DIS - Uveitis Management II - Week 5 Flashcards
List four night time options for a q1h dosage of steroid to treat acute anterior uveitis. Note which of these is generally for the worst uveitis cases and which is not very helpful.
One drop every hour, including at night
-for the worst cases
Loading dose before bed
-i.e. a drop every minute for 5 minutes
A few drops at bed time and two more mid-sleep (i.e. during a night time loo visit)
Steroid ointment noce
-not very helpful
Give the relative anti-inflammatory effects of the following steroids:
Dexmethasone
Prednisolone
Fluoromethalone
Dexmethasone - 100%
Prednisolone - 90%
Fluoromethalone - 75%
Describe the penetrance (not strength) of the following formularies of steroids (highest to lowest) and note which are good to use in anterior uveitis treatment and which should not be used. Explain what ocular structure affects penetrance.
Fluoromethalone acetate (flarex)
Fluoromethalone (FML)
Prednisolone phosphate
Hydrocortisone ointment
Dexmethasone phosphate
Dexmethasone (maxidex)
Prednisolone acetate (pred forte)
Good penetrance
Prednisolone acetate (pred forte) - 100%
Fluoromethalone acetate (flarex) - 90%
Dexmethasone (maxidex) - 75%
Poor penetrance
Dexmethasone phosphate
Fluoromethalone (FML)
Prednisolone phosphate
Hydrocortisone ointment
-do not use these primarily to treat AAU
-they may have use only at the end of tapering
Corneal epithelium affects penetrance
Can high dose steroids be maintained long term?
No
What is a requirement to begin tapering the dosage of steroids and for how long after should the dose be maintained? What should patients be warned of?
Reduce the dose gradually but only with improvement to signs/symptoms
Maintain the dosage for 3-5 days afterr imrovement
Warn patients about rebound
List four possibilities for tapering steroids.
Reduce dosing frequency (binary)
Reduce steroid concentration
-not viable in australia
Adjust steroid potency by changing medications
-flarex for pred forte
Other NSAIDs for longterm management
-cyclosporin
Are NSAIDs useful for primary treatment of acute anterior uveitis?
Not
-they have insufficient potency or clinical efficacy
Note 5 significant side effects of topical steroids.
Increased IOP
-steroid responder
Secondary infection/reactivation of infection
Masking of clinical signs
Delayed wound healing
Posterior sub-capsular cataract
Note 2 minor side effects of topical steroids.
Transient discomfort/burning/stinging
Worsening of dry eye
What is the likelihood of cataracts with short-term topical steroid use? How does this risk compare to oral steroids - which is more likely to cause cataracts?
Very unlikely to get cataract from short-term topical steroids
Greatest risk of steroid is from oral steroid
-more than 15mg/day for >6 months
What is the initial IOP response in acute anterior uveitis? Explain why this is so.
Decrease in IOP
-reduced aqueous production by inflamed ciliary body
What happens to IOP after the initial response? Give 5 possible reasons to why this may happen. Note which of these indicates the steroid given was not aggressive enough. What technique can rule out some of these possibilities?
IOP subsequently rises after the initial drop and may be due to:
-associated trabeculitis - steroid not agressive enough
-steroid responder
-debris/blood in the TM
-bombe following pupil block (posterior synechiae)
-PAS - steroid not agressive enough
Gonioscopy will rule out the last three options
When treating acute anterior uveitis with steroids, in what three cases is medical treatment necessary?
IOP >30mmHg
IOP >8mmHg above baseline for >2 weeks
If you begin to see glaucomatous signs
-disc responses etc
Describe how the general population responds to topical steroid (steroid responder) and give percentages.
3% - high IOP response
30% - moderate response
66% little/no response
For the following steroids, order them by the IOP response they elicit
Pred forte
Maxidex
Flarex
Maxidex > pred forte»_space; flarex
What type of secondary infection is particularly more likely with steroid use?
Viral
What should you do if you begin to see glaucomatous changes to the eye or the IOP is too high (>30) when using steroids to treat acute anterior uveitis? What should you not do (2)? What drug should be avoided and why?
