Mainstays of treatment are cycloplegics and topical steroids. Aim is to prevent complications and increase comfort.

Cycloplegic Agents

Cycloplegic agents decrease pain by paralyzing the ciliary body. They decrease cells and flare by minimizing vascular permeability. And, they prevent posterior synechiae by keeping the pupil mobile and in partial mydriasis.

• Mild
  • Cyclopentolate 1%
  • Homatropine 5%---drug of choice
  • Dosage is typically tid--but can be used up to every hour in severe cases
• Moderate (same as mild)
• Severe
  • Scopolamine 0.25%
  • Atropine 1% (good for in office use)
  • Typically given bid or tid

If poor dilation noted, can increase dosage or concentration.

Maximum Strength Topical Steroids

For moderate to severe anterior uveitis, the drug of choice is Prednisolone Acetate 1% (Pred Forte) or the generic (Econopred Plus). The generic DOES work as well as brand name Pred Forte. Don't forget the "Plus" on Econopred. Econopred without the "Plus" is only 0.12%.

Strategies

If a patient becomes a steroid responder to a topical drop, switch to a "softer" steroid and/or add a glaucoma medication. (Avoid Prostaglandins and Pilocarpine because they increase inflammation.) Lotemax is a good choice for a steroid responder.

Considerations

Treat anterior uveitis AGGRESSIVELY!!

For severe AU, you can put the patient on Pred Forte q 15 minutes at first to get inflammation under control. It is best to start tapering steroids when there are few to no cells present. With severe uveitis, if the patient has a significant amount of pain and inflammation, be sure to reexamine within 48-72 hours.

In chronic uveitis cases, be sure to use a cycloplegic to prevent complications. Slowly taper steroids over weeks to months. It is possible that the patient may never be cell free.

What if topical steroids are NOT reducing the inflammation?

• First increase the dosage regimen (q 15 minutes-1 hour if necessary)
• Consider overnight use of steroid
• FML ointment or can use Tobradex ointment
• Subconjunctival injection of Kenalog works well when uveitis is severe or not responding to topical steroids

Typically, topical steroid treatment or injection of Kenalog works very well on anterior uveitis. If the inflammation is in just one eye, consider a subconjectival injection. If steroid injection does not work, what would you consider?

• Consider oral steroids when both eyes are involved. Depending on body weight, give the patient about 40-60 mg/day for two weeks; then taper

  OR

• Refer to uveitis specialist for possible immunosuppressive treatment

NSAIDs and Uveitis NSAIDs typically do not work as well as steroids against uveitis because they do not lessen WBCs very well. (NSAIDs only block the cyclooxgenase pathway and not the lipoxgenase pathway which controls WBCs.) NSAIDs do work well against edema and pain. Rebound inflammation can sometimes be controlled by tapering off the steroid and onto a topical/oral NSAID. Think NSAIDs if you want to reduce pain but not the body's immune response.

Questions to Ask the Uveitic Patient

• Recent injury or surgery?
• Lower back pain?
• Joint stiffness/swelling?
• Rashes? Sores? Patches of skin depigmentation?
• Shortness of breath? Chronic cough? Sputum production?
• Chronic GI disturbance?
• Urethritis? Past sexual history?
• Birthplace? Home? Ethnic origin? Travel?
• General well being?

When to Order Tests

Initial Presentation

• No relevant symptoms (no workup)
• Known uveitis-associated disease (no workup)
• Symptoms of uveitis-associated disease previously undiagnosed

"Rule of Thumb" . . . order tests when

• Recurrent
• Recalcitrant
• Granulomatous
• Children younger than 15 years old

Lab Testing Screening Panel
NonGranulomatous Shotgun approach: CBC with diff (helps determine whether etiology is bacterial or viral) ESR or CRP VDRL/FTA-ABS Consider HLA-B27 (inexpensive to run) Lyme titer in endemic regions	Granulomatous CBC with diff ESR or CRP Chest X-ray VDRL/FTA-ABS ACE (?) PPD (?)

	URL: http://www.opt.indiana.edu/ce/antuve/tx.htm Revised: April 10, 2006
	IU Optometry home page: http://www.opt.indiana.edu/ Comments (content): Dr. Julie Torbit at jtorbit@indiana.edu Comments: Web Administrator Page design and coding: Terri Greene Copyright © 2006, The Trustees of Indiana University