Download Uveitis acute ant

Version 1, 28.09.09
Condition
Aetiology
Predisposing
factors
Symptoms
Uveitis (anterior, acute and recurrent)
Anterior uveitis (the most common form of uveitis; annual incidence 12 per
100,000)
- iritis: inflammation predominantly affects iris
- iridocyclitis (more common): inflammation predominantly affects iris and
anterior part of ciliary body (pars plicata)
A second acute presentation of anterior uveitis (in less than 6-12 weeks) is
referred to as recurrent acute uveitis
A third presentation reclassifies condition as recurrent uveitis, which requires
complete medical evaluation
Endogenous aetiology
- systemic disease (eg Reiter’s syndrome, Behçet’s syndrome, ankylosing
spondylitis, juvenile rheumatoid arthritis, inflammatory bowel disease,
psoriasis, sarcoidosis, Vogt-Koyanagi-Harada syndrome)
- prior infections (eg herpes simplex, herpes zoster, tuberculosis, syphilis,
leprosy, mycotic, parasitic)
- idiopathic (not associated with an underlying systemic disease)
- specific uveitis entities with distinct characteristics, eg:
- Fuchs’s heterochromic iridocyclitis
- Posner-Schlossman syndrome
- anterior segment ischaemia
- non-specific uveitis entities
Exogenous aetiology
- external injury or infection
Age over 20 years in 90% of cases
Major histocompatibility complex antigen HLA-B27 is positive in 8% of the
population, but in 50% of all patients with this condition
Onset usually sudden at first episode, gradual at subsequent episodes
Usually unilateral (if bilateral, more likely to become chronic)
Pain (dull/ache)
Photophobia
Redness
Decreased vision
Lacrimation
NB If condition recurrent, eye may be asymptomatic and white despite
presence of inflammation
COMMENTS
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Hyperaemia: circumcorneal (‘ciliary injection’)
Keratic precipitates (KP)
Aqueous cells
Aqueous flare
Raised intraocular pressure in some cases
Posterior synechiae possibly causing pupil block and iris bombé
Iris nodules: Koeppe (small, near pupil), Bussaca (large, far from pupil)
Anterior vitreous cells indicate intermediate  posterior uveitis
Posterior segment examination is essential: check for cystoid macular
oedema & posterior uveitis
Other signs include sluggish pupil reactions, cataract, chronic corneal
oedema including bullous keratopathy
NB If condition recurrent, signs may be less apparent, and will vary
according to severity and the specific underlying disease
Differential
Glaucoma (acute angle closure)
diagnosis
Other causes of acute red eye
Lens-induced uveitis, intraocular foreign body
Other forms of uveitis
- intermediate uveitis: involves posterior ciliary body (pars plana),
anterior choroid
- posterior uveitis: involves choroid posterior to vitreous base, retina
(almost always chronic)
- panuveitis: inflammation of the entire uveal tract (always chronic)
Management by Optometrist
NonFirst episode:
pharmacological
Check intraocular pressure
Sunglasses for photophobia
Spectacle near addition for cycloplegia
Patients should be instructed to return immediately if they experience
deterioration of vision or increased pain
Second or subsequent episode:
Monitor for ocular complications, including raised intraocular pressure
Pharmacological
First episode:
Topical cycloplegic (check AC depth first): g. cyclopentolate 1% tds to
prevent synechia formation and provide symptomatic relief
Second or subsequent episode:
Reinstate uveitic therapies
Signs
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Topical steroid (first exclude herpes): e.g. g. prednisolone acetate 1% 2hourly until eye is white or inflammation controlled, then taper off
Cycloplegic: g. cyclopentolate 1% tds initially, then taper off
DO NOT COMMENCE TREATMENT IF PATIENT IS A KNOWN STEROID
RESPONDER OR HAS HAD AN EPISODE OF HYPERTENSIVE UVEITIS
Management
First episode:
A3: first aid measures and urgent referral to Ophthalmologist
category
A2: if reduction in vision, severe pain or raised IOP, requires emergency
(same day) referral to Ophthalmologist
Second or subsequent episode:
B1: pharmacological management of second or third episode followed by
routine referral at third episode
Following medical investigation of underlying cause, it may be appropriate
for the Optometrist to manage subsequent episodes in collaboration with the
Ophthalmologist
Possible management by Ophthalmologist
Cycloplegia (g. cyclopentolate 1%)
Topical steroid (e.g. g. dexamethasone 0.1% or g. prednisolone acetate 1%)
Treat secondary glaucoma
Sub-Tenon’s steroid injection may be required
Possible systemic immunosuppression
At third episode, investigate aetiology of uveitis and refer appropriately for
further medical investigation
Evidence Base
Curl A, Mattos K, Pavésio C: Uveitis (acute anterior). Clin Evid 2005; 14:
179-43
Authors’ conclusion: Available RCTs are too small to prove clinically
important differences between steroid eye drops and placebo, or between
steroid and non-steroidal eye drops. The limited evidence suggests that
steroid eye drops are more effective than non-steroidal eye drops and that
newer topical steroids (e.g. rimexolone 1%) may be as effective as
prednisolone but with less risk of adverse reactions.
Centre for Evidence-based Medicine Level of Evidence = 2b