Download Uveitis (anterior, acute and recurrent)

CLINICAL MANAGEMENT GUIDELINES
Uveitis (anterior, acute and recurrent)
Aetiology
Predisposing factors
Symptoms
Signs
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)
o specific uveitis entities with distinct characteristics, eg:
- Fuchs 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
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
Uveitis (anterior, acute and recurrent)
Version 3 22.07.13
1 of 3
© College of Optometrists
CLINICAL MANAGEMENT GUIDELINES
Uveitis (anterior, acute and recurrent)
Differential diagnosis
Glaucoma (acute angle closure)
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
Practitioners should recognise their limitations and where necessary seek further advice or refer
the patient elsewhere
Non pharmacological
First episode:
Check intraocular pressure
Sunglasses for photophobia
Patients should be instructed to return immediately if, before their HES
appointment, they experience deterioration of vision or increased pain
Second or subsequent episode:
Monitor for ocular complications, including raised intraocular pressure
Spectacle near addition for cycloplegia
Pharmacological
First episode:
Topical cycloplegic (NB check AC depth first): gutt. cyclopentolate 1%
tds
(to prevent synechia formation and provide symptomatic relief)
Second or subsequent episode:
Reinstate uveitic therapies
Topical steroid (first exclude herpes): e.g. gutt. prednisolone acetate 1%
2-hourly until eye is white or inflammation controlled, then taper off
Cycloplegic: gutt. 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 Category First episode:
A3: first aid measures and urgent (within one week) referral to
Ophthalmologist
A1: 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 (gutt. cyclopentolate 1%)
Topical steroid (e.g. gutt. dexamethasone 0.1% or gutt. prednisolone
acetate 1%)
Treat secondary glaucoma
Sub-Tenon’s steroid injection may be required
Possible systemic immunosuppression
At third episode, may investigate aetiology of uveitis and possibly refer
Uveitis (anterior, acute and recurrent)
Version 3 22.07.13
2 of 3
© College of Optometrists
CLINICAL MANAGEMENT GUIDELINES
Uveitis (anterior, acute and recurrent)
appropriately for further medical investigation
Evidence base
Islam N, Pavesio C: Uveitis (acute anterior). Clin Evid (Online). 2010 Apr
8;2010.
Authors’ conclusion: ‘Topical corticosteroids have been standard
treatment for anterior uveitis since the early 1950s, especially for people
with acute or severe uveitis. Placebo controlled RCTs are unlikely to be
conducted and evidence is therefore based on consensus. The studies
examining the effects of NSAID eye drops or mydriatics were either too
small or of insufficient quality to allow us to judge their effectiveness in
treating uveitis.’
(The Oxford 2011 Levels of Evidence = 2)
Uveitis (anterior, acute and recurrent)
Version 3 22.07.13
3 of 3
© College of Optometrists