Dr.Jaya Kaushik, Dr.Poninder Kumar Dogra,Dr.(Lt Col) Alok Sati,Dr.(Maj General) J K S Parihar
Purpose:
To evaluate the outcome of concurrent Ahmed glaucoma valve (AGV) and phacoemulsification with posterior chamber intraocular lens implantation under infliximab cover in refractory uveitic glaucoma (UG). Methods: In this prospective interventional case series, 36 eyes of 36 patients with refractory UG underwent surgery under intravenous infliximab cover. The success rate was defined as intraocular pressure (IOP) 5 to 21 mm Hg with or without anti glaucoma medications (AGM), without additional glaucoma surgical intervention. Results: The mean IOP was reduced from approx 40.8 mm Hg to 13.2 mm Hg in all the cases, and mean number of Anti glaucoma medication from 4 to one drug or no drug. The IOP and number of anti glaucoma drugs were significantly reduced after surgery at 2 years. Kaplan-Meier survival analysis showed a cumulative probability of success for IOP control of 92% at 2 years of follow-up. Conclusions: Combined AGV and phacoemulsification is an effective treatment for controlling refractory UG with complicated cataract under infliximab cover as immunomodulator.
Introduction
Management of glaucoma secondary to uveitis poses a great challenge as medical therapy is often ineffective and requires either filtering surgeries or glaucoma drainage implants. After any surgical treatment in these patients there is always risk of reactivation of nonresolving uveitis which often affects its postoperative structural and functional outcome. The failure rates of trabeculectomy with or without anti fibrotic agents are higher in uveitic glaucoma due prolonged and recurrent inflammation. Behcet syndrome is a chronic, recurring systemic disorder characterized by nonspecific vasculitis in multiple organs occurring in young males commonly associated with recurrent anterior or posterior uveitis.
Glaucoma drainage implants have been studied earlier in management of uveitic glaucoma and there were encouraging results noted in such cases. However risk of failure of surgery always there due to prolonged postoperative inflammation.
Systemic immunomodulators have been proven to control postoperative inflammation in cases of uveitic glaucoma. However no agent has been uniformly found to be effective in controlling inflammation due to various molecular pathologies of different etiologies of uveitis. The potential role of systemic infliximab has been studied earlier and found to be effective against controlling inflammation in uveitis specially in Behcet disease. The use of Infliximab in cataract extraction with trabeculectomy in cases of Uveitic glaucoma with complicated cataract has been studied earlier. However, Ahmed glaucoma valve with phacoemulsification with intraocular lense implantation under systemic Infliximab cover has not been reported so far.
Aim:
To evaluate the outcome of concurrent Ahmed glaucoma valve (AGV) and phacoemulsification with posterior chamber intraocular lens implantation under infliximab in refractory uveitic glaucoma (UG).
Material and method:
In this prospective interventional case series 36 patients with refractory uveitic glaucoma with cataract attending ophthalmology services of a tertiary level institute from duration of 2007 to 2011 were enrolled. The study was conducted as per the guidelines laid down by Declaration of Helsinki. Institutional ethical clearance was obtained for the study. Patients were enrolled according to following inclusion criteria: cases of uveitis based on signs of chronic inflammation such as posterior synechiae, non dilating pupil, irregular pupil with anterior or posterior synechiae, keratic precipitates treated with topical or systemic steroids and cycloplegics, uncontrolled refractory glaucoma with IOP > 21 mm Hg with uveitis on maximum antiglaucoma medication, visually significant complicated cataract and 3 months of quiescence before surgery. Exclusion criteria was corneal or other ocular disorders (those not included in inclusions criteria), biologics and use of other immunosuppressives. Systemic evaluation of uveitis was carried out with Human leucocyte antigen typing for specific diseases such as ankylosing spondylitis or Behcet disease.
A comprehensive ophthalmic examination included visual acuity assessment by Snellen’s chart, slit lamp evaluation, gonioscopy, CCT by Pachymetry, fundus examination by 90 D lens and IOP measurement by Goldmann applanation tonometry. IOL Master was used for biometry to calculate the power of IOL required during cataract surgery. Outcome measures analyzed were success rate (IOP 5 to 21 mm Hg with or without anti glaucoma medications, without additional glaucoma surgical intervention), mean number of anti glaucoma medications, visual acuity, and various intraoperative and postoperative complications.
Surgical technique
All procedures were carried out by an experienced surgeon in a tertiary level hospital. Under peribulbar anesthesia superior rectus bridal suture was taken. Fornix based conjunctival flap was raised in superotemporal quadrant. A deep subconjunctival pocket was created by wire vectis to accommodate the valve plate. The Ahmed glaucoma valve (model FP 7: New India Medical) was primed by flushing with balanced salt solution by 27 gauze cannula in a 2 ml syringe. The valve plate was anchored to sclera 8 mm away from limbus by 7-0 prolene sutures. A 4.5×4.5 mm partial thickness sclera flap is raised to cover the valve tube before it enters into anterior chamber.
Phacoemulsification was carried out by 2.8 mm incision by direct chop method. In some cases mechanical dilatation of pupil was carried out and subsequently single piece hydrophobic acrylic IOL was placed with closure of incision by stromal hydration. After phacoemulsification entry into anterior chamber was performed by 22- G needle bent to 45 – 60 degree angle with tube cut in fashion having bevel up and 2 – 2.5 mm tube inside the anterior chamber. Scleral and subconjunctival flaps were closed with 10-0 monofilament nylon sutures. Intravenous infliximab was administered in dosage of 5 mg/kg/day in 0, 2 and 6 weeks and then every 2 month for period of 2 years under supervision of rheumatologist.