You should not cease steroid therapy
Begin glaucoma therapy
-can be medical
-can be surgical
-do not use pilocarpine
-avoid using PGAs as they may exacerbate inflammation
List 3 reasons why cycloplegics/mydriatics are used in the management of acute anterior uveitis.
Relieves pain/photophobia
Reduces ciliary/sphincter spasm
Breaks synechiae
What does the breakage of posterior synechiae reduce the risk of (3)?
Iris bombe
Glaucoma
Cataract
True or false
Posterior synechiae can form even in the dilated iris position.
True
When should the use of cycloplegics/mydriatics be discontinued when treating acute anterior uveitis and why?
When inflammation is well-controlled
-synechiae is unlikely to form
What innervation does the iris sphincter muscle receive and via what neurotransmitter? What types of drugs inhibit the action of this muscle? List 3.
Parasympathetic innervation
-muscarinics/ACh
Block with anti-cholinergics
-atropine
-homatropine
-tropicamide
What innervation does the iris dilator muscle receive and via what neurotransmitter? What types of drugs stimulate this muscle? List 3.
Sympathetic innervation
-adrenergics
Stimulate alpha receptors with sympatho-mimetics
-alpha1 - phenylephrine
-alpha2 - apraclonidine, brimonidine
What drug class is the first choice for cycloplegia/mydriasis when treating acute anterior uveitis? What are two options if synechiae are already present?
Anti-cholinergics
-stronger agent
-second agent (activate dilator
What drug induces the most powerful dilation? What is the dosage and what concentration?
Atropine
1% tid usually
What is released with iris inflammation/injury/surgery and what does it do? What effect does atropine have on it?
Substance P is released
-causes iris sphincter contraction
Atropine counteracts the effects of substance P
How long can mydriasis last for after inflammation subsides in acute anterior uveitis?
1-2 weeks longer
Is homatropine more or less potent vs atropine?
Less
In what case is homatropine preferred to treated acute anterior uveitis? Is it available in australia?
If pupil mobility is needed
-not available in australia right now
Describe the use of cyclopentolate to treat acute anterior uveitis and why (3).
Other agents preferred
-a chemoattractant to leukocytes
-weaker
-shorter lasting
In what cases is cyclopentolate often preferred to treat acute anterior uveitis and which country?
For milder AAU in new zealand
Describe the use of cyclopentolate to treat acute anterior uveitis and why (2)?
Too weak to use in uveitis treatment
-except at the first visit
What is needed to break posterior synechiae?
Mydriatic of sufficient strength
-atropine usually
When is posterior synechiae less likely to form?
When the iris and lens are separated
True or false
Pred forte does not contain phenylephrine
False
It has some
What concentration of phenylephrine is typically used? What is the risk of higher concentrations? Is it recommended for optometric use?
2.5%
10% available in office
-considerable risk of acute systemic hypotension
Not recommended for optometric use
Explain how steroids may help break posterior synechiae (2).
Softens them via fibrinolysis
Softens and breaks once mydriatic applied
List 5 systemic effects of atropine overdose.
Facial flushing
Itching
Swelling
Dizziness
Breathing difficulty
List 5 side effects of atropine use. List an additional 2 in elderly patients and why.
Ventricular fibrillation
Tachycardia
Dizziness
Nausea
Loss of balance
In elderly
Extreme confusion
Hallucination
-crosses the blood barrier
Is it better to do warm or cold compresses for acute anterior uveitis? Why (2)?
Warm
-comfort and assists in breaking synechiae
When should a case of acute anterior uveitis be next reviewed after initial presentation? What are two objective findings you expect to see?
First review in 1-2 days
Condition should be at least no worse than before
Cells may not be less
What do you expect of the following on first review of acute anterior uveitis?
Symptoms
Pain
Sleep
Redness
Blurriness
Symptoms should be improving
Less pain
More sleep
Less red
More blurred
If you see improvement on first review of acute anterior uveitis, what should the steroid dosing be like and for how long? What about cycloplegics?
