Week 6 - Inflammatory eye diseases Flashcards
Anti-inflammatory drugs used in eyecare
• Sympathomimetics*
• NSAIDs
-Systemic
- Topical Ocular
• Corticosteroids
What are Sympathomimetics? How do they work?
• used in differential diagnosis
• Active ingredient: adrenergic alpha agonists
• Promote contraction of smooth muscle which lines conjunctival blood vessel walls
• Vasoconstrictive action on conjunctival blood vessels
What type of sympathomimetic is available to us?
• used in differential diagnosis Episcleritis vs Scleritis
• Phenylephrine hydrochloride 2.5% and 10%
• Mydriatic and vasoconstrictive properties on conjunctiva and episcleral. Does not vasoconstrict deeper , larger scleral BVS
Entry Level Optometrists, Orthoptists, IP/Shared Care Practitioners
Sympathomimetics contraindications:
• Hypersensitivity
Systemic adrenergic effects mean that these drugs should not be used in patients with:
• cardiac disease, hypertension, aneurysms, tachycardia
• Asthma
• Thyrotoxicosis
• long-standing insulin-dependent diabetes
•Patients on MAOIs, tricyclic antidepressants and antihypertensive agents
• Patients with closed-angle glaucoma or narrow angles
Sympathomimetics systemic cautions and ocular side effects:
• Risk of systemic effects; avoid 10% in infants and elderly
• Ocular side effects:
- Photophobia
- Corneal clouding (10% concentration and damaged epithelium)
- mydriasis (action on pupil dilator muscle)
- Check anterior chamber angle
Inflammatory cascade:
• Phospholipids from the cell’s plasma membrane is where prostaglandins synthesise
• Phospholipase A2 enzyme becomes active when inflammatory response
• Arachidonic acid is transformed via
- Cyclo-oxygenase enzyme into Prostaglandins
- or Lipoxygenase enzyme into Leukotrienes
NSAIDS:
• Non-Steroidal Anti-Inflammatory Drugs.
• Inhibit action of the cyclo-oxygenase (COX) enzyme.
- However doesnt inhibit leukotrines via Lipoxygenase enzyme, therefore there will still be some inflammatory mediators
Cyclo-Oxygenase (COX) types:
- COX-1: Normal processes in uninflamed tissues
• Stomach acid levels
• Gastric protection - COX-2: Synthesis of prostaglandins in inflamed tissues
• Many NSAIDs are non-selective
• Inhibition of COX-1 has the potential to cause gastro-intestinal side effects (e.g. nausea, stomach ulcers, peptic bleeding)
Systemic NSAIDs: indications
• Wide range of indications
• Three major properties:
- Anti-inflammatory (control inflammatory response)
- Analgesic (relief from pain)
- Anti-pyretic (control fever)
• Some are available as GSL and P medications
• Eye care practitioners may recommend that patients use systemic NSAIDs to manage mild to moderate pain (e.g. corneal abrasion)
Types of Systemic NSAIDs and cautions:
• Ibuprofen +
• Aspirin +
• Diclofenac Sodium PoM*
• Naproxen PoM*
Available to entry level optometrists/orthoptists +
Only available to IP practitioners*
Cautions:
• Not be used by patients with an allergy to aspirin
• Avoid in patients with blood clotting disorders
• Avoid in patients with gastro-intestinal problems
Topic ocular NSAIDs: used for
• Greater therapeutic effect on ocular region
• Reduced risk of systemic side effects
• Minimal ocular side effects
• Some patients may develop a hypersensitivity
• Used to control and provide relief from the symptoms of ocular inflammation:
- Corneal abrasion
- Seasonal allergic conjunctivitis
- Episcleritis
- Ocular procedures/surgery
Topic ocular NSAID’s Availability and types:
• Only available as PoMs
• Typical dosing regimen: 2-4 times per day
• Diclofenac Sodium
• Flurbiprofen
• Ketorolac
• Nepafenac
IP/Shared Care Practitioners ✔️
Corticosteroids:
• Steroids are hormones which naturally occur within the body
• Steroids regulate innate responses (e.g. inflammation, allergy, immune system)
• Corticosteroids: both naturally occurring steroids and the synthetic medications which are designed to mimic their action
• Mode of action: inhibit release of phospholipase A2 enzyme
Corticosteroids: Indications
• Used to control ocular inflammation
