DIS - Uveitis Management I - Week 5 Flashcards
What four things can untreated uveitis lead to?
Glaucoma
Cataract
Macular damage
Blindness
What kinds of uveitis are treatable by optometrists (3)?
Anterior uveitis
-iritis
-iridocyclitis
Acute
-not chronic
What eye segment are optical agents only effective in?
Only effective in anterior segment
What does posterior segment inflammation typically require for management (5)?
Careful diagnosis
Injection of anti-inflammatories
Oral anti-inflammatories
Systemic antibiotics
Systemic immunosuppressants
What is the role of optometrists in acute anterior uveitis (3)?
Detecting and delivering primary care
Differentiating AAU to other causes
Detecting systemic associations
What is the role of optometrists in chronic anterior uveitis and posterior uveitis (2)?
Detecting and referring both
Co-management when appropriate
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
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
What structure of the eye must be intact before you consider topical steroid for an eye you suspect has anterior uveitis?
corneal epithelium
If you suspect anterior uveitis and there is high IOP, what does this suggest of aetiology?
Viral aetiology
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
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
What question should be asked after you detect uveitis?
Why do they have it
-i.e. is a systemic condition also present
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
List 8 medical systems that are typically associated with uveitis.
Rheumatological
Respiratory
Dermatological
Genito-urinary
Gastro-intestinal
ENT
Constitutional
Immunological
List four spondylo-arthropy conditions associated with uveitis.
Ankylosing spondylitis
Juvenile idiopathic arthritis
Reactive arthritis
Psoriatic arthritis
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
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
List four pulmonary/respiratory conditions associated with uveitis.
Sarcoidosis
TB
HIV
-pneumocystis carinni - pneumonia
List three genito-urinary conditions associated with uveitis.
Syphilis
Reactive arthritis
Behcets disease
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
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
List five gastro-intestinal conditions associated with uveitis.
Sarcoidosis
Crohns disease
Ulcerative colitis
Hepatitis
CMV
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
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?
No
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?
No
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
