This issue of Asian Journal of Ophthalmology focuses on a rare, but no less challenging, form of glaucoma, namely glaucoma associated with uveitis. Although it only represents a small proportion of all glaucomas, complex diagnostic and management decisions are required to treat the condition successfully, especially when intraocular inflammation is coupled with raised intraocular pressure (IOP).¹ When treating these patients, the physician must first diagnose the aetiology of the uveitis and then evaluate the effects of the inflammatory process and the proposed therapy in order to treat the dual pathology successfully.

The article by Dr Justine Smith, Managing Uveitic Glaucoma, addresses these issues in a very orderly manner.² The difficulty in correctly diagnosing the cause of the uveitis is highlighted and special attention drawn to detailed examination of the anterior and posterior segment signs. These telltale clues will often provide the pathogenesis of the associated increase in IOP. This knowledge is crucial in order to target the specific glaucoma therapy accurately. Information such as the angle anatomy (open or closed) or whether anterior peripheral synechiae or neovascularisation is present will guide the physician to the correct course of action. Laser iridotomy, which is indicated when the IOP rise is due to pupillary seclusion would be inappropriate when the cause of the narrow angle is anterior peripheral synechiae. The choice of medical treatment can also be difficult because steroids, the mainstay of treatment of ocular inflammation, are associated with increased IOP in steroid responders while miotics can exacerbate the underlying inflammation.

As far as surgical options are concerned, the 1- and 2-year cumulative success rates of 81% and 73%, respectively, for trabeculectomy alone in patients with glaucoma associated with uveitis are encouraging, especially without the use of adjunct antimetabolites such as 5-fluorouracil or mitomycin-C.^3,4 Nonetheless, the authors have admitted that there may have been an age bias in their study, whereby more of the younger patients (less than 40 years) underwent Molteno implantation. The 5-year success rate for these patients was 79%. However, although the ethnicities of the patients were not mentioned, one could assume that the majority would be Caucasians and a parallel conclusion cannot be drawn for our Asian patients.

It is well known that drainage surgery in the black population has a higher failure rate than that of Caucasians due to their exaggerated healing response.⁵ The article by Aung and Seah highlights the success rates of drainage implants in the Asian population, with successful IOP control in 73.5% of eyes (85.5% if qualified successes were included) which is comparable with Western series.⁶ Their series, which incidentally included 7 (of a total of 83) patients with uveitis, confirm that surgery can be successful, even when medical treatment has failed.

I hope that our readers can draw on the experience of these authors for use in their own clinics, wherever they may be in Asia.

1. Panek WC, Holland GN, Lee DA, Christensen RE. Glaucoma in patients with uveitis. Br J Ophthalmol 1990;74:223-227.
2. Smith J. Managing uveitic glaucoma. Asian J Ophthalmol 1999;1(4):8-11.
3. Hill RA, Nguyen QH, Baerveldt GB, et al. Trabeculectomy and Molteno implantation for glaucomas associated with uveitis. Ophthalmology 1993;100:903-908.
4. Prata JA, Neves RA, Minkler DS, et al. Trabeculectomy with mitomycin C in glaucoma associated with uveitis. Ophthalmic Surg 1994;25:616-620.
5. Broadway D, Grierson I, Hitchings R. Racial differences in the results of glaucoma filtration surgery: are racial differences in the conjunctiva profile important? Br J Ophthalmol 1994;78:466-475.
6. Aung T, Seah S. Glaucoma drainage implants in Asian eyes. Ophthalmology 1998;105:2117-2122.

HB Hoh
Malaysia