Uveitic Glaucoma
Elevated eye pressure caused by inflammation inside the eye (uveitis) — a condition that often involves more than one mechanism at once and requires careful, coordinated management.
Overview
Uveitic glaucoma is elevated eye pressure that develops as a complication of uveitis — inflammation inside the eye. Unlike most glaucomas, which usually have a single dominant mechanism, uveitic glaucoma often involves several mechanisms happening at once: direct inflammation of the drainage tissue (trabeculitis), scarring that physically narrows or closes the drainage angle (synechiae), and a pressure-raising response to the steroid medications used to treat the inflammation itself.
Symptoms
- Eye pain, redness, and light sensitivity from the underlying uveitis
- Blurred vision, sometimes with floaters
- Halos around lights or a dull ache when pressure spikes acutely
- In chronic, low-grade cases, no symptoms at all despite ongoing pressure elevation
How Common Is It?
Elevated eye pressure or glaucoma develops in a meaningful share of uveitis patients over time — commonly cited estimates suggest roughly 1 in 5 to 1 in 4 people with chronic uveitis will experience it at some point, though the risk varies considerably depending on the specific type and cause of uveitis.
Certain forms of uveitis carry a notably higher glaucoma risk, including herpetic uveitis, Fuchs heterochromic iridocyclitis, sarcoid-associated uveitis, and juvenile idiopathic arthritis-associated uveitis in children.
Genetics & Risk Factors
Risk is driven mainly by the underlying cause of uveitis rather than a distinct genetic pattern of its own. Conditions like HLA-B27-associated uveitis, sarcoidosis, and juvenile idiopathic arthritis each carry their own genetic and systemic associations and are frequently investigated when uveitic glaucoma is diagnosed.
A personal or family history of autoimmune disease may prompt a broader systemic workup alongside eye-focused treatment.
Ocular Findings on Exam
Exam findings depend on the underlying uveitis but often include white blood cells and protein ('cell and flare') in the front chamber of the eye, keratic precipitates (inflammatory deposits on the back of the cornea), and posterior synechiae (adhesions between the iris and lens).
Gonioscopy is essential to distinguish an open angle with inflamed drainage tissue from a partially or fully closed angle due to peripheral anterior synechiae (scar adhesions between the iris and the drainage angle) — the two situations are managed differently.
Testing & Diagnosis
- Gonioscopy to determine whether the angle is open (trabeculitis) or affected by synechial closure
- Slit-lamp grading of anterior chamber inflammation
- Targeted laboratory workup for the underlying cause of uveitis when indicated (e.g. HLA-B27, ACE/chest imaging for sarcoidosis, syphilis and tuberculosis screening)
- Frequent IOP checks while on steroid therapy to catch a steroid response early
- OCT and visual field testing once inflammation is controlled, to assess for lasting optic nerve damage
Treatment Options
Controlling the Inflammation
Treating the underlying uveitis (often with topical, and sometimes oral or injected, corticosteroids or steroid-sparing immunosuppressive therapy) is usually the first priority, since ongoing inflammation continues to damage the drainage angle.
Managing the Steroid Response
Because steroids themselves can raise pressure, we monitor closely and may switch to a lower-pressure-effect steroid or add IOP-lowering drops if a steroid response develops.
Eye Pressure-Lowering Drops
Standard glaucoma drop classes are used, though prostaglandin analogs are sometimes avoided during active inflammation, and drugs that constrict the pupil are generally avoided given the risk of worsening synechiae.
Addressing Synechiae
When scar tissue has narrowed or closed the angle, laser or surgical intervention may be needed in addition to medical therapy.
Tube Shunt Surgery
When surgery is needed, tube shunt implants are generally preferred over traditional trabeculectomy in eyes with a history of significant uveitis, because chronic inflammation increases the risk of scarring and failure with trabeculectomy.
How This Differs From Other Glaucomas
Uveitic glaucoma is distinctive because it can involve multiple mechanisms at the same time — inflammation of the drainage tissue, physical scarring of the angle, and a medication (steroid) side effect — so the treatment plan has to identify and address each contributing factor rather than relying on a single approach.
Surgical decision-making also differs: because chronic inflammation increases scarring after standard trabeculectomy, tube shunt surgery is favored much more often here than it would be in an eye without a uveitis history.
Frequently Asked Questions
Does all uveitis lead to glaucoma?
No. Only a subset of uveitis patients develop elevated eye pressure, though the risk varies depending on the type and chronicity of the underlying inflammation.
Why do steroids sometimes make eye pressure worse?
Steroid eye drops are often needed to control inflammation, but in a subset of patients they also raise eye pressure directly (a 'steroid response'), which is why pressure must be checked frequently while on steroid therapy.
Why would I need a tube shunt instead of standard glaucoma surgery?
Chronic inflammation increases scarring after traditional trabeculectomy surgery, so tube shunt implants are often preferred in eyes with a history of significant uveitis.
Will treating the uveitis also fix my eye pressure?
Sometimes, but not always. Even after inflammation is controlled, scarring in the drainage angle from prior episodes can leave eye pressure elevated, requiring ongoing glaucoma-specific treatment.
See a glaucoma specialist. Dr. Robert Gunzenhauser is Harvard-educated and UCLA fellowship-trained in glaucoma, providing expert diagnosis and treatment for Uveitic Glaucoma at Inland Glaucoma Center in Upland, CA.