Inflammatory Glaucoma

Raised IOP in the context of intraocular inflammation: can be challenging

Note: pilocarpine can increase breakdown of blood-aqueous barrier and worsen inflammation

Open angle

• Acute trabeculitis: associated with herpetic disease

• Trabecular meshwork blockage

• IOP tends to normalise after inflammation settles

• Chronic: may be due to trabecular scarring or chronic trabeculitis

  • Managed as per POAG albeit with poorer outcomes

• Steroid-induced

  • Risk increases with longer steroid usage (30% after 6 weeks of topical steroid)

  • Increased risk with

    • Myopia
    • POAG (90% steroid response compared to 30% in normal eyes)
    • Diabetes

  • Mechanisms

    • Prostaglandin inhibition
    • Structural changes in the ECM and TM

  • Requires reduction in potency and frequency of topical steroids (compared to the need to increase the steroids in trabeculitis!)

  • May be dose-dependent

    • Topical and intravitreal steroids have highest risk (intravenous, parenteral and inhaled have lowest risk)

Angle-closure

• Seclusio pupillae: 360 of posterior synechiae leading to iris bombe and appositional angle closure

  • Aim to minimize PS formation while treating attacks of uveitis
  • Laser PI: needs to be larger than in AACG

• Synechial closure: peripheral anterior synechiae leading to angle closure

  • Associated with granulomatous inflammation
  • Laser PI
  • Other management as for POAG

• Uveal effusion: anterior rotation of ciliary body

• Exudative RD pushing iris-lens forwards (rare)

Posner-Schlossman syndrome

• Recurrent unilateral painless high IOP

• White eye

• Typically affects young females

• Possibly related to HSV trabeculitis

• 40% are HLA-B54 positive

• Clinical features

  • Visual blurring
  • Haloes
  • Minimal flare/occasional cells/KPs
  • No synechiae
  • Open angle on gonioscopy

• Management

  • Topical steroid
  • Topical IOP-lowering therapy

Fuchs’ heterochromic cyclitis/uveitis

• Mild chronic anterior uveitis

• Iris heterochromia: usually the lighter iris is the involved eye (diffuse iris stromal atrophy)

• Cataract

• Glaucoma in 10-30%: may be difficult to control

• Affects young adults

• M=F

• >90% unilateral

• Associated with rubella

• Clinical features

  • White eye
  • Stellate KPs widespread over endothelium
  • Mild AC activity
  • Iris atrophy (‘moth-eaten’)
    • Transillumination defects
  • Iris heterochromia: ‘becoming bluer’
  • Iris nodules
  • Cataract: especially posterior cortical/subcapsular
  • Vitritis
  • Open angle with ‘twig-like’ neovascularisation on gonioscopy: may bleed after paracentesis during cataract surgery (Amsler-Verrey sign)

• Management as for POAG if relevant. Does not normally require treatment for inflammation