Uveitic Glaucoma: What You Need to Know

What is Uveitic Glaucoma?

Uveitic glaucoma is a type of secondary glaucoma that develops as a complication of uveitis – inflammation of the uvea, the middle layer of the eye that includes the iris, ciliary body, and choroid. When inflammation obstructs the normal out‑flow of aqueous humor, intra‑ocular pressure (IOP) rises, damaging the optic nerve and potentially leading to irreversible vision loss. Unlike primary open‑angle glaucoma, uveitic glaucoma is directly linked to an underlying inflammatory process and often requires both pressure‑lowering and anti‑inflammatory treatment.

Proper management is crucial because the disease can progress rapidly, especially during active uveitis attacks. Early detection, prompt treatment, and regular monitoring can preserve vision and improve quality of life.

Common Causes

Uveitic glaucoma can arise from several ocular and systemic conditions that trigger inflammation within the eye. The most frequent culprits include:

• Anterior uveitis (iritis) – inflammation confined to the iris and ciliary body.
• Intermediate uveitis (pars planitis) – affects the vitreous and peripheral retina.
• Posterior uveitis – inflammation of the choroid or retina (e.g., toxoplasmosis).
• Panuveitis – inflammation involving all layers of the uvea.
• Herpes simplex or varicella‑zoster virus infection – viral uveitis often leads to angle closure.
• Sarcoidosis – a systemic granulomatous disease that can involve the eye.
• Behçet’s disease – causes recurrent oral/genital ulcers and severe ocular inflammation.
• Juvenile idiopathic arthritis (JIA) – particularly the oligoarticular subtype associated with chronic anterior uveitis.
• Syphilis, Lyme disease, or tuberculosis – systemic infections that may present with uveitis.
• Drug‑induced uveitis – e.g., prolonged use of topically administered corticosteroids can paradoxically raise IOP.

Associated Symptoms

Because uveitic glaucoma combines features of both inflammation and elevated eye pressure, patients often notice a mix of symptoms:

• Redness of the eye (conjunctival injection)
• Eye pain or aching, especially with eye movement
• Photophobia (light sensitivity)
• Blurred or hazy vision
• Floaters or “spots” drifting in the visual field
• Decreased peripheral (side) vision
• Halos around lights, particularly at night
• Headache around the forehead or behind the eyes
• Visible swelling of the cornea (edema) or anterior chamber “flare” on examination

When to See a Doctor

Uveitic glaucoma can progress silently; therefore, any of the following warrants prompt ophthalmic evaluation:

• New or worsening eye pain, redness, or photophobia
• Sudden decrease in visual acuity or peripheral vision
• Seeing halos, flashing lights, or a “curtain” over part of the visual field
• History of uveitis with a recent flare‑up
• Recent eye surgery or trauma followed by inflammation
• Known systemic disease associated with uveitis (e.g., sarcoidosis, Behçet’s) and any change in eye symptoms

Diagnosis

Diagnosing uveitic glaucoma involves a step‑wise approach that confirms both inflammation and elevated IOP.

Clinical Examination

• Visual acuity testing – establishes baseline vision.
• Slit‑lamp biomicroscopy – evaluates anterior chamber cells/flare, synechiae (adhesions), and corneal clarity.
• Gonioscopy – inspects the drainage angle for peripheral anterior synechiae (PAS) or angle closure.
• Tonometry – measures intra‑ocular pressure; readings >21 mm Hg are suspicious.
• Fundus examination – looks for optic nerve cupping, retinal edema, or choroidal lesions.

Imaging & Laboratory Tests

• Optical coherence tomography (OCT) – quantifies retinal nerve‑fiber layer loss.
• Ultrasound biomicroscopy (UBM) – visualizes angle anatomy when gonioscopy is difficult.
• Blood work – tests for infectious or autoimmune causes (e.g., HLA‑B27, ACE, lysozyme, VDRL, QuantiFERON).
• Anterior chamber tap – rarely performed, but may identify viral DNA (HSV, VZV, CMV) via PCR.

Diagnostic Criteria

Uveitic glaucoma is diagnosed when a patient meets all three of the following:

1. Documented intra‑ocular inflammation (anterior, intermediate, posterior, or panuveitis).
2. Elevated IOP on two separate occasions, or IOP within the high‑normal range with evidence of optic‑nerve damage.
3. Exclusion of primary glaucoma causes (e.g., open‑angle anatomical predisposition).

Treatment Options

Treatment is two‑pronged: control inflammation and lower intra‑ocular pressure while preventing damage to the optic nerve.

Medical Therapy

• Topical corticosteroids (prednisolone acetate, difluprednate) – first‑line for acute inflammation. Use the lowest effective dose to minimize steroid‑induced IOP rise.
• Non‑steroidal anti‑inflammatory drugs (NSAIDs) – topical (ketorolac) or oral (ibuprofen) as steroid‑sparing agents.
• Immunomodulatory therapy for chronic or recurrent uveitis: methotrexate, mycophenolate mofetil, azathioprine, or biologics (adalimumab, infliximab).
• IOP‑lowering medications – typically start with agents that do not worsen inflammation:
  • Beta‑blockers (timolol, betaxolol)
  • Alpha‑agonists (brimonidine)
  • Carbonic anhydrase inhibitors (dorzolamide, brinzolamide)
  • Prostaglandin analogues (latanoprost) – use cautiously; can exacerbate inflammation in some patients.
• Systemic antivirals** for viral uveitis (e.g., acyclovir, valacyclovir, ganciclovir) when HSV, VZV, or CMV is identified.