Laser therapy
Among different laser therapies, laser peripheral iridotomy and laser trabeculoplasty are the most common procedures for secondary glaucoma. Both methods involve creating new outlets for the aqueous humour to flow out of, effectively reducing the IOP. In peripheral laser iridotomy, the opening is created in the iris tissue while in trabeculoplasty, this opening is made in the trabecular meshwork. Further, there are two types of laser trabeculoplasty: argon laser trabeculoplasty and selective laser trabeculoplasty.Laser peripheral iridotomy has high efficacy in the treatment of pigmentary glaucoma. Argon laser trabeculoplasty is effective in the management of corticosteroid and pigmentary glaucoma. However, this is often contraindicated due to high rates of failure in patients with uveitic glaucoma. For uveitic glaucoma, treatment with selective laser trabeculoplasty is associated with fewer adverse effects and risks of failure. Surgical treatment
Surgical procedures are effective in cases where pharmacological management is not successful or suitable. Such methods work by facilitating aqueous outflow through the modification of the obstructing trabecular meshwork using trabeculectomy, goniotomy, non-penetrating deep sclerectomy or canaloplasty. Alternatively, introduction of new drainage pathways may also be achieved by the implantation of glaucoma shunts or glaucoma drainage devices.Trabeculectomy is held as the gold standard for surgical management of glaucoma. Studies indicate that treatment of uveitic glaucoma using trabeculectomy with antimetabolites administration has a high success rate of 62%-81%. Thus, it is also commonly used in the treatment of pigmentary glaucoma.
Other side effects include increased risk of miosis-induced headaches, blurred vision, retinal detachment and damage to the blood-aqueous barrier.Alternative drugs which can reduce the synthesis of aqueous humour, called aqueous suppressants, or increase the drainage of aqueous humour emerged as effective first-line treatments. Aqueous suppressants include beta-blockers, alpha-agonists and carbonic anhydrase inhibitors. They are particularly effective in treating corticosteroid, uveitic, aphakic, pseudophakic, ghost-cell and post-traumatic glaucoma. Prostaglandin analogues increase aqueous drainage and are thus used in the reduction of IOP. There are contradictory findings regarding the occurrence of prostaglandin analogue mediated side effects in the treatment of uveitic glaucoma. It was previously identified that the side effects comprise damage to the blood-aqueous barrier, cystoid macular oedema, risk of developing anterior uveitis and recurrence of keratitis caused by herpes simplex virus. However, current scientific evidence only supports the reactivation of herpes simplex keratitis among the other side effects.In uveitic and inflammatory glaucoma, reduction in inflammation is a critical step during the treatment and management process. This is commonly done using corticosteroids coupled with immunosuppressants. Steroidal treatment is also used in management of aphakic, pseudophakic, and post-traumatic glaucoma. Inflammatory glaucoma may further be treated using cycloplegics, a class of drugs that treats pain, ciliary spasm, uveoscleral tract blockage and disrupted blood-aqueous barrier linked with this form of glaucoma. While some studies recommend the use of anti-vascular endothelial growth factor drugs for inhibition of neovascularization in neovascular glaucoma, there is a lack of substantial evidence for the effectiveness of this treatment method.