yields a bit more of a stair-step pressure control over the first few weeks postop until the tube opens. It doesn’t solve all of your problems, unfortunately, and, occasionally, the slits don’t work and the pressure does drop from 55 to 5 when you open the tube or it opens by itself in a month. Generally speaking though, in my experience it’s safer than having an immediate pressure drop the day after the surgery.

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