Sarcoidosis and glaucoma
Last reviewed: 23.04.2024
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Sarcoidosis is a systemic disease characterized by the formation of noncaseating, granulomatous inflammatory infiltrates in the lungs, skin, liver, spleen, central nervous system and eyes.
Eye damage is observed in 10-38% of patients suffering from systemic sarcoidosis. Sarcoidosis of the eye, manifested as anterior, middle, posterior or panoveitis, leads to the development of chronic granulomatous uveitis.
Epidemiology of glaucoma associated with sarcoidosis
In the African American population, sarcoidosis occurs 8-10 times more often than in the white population and is 82 cases per 100,000. The disease can develop at any age, but is more common in patients 20-50 years of age. About 5% of adult uveitis and 1% of uveitis of children are associated with sarcoidosis. In 70% of cases of eye lesions in sarcoidosis, the anterior segment is affected, and the posterior segment lesion is observed in less than 33%. Approximately 11-25% of patients with sarcoidosis develop secondary glaucoma, more often with lesion of the anterior segment. African American patients with sarcoidosis develop secondary glaucoma and blindness more often.
What causes sarcoidosis?
The development of ocular hypertension and glaucoma in patients with sarcoidosis occurs with obstruction of the trabecular network as a result of a chronic inflammatory process, as well as when the angle of the anterior chamber is closed due to the formation of peripheral anterior and posterior synechia and iris bombardment. To disturb the outflow of the intraocular fluid, neovascularization of the anterior segment of the eye and prolonged administration of glucocorticoids can also result.
Symptoms of glaucoma associated with sarcoidosis
In most adult patients with sarcoidosis, the lungs are affected, coughing, wheezing, wheezing, or shortness of breath during physical exertion. Other manifestations of sarcoidosis include general symptoms, such as fever, fatigue, and weight loss. Often at the time of diagnosis, the symptomatology may be absent. When the eyes are affected, patients tend to complain of pain in the eyes, redness, photophobia, floating opacities, blurring of the image or reduction in visual acuity.
Course of the disease
Sarcoidosis of the eye can be acute and self-stopping or have a chronic recurrent or continuous course. The prognosis for the chronic form of sarcoidosis uveitis is most unfavorable in connection with the development of complications (glaucoma, cataracts or macular edema).
Diagnosis of glaucoma associated with sarcoidosis
Differential diagnosis of sarcoidosis should be carried out with other conditions in which a granulomatous panoveitis develops, for example, with Vogt-Koyanagi-Harada syndrome, sympathetic ophthalmia and tuberculosis. It should be borne in mind the possibility of eye damage in syphilis, Lyme disease, primary intraocular lymphoma and parsplanitis.
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Laboratory research
The diagnosis of "sarcoidosis" is posed by the detection of noncaseating or non-necrotic granulomas or granulomatous inflammation in the patient's tissue biopsy, in which other granulomatous diseases (tuberculosis and fungal infection) were excluded. In the initial diagnosis of sarcoidosis, lung radiography should be performed and the serum angiotensin-converting enzyme (ACE) level determined. The concentration of lysozyme in the serum can be increased, which is less specific than the concentration of ACE, a marker of the disease. However, the concentration of ACE can be increased in healthy children, so this criterion for children is less valuable in diagnosis. An increase in the ACE content in the intraocular and cerebrospinal fluid in patients with sarcoidosis of the eyes and central nervous system (respectively, sarcoidosis uveitis and neurosarcoidosis) is shown. Of the additional studies to confirm the diagnosis, the study of immunological tolerance, functional pulmonary tests, a study with Ga-contrasting, computed tomography of the thorax, bronchoalveolar lavage and transbronchial biopsy help confirm the diagnosis.
Ophthalmological examination
The lesion of the eyes in sarcoidosis, as a rule, is bilateral, although it can be either one-sided or with a pronounced asymmetry. More often with sarcoidosis develops granulomatous uveitis, but can be non-granulomatous. The examination reveals granulomas of the skin and orbits, an increase in tear glands and nodular conjunctival formation of the eyelids and on the cheeks. When examining the cornea, usually identify large sebaceous precipitates and coin-like infiltrates, less often observe clouding of the endothelium in the lower part of the cornea. With extensive posterior and peripheral anterior synechia, intraocular pressure increases and secondary inflammatory glaucoma develops, associated with the closure of the anterior chamber angle or the bombardment of the iris. Often, with severe inflammation of the anterior segment of the eye, the nodules of Coeppe and Busacca (Busacca) on the iris are revealed.
The lesion of the posterior segment of the eye in sarcoidosis is less frequent than that of the anterior segment. When examining the vitreous, inflammation with opacities and the accumulation of inflammation products in its lower part is often detected. When examining the fundus, various changes can be detected, including peripheral retinal vasculitis, peripheral exudation as a snow drift, hemorrhages, retinal exudates, perivascular nodular granulomatous formations, Dalen-Fuchs nodes, retinal and subretinal neovascularization, and neovascularisation of the optic nerve disk. You can also find granulomas in the retina, choroide or optic nerve. Reduction of visual acuity in sarcoidosis occurs due to the formation of cystic macular edema, optic neuritis with its granulomatous infiltration and secondary glaucoma.
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Treatment of glaucoma associated with sarcoidosis
The main method of treatment of both systemic and ocular sarcoidosis is glucocorticoid therapy. If the anterior segment is affected, their eyes are applied topically or inward. Systemic treatment is necessary for bilateral bilateral uveitis. In sarcoidosis, the effectiveness of other immunosuppressive agents is shown, for example, the use of cyclosporine and methotrexate. They should be used in case of chronic course of the disease and the need for long-term treatment with glucocorticoids. Treatment of glaucoma with drugs that reduce the formation of intraocular fluid should be carried out as long as possible. Argon-laser trabeculoplasty often has no effect. The method of choice for the pupil block is laser iridotomy or surgical iridectomy. If the intraocular pressure is still high, it is recommended that either a filtration operation or tubular drainage is implanted. The effectiveness of surgical treatment is increased if the inflammatory process is stopped before the operation. For trabeculectomy, especially for African-American patients, antimetabolites are recommended.