Department of Ophthalmology, Massachusetts Eye and Ear, Boston, Massachusetts, USA; Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA; The MyungSung Christian Medical Center (MCM) Eye Unit, MCM General Hospital and MyungSung Medical School, Addis Ababa, Ethiopia.
Center for Clinical Trials and Evidence Synthesis, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA; Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
Am J Ophthalmol. 2020 Nov;219:303-316. doi: 10.1016/j.ajo.2020.06.038. Epub 2020 Jul 3.
To evaluate long-term risk and outcomes of glaucoma in eyes with intermediate, posterior, and panuveitis managed with systemic or fluocinolone acetonide (0.59 mg, "implant") therapy.
Prospective Follow-up of the Multicenter Uveitis Steroid Treatment (MUST) Clinical Trial Cohort.
Patients with intermediate, posterior, or panuveitis randomized to implant or systemic therapy (corticosteroid plus immunosuppression in >90%) were followed prospectively for glaucoma incidence and outcome.
Among 405 uveitic at-risk eyes of 232 patients (median follow-up = 6.9 years), 40% (79/196) of eyes assigned and treated with implant and 8% (17/209) of eyes assigned and treated with systemic therapy (censoring eyes receiving an implant on implantation) developed glaucoma (hazard ratio [HR] = 5.9, 95% confidence interval [CI] 3.2, 10.8; P < .001). Adjustment for intraocular pressure (IOP) elevation during follow-up only partially mitigated the association of implant treatment with glaucoma incidence: HR = 3.1 (95% CI 1.6, 6.0); P = .001. Among 112 eyes of 83 patients developing glaucoma, the 5-year cumulative incidence following diagnosis of sustained (2 or more consecutive visits) worsening of mean deviation by ≥6 dB was 20% (95% CI 12%, 33%); 5-year cumulative incidence of sustained worsening of cup-to-disc ratio by ≥0.2 was 26% (95% CI 17%, 39%).
The implant has substantially higher risk of glaucoma than systemic therapy, a difference not entirely explained by posttreatment IOP elevation. Management of IOP elevation was effective in preventing worsening of glaucoma for the large majority of cases, but even under expert clinical management, some glaucoma worsened. Uveitis cases should be monitored carefully for IOP elevation and glaucoma indefinitely.
评估接受全身或氟轻松醋酸酯（0.59mg，“植入物”）治疗的中间型、后段型和全葡萄膜炎患者的青光眼长期风险和结局。
多中心葡萄膜炎皮质类固醇治疗（MUST）临床试验队列的前瞻性随访。
将随机分配至植入物或全身治疗（>90%的皮质类固醇加免疫抑制治疗）的中间型、后段型或全葡萄膜炎患者前瞻性随访青光眼的发病和结局。
在 232 例患者的 405 只高危葡萄膜炎眼中（中位随访时间=6.9 年），79/196 只接受植入物治疗和分配的眼（40%）和 17/209 只接受全身治疗和分配的眼（对接受植入物治疗的眼进行植入物植入时的删失）发生青光眼（风险比[HR] = 5.9，95%置信区间[CI] 3.2，10.8；P<.001）。仅调整随访期间眼压（IOP）升高部分减轻了植入物治疗与青光眼发病之间的关联：HR=3.1（95%CI 1.6，6.0）；P=0.001。在 83 例患者的 112 只发生青光眼的眼中，诊断为平均偏差持续（2 次或以上连续就诊）恶化≥6dB的 5 年累积发生率为 20%（95%CI 12%，33%）；5 年杯盘比持续恶化≥0.2 的累积发生率为 26%（95%CI 17%，39%）。
植入物治疗的青光眼风险明显高于全身治疗，这种差异不能完全用治疗后眼压升高来解释。尽管进行了眼压升高的管理，但大多数情况下仍能有效预防青光眼恶化，但即使在专家临床管理下，一些青光眼仍会恶化。葡萄膜炎病例应无限期仔细监测眼压升高和青光眼。
