what is the first line Tx for pt w/ glaucoma + uveitis?

[eyeDockim]

I have a question regarding Rxing topical drop to pt with uveitis
Lets say, Pt has both Uveitis and glaucoma.
Rxing PGs will make worse b/c it will cause more inflammation.

Then i think the best choice topical Tx will be either Beta-blocker or Alpha-agonists
But doesnt Rxing BB make worse too? b/c BB will dilate the blood vessels then cells and flares are more spread out.

Then is AA is the first line Tx in this case?

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[310]

From an academic standpoint, you'd probably go with timolol or a CAI. I have not heard of timolol aggravating uveitis. Alpha agonists (alphagan) and pilocarpine are miotics so those are out since you want a big pupil.

Clinically, you'd start with timolol or cosopt if you need an acute drop. If the IOP isn't amazingly high, it's fine to use prostaglandins because they don't influence uveitis much in reality.

If the patient has active uveitis, controlling the uveitis itself will often control the eye pressure better than any glaucoma med will.


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[thiaeyemd]

You gotta treat the underlying uveitis..if the IOP is through the roof, then possner schlossman is really high on the Ddx.

 

[taco bell]

refractory uveitic glaucoma (fuchs, posner, recurrent ant uveitis, JIA) needs a tube shunt surgical procedure.. no need to wait on this - get the tube in ASAP

 

[luvely]

Just to add a question, if the patient's pressure spikes on Predforte would you switch to Lotemax or continue with the Predforte to hit the uveitis hard since you will taper anyhow?

Thanks!

 

[310]

Just to add a question, if the patient's pressure spikes on Predforte would you switch to Lotemax or continue with the Predforte to hit the uveitis hard since you will taper anyhow?

Thanks!

Continue pred and treat the iop. Refer out if needed.


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[luvely]

Continue pred and treat the iop. Refer out if needed.


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My preceptor pretty much said the same thing today, thanks!

 

[eye love lamp]

No one really touched in this so far, but what is the cause of the ocular hypertension? Is this acute anterior uveitis? What is the etiology/chronicity? Do they have PAS and CACG? Pupillary block from posterior synechiae? Most acute anterior uveitic entities will lower IOP, why is this higher? Is there a trabeculitis from herpes? Is this only from steroid response? How long have they been on steroids? What dose?

What is the IOP? What is the baseline IOP? What does the nerve look like? What do you see on gonio?

There are a lot of things that need to be taken into consideration before you can think about a treatment modality. All of the above responses are wrong. You cannot blindly treat this patient without the above information.

 

[310]

^well, I'm assuming we aren't talking about closed angles or pupillary block or else the OP would've said so. And you're wrong. You never have all of that information, ever, so have to work with what you have and follow them.


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[eye love lamp]

^well, I'm assuming we aren't talking about closed angles or pupillary block or else the OP would've said so. And you're wrong. You never have all of that information, ever, so have to work with what you have and follow them.


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If this is your approach to treating patients with uveitic glaucoma then you have no business treating patients with this disease.

If the OP said the patient had uveitic glaucoma, he/she is saying that there is already optic nerve damage. Even if it's the first time ever seeing the patient, you should have most of the above information before you can think of a treatment. You can't just assume the angle is open and there's no pupillary block.

From the initial encounter you can get the following information:
1. The type of uveitis. Anterior? Intermediate? Panuveitis? How severe? Those will take you in different directions for the treatment of inflammation.
2. The chronicity of uveitis. Ever have these symptoms before? Ever get treatment before? Are there signs on exam that would tell you (posterior synechiae, angle pigmentation, comparison to the other eye) that this is chronic?
3. Clues that lead you to the type of uveitis. Systemic conditions? Review of systems? History of zoster ophthalmicus? Medication use? Hypopyon?

In terms of the glaucoma, you can get the following on the first visit:
1. The IOP - is it 21, 31, 61? How does this compare to the other eye? (assuming this is unilateral).
2. The angle - open or closed? PAS? Is there NVI? Could this be neovascular glaucoma instead?
3. The optic nerve - are we dealing with a 0.2 C/D (and thus this is ocular hypertension) or a 0.99 close to snuff out? Is it symmetric or asymmetric to the other eye? OCT RNFL will not be useful here.
4. Steroids - have they been on them before? Did they come into your office on Q1H dexamethasone? Could this be a steroid response?


Even if it's the first time you've seen the patient, you can't think about treatment until you have the above information. To do otherwise is poor medicine.

 

[east]

I agree eye love lamp. Present the damn case first. No real conclusions can be drawn until full case is known. Way to many assumptions going on here.