DIS - Uveitis Management I - Week 5 Flashcards by B H

What four things can untreated uveitis lead to?

Glaucoma
Cataract
Macular damage
Blindness

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What kinds of uveitis are treatable by optometrists (3)?

Anterior uveitis
-iritis
-iridocyclitis
Acute
-not chronic

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What eye segment are optical agents only effective in?

Only effective in anterior segment

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What does posterior segment inflammation typically require for management (5)?

Careful diagnosis
Injection of anti-inflammatories
Oral anti-inflammatories
Systemic antibiotics
Systemic immunosuppressants

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What is the role of optometrists in acute anterior uveitis (3)?

Detecting and delivering primary care
Differentiating AAU to other causes
Detecting systemic associations

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What is the role of optometrists in chronic anterior uveitis and posterior uveitis (2)?

Detecting and referring both
Co-management when appropriate

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What must be excluded if you suspect anterior uveitis for it to be considered anterior uveitis?

Anterior uveitis is only anterior uveitis when you have excluded the possibility of posterior uveitis

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What must you be sure of before considering topical steroid for an eye you suspect has anterior uveitis?

No infection in anterior uveitis
Look for infection in:
-anterior segment
-posterior segment
-careful history
-especially rule out HSV keratitis

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What structure of the eye must be intact before you consider topical steroid for an eye you suspect has anterior uveitis?

corneal epithelium

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If you suspect anterior uveitis and there is high IOP, what does this suggest of aetiology?

Viral aetiology

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What must be done before topical steroids in suspected infectious uveitis? Does this apply to both anterior and posterior, or just one?

No steroids without antibiotic control
-applies to both anterior and posterior uveitis

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What is the level of primary care for acute vs chronic anterior uveitis in optometric practice?

Acute - significant primary care role
-because AAU generally requires only short-term therapy
Chronic - limited primary care role

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What question should be asked after you detect uveitis?

Why do they have it
-i.e. is a systemic condition also present

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What aspect of history should be reviewed if you detect uveitis? What questions specifically?

Return to history taking
-medical systems review
Specific and directed questions on systemic diseases
-do so even if you have already asked

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List 8 medical systems that are typically associated with uveitis.

Rheumatological
Respiratory
Dermatological
Genito-urinary
Gastro-intestinal
ENT
Constitutional
Immunological

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List four spondylo-arthropy conditions associated with uveitis.

Ankylosing spondylitis
Juvenile idiopathic arthritis
Reactive arthritis
Psoriatic arthritis

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List four targeted history questions to ask if you suspect spondylo-arthropathy for a case of uveitis.

Pain/stiffness in joints
-which joints
-how many joints
-onset/duration
-age of patient

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List four targeted history questions to ask if you suspect a respiratory/pulmonary disease for a case of uveitis.

Shortness of breath - dyspnoea
Chest pain
Cough
-duration
-phlegm/sputum

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List four pulmonary/respiratory conditions associated with uveitis.

Sarcoidosis
TB
HIV
-pneumocystis carinni - pneumonia

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List three genito-urinary conditions associated with uveitis.

Syphilis
Reactive arthritis
Behcets disease

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What five things would you be on the lookout for if you suspect a genito-urinary cause for a case of uveitis.

Urethritis
Gonnococcal vs non-gonnococcal
Discharge
-milky/puslike
Stinging/burning on urination
Painful/difficult urination
-dysuria

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What three things would you be on the lookout for if you suspect a gastro-intestinal cause for a case of uveitis.

Diarrhoea
Jaundice
Hepato-splenomegaly

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List five gastro-intestinal conditions associated with uveitis.

Sarcoidosis
Crohns disease
Ulcerative colitis
Hepatitis
CMV

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What six things would you be on the lookout for if you suspect a dermatological cause for a case of uveitis.

Rash
-pain/distribution
Alopecia
Vitiligo
Keratoderma blennorrhagica
-pustules/crusts/hyperkeratosis
White/scaly skin
Nodules

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List five dermatological conditions associated with uveitis.

Sarcoidosis Psoriasis Zoster Reactive arthritis VKH

What four things would you be on the lookout for if you suspect an ENT cause for a case of uveitis.

Oral ulcers Impaired immunity Salivary/lacrimal gland dysfunction Sinusitis

What uveitis associated ENT disease is indicated for ulcers with and without pain?

