Identifying high-risk eyes for glaucoma surgery in cytomegalovirus anterior uveitis

Cytomegalovirus (CMV) has recently emerged as a significant cause of anterior uveitis (AU) with intraocular pressure (IOP) elevation and corneal endothelial damage. The purpose of this study is to investigate the long-term prognostic factors for glaucoma surgery in patients with CMV-AU. In this retrospective cohort study, immunocompetent patients with CMV-AU were included from one academic institution and a uveitis-specialized private clinic between May 2015 and Mar 2024. Upon confirmation of polymerase-chain-reaction results, patients received anti-viral therapy (oral valganciclovir or 2% topical ganciclovir). When intraocular pressure was not controlled, glaucoma surgery (glaucoma filtering surgery or glaucoma drainage device) were performed. Indicators of glaucoma surgery were analyzed using Kaplan-Meir survival analyses and Cox-proportional hazard model. A total of 149 consecutive patients with CMV-AU included with a mean age of 44.5 ± 16.5 years; 65.1% being male. The baseline corneal endothelial cell (EC) density in affected eyes was 2088 ± 695 cells/mm². During follow-up, glaucoma surgery was performed in 24 patients (16.1%), of whom 75% underwent glaucoma filtering surgery and 25% underwent drainage device implantation. The median survival time from the first onset of the disease to glaucoma surgery was 73.0 ± 11.6 months. In the univariate Cox-regression analyses for receiving glaucoma surgery, baseline EC < 1000 cells/mm² (Exp(B) = 4.142, p = 0.013), baseline BCVA < 0.3 (Exp(B) = 2.733, p = 0.029), and number of anti-glaucoma medications at quiescent phase ≥ 2 (Exp(B) = 2.645, p = 0.024) were significantly associated with the future requirement for glaucoma surgery. In the multivariate analyses, baseline EC < 1000 cells/mm² was the only significant factor for predicting glaucoma surgery (Exp(B) = 3.960, p = 0.022). In conclusion, baseline corneal endothelial cell density can serve as a useful indicator for future requirement of glaucoma surgery in CMV-AU.