Anterior Uveitis Treatments

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2 and 5 %- 1 drop TID or QID (AA)- has less psychosomatic effects than others like it

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Homatropine

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0.25%- 1 drop QD-TID

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Scopolamine

Front 3

0.5%, 1%, 2% 1 drop QD to TID
- can get posterior synechiae because it dilates the eye so well

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Atropine

Front 4

0.5%, 1% & 2% ,1 or 2 drops qd to qid for milder or traumatic cases
• *Does not work well enough or long enough

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Cyclopentolate

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2.5-10% 1 drop with any of the above, not for chronic Tx
• *Does not last long enough to do anything with

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Phenylephrine

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CNS effects with these two?

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Scopolamine and Cyclopentolate

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Cardio effects especially in older people

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10% phenylephrine- only use to break PS

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These two can cause a secondary PS?

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Scopolamine and Atropine

Front 9

2 steps to treating a long standing posterior synechiae? Also, what do you do if steps 1 and 2 don't work?

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1. 2.5 or 10% phenylephrine
2. 1% tropicamide every 20 minutes, four times
3. add 1 drop of atropine is not working

Front 10

• 0.125% & 1% The generic does not suspend well, so have the patient shake the suspension 100 times before instilling it in the eye
• *Sign on Dispense as written and write Trade Name Medically Necessary under the SIG!!

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Pred Forte- Acetate

Front 11

• 0.125%, 0.5%, 1% steroid that's too weak to do the job

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prednisolone sodium phosphate (Inflamase Forte)

Front 12

• 0.25 & .50% Use for patients who have a mild traumatic uveitis. steroid

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Loteprednol etabonate (Alrex & Lotemax)

Front 13

0.1 and 0.25% steroid that comes in an ointment too

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Flurometholone – alcohol (FML, Fluor- op),

Front 14

0.05% no generic for this steriod QID, tx uveitis

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• Durezol (difuprednate emulsion)

Front 15

#1 soft steroid.Use for mild cases of traumatic uveitis, or if you are tapering a patient down because they have had a steroid response.
• Broken down rapidly by esterases in the body after it exerts its effect, doesn’t remain in the anterior chamber and the trabecular meshwork as other steroids. reduces contact time with cornea

Back 15

• Loteprednol etabonate (Alrex 0.2% & Lotemax 0.5%)

Front 16

what to use for mod to severe inflammation- "acute anterior uveitis"

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• Pred Forte (not generic) or Durezol

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• Mild to moderate inflammation

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Lotemax

Front 18

Overnight suppression

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FML ointment

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• Anti-inflammatory Effectiveness of Topical Steroids with an Intact Corneal Epithelium

"minimally effective"

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.5% Dexamethasone sodium phosphate (ointment)
• 0.1% Dexamethasone sodium phosphate

Front 20

• Anti-inflammatory Effectiveness of Topical Steroids with an Intact Corneal Epithelium
"moderately effective"

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• 1% prednisolone sodium phosphate
• 0.1% fluorometholone alcohol

Front 21

• Anti-inflammatory Effectiveness of Topical Steroids with an Intact Corneal Epithelium

"most effective" (3)

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• 0.1% Dexamethasone alcholol; 0.1% fluorometholone acetate; 1% Rimexlone
• 1% Predisolone acetate
• difuprednate ophthalmic emulsion 0.05%

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Plan for Durezol/ Pred Forte

Back 22

1 gtt. q1-2 h (may use a loading dose-one drop every 15 mins. for 6 hrs.) initially for 1-2 days or until symptoms & signs decrease by 50%, then q2-3h for 2-4 days, then taper slowly, may take as long as 6-8 weeks


• *Be more specific with the dosing instead of 2-3 hours
• *Have the patient use every 2 hours once it gets better
• *For severe uveitis do a loading dose every 15 minutes for 6 hours and then go to once an hour after that.
• *Always see the patient back the next day to make sure the patient got the medicine and that they are taking the medicine correctly

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How to taper steroids?

Back 23

: Once most of cells (1+ or less) have cleared but still may see some flare, decrease by half the dose for 3-5 days- May use Lotemax for tapering or other soft steroid. QID, TID, BID, QD each for 5 to 7 days
• *These patients will be on drops for 6 to 8 weeks

Front 24

steroid responders with glaucoma can use what?

Back 24

Lotemax. others cause decrease aw outflow throught TM

Front 25

Complications of steroids?

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• IOP response elevation in 20-30% of population as early as 5- 14 days, usually 3-4 weeks
• Cataract PSC: 50% in 10 months if chronic use
• Infection risks increased: Bacterial, HSV, fungal
• Inhibit wound healing

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How to manage a steroid responder?

