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OD3 - Clinical Optometry Practice > DIS - Uveitis Management I - Week 5 > Flashcards

DIS - Uveitis Management I - Week 5 Flashcards

1
Q

What four things can untreated uveitis lead to?

A

Glaucoma
Cataract
Macular damage
Blindness

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2
Q

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

A 
Anterior uveitis
-iritis
-iridocyclitis
Acute
-not chronic
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3
Q

What eye segment are optical agents only effective in?

A

Only effective in anterior segment

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4
Q

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

A 
Careful diagnosis
Injection of anti-inflammatories
Oral anti-inflammatories
Systemic antibiotics
Systemic immunosuppressants
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5
Q

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

A

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

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6
Q

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

A

Detecting and referring both

Co-management when appropriate

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7
Q

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

A

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

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8
Q

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

A 
No infection in anterior uveitis
Look for infection in:
-anterior segment
-posterior segment
-careful history
-especially rule out HSV keratitis
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9
Q

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

A

corneal epithelium

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10
Q

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

A

Viral aetiology

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11
Q

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

A

No steroids without antibiotic control

-applies to both anterior and posterior uveitis

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12
Q

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

A

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

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13
Q

What question should be asked after you detect uveitis?

A

Why do they have it

-i.e. is a systemic condition also present

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14
Q

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

A

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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15
Q

List 8 medical systems that are typically associated with uveitis.

A 
Rheumatological
Respiratory
Dermatological
Genito-urinary
Gastro-intestinal
ENT
Constitutional
Immunological
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16
Q

List four spondylo-arthropy conditions associated with uveitis.

A

Ankylosing spondylitis
Juvenile idiopathic arthritis
Reactive arthritis
Psoriatic arthritis

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17
Q

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

A

Pain/stiffness in joints

  • which joints
  • how many joints
  • onset/duration
  • age of patient
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18
Q

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

A 
Shortness of breath - dyspnoea
Chest pain
Cough
-duration
-phlegm/sputum
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19
Q

List four pulmonary/respiratory conditions associated with uveitis.

A

Sarcoidosis
TB
HIV
-pneumocystis carinni - pneumonia

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20
Q

List three genito-urinary conditions associated with uveitis.

A

Syphilis
Reactive arthritis
Behcets disease

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21
Q

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

A 
Urethritis
Gonnococcal vs non-gonnococcal
Discharge
-milky/puslike
Stinging/burning on urination
Painful/difficult urination
-dysuria
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22
Q

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

A

Diarrhoea
Jaundice
Hepato-splenomegaly

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23
Q

List five gastro-intestinal conditions associated with uveitis.

A 
Sarcoidosis
Crohns disease
Ulcerative colitis
Hepatitis
CMV
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24
Q

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

A 
Rash
-pain/distribution
Alopecia
Vitiligo
Keratoderma blennorrhagica
-pustules/crusts/hyperkeratosis
White/scaly skin
Nodules
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25
Q

List five dermatological conditions associated with uveitis.

A 
Sarcoidosis
Psoriasis
Zoster
Reactive arthritis
VKH
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26
Q

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

A

Oral ulcers
Impaired immunity
Salivary/lacrimal gland dysfunction
Sinusitis

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27
Q

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

A

Painful
-behcets disease
Painless
-reactive arthritis

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28
Q

List three constitutional syptoms that can indicate uveitis.

A

Fever
Night sweats
Flu-like symptoms

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29
Q

List three diseases associated with fever indicating uveitis.

A

Reactive arthritis
Inflammatory bowel disease
HIV

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30
Q

List three diseases associated with night sweats indicating uveitis.

A

TB
Malignancy
Sarcoidosis

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31
Q

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

A

AMPPPE

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32
Q

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

A

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

33
Q

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

A 
C-reactive protein
-marker produced only in acute inflammation
Angiotensin converting enzyme
-level indicates granulomatous response
X-ray
34
Q

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

A 
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
35
Q

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

A

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

36
Q

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

A

Full blood exam

-general exclusion

37
Q

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

A 
Venereal disease research lab test
-non-specific treponemal test
Rapid plasma reagin
Fluorescein treponemal antibody
-non-reactive, positive for life
38
Q

Define HLA.

A

Human leukocyte antigens

-histocompatibility protein on leukocyte surface

39
Q

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

A

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

40
Q

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

A

Clear male predominance

18 to 32% of all anterior uveitis in western countries

41
Q

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?

A

20-40
High frequency of recurrence
Mostly acute

42
Q

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

A

Yes

43
Q

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

A

No

44
Q

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?

A

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

45
Q

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?

A

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

46
Q

List 7 common B27 related diseases.

A 
Ankylosing spondylitis
Undifferentiated spondylo-arthropathy
Reactive arthritis
Psoriatic arthritis
Inflammatory bowel disease
Crohns disease
Ulcerative colitis
47
Q

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

A

Primary care

-if it looks isolated

48
Q

Should you refer every recurring case of acute anterior uveitis?

A

Yes

49
Q

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

A

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

50
Q

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

A 
Severe attacks
Grade 3-4 cells and flare
Extensive synechiae
Hypopyon
Plastic A/C
Uni-ocular patients
Young patients (<15yo)
Slow/no improvement
51
Q

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.

A

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

52
Q

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

A 
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
53
Q

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

A 
Determining underlying cause
Controlling the inflammation
Controlling complications of
-the inflammation
-the treatment
Must ask yourself why a patient has uveitis before you proceed
54
Q

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

A

Aggressively

  • minimise structural damage
  • relieve symptoms of pain/photophobia
55
Q

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

A

No, too weak for acute

56
Q

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

A

Topical corticosteroids
Cycloplegia/mydriasis
Periocular steroid injection for severe cases

57
Q

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

A

Break recently formed synechiae

Prevent new synechiae forming

58
Q

Can topical steroids be used for posterior uveitis? Explain.

A

No, they do not have enough penetrance

-generally adequate enough for AAU

59
Q

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

A

High initially, adjust downwards quickly but according to response

60
Q

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

A

Several weeks (6 to 8)

61
Q

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

A

Taper over however long the steroids have been used for

i.e. if used for a month, taper over a month

62
Q

Define standard dosing.

A

Regular application of drug

63
Q

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

A

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

64
Q

Give an example of a pulse dose over a week.

A 
Day 1-3 - q2h (waking hours)
Day 4 - q4h
Day 5 - tid
Day 6 - bd
Day 7 - stop
65
Q

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

A

More or less no risk of either

66
Q

What should dictate how you taper steroids?

A

Acceptable improvement in condition

67
Q

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?

A

Over-treat

-most common reason is insufficient dosing

68
Q

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.

A 
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
69
Q

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

A

Relatively weak

Reserved for tapering

70
Q

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

A

q1h

-for the first day and subsequent days

71
Q

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

A

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

72
Q

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

A

Yes

73
Q

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

A

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

74
Q

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

A

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

75
Q

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).

A

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

76
Q

What does gradual withdrawal of steroids reduce (2)?

A

Risk of anti-inflammatory effects

Local rebound inflammation

77
Q

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

A

No

78
Q

Suggest a taper over 7 weeks for steroids.

A 
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
79
Q

Is acute anterior uveitis a short-term fix?

A

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

OD3 - Clinical Optometry Practice (114 decks)

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