Uveitis mx

Question 1

When is a referral required for uveitis

Answer 1

Severe attacks, gr 3-4 cells and flare, hypopyon, young, uniocular, plastic AC, extensive synechiae, slow/ no improvement, no change in symptoms in 6- 7 days

Question 2

Tx for acute anterior uveitis

Answer 2

• topical corticosteroids, cycloplegia/mydriasis
• severe cases: periocular steroid injection
  Topical NSAID - ineffective in acute disease

Question 3

When to use pulse dosing

Answer 3

when antigen no longer present (e.g. allergic conjunctivitis, traumatic AAU) = higher dose –> no taper (no rebound inflammation risk)

Question 4

How does standard dosing in acute anterior uveitis work

Answer 4

Loading dose = high dose/ potent steroid

Once improvement –> reduce dose slowly (gradual taper)

Question 5

Topical steroids in AAU

Answer 5

Pred forte (prednisolone acetate) = most effective intraocular steroid - better corneal penetration, contains phenylephrine (adds mydriasis)

Maxidex (dexamethosone) - highest IOP response, highest anti-inflamm effect in tissue, not as penetrative as pred forte

Flarex (Fluorometholone acetate) = good penetrance but weak (not potent) - reserved for tapering

Lotemax (believe to be as good as maxidex and pred forte)

Soft steroids

Question 6

Starting doses of AAU

Answer 6

q1h, q2h (grade 1-2 cells) 
Loading dose (if late to tx): e.g. q15mins, q30min (first 1-2 hours) or q5mins x4 (in office)

Question 7

what are tx options during sleep for AAU

Answer 7

• 1 drop every hour
• or loading dose before bed - e.g. 1 drop every min for 5 mins
• or few drops at bed time + 2 drops mid-sleep
• or steroid ointment noce (only hydrocortisone - not v helpful)

Question 8

Rankings of steroid anti-inflammatory effects and penetrance of cornea

Answer 8

Anti-inflamm effects: Dexamethosone > Prednisolone > Fluoromethalone

Penetrance of cornea: Pred Forte > Flarex> Maxidex

Question 9

What are side effects of topical steroids

Answer 9

• Increased IOP = steroid responder (IOP > 30mmNg/ >8mmHg above baseline for 2 wks) - tx: bb, aa (not PGA)
  - IOP response: maxidex > pre forte > flarex
• secondary infection
  Delayed wound healing
  posterior subcapsular cataract

Question 10

What is the role of cycloplegics/ mydriasis?

Answer 10

• relieve pain, photophobia, decrease ciliary/ sphincter spasm
• dilate pupil - break synechiae (decrease risk of iris bombe, glaucoma, cataract)
• discontinue when inflamm controlled

Question 11

Types of cycloplegic/ mydriatic drugs

Answer 11

• Atropine 1% (tid)
• Homatropine - tid/qid
• Cyclopentolate
  Tropicamide (too weak for uveitis)

Question 12

Role of atropine

Answer 12

• counteracts action of substance P (induces sphincter contraction, decreases vascular permeability)
• breaks synechiae
• mydriasis can last for 1-2 weeks (after inflamm susbides)
• caution risk of overdose
  AE: tachycardia, dizzy, nausea, lose balance

Question 13

Role of homatropine

Answer 13

• less potent, preferred if pupil motility needed

Question 14

Role of Cyclopentolate

Answer 14

= chemo-attractant to leukocytes

- weaker/ shorter lasting, preferred for mild AAU (NZ)

Question 15

Role of Tropicamide

Answer 15

• Too weak for uveitis - does not last long enough

Question 16

How to break posterior synechiae

Answer 16

• Drugs: mydriatic (atropine), pred forte (contains phenylephrine)
• cotton bud - soak with epinephrine on limbus adjacent to PS
• Subconj injection = Mydricaine
• Steroids - fibrinolysis

Question 17

How to manage chronic anterior uveitis

Answer 17

• long term mx/tx, ophthal care

- on-going steroid control - e.g. pred forte qd or every 2nd day

Question 18

Posterior uveitis mx

Answer 18

• ophthal mx
• systemic / oral corticosteroid (+/- antibiotic / antiviral)
• systemic tx - treat autoimmue aspects of uveitis

Question 19

What other additional methods to help AAU px

Answer 19

• topical NSAID = acular, voltaren, ocufen (less effective than steroid)
• hot compress (q3h-4h) - comfort
• sunglasses - photophobia, mydriasis
  Temporary near rx - cycloplegia