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• If inflammation under control and tapering has been initiated, then just continue to taper & IOP should be reduced
• If inflammation is improving, yet requires more therapy for several days, then switch to Lotemax
• Add a glaucoma drug like a beta-blocker, an alpha agonist or topical CAI or combination drop until IOP level is acceptable

Front 27

one with most PSCs? steroid

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10mg/ day oral pred for a year

also can cause central serous choroidopathy

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• Steroids Contraindicated In

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• Acute herpes simplex infection
• Vaccinia, varicella
• Tubercular lesions
• Rheumatic corneal stromal diseases
• Corneas susceptible to perforation
• Fungal, mycobacterial, acute purulent conjunctivitis, bacterial keratitis

Front 29

specific ocular effects of steroids?

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• PSC, ocular hypertension or glaucoma, secondary ocular infection, retardation of corneal epithelial healing, keratitis, corneal thinning or melting, scleral thinning, mydriasis, ptosis, transient ocular discomfort

Front 30

TX CME?

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CME 1 gtt Nevanac/Acular/Voltaren treat qid for 1-3 mos
• Typically continue topical steroids at QID

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Complications of NSAIDS?

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• Topical – transient ocular irritation on instillation, corneal infiltrates, corneal thinning or melting after anterior segment surgery with generic diclofenac than with Voltaren
• Common: GI bleeding, HA’s (Indomethacin 10-15%)
• Uncommon: R/O aspirin sensitivity and asthma, GI ulcers & liver toxicity

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advantages of periocular depot injections vs topically administering?

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• Therapeutic concentrations behind the lens can be achieved
• Longer lasting effect can be achieved with depot preparations ie: triamcinolone acetonide (kenalog) or methylprednisolone acetade

Front 33

drug examples of periocular depot injcetions?

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• Subtenon injection: 0.2cc-0.5cc triamcinolone acetonide 40mg/ml (Kenalog) or Depo-Medrol (methylprednisolone acetate) 60mg, or betamethasone
• Triamcinolone may last several months
• Possible complications

Front 34

complications of periocular depot injections?

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• subconjunctival heme, steroid induced glaucoma, orbital heme, globe perforation, long-term complication: scleral thinning, ptosis. good is you can avoid systemic complicatons.

Front 35

60-80 mg PO (0.5-1.5 mg/kg wt./day), tapering 10mg every 2-3 days, with meals to reduce gastric distress, antacids, H2 blockers (*To protect the stomach from abrasion, Prilosec is the most common)

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oral pred- Tagamet (cimetidine)

Front 36

4mg tabs taken 6,5,4,3,2,1 over 6 days (commonly prescribed for poison ivy)
• *It is very inexpensive.

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• Generic prednisone & methylprednisolone –Medrol Dosepak- The problem with the dosepak is the only therapeutic dose is in the first day.
• *The dosepak is also available in generic so it is cheaper than it used to be.

Front 37

severe AU not responsive to topical?

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peri ocular depot inj.

Front 38

AU unresponsive to topical steroids, interm UV, posterior UV in kids

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oral steroids

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what to check with oral steroids?

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• Must check for peptic ulcer, diabetes *(Causes the glucose levels to go up. Have the patient monitor their glucose levels more closely and have them use a sliding scale for administering their insulin), pregnancy, TB before treatment

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huge problem with oral steroids?

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• Complications Cushing’s Syndrome
• Round or moon face, buffalo hump, obesity (90%) , Red face( 84%), acne, Growth retardation in younger people, Excess hair(72%) or baldness, Peripheral edema, HTN( 85%), Osteoporosis(55%), Muscle weakness(58%), Diabetes(80%), kidney stones, Depression, psychosis(55%), euphoria, insomnia, Menstrual dysfunction(76%), infertility, impotence, Immunocompromise

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• Used in severe sight-threatening uveitis if unresponsive to steroids, intolerable steroid side-effects ie: Cushings, IOP, DM. ; non-infectious
• Work by their cytotoxic effects interfere with the cellular immunity system.

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immunosuppresive therapy


• Alkylating agents: Chlorambucil (Leukeran)
• Cytotoxic Agents: Cyclophosphamide (Cytoxan)
• Antimetabolites: Methotrexate & Azathioprine: JRA cases
• *Anti-metabolite, but they need to have their liver enzymes taken frequently
• Dapsone
• Cycloporine A (anti-T cell immunosuppressive agent with no effect on bone marrow): VKH & Bechet’s syndrome
• Many potentially serious systemic side effects & require immunologic consultation: Complications- hypertension, leukopenia & nephrotoxity: blood count & liver function monthly

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DOs of steroids

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o Shake steroid suspensions
o Wear sun Rx
o Taper slowly: reduce dose by half every 3-5 days if under control
o DFE
o Rule out infectious keratitis (e.g. Herpes simplex) *If you don’t know what it is don’t treat it
o Consider systemic evaluation and laboratory
• *If it is unilateral or bilateral first time occurrence you usually do not work these patients up unless it is severe
• HLA-B27 is a genetic marker. It is not specifically associated with anklosing spondylitis because it is also associated with Reiter’s Syndrome
o Consider IVFA/OCT and NSAIDs if CME *IVFA is not used as much as it used to now that we have OCTs!
o Patient education and complications

