1. GLAUCOMA DRAINAGE DEVICE COMBINED WITH PHACOEMULSIFICATION IN
UVEITIC GLAUCOMA AND CATARACT—4 YEARS FOLLOW UP
Virna Dwi Oktariana Asrory1, Widya Artini1
Ophthalmology, Cipto Mangunkusumo hospital/ Faculty of medicine universitas Indonesia, Jakarta Pusat, Indonesia
Purpose: To present the case of uveitic glaucoma due to tuberculosis underwent phaco implant surgery in 4 year follow up
Methods: A case report and observation until 4 years
Results:
woman, 35 years old, came with chief complaint of blurred vision in both eyes since a year ago. She had recurrent redness of the eye, had underwent trabeculectomy on both eyes a month prior the admission. The visual acuty OU was light perception, the IOP RE 17 mmHg and LE 39 mmHg. Both eyes had pupil seclusion, rubeotic iridis and the lens was hazy. The patient had work up for uveitis and got anti tuberculosis, steroid orally and topically, then underwent combined phaco implant procedure each eye in a month range. After two months the visual acuity of both eyes 6/30, the IOP RE 8.3 mmHg and LE 10.3 mmHg. In a year she had laser capsulotomy on left eye and few months later on the right eye. The tuberculosis regiment
stopped after a year and no sign of further infection. The oral steroid was tapered in one and a half year. Topical steroid was maintained for a year and if there was any sign of recurrence of uveitis. After 4 years, the VA RE was 6/12 cc and LE was 6/20 cc. The patient controlled routinely every 4 months.
Conclusions: The uveitic glaucoma and complicated cataract could be managed with combined procedure and uveitic treatment
A woman, 35 years old, came to Kirana Cipto Mangunkusumo hospital on September 23rd 2013 with chief complain blurred vision of both eyes since 13 months before admission. Patient came from Yogyakarta. There were recurring redness of both eyes, pain in the eye, sensitivity to light, and massive headache. There were no nausea or vomiting. The patient went to an ophthalmologist and said that there was an inflammation in the eye. The patient had given some eye drops but the eye did not get better. Seven months before admission, patient complaint of photopsia and floaters. She went to an Eye Centre at Jakarta and got ocular ultrasound examination. The ultrasound examination showed that there was an increased in choroidal thickness and the retina was attached (Figure 1). The patient was told that her disease was an end-stage. The intraocular pressure of her eye was also very high that the machine was error several times. She was medicated by intravenous anti-glaucoma medicine but the intraocular still high. One month before admission she undergone a trabeculectomy surgery for both eyes in an Eye Centre in Yogyakarta, but 2 weeks later the flap was closed. Then she was referred to Cipto Mangunkusumo hospital for the evaluation and the treatment of her glaucoma. The patient last medicine was timolol 0,5 % ED 2 x ODS, brinzolamide ED 3 x ODS, and betamethasone ED 6 x ODS. D D
Figure 1. USG examination 7 months prior to RSCM
Figure 2. Both eye condition at initial visit to RSCM
At RSCM Patient was diagnosed as panueveitis of both eyes DD/ Vogt Koyanagi Harada (VKH) syndrome, glaucoma secondary to uveitis on both eyes, and complicated cataract of both eyes. The patient was planned to undergo Ahmed® implant and phacoemulsification and intraocular lens implantation (IOL) surgery for both eyes. She was also given therapy with oral acetazolamide 3 x 1, Kalium tablet 2 x 1, timolol 0,5% ED 2 x ODS, brinzolamide ED 3 x ODS, betamethasone ED 6 x ODS, methylprednisolone 1 x 48 mg, and cyclosporine A 2 x 100 mg. The patient was also asked to perform the laboratory and radiology examination for complete uveitis work-up.
On September 26th 2013, the patient underwent Ahmed® implant and phacoemulsification and intraocular lens implantation (IOL) surgery on the left eye. On October 21th 2013, the Ahmed® implant and phacoemulsification + IOL surgery for the right eye was done. Three days after the surgery, the visual acuity for the right eye was 6/30 and for the left eye was 6/30. The IOP for the right eye and left eye was 5 mmHg and 26 mmHg respectively.
Figure 3. The eye condition after the surgery
The patients had tuberculosis treatment for a year and also had oral and topical steroids. . The oral steroid was tapered in one and a half year. Topical steroid was maintained for a year and if there was any sign of recurrence of uveitis. After 4 years, the VA RE was 6/12 cc and LE was 6/20 cc. The IOP of the RE was 11 mmHg and the left eye was 13 mmHg without glaucoma medications. The patient controlled routinely every 4 months.
Conclusions: The uveitic glaucoma and complicated cataract could be managed with combined glaucoma and cataract procedure and appropriate uveitic treatment. This case showed a patient with well controlled IOP and functioning vision after 4 years of follow up.
References
1. Siddique et al. Glaucoma and Uveitis. Survey of Ophthalmology. 2013;58(1):1-7.
2. Foster CS, Vitale AT. Diagnosis and treatment of Uveitis, in Foster CS, Vitale AT (eds). WB Saunders; 1st ed p.17-23
3. Mahajan D VP, Garg SP. Uveitis and Glaucoma : A critical Review. Journal of Current Glaucoma Practice.2011;5(3):14-30
4. Bansal Reema GV, Gupta Amod. Current approach in the diagnosis and management of panuveitis. Indian J ophthalmol. 2010;58(1):45-54
5. Pooja Sharma RB, Vishali Gupta, Amal Gupta. Diagnosis of tubercular uveitis by quantitative polymerase chain reaction. J ophthalmic inflamm. 2011;1(1):23-1
6. M Ahmad et al. Tuberculosis uveitis. Middle East Afr J Ophthalmol. 2009;16(4):
7. Ujwala B. Cataract surgery in patients with history of uveitis. Saudi Journal of Ophthalmology. 2012;26(1):55-60
8. M.F. Estafanous, C.Y. Lowder, D.M. Meisler, R. Chauhan. Phacoemulsification cataract extraction and posterior chamber lens implantation in patients with uveitis. Am J Ophthalmol, 131 (5) (2001), pp. 620–625
9. Ester C. Surgical outcomes of uveitic glaucoma. J Ophthal Inflamm Infec. 2011;1:43-53
10. Ozdal et al. Ahmed valve implantation in glaucoma secondary to chronic uveitis. Eye (Lond). 2006;20(2):178-83