• Reduces sensation of pain
• Reduces risk of ocular tissue damage due to prolonged inflammatory reactions and scarring
- Scleritis
- Anterior uveitis
- Severe allergic conjunctivitis
- Ocular surgery
• All PoMs
IP / Shared Care Practitioners ✔️
Corticosteroid dosing:
• Initially intensive (e.g. 1 drop every 2 hours for first 48 hours)
• Reduce to normal therapeutic dose (e.g. QDS)
• Abrupt cessation may cause rebound effect
• ‘Taper’ dose gradually over a number of weeks
• Balance of tapering versus risks associated with prolonged use
Corticosteroids drugs available
• Fluoromethalone
• Betamethasone
• Loteprednol
• Prednisolone
• Dexamethasone
• Can be found in combination with antibiotic
Entry Level Optometrists X
Orthoptists X
IP / Shared Care Practitioners ✔️
Steroids - Contraindications
• Undiagnosed red eye
• Infectious keratitis* (e.g. a viral infection of the cornea)
• Corticosteroids suppress the immune system and reduce the body’s ability to fight infection
• *Initial use is contraindicated BUT delayed use can improve long term visual prognosis for corneal ulcers (Kadmiel et. al., 2016)
Steroids - Adverse drug reactions
• Rise in IOP => Steroid glaucoma
• Significant rise in IOP in ‘steroid responders’
• Measure IOP at baseline and every 2-4 weeks
• IOP typically returns to normal level 1-2 weeks after cessation of treatment
• Steroid cataract (posterior sub-capsular cataract)
• Delayed corneal healing
• Peripheral corneal thinning
• Central Serous Retinopathy (CSR)
Episcleritis: Symptoms and Signs
Idiopathic inflammation of the vascular connective tissue sheath between sclera and conjunctiva
Symptoms
• acute onset
• majority are unilateral
• painless
• Mild irritation/ache discomfort/tender
• can be recurrent
** Signs **
• hyperaemia; Sectoral or Diffuse
• nodule (Approx 20%) within the area of hyperaemia
• VA unaffected in all types of episcleritis
• no other signs of inflammation
Episcleritis - Management for entry level optometrist
• Self limiting 7-10days
• Reassurance and advice to return if persists or worsens
Discomfort?
• Artificial Tears prn
Persisting after 1 week?
• Liaise with GP/IP practitioner to arrange PoM rx
• 7 day course soft steroid
• FML 0.1% / Betamethasone 0.1% / prednisolone
0.5% bds, 1 week
Persisting after 1-2 weeks?
•Refer to HES
• May require increased dosing
• Investigation for systemic cause in recurring
cases
Episcleritis - Management for IP optometrist
• Self limiting 7-10days
• Reassurance and advice to return if persists or worsens
Discomfort?
Artificial Tears prn
- All the same as entry level *
Things to remember when prescribing steroids:
• Check IOP before commencing tx
• If tx >1 week review IOP weekly
• May require taper of tx
Other Treatment Options:
- Systemic NSAID
- Topical ocular NSAID
Considerations when managing episcleritis:
• The majority of cases are self limiting
•Topical ketorolac is not significantly better than artificial tears in treating the signs or symptoms of idiopathic episcleritis
Scleritis:
• severe inflammatory disease of the sclera
• Anterior (90% of cases) or posterior (10% of cases) but not mutually exclusive
• Idiopathic or linked to systemic inflammatory disease
Scleritis categories:
• Anterior Scleritis
•Non-Necrotising (75%)
- Diffuse (60%)
- Nodular (40%)
• Necrotising (15%)
- With inflammation
- Without inflammation
•Posterior Scleritis (10%)
Scleritis : Symptoms
• Pain
•around the eye and forehead.
•May describe ache on brow or even jaw
•Can be intense
•Can be on eye movement
• Unilateral or bilateral
•Redness
•Blurred vision
• Gradual onset
• Previous Hx
• Photophobia
Anterior scleritis: Non-necrotising Signs
• Diffuse - without a nodule
• Nodular - fixed nodule, won’t move with manipulation
• Hyperaemia richer, darker colour (no blanching with phenylephrine)
• Possibly anterior chamber activity
Anterior scleritis: Necrotising Signs
Anterior Scleritis: Necrotising
• With inflammation - hyperaemia
• Avascular patches - dark blue-grey
• Without inflammation - dark blue-grey plaques BUT NO hyperaemia.
