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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