Experts’ opinion – Case 1

Alex Levin

The vision is fairly good so I would hold off on YAG until after glaucoma controlled as YAG can rarely cause an IOP spike. My glaucoma intervention would depend on cause of uveitis If there was a significant anterior uveitis immediately preceding or during the onset of glaucoma then this may be uveitic glaucoma in which case my first procedure would be a goniotomy: easy, fast, minimal impact on the eye and therefore worth a try.  If this has occurred without any history of anterior uveitis, then the mechanism may be steroid induced, despite the low dose of prednisolone.  In that case I would try a switch to fluorometholone or stopping steroids. The Last possibility is glaucoma following cataract surgery if that timing fits, in which case my first procedure would be a tube, preferably without a flow restriction device (e.g. Molteno) to avoid later clogging should uveitis return. One other thought:  sympathetic is so rare that I would want a full uveitis workup (ANA etc.) to rule out other causes.

 

Denise Satterfield

I would do trab and YAG simultaneously under same anesthesia, and if the anterior vitreous face against the PCO was a problem, could do anterior vitrectomy and direct posterior capsulotomy if necessary at the same time.

 

Frank Martin

Trabeculectomy followed by YAG capsulotomy

This child is at risk of losing vision from glaucoma in the left eye as well as from sympathetic ophthalmia. There is also some risk of left amblyopia developing. The child probably already has a degree of amblyopia in the left eye. Glaucomatous visual loss is not reversible.I would arrange for the child to be immunosuppressed and then proceed with trabeculectomy. Any procedure including trabeculectomy and YAG capsulotomy carries the risk of reactivating sympathetic ophthalmia. This risk is greater if IOP is elevated. It is for this reason that I would aim to control the secondary glaucoma before proceeding with the YAG capsulotomy. In a four-year-old the risk of amblyopia developing is not a major concern.

It is very important for this child to have ongoing review.

 

 

Mary O’Hara

I had a similar case of sympathetic ophthalmia. My patient was treated with argon laser photocoagulation for Coat’s disease of the right eye at age 14 months. The right eye went on to total retinal detachment and then elevated intraocular pressure that was addressed with trans-scleral diode laser CPC after which the eye became phthisical. At age 27 months, he presented to our clinic with a blind painful right eye and an intermittently red left eye. The left eye had a shallow anterior chamber and 360 degrees posterior synechiae with elevated intraocular pressure (48 mm Hg). B scan showed thickened choroid and the retina was similar to your patient. The diagnosis of sympathetic ophthalmia of the left eye was entertained and the patient was placed on high-dose oral steroids and a trabeculectomy was done emergently. The right eye was enucleated in an attempt to control the sympathetic response. The child was then placed on infliximab and methotrexate which controlled the inflammation and the choroidal thickening but the intraocular pressure was uncontrolled and so a glaucoma drainange device and cataract extraction were performed. We elected not to place an intraocular lens because of concerns about inflammation and he has done well in aphakic spectacles with corrected visual acuity of 20/40 in his remaining eye. A penetrating keratoplasty (PK) was done when the cornea decompensated. He subsequently ruptured the PK when he fell, despite wearing RecSpecs at the time! The original graft was salvaged. At the mother’s request, we considered discontinuation of infliximab and methotrexate as he had been quiet for several years. However, he broke through with uveitis during a growth spurt, so we realized that continued immunosuppression therapy was necessary. Recently, his intraocular pressure has been rising again and we are treating it medically. We are considering a second glaucoma drainage device if medication fails to control the intraocular pressure.From our experiences with our patient, we would recommend a glaucoma drainage device for control of his intraocular pressures. Also, the child needs to be followed carefully for recurrence of sympathetic ophthalmia. Although sympathetic ophthalmia in a child is a rare condition, several reports have documented recurrence, either soon after or years after, cessation of immunomodulating therapy. In the above case, growth of the child spurred a recurrence that was relieved with increasing therapy dose to reflect the child’s increased size. 

 

Peng Khaw

From what I can see from the presented history, this patient has presented with recurrent presumed sympathetic ophthalmitis in her left eye following trauma to the right eye which presumably has severely damaged the vision in the other eye. There appear to be some difficulties in follow up because of lost to follow up and then the recurrence of uveitis. The patient now has a persistent raised intraocular pressure with increasing cupping and also posterior capsular opacification.In the presence of persistent inflammation the prognosis for any form of drainage surgery is generally poor because of the persistent stimulus for would healing. In addition, a patient like this must take regular doses of high dose steroids including topical steroids and this will further exacerbate the pressure rise. The meshwork is almost certainly microscopically compromised permanently, therefore some sort of by-pass surgery is required for long term pressure control. Any form of cyclodestruction in an only eye and especially one with inflammation has a much higher risk ratio. Therefore, in this patient I would opt to carry out tube drainage surgery. The advantage of tube surgery in this patient is that it is less likely to fail than trabeculectomy and is better able to withstand the multiple challenges of inflammation this eye is likely to face.In addition, in eye with uveitis, they are more likely to become hypotonous. It is much easier to deal with hypotony with a tube. The longer term hypotony in terms of a tube and in terms of occlusion for withdrawal of the tube than it is with trabeculectomy where the tissues may be soft and difficult to secure particularly as anti-metabolite would need to be used with a trabeculectomy. During surgery multiple efforts would need to be taken to secure the flow of aqueous. What I would do is place a supramid suture into the tube and then tie off the tube with Vicryl which opens after 6 weeks and also place an anterior slit valve to allow drainage of the pressure in the interim. During this period the patient can be covered with pre-operative and post-operative high dose steroids and it might also be worth considering a small amount of intercameral VEGF antagonist to neutralise VEGF and hence severe leakage and fibrinous production of membrane. I would aim to control the pressure first and then carry out YAG laser treatment later unless the need was so urgent visually as in these patients sometimes YAG laser capsulotomy can cause quite a significant rise in the pressure.

The risk of complications such as cystoid macular oedema apart from immunosuppression liaising with systemic paediatric rheumatologists, one might also consider the use of Atropine plus or minus NSAIDS to stabilise the blood aqueous barrier and also the systemic immune suppressant agents.

 

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