• Can be asymptomatic
Posterior scleritis: Signs
• Retinal swelling/oedema/disruption
Scleritis management
Entry Level Optometrists AND IP Optometrists
• Ensure dilated fundus exam has been performed
• Might suggest oral analgesic as first aid measure
• Call HES and arrange same day referral - letter in hand to Px
• Px requires topical and systemic anti - inflammatory tx
• May also require immunosuppressants
• Investigation for systemic associations
uveitis: Types
• Inflammation of the uvea, subdivided based upon the structures affected;
anterior, intermediate, posterior, panuveitis.
Anterior Uveitis
• Inflammation of iris and anterior ciliary body
• Most common (75% of cases)
• Idiopathic, systemic disease or prior infection
Intermediate Uveitis
• Inflammation of the posterior ciliary body, anterior vitreous and peripheral choroid/retina
Posterior Uveitis
• Inflammation of the vitreous, choroid and retina
Anterior uveitis: Symptoms
• Acute onset (less acute, more gradual with subsequent episodes)
• Unilateral (bilateral less common - chronic)
• Pain - dull ache
• Photophobia
• Redness
• Blurred vision
• Lacrimation
• In recurrent cases less symptoms
Anterior uveitis : Signs
• Hyperaemia - circumlimbal injection
• Keratic precipitates
- Fine
- Large (mutton fat)*
• Anterior Chamber Activity
- Cells
- Flare
- Hypopyon
• Increased IOP
• Posterior synechiae
- Pupil block
- Iris bombe
• Iris nodules
- Коерре
- Bussacca
Intermediate uveitis: Symptoms and Signs
Symptoms
• Gradual (days) blurred vision
• Floaters
• Absence of pain and redness
** Signs **
• Reduced VA
• Vitritis (cells in vitreous)
• Snowballs
• Snowbanking
Posterior uveitis: Symptoms and Signs
Symptoms
• Gradual (days) blurred vision
• Floaters
• Absence of pain and redness
** Signs **
• Reduced VA
• Vitritis (cells in vitreous)
• Snowballs
• Snowbanking
• Choroiditis
• Retinitis
• Vasculitis
• СМО
Anterior uveitis - Management (treatment)
• Assess both eyes - bilateral disease, increased likelihood systemic involvement
• Perform dilated fundus exam BOTH EYES - exclude vitreous, choroid or retinal involvement
• Assess cornea in detail - exclude herpetic disease or infection
• Check IOP
• Immobilise iris and ciliary body - reduce pain and break synechaie (CYCLOPLEGIC - cyclopentolate 1%)
Anterior uveitis - Management ( Advice)
• Explain the diagnosis
• Advise Sunglasses for photophobia
• Spectacle near addition for cycloplegia
• Warn patients of possible recurrence and educate on early symptoms of recurrence
Anterior uveitis - Management ( Entry level )
• IF 1st episode, unilateral, no known systemic aetiology, no posterior involvement - liaise with IP Optometrist or GP to manage in community
OR ELSE
• SAME DAY referral to IP Optometrist
• OR SAME DAY referral to HES (ALWAYS call ahead for advice)
Anterior uveitis - Management ( IP Optometrist )
• Cyclopentolate 1% tds
• Prednisolone 1% or dexamethasone 1% drops every waking hour for 2 days
• Review after 2 days - assess IOP and symptoms
• If improving monitor weekly:
• Taper steroid:
• every second waking hour for 7 day
• 6 times a day for the next 7 days
• 4 times a day for the next 7 days
• Continue to taper if eye is quiet after 21 days
• Refer if posterior involvement
Anterior uveitis - Second or subsequent episode Management ( IP )
Second or subsequent episode:
If first episode resolved well, management as above in the Community.
• Second or third episodes may need referral for further investigation of underlying cause.
It is a general rule that topical steroids should not normally be prescribed for more than 6 weeks in any 4 month period and that IOP should be monitored during use.
Tapering should be gradual over 6 weeks
When should Anterior uveitis be referred to HES:
• Children
• Granulomatous signs
• Bilateral
• Hypopyon
• Unable to break synechaie
• If after 2 days - raised IOP, severe pain or significant loss in vision
• Posterior segment involved
• Suspicion of systemic involvement
