inflammatory conditions

Question 1

non-granulomatous vs granulomatous anterior uveitis

Answer 1

Anterior uveitis is traditionally classified as ‘non-granulomatous’ or ‘granulomatous’, based on the nature of the keratic precipitates

non-granulomatous uveitis typically has an acute onset and shows fine KP. It is more likely to be idiopathic
granulomatous uveitis typically presents as a chronic condition showing large, ‘mutton fat’ KP and iris nodules. It is more likely to be associated with systemic conditions

Question 2

when do we think high risk of systemic association for anterior uveitis

Answer 2

bilateral involement
more than one episode
mutton fat keratic precipitates
retinal inflammtion seen on OCT
vitreous inflammation
other GH problems

Question 3

why do we put cyclo in for anterior uveitis

Answer 3

Immobilise iris and ciliary body – reduce pain and break synechaie (CYCLOPLEGIC – cyclopentolate 1%)

Question 4

nodular episcleritis management

Answer 4

SOFT steroid
Fluorometholone 0.1% eye drops 4x daily (reduce by 1 drop a week to zero)
Measure IOP before and during Tx, review in a week
nodular usually need mild soft steroid or when particularly symptomatic

Question 5

when inflammation - what happens to the pupil

Answer 5

it usually goes smaller

Question 6

anterior uveitis management pharmacological

Answer 6

dilate patient to check for int and post uveitis - helps relieve px as well (cyclo) Cyclopentolate 1% eye drops 3 times daily

hard steroid for penetration, Prednisolone 1%, >1 drop every waking hour for 48 hours, measure IOP before and after tx
taper dose on improvement - longer taper
check the next day and the 2nd day and every week

Question 7

anterior uveitis 2 day review - condition worse

Answer 7

Phone ophthalmology to discuss next steps
At the request of Ophthalmology, you may be asked to prescribe or co-prescribe
Omeprazole 20mg daily for gastric protection
POM Prednisolone 30mg daily for one week, 20mg daily one week, 15mg daily one week, 10mg daily one week, 5mg daily then stop

Question 8

anterior uveitis 2 day review - condition better

Answer 8

Continue Cyclopentolate 1% eye drops 3 times daily for 7 days and then stop
Reduce POM Prednisolone 1% eye drops as follows:
Every second waking hour for 1 week
Then 6 times a day for the next 1 week
Then 4 times a day for the next 1 week
Then 3 times a day for the next 1 week
Then 2 times a day for the next 1 week
Then 1 times a day for the next 1 week, then stop

Question 9

anterior uveitis after 1 week of pred forte

Answer 9

Re-examine the patient
Check the IOP
If no better, phone ophthalmology to arrange for an urgent appointment
If better, first, and even recurrent cases, if responsive to treatment, do not need to be referred for further investigation by ophthalmology
Some Boards, however, may wish you to contact ophthalmology regarding second or subsequent presentations to discuss whether further assessment and/or investigation may be indicated, even if patient better

Question 10

when would you refer same day anterior uveitis even if IP

Answer 10

Refer same day if:
Patient is a child
Patient is on already systemic treatment for uveitis (oral steroids, immunosuppressants, biologics or similar) (Patients on systemic treatment for non-ocular reasons do not need to be referred)
Bilateral involvement
New posterior synechiae or non-dilating pupil
IOP > 30 mmHg
Hypopyon or vitritis
Macular oedema
Choroiditis
Vasculitis
You cannot see anterior chamber cells, but symptoms or other signs point to anterior uveitis