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

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

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Give the relative anti-inflammatory effects of the following steroids:
Dexmethasone
Prednisolone
Fluoromethalone

Dexmethasone - 100%
Prednisolone - 90%
Fluoromethalone - 75%

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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

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Can high dose steroids be maintained long term?

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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

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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

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Are NSAIDs useful for primary treatment of acute anterior uveitis?

Not
-they have insufficient potency or clinical efficacy

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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

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Note 2 minor side effects of topical steroids.

Transient discomfort/burning/stinging
Worsening of dry eye

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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

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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

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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

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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

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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

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For the following steroids, order them by the IOP response they elicit
Pred forte
Maxidex
Flarex

Maxidex > pred forte&raquo_space; flarex

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What type of secondary infection is particularly more likely with steroid use?

Viral

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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

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List 3 reasons why cycloplegics/mydriatics are used in the management of acute anterior uveitis.

Relieves pain/photophobia
Reduces ciliary/sphincter spasm
Breaks synechiae

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What does the breakage of posterior synechiae reduce the risk of (3)?

Iris bombe
Glaucoma
Cataract

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True or false
Posterior synechiae can form even in the dilated iris position.

True

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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

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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

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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

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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

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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