Painful -behcets disease Painless -reactive arthritis

List three constitutional syptoms that can indicate uveitis.

Fever Night sweats Flu-like symptoms

List three diseases associated with fever indicating uveitis.

Reactive arthritis Inflammatory bowel disease HIV

List three diseases associated with night sweats indicating uveitis.

TB Malignancy Sarcoidosis

List a disease associated with fever-like symptoms indicating uveitis.

AMPPPE

If you suspect uveitis secondary to ankylosing spondylitis, what test would you order (2)? What does it specify?

Erythrocyte sedimentation rate -non-specific indicator of systemic inflammation X-ray

If you suspect uveitis secondary to sarcoidosis, what test would you order (3)? What does it specify?

C-reactive protein -marker produced only in acute inflammation Angiotensin converting enzyme -level indicates granulomatous response X-ray

If you suspect acute anterior uveitis with arthritis, what test would you order (2)? What does it specify?

Antinuclear antibody -IgM/A/G to nuclear DNA of leucocytes Rheumatoid factor -detects RF -an IgM developed against IgG in adult rheumatoid -used to diagnose arthritis

If you suspect uveitis secondary to TB, what test would you order (4)? What does it specify?

Erythrocyte sedimentation rate -non-specific indicator of systemic inflammation Chest x-ray Purified protein derived-standard -active protein of mycobacterium tuberculosis Quantiferon -interferon based blood test of m. tuberculosis

If you suspect uveitis secondary to leukaemia/lymphoma, what test would you order? What does it specify?

Full blood exam -general exclusion

If you suspect uveitis secondary to syphilis, what test would you order (3)? What does it specify?

Venereal disease research lab test -non-specific treponemal test Rapid plasma reagin Fluorescein treponemal antibody -non-reactive, positive for life

Define HLA.

Human leukocyte antigens -histocompatibility protein on leukocyte surface

What percentage of normal people are positive for HLA B27? What about those with ankylosing spondylitis and psoriatic arthritis?

Normal - 5 to 8% AS - 85% PA - 75%

Is there any difference between genders for HLA B27 positive populations? What percentage all people with anterior uveitis in all western countries are positive?

Clear male predominance 18 to 32% of all anterior uveitis in western countries

When does the first episode of anterior uveitis in those positive to HLA B27 typically occur? Is there a high or low frequency of recurrence? What kind of uveitis is it?

20-40 High frequency of recurrence Mostly acute

Is there a high frequency of underlying previously undiagnosed rheumatological disease or irsk present in those positive to HLA B27?

Yes

Is there a difference between gender in those who are negative for HLA B27?

When does the first episode of anterior uveitis in those negative to HLA B27 typically occur? Is there a high or low frequency of recurrence? What kind of uveitis is it? Do these individuals typically have an underlying systemic disease?

30 to 50 Recurrence uncommon Mostly chronic Underlying systemic disease often absent

What percentage of individuals with acute anterior uveitis will test positive and negative for HLA B27? What percentage of those who test positive will have a B27 related disease?

50% positive for HLA B27 -50% of these individuals will have B27 related disease 50% negative for HLA B27

List 7 common B27 related diseases.

Ankylosing spondylitis Undifferentiated spondylo-arthropathy Reactive arthritis Psoriatic arthritis Inflammatory bowel disease Crohns disease Ulcerative colitis

Should the first attack of acute anterior uveitis have treatment mainly by primary care or referred?

Primary care -if it looks isolated

Should you refer every recurring case of acute anterior uveitis?

Yes

What are the two views on how to manage first attacks of acute anterior uveitis and recurring cases? Explain the logic behind each view.

First view -if first attack is isolated, treat with primary care -refer every recurring case -repeat attacks suggest different/underlying aetiology or Second view -refer every first attack -to detect any underlying disease -subsequent attacks wont need referrals as underlying casue will have been found

In what 8 cases of acute anterior uveitis should you definitely refer?

Severe attacks Grade 3-4 cells and flare Extensive synechiae Hypopyon Plastic A/C Uni-ocular patients Young patients (<15yo) Slow/no improvement

Is it easy to justify waiting to see if there is slow/no improvement with a case of acute anterior uveitis - to decide whether or not to refer? Explain.

