Consider Medication Washout for Some Glaucoma Patients

By Reuters Staff

April 29, 2020

NEW YORK (Reuters Health) - Patients with uveitic glaucoma (UG) whose intraocular pressure (IOP) is under control and do not have uveitis recurrence may benefit from ocular hypotensive treatment washout, new findings show.

Stopping hypotensive treatment increased IOP in patients with primary open-angle glaucoma (POAG), ocular hypertension (OHT) and UG, but the increase was significantly lower in the UG patients, Dr. Kin Sheng Lim of St. Thomas Hospital in London and colleagues report in the British Journal of Ophthalmology.

"Our study reinforces that uveitis and elevated IOP is largely caused by active inflammation and steroid treatment," they write. "Therefore, once quiescent, there may be a justification to consider treatment washout in order to reduce or eliminate anti-glaucoma therapy in some of these patients."

While topical hypotensive treatment is a mainstay of glaucoma therapy, Dr. Lim and his colleagues note, it is typically started based on a single elevated IOP measurement.

To investigate their hypothesis that type of glaucoma diagnosis might influence the effects of medication washout, the authors reviewed data from their glaucoma research unit on 120 patients with POAG, OHT and UG participating in clinical trials from 2013 to 2017. All patients went at least one month without topical ocular hypotensive treatment.

The analysis included 110 eyes with POAG, 33 eyes with OHT and 43 eyes with UG. Mean IOP before washout was 18.1 mm Hg in the POAG eyes, 18.8 mm Hg with OHT and 17.9 mm Hg with UG. Post-washout, mean IOPs were 26.6 mm Hg in POAG, 26.4 mm Hg in OHT and 23.1 mm Hg with UG.

Post-washout IOP was below 22 mm Hg for 12.7% of the eyes with POAG; 6.1% of those with OHT and 51.2% of eyes with UG.

"This is suggestive that in majority of these patients, permanent damage to the trabecular meshwork has yet to occur, and that UG cases are being overtreated (in terms of their IOP control) beyond the acute phase of IOP elevation," Dr. Lim and his team write. They note that corticosteroids, which may be used to treat glaucoma, can themselves contribute to increased IOP.

"Nonetheless, once the inflammatory episode subsided, the tapering of steroids would normalise IOP levels in cases of steroid response," they add. "Further monitoring of IOP in quiescent uveitis cases can reduce unnecessary prescriptions and subsequently side effects. In addition, this will reduce financial burden on already stretched healthcare systems worldwide."

SOURCE: British Journal of Ophthalmology, online April 10, 2020.