Case
presentation
Veronika Yehezkeli
Avner Belkin
Case #1
6 YO with OS Ant uveitis +CME , BK
• PMH- JIA, receiving intra-articular steroidal
injections
• Tx: Danalon , Pred-Forte  MTX
IOP till 40 in LE, started Uramox 125X2.
Uveitis attack every 2-3 months BE 
Humira  Remicade.
2014
2019
2015–2017
IOP - Mid-twenties with normal CDRBE, treated with Azargax2 , travatan X1
05/2020
UVEITIS
ASSOCIATED
OHT OU+/STEROID
RESPONSE
LE  Referred to GATT
‫סרט הניתוח‬
Case #2
• 2018- 20 YO F , RE chronic Ant.
Uveitis Tx: MTX
• 2019- RE IOP 27 mmHg, started
Azarga 2/0 with mid low-twenties.
• 3/2020 –IOP 36/25 mmHg.
Uramox 250X3, Azarga 2/2 ,
alphagan 2/2
6/2020
6/2020
IOP 37/25
SYMPTOMATIC
CATARACT RE
REFERRED TO
PHACO GATT RE
Case #3
50 YO M
Bilateral alternating
ant. Uveitis since
2014 (Positive HLA
B-27)
Phaco Trab LE 30 y
ago (At age 20) 
CPA  cosopt ,
alphagan.
No medication to
RE (normal IOP).
ER 2019- IOP 34 RE.
Cosopt + alphagam
 15 mmHg.
9/2020Glaucoma
clinic
IOP 34/5 mmHg (on
Cosopt 3/0, alphagan
3/0, uramox 250X3,
PF1/0)
CD – 0.6 LE
Case #4
•
•
•
•
•
54 YO M
POH : POSSNER SHLOSMAN LE
2017- AGV, 2020- Trab  Needling
Tx: Alphagan 0/2, Azarga 0/2, Xalatan 0/1
VA 6/6.5 , IOP – high teens, ferro total
cup.
13yo
20 yo
• IOP 39
• w/o
glaucomatous
damage
• LE GATT
• IOP 36
• w/o
glaucomatous
damage
• RE PHACO
GATT
50 yo
• IOP 34
• Mild
glaucoma
• RE PHACO
GATT
54 yo
• IOP 18
• Advanced
glaucoma
• LE GATT
Uveitic
Glaucoma
GATT
20% of uveitis
patients in the United
States develop
glaucoma.
Steroid usage and
number of years since
diagnosis 
correlated with raised
IOP.
Herbert HM, Viswanathan A, Jackson H, et al. Risk factors for elevated
intraocular pressure in uveitis. J Glaucoma. 2004;13:96--9
Pathogenesis
• Insufficient anti-inflammatory
therapy.
• Steroid response.
• Chronic structural damage to the
TM secondary to inflammation.
Mechanisms
• Open angle.
• Closed angle.
Special considerations in patients with
UG
Young
patients
• Invasive options 25-30% of cases.
Management
• The preferred
approach is
controversial.
Trabeculectomy
• The results are variable and are
particularly poor in young
patients.
• Postoperative complications
diminishing the success rates of
trabeculectomy in eyes with
inactive uveitis.
• Kaburaki T, Koshino T, Kawashima H, et al. Initial
trabeculectomy with mitomycin C in eyes with uveitic
glaucoma with inactive uveitis. Eye. 2009;23:1509e17
A progressive loss of the
cumulative probabilities of overall success
particularly after
the first 36 months postoperatively.
Eighteen eyes needed a second procedure to
control the IOP.
•
•
Retrospective study included 70 eyes
of 50 patients with uveitic glaucoma
who underwent MMC Trab.
The mean follow-up period was 77.0
months (± 40.9).
Glaucoma
Drainage
Device
Implantation
•
•
Particularly useful in cases with significant conjunctival
scarring due to previous surgery.
Success rates of 77% and 50% at 1 and 4 years, respectively
The proportion of eyes requiring
secondary surgery related to the
GDD (6.1%) is similar to other
studies reporting 0–13%
BUT…
1. 16-year-old phakic female with a preoperative
IOP of 25 to 33 mm Hg had 360-degree GATT;
her IOP remained stable at 6 to 10 mm Hg over
14 months.
2. 23-year-old pseudophakic female with a
preoperative IOP of 28 to 34 mm Hg had 180degree GATT; her IOP reduced to 8 mm Hg over
10 months.
3. 8-year-old aphakic male with a preoperative
IOP of 21 to 32 mm Hg had 360-degree GATT;
his IOP remained stable at 13 to 15 mm Hg
over 21 months.
In all of the patients,
GATT was effective in
reducing IOP by 40%
to 66%.
Back to our
patients…
01
02
03
04
LE GATT
250
RE PHACO +
PCIOL + 360
GATT
RE PHACO +
PCIOL + 360
GATT
LE Hemi
GATT
• 4m PO: VA
6/6,
• IOP 36  17
on Azarga*2.
• 2.5 m PO – VA
6/6,
• IOP 34  15
• 5m PO-VA
6/10,
• IOP 39 15
• 20d PO: VA
6/6.5
• IOP 18 3
Take home message
• GATT is a promising minimally
invasive surgical option for
uveitic glaucoma.
• Should be considered early in
a treatment paradigm in all
stages of the disease.