Typically wait 5-7 days Hard to justify waiting this long A lot of damage can occur

Who should you refer acute anterior uveitis cases to (2) and for what?

GP/physician -medical tests where indicated --when positive during history taking -interpretation of their outcomes -medical systems review Ophthalmologist -for care if they fit criteria for referral

What are the three essentials of therapeutic management of anterior uveitis?

Determining underlying cause Controlling the inflammation Controlling complications of -the inflammation -the treatment Must ask yourself why a patient has uveitis before you proceed

Do you treat acute anterior uveitis aggressively or conservatively? Explain why (2).

Aggressively -minimise structural damage -relieve symptoms of pain/photophobia

Are topical NSAIDs commonly used for acute anterior uveitis? Explain.

No, too weak for acute

What are the two principal drug classes used to treat acute anterior uveitis? What may sometimes be done in severe cases?

Topical corticosteroids Cycloplegia/mydriasis Periocular steroid injection for severe cases

What is the treatment objective with posteriior synechiae in acute aterior uveitis (2)?

Break recently formed synechiae Prevent new synechiae forming

Can topical steroids be used for posterior uveitis? Explain.

No, they do not have enough penetrance -generally adequate enough for AAU

What is the dosage like for steroids to treat acute anterior uveitis?

High initially, adjust downwards quickly but according to response

How long does treatment with steroids last for acute anterior uveitis?

Several weeks (6 to 8)

What is a general rule of thumb on how to taper steroid use?

Taper over however long the steroids have been used for i.e. if used for a month, taper over a month

Define standard dosing.

Regular application of drug

Define pulse dosing. When is it useful? Is it used for typical acute anterior uveitis?

High dose followed by rapid (or no) taper as its unlikely to invoke systemic effects

Give an example of a pulse dose over a week.

Day 1-3 - q2h (waking hours) Day 4 - q4h Day 5 - tid Day 6 - bd Day 7 - stop

Is there a risk of rebound inflammation or IOP rise with pulse dosing (assuming they are not an IOP responder)?

More or less no risk of either

What should dictate how you taper steroids?

Acceptable improvement in condition

When considering topical steroids for acute anterior uveitis, is it better to over-treat or under-treat? What is the most common reason for failure to control inflammation?

Over-treat -most common reason is insufficient dosing

What is the most effective topical steroid for acute anterior uveitis? Which has the highest anti-inflammatory effect? Explain why. Note the most popular choice and the one with the highest IOP response.

Pred forte -most effective intraocular steroid -most popular/first choice Maxidex -highest anti-inflammatory effect -in the eye, roughly equivalent to pred forte -highest IOP response

What is flarex for acute anterior uveitis often reserved for? Is it strong?

Relatively weak Reserved for tapering

What do most uveitis specialists recommend as the initial dosage of topical steroid for acute anterior uveitis and for how long?

q1h -for the first day and subsequent days

Suggest three good loading doses at the start of treatment for acute anterior uveitis.

q15m or q30m for the first 1-2h q5min x 4 -in office if available

Should a high dose be maintained for a long time even after control of inflammation is evident?

Yes

What are four dangers to the optometrist and patient with using steroids to treat acute anterior uveitis?

Steroid too weak Dosage too infrequent Tapering too rapidly Finishing steroid too soon

How long should treatment of acute anterior uveitis last and over what time should it be tapered? What are exceptions to this (2).

Aim to finish steroids after 6-8 weeks of treatment Decrease steroids slowly with improvement -over 4-6 weeks Unless -IOP rises significantly -infection appears

Suppose you are streating acute anterior uveitis with steroids and IOP rises or an infection appears (or both). Can you withdraw steroids without tapering? Explain (3).

Cannot withdraw anti-Inflammatories without correct tapering Consider -IOP treatment -antibiotic cover -subsitute less potent steroid/softer steroid/NSAID (?)

What does gradual withdrawal of steroids reduce (2)?

Risk of anti-inflammatory effects Local rebound inflammation

Are topical steroids likely to affect the adrenal cortex like oral?

Suggest a taper over 7 weeks for steroids.

q1h for 7 days q2h for 7 days q3h for 7days qid for 7 days tid for 7 days bid for 7 days qd for 7 days

Is acute anterior uveitis a short-term fix?

No, patients must understand this considering treatment with steroids and tapering