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DONTS of steroids

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o Use aspirin or ibuprofen if concurrent hyphema *Common in traumatic uveitis
• *UGG Syndrome (Is Uveitis Glaucoma and Hyphema and occurs after cataract surgery)
o Use beta blockers if asthmatic
o Fail to monitor IOP, after 1 week. If you need to, use the tonopen. If the patient has a latex allergy it is a good idea to rinse the eye out.
o Use antibiotic steroid combinations because *the tobramycin will chew up the cornea long-term

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Thinks of systemic involvement in the following cases:

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• Moderate to severe, mutton fat KPs, Chronic (*Think Fuch’s or Herpes), recurrent, associated with posterior involvement, bilateral, alternating, unresponsive to treatment *Typical in 70 year old patients who have lymphoma, signs & symptoms suggestive of systemic disease

Front 45

When should you order labs?

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• Recurrent
• Chronic
• Posterior pole signs
• Bilateral
and poor response to TX

Front 46

The labs to order? IMPORTANT******

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o Complete Blood Count-CBC (viral, bacterial, leukemia)
o Erythrocyte sedimentation rate-ESR (nonspecific test for inflammation)
o Antinuclear antibody testing-ANA (SLE,JRA)
o Human leukocyte antigens-HLA-B27
o Angiotensin-converting enzyme-ACE & lysozyme levels (Sarcoidosis)
o Tests for syphilis-RPR, FTA-ABS
o Chest Xray- TB, sarcoid
o Sacroiliac joint films-Ankylosing spondilitis
o Purified protein derivative skin test-PPD (TB)
o Enzyme-linked immunosorbent assay (toxoplasmosis, toxocariasis)

Front 47

what's cheaper lotemax of pred forte?

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lotemax

Front 48

tx • Blunt trauma with mild iritis with intact cornea & no hyphema

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pred forte

Front 49

tx • Idiopathic or HLA-B27 acute anterior uveitis with 3 + cells & fibrin, a few synechiae

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These patients have hyphemas common in HLA-B27
o *Put this patient on Durezol every hour (loading dose) and homatropine 5% TID
o *If the patient has a traumatic uveitis, they are achy and the pupil is miotic put them on homatropine 5% bid.

Front 50

TX trauma to iris- intact cornea?

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• Cycloplegic: In office 1-2 gtts. 5% Homatropine; 5ml bottle
• Steroid: Lotemax or 1% Pred Forte qid for 2-4 days
• Instructions
o Shake bottle
o Taper per instructions
• Note
o Follow-up in 1-2 days
o Monitor IOPs
o Slit Lamp and DFE

Front 51

TX and f/u Moderate to Severe Anterior Uveitis

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• Cycloplegic: 5% Homatropine sol. Tid to qid for 5 days; 5ml bottle
o Taper per instructions
o Use cycloplegics every evening until anterior chamber is free of cells
• Topical Steroid: 1% Pred Forte Ophth. Susp. q1-2 h for 5 days, then as directed; 15ml bottle; No generic
• Follow-up
o Every 1-2 days in the acute stage, thereafter as needed
o At each visit: VA, anterior chamber & IOP should be evaluated
o Taper slowly to avoid rebound reaction once anterior chamber reaction has improved significantly: q2h to q4h (3-5 days), then tid (3-5 days), bid then qd
• Steroids are discontinued once all cells have disappeared

Front 52

TX HZO-Uveitis & Stromal Keratitis & Elevated IOP

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• Cycloplegic: 5% Homatropine bid x 1 week
• Antiglaucoma meds: 0.25% timolol sol. qam x 1 week, 5ml bottle or .15 or .2 % Alphagan bid or a Azopt bid or Combigan BID
• Note: make sure if elevated IOP not due to inflammation- increase dose of steroid
• Topical steroid: 1% Pred forte ophth susp. Q 2-4 h
o Taper slowly over weeks or months

Front 53

TX Chronic herpes simplex uveitis

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• Oral Acyclovir
• Topical steroid -> steroid responder, tube shunt surgery
• Cycloplegic
• Iris atrophy is especially common in HSV

Front 54

TX glaucomatocyclitic crisis

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• Topical beta blocker: .25-.5% timolol qam to bid &/or
• Topical alpha agonist: .15-.2% Alphagan bid to tid &/or
• Topical CAI: Trusopt or Azopt bid to tid or may substitute a systemic CAI if IOP significantly increased
• Combigan, CoSopt
• Systemic CAI: Diamox sequel 500mg po bid
• Topical steroid: 1% Pred Forte qid
• Taper per IOP response: usually respond in 1-2 d.