Results:
36 eyes of 36 patients (24 male and 12 female) fulfilling the inclusion criteria were included in this study. The mean age was 37.26±10.5SD years. The most common etiology was idiopathic bilateral panuveitis followed by Behcet disease followed by recurrent chronic anterior uveitis in ankylosing spondylitis. The mean time interval between last attack of uveitis and surgery was 3 to 9 months in all cases. 28 patients were on maintenance dosage of topical dexamethasone 0.1% and oral steroid 5 mg daily. Before surgery the visual acuity ranged from 20/125 to hand movement close to face. 26 eyes had vision of 20/40 or even better postoperatively. Six patients had advanced glaucomatous changes and four patients had poor vision due to vitritis. The average IOP reduced from 37.8±11.67 mm Hg to 12.2±2.8 mmHg after Ahmed glaucoma valve after 2 years follow up.
The mean number of antiglaucoma drugs also reduced significantly from 3.4±1.2 to 0.4±0.1 after the surgery at 2 years. The IOP control was adequately achieved in 24 eyes at 2 years follow up. Two eyes had uncontrolled IOP despite 3 drugs and essentially required cyclodestructive procedures. During surgery floppy iris and miotic pupil was seen in all the cases. Postoperatively, choroidal effusion was initially noted in three cases which had resolved in due course of time. Posterior capsular opacification was noticed in all cases within one year of surgery and YAG laser capsulotomy was performed. Tube blockage due to floppy iris incarceration into the tube was noticed in two eyes which was cleared with the help of YAG laser.
Discussion
An International study group had proposed set of criteria to diagnose Behcet’s disease (1). These are recurrent oral ulcers plus any two of four other manifestations (a) recurrent genital ulcers, (b) eye lesions, (c) skin lesions and(d) positive pathergy test. The most common ocular manifestation of Behcet Syndrome are anterior uveitis, Posterior uveitis, Panuveitis ,Retinal vasculitis and episcleritis. The ocular lesion in Behcet Syndrome are known to be progressive by successive recurrent attacks, Inflammation in eye always remain symptomatic as in ocular lesion inflammation recedes slowly and fresh attack may supervene without complete healing of older ones [1]. Patient may develop sight threatening ocular disease such as cystoids macular oedema, secondary glaucoma, cataract, branch retinal vein occlusion or retinal vasculitis.
Ahmed glaucoma valves are being increasingly gaining importance in the management of uveitic glaucoma nowadays. The reported success rate of Ahmed valve in uveitic glaucoma ranged from 39 % to 100 % in earlier studies. To our knowledge there is only one published report describing glaucoma surgery in case of Behcet syndrome with infliximab therapy [2, 3]. In two other reports describing phacoemulsification in Behcet disease on infliximab therapy[4, 5]. Trabeculectomy with mitomycin C has provided long-term safety and was effective in reducing IOP in cases with secondary glaucoma associated with BD [6,7].
The results from this study revealed that AGV implantation with phacoemulsification and simultaneous administration of infliximab is safe and effective for Behcet’s disease associated secondary glaucoma and cataract with manageable side effects due to drastic improvement in anterior chamber reaction. To best of our knowledge this is first report in which use of AGV implant with phacoemulsification done as primary intervention to control glaucoma and cataract in such patients. After long term follow ups of 5 years patient had well controlled IOP without any medication with good visual recovery except during phases of recurrence of uveitis. In our series, we reported 92% success rate that depend on the criteria based on IOP 5 to 21 mm Hg without additional glaucoma surgery. Two eyes were labelled as failed cases due to the uncontrolled IOP with maximum anti glaucoma medications which further required cyclodestructive procedure.
The visual improvement was noticed in 9 (43%) eyes out of 21 eyes with uveitic glaucoma after Ahmed valve implantation an earlier study by De Mata, et al. Usually the visual gain is not expected after glaucoma surgery. However, we reported a visual acuity improvement of 20/40 or better in 18 (69%) patients out of 26 patients. This was mainly due to the phacoemulsification and IOL implantation for complicated cataract in addition to Ahmed valve implantation.
A significant reduction in number of anti glaucoma medications was noticed after the surgery. Mean number of anti glaucoma medication after the Ahmed valve implantation was 0.4 ± 0.1. This was comparable to the earlier study by De Mata, et al.
Any surgical intervention in uveitis is associated with chances of reactivation of uveitis with significant inflammation in postoperative period resulting in manly complications associated with poor anatomical and structural outcome.The role of TNF-alpha blocker infliximab has been explored in many uveitis entities in which conventional steroid and immunosuppressive therapy has failed and it was found to be a valuable option for the treatment of refractory. uveitis . Infliximab has been found to be an effective agent in the treatment of Behçet’s disease and ankylosing spondylitis in earlier studies. A successful use of infliximab therapy in patients with Behçet’s disease undergoing cataract and glaucoma surgery was reported in earlier small case series.
The findings of our study is limited by lesser number of subjects, lack of randomization, absence of control and masking of observer and subjects. However, prospective nature and length of follow-up are the key factors which strengthen our findings. None of the patients was lost to follow-up.
Conclusion
In conclusion, combined Ahmed valve placement and phacoemulsification with PCIOL implantation is an effective treatment for controlling uveitic glaucoma with complicated cataract. The success rate might be further enhanced by the use of infliximab as it helps to keep eyes in complete remission phase and avoid further reactivation of inflammation without any serious systemic side effects. However, further study involving large number of subjects and control group is required to further strengthen the findings.
Disclosure Statement
There is no proprietary interest, and no grants and funds were received in support of the study.
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