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Address inflammation in glaucoma

My best practices for how to control it before it controls your patient’s outcome.

Glaucoma accounts for 10 million visits to physicians each year, yet only 50% of the approximately 3 million people living with glaucoma in the United States are aware that they have the condition.1 Left untreated, glaucoma results in blindness, and 10% of the patients receiving proper treatment will still become blind.1 Although it’s an incurable disease, surgical intervention offers many people relief. However, controlling inflammation remains one of the most challenging aspects of managing patient surgical outcomes.

Below, I detail my battle-tested strategies for gaining that control and saving vision.

IDENTIFY THE RISK

The primary goal of surgery is to preserve the patient’s vision. Other important outcomes include adequately lowering IOP and minimizing complications.

With surgical intervention comes a host of preoperative, intraoperative and postoperative challenges. Preoperatively, the astute ophthalmologist must determine the surgical intervention most suitable for the patient. This often proves a challenging prospect, as selecting the most appropriate surgical procedure is not a “one-size-fits-all” approach. Performing identical surgical procedures can produce highly variable results among patients.

As with any surgery, traditional and micro-invasive glaucoma surgery (MIGS) carry a risk of infection, bleeding and inflammation (Figure 1, page 46). Postoperatively, patients can expect some level of inflammation in the wound-healing process. While one cannot predict the degree of inflammation patients will encounter, several factors increase the risk for inflammation. These include predisposition to inflammation, prior surgical intervention and degree of surgical invasiveness.

Figure 1. Postoperative inflammation and bleeding after a MIGS procedure can threaten the overall outcome if not well controlled.

Additionally, certain circumstances can greatly increase inflammatory risk. Patients with a history of uveitis often face greater inflammatory challenges. Whether uveitis includes systemic disease (e.g., autoimmune conditions such as sarcoidosis, rheumatoid arthritis, ulcerative colitis, etc.) can determine the course of treatment. Patients whose condition is contained to the eye can be treated locally, while uveitis patients who have systemic involvement often require systemic pharmacotherapy and rheumatologist consultations to address adequate control and flare-up prevention.

Some conditions, such as diabetes, retard the healing process. Patients with histories of previous ophthalmic surgeries often already have scar tissue. Subsequent surgery can warrant the need for greater tissue manipulation in patients who are already more susceptible to inflammation because of prior trauma.

Another factor that can be a predictive indicator of inflammation is melanin content. People of color, particularly African Americans, often have more inflammation and are more susceptible to prolonged inflammation and scar tissue.2 The literature cites iris pigmentation, corneal thickness, cellular profile of the cornea, more aggressive healing activity, socioeconomic circumstances (less disposable income often resulting in less ability to purchase medication) and the amount of preoperative pharmacological treatment taken as the contributing factors.

THE SURGEON’S CHECKLIST

To determine the appropriate course of treatment, clinicians should evaluate risk factors and other parameters. These include the stage of glaucoma (i.e., early, moderate or severe), the degree by which ocular pressure needs to be reduced (i.e., 2-7, 8-15, or > 16 mm Hg), prior inflammatory history and eye anatomy. Important anatomical features include virginal status of the eye, surgical history and prior signs of inflammation (i.e. anterior or posterior synechia, endothelial or lenticular pigment, Figure 2). As previously noted, ophthalmologists should consider race when appropriate.

Figure 2. Posterior synechia and pigmentation on the anterior capsule indicate prior or active inflammation.

Physicians must make careful pre- and intra-ophthalmic considerations to prevent inflammation during glaucoma surgery, and treatment varies depending on the condition and health of the patient’s eye. Virgin eyes are often easier to treat. In most cases, routine care of pretreating the eyes with a combination of corticosteroid, nonsteroidal anti-inflammatory drug (NSAID), plus an antibiotic eye drops normally suffices. Corticosteroids are typically administered intraoperatively, and the patient receives a postoperative routine to follow of similar preoperative drops once the operation is complete.

Patients with a past surgical or inflammatory history typically require more aggressive pre- and intraoperative treatment. This may include an in-office sub-Tenon’s injection of triamcinolone (Kenalog, Bristol-Myers) around the affected area in patients who have uveitis days to weeks before surgery. Intraoperatively, the surgeon may administer subconjunctival triamcinolone, intravenous solumedrol and/or intracameral dexamethasone to help prevent and control inflammation.

AFTER SURGERY

Postoperative pharmacological management includes topical steroid drops of varying strengths (i.e., difluprednate [Durezol; Novartis] or prednisolone [Pred Forte; Allergan]) and NSAIDs. Oral corticosteroids may also be prescribed.

Like any treatment, these options do not come risk-free. For example, while many physicians may enjoy that difluprednate allows them to reduce adjunctive pharmacological regimens because of its potency, the medication can quickly increase IOP in some patients. A common strategy to counter these challenges is to incorporate corticosteroids such as loteprednol, (Lotemax, Bausch + Lomb) and fluorometholone (FML, Allergan), which can decrease steroid response by decreasing potency. Moreover, adding or substituting NSAIDs in the prescription regimen and increasing the NSAID dose frequently can also help manage inflammation.

Postoperatively, aggressive steroid pharmacotherapy is, perhaps, the best strategy to squash inflammation quickly. Not only does aggressive treatment quickly control inflammation, but it also helps reduce the risk for long-lingering symptoms, like prolonged iritis, which automatically increases the propensity for tissue scarring (i.e., bleb scarring, formation of synechia).

Overall, successful outcomes in surgical intervention in glaucoma require planning well ahead and individualization of therapy. OM

REFERENCES

  1. Glaucoma Facts and Stats. Glaucoma Research Foundation. Available at: https://www.glaucoma.org/glaucoma/glaucoma-facts-and-stats.php . Accessed April 18, 2018.
  2. Salim A. Du H, Boonyaleephan S, Wan S. Surgical outcomes of the Ex-PRESS glaucoma filtration device in African American and white glaucoma patients. Clin Ophthalmol 2012; 6:955-962. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC3392916 . Accessed July 12, 2018.

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