Continue high dose (i.e. q1h) for 5-7 days before reviewing again
Continue cycloplegics until synechiae risk passes
What are 6 things you should consider if there is no improvement to acute anterior uveitis on first review?
Continue full therapy for one more day
-was the initial drug/dosage appropriate
-is the regimen being followed? compliance check
-close monitoring, including by telephone
-if satisfied, one more day of full therapy and review next day
-ensure the bottle is being shaken
-reconsider diagnosis
When should you begin to taper steroids when treating acute anterior uveitis?
If continued improvement on review day 6-10, then carefully taper
How often should you review acute anterior uveitis? What must you check at every visit?
Every 3-5 days
-must check IOP
When reviewing acute anterior uveitis while tapering, what should you do if inflammation resumes?
Re-instate higher doses
When should cycloplegia be stopped?
After 10-14 days only with good improvement
What percentage of acute anterior uveitis patients will have more than one attack?
> 50%
Does aggressive treatment of acute anterior uveitis increase or decrease the risk of recurrence?
Decrease
What four posterior segment complications should you look out for when treating acute anterior uveitis?
Cystoid macular oedema
Disc oedema
Tissue damage
What should you do if IOP reaches >30mmHg when treating acute anterior uveitis?
Use aqueous suppressants
What should you look out for after the last drop of steroid when treating acute anterior uveitis and how long after?
Look for rebound inflammation a few days after the last drop
What 5 things should you not do when treating acute anterior uveitis?
Dont use weaker steroids or low doses
Dont terminate treatment early
Dont use miotics (pilocarpine)
Dont refer for ALT or surgery unless inflammation is controlled
Dont use cyclopentolate
What type of uveitis are periocular injections of steroids predominantly used in? List 5 additional cases it is used.
Posterior uveitis
But also used in
-severe anterior uveitis (hypopyon/exudate)
-intermediate uveitis
-chronic uveitis
-poorly compliant patients
-at surgery
List 5 major side effects that may occur with periocular injection of steroids.
Glaucoma (30%)
Cataract
Endophthalmitis
Retinal detachment
Haemorrhage
What is a steroid implant? How long does it last?
Implant that has controlled release of steroid for up to three years
List four side effects that may occur with steroid implant. List two the most common first and percentage of occurence.
Cataract - 100%
Glaucoma - >30%
Hypotony
Retinal detachment
What is generally the ophthalmological care for chronic anterior uveitis?
Pred forte dq or every second day
-optometrists should best refer cases of chronic uveitis
-co-management is an option
What is the ophthalmological management of posterior uveitis (2)?
Systemic/oral corticosteroids
May or may not have antibiotic/antivirals
When is the auto-immune aspects of uveitis treated (2)? Are these in addition to steroids or replacing them?
For sight threatening uveitis
Intolerable side effects of steroids
-added to or replaces steroid use
List 5 drug classes used to treat the auto-immune aspects of uveitis. Give some examples for each and what they do.
Antimetabolites
-methotrexate (antifoliate)
-azothyaprine (antipurine)
-chlorambucil (alkylating agent)
-cyclophosphamide (alkylating agent)
-cyclopsorin (T cell suppression)
-tacrolimens
TNF inhinitors
-etanercept
-infliximab
-adalimunab
Interferons
-B-cell inhibitors (rituximab)
-interleukim 1 inhibitors (anakira)
Do systemic steroid sparing agents take longer or quicker than steroids to act? what are they typically used in and at what kind of doses? Compare the side effect profile to steroids.
Usually takes longer than steroids to act
Many are used in chemotherapy but at higher doses
Has side effects but much less than steroids
What is the intent of steroid sparing agents? Explain its use (2).
To allow patients to stop systemic steroids
-start sparing agent at the same time as steroid or after the initial high steroid dosage
-when agent should be working, start tapering steroid
Should oral sterods ever be stopped abruptly?
Never, always taper
Can NSAIDs be of use for acute anterior uveitis patients?
Yes, cystoid macular oedema
-limited use however
What is recommended to help cope with the mydriasis from atropine use for acute anterior uveitis?
Sunglasses
What can be done for comfort for patients with acute anterior uveitis?
Warm compresses as needed
