Surgical Management of Open-Angle Glaucoma Associated with Uveitis

■ Uveitic glaucoma poses special challenges for the internist, rheumatologist, uveitis specialist, glaucoma specialist and the patient. ■ Exuberant inflammation, severe conjunctival scarring, iris neovascularization, corticosteroid-induced cataracts, medication side effects and the increased risk of hypotony make uveitic glaucoma especially difficult to manage. ■ Careful preoperative evaluation insures that the correct diagnosis is made and an appropriate treatment plan is implemented. It is imperative that pre- and postoperative intraocular inflammation be controlled adequately with judicious medication use. ■ When conservative measures fail, glaucoma drainage devices can provide an effective means of lowering intraocular pressure. Although several different, effective drainage implants are available, we prefer to use the modified 250 mm2 BGDD for the majority of our uveitic patients with elevated IOP. ■ Innovations in implantation technique and glaucoma drainage device modifications have improved our ability to achieve and maintain a low IOP in these challenging uveitic eyes. ■ Careful preoperative planning and meticulous attention to operative technique can minimize complications and enhance surgical safety and efficacy

Glaucoma drainage implants and vitreoretinal surgery

Glaucoma drainage implants can effectively lower the intraocular pressure in eyes that have undergone prior vitrectomy or scleral buckling surgery. Acute angle closure without pupillary block may develop after scleral buckling surgery, particularly in eyes with pre-existent narrow chamber angles treated with anteriorly positioned, high-encircling elements, and extensive cryopexy. A drainage implant is indicated when conjunctival scarring and recession from a prior scleral buckling surgery reduce the likelihood of a successful trabeculectomy. Vitreoretinal surgeons often encounter patients with neovascular glaucoma associated with diabetic retinopathy, central retinal vein occlusion, prior complicated surgery, or trauma that requires a vitrectomy in conjunction with a Baerveldt Glaucoma Drainage Device (BGDD). Careful assessment of the conjunctiva, cornea, and lens is necessary to determine whether the BGDD tube should be implanted through the limbus or the pars plana. Pars plana tube insertion requires a complete vitrectomy, with special attention being paid to clearing the vitreous base in the quadrant of tube insertion