Update on management of Anterior Uveitis Parthopratim Dutta Majumder Senior Consultant, Department of Uvea & Intraocular Inflammation Medical Research Foundation, Sankara Nethralaya
ABCD of Treating a Case of Anterior Uveitis is it limited only to Anterior chamber
ABCD of Treating a Case of Anterior Uveitis is it limited only to Anterior chamber Associated feature of intermediate, posterior or panuveitis Dilated examination of fundus Spill-over uveitis of vitreous inflammation
ABCD of Treating a Case of Anterior Uveitis is it Bilateral or Unilateral
ABCD of Treating a Case of Anterior Uveitis is it Bilateral or Unilateral Bilateral Rule out systemic Disease Bilateral (alternating) HLA B-27 associated uveitis Unilateral Rule-out viral infections
ABCD of Treating a Case of Anterior Uveitis What is the Course of the inflammation
ABCD of Treating a Case of Anterior Uveitis Acute Chronic What is the Course of the inflammation
ABCD of Treating a Case of Anterior Uveitis What is the Degree of Inflammation
ABCD of Treating a Case of Anterior Uveitis Fibrinous Uveitis Uveitis with cells 1+ What is the Degree of Inflammation
SUN Classification Disease Activity S t a n d a r d i z a t i o n o f U v e i t i s N o m e n c l a t u r e Parameters Anterior Chamber Cells Anterior Uveitis Improved Activity Worsening activity Two-step decrease in level of inflammation or decrease to grade 0 Two-step increase in level of inflammation or Increase from grade 3+ to 4+ Inactive 0 cells Remission Inactive disease for 3 months after discontinuing all treatments
Topical Corticosteroid Cycloplegic Periocular Oral Steroid 1 2 Topical NSAID 5 Immunosuppressives 6 3 4
Topical Corticosteroid Prednisolone acetate 1% Dexamethasone phosphate 0.1% Betamethasone sodium phosphate 0.1% Which one to use?
Topical Corticosteroid Two factors are very important in choosing topical steroid Is it a suspension or solution? What is the moiety of corticosteroid preparation?
Topical Corticosteroid Solution Betamethasone sodium phosphate 0.1% Suspension Prednisolone acetate 1% Emulsion Difluprednate 0.05% Poor penetration Cause less discomfort Requires less patient compliance Better penetration Cause more discomfort Requires more patient compliance
Prednisolone acetate 1% Dexamethasone phosphate 0.1% Betamethasone sodium phosphate 0.1% Corneal Stroma: hydrophilic Corneal Epithelium: lipophilic Moieties Acetate : both lipophilic + hydrophilic moieties Phosphate : hydrophilic moieties
Topical Corticosteroid Preparation Potency Anterior Chamber Concentration after topical use Prednisolone acetate 1% (1.0) Dexamethasone phosphate 0.1% (6.25) Betamethasone sodium phosphate 0.1% (6.25) 610 ng/ml 31 ng/ml 08 ng/ml Prednisolone acetate 6 times less potent on molar basis But has higher absorption than others
Cycloplegic Supportive measures What they do? To relieve pain by immobilizing the iris To prevent synechiae To stabilize the blood-aqueous barrier and help prevent further protein leakage
Cycloplegic Atropine 0.5%, 1%, 2% Homatropine 2%, 5% Cyclopentolate 0.5%, 1%, 2% (not preferred) Phenylephrine 2.5% (Not a cycloplegic)
Periocular Steroid Periocular injections of corticosteroid can be given in two spaces Subconjunctival space Cataract Surgery: usually short acting steroid Hypotony: long acting steroid Subtenon Space Anterior Uveitis Intermediate Uveitis Cystoid macular edema
Periocular Steroid Drugs used for periocular steroid Methylprednisolone acetate Triamcinolone acetonide Less water solubility (depot action) 2-4 months Dexamethasone acetate More water solubility 7-10 days
Oral Steroid How to manage a case of Severe Non-granulomatous Uveitis with Hypopyon? Cells 3+; Flare 3+, Hypopyon Topical Prednisolone Acetate one hourly, Atropine eye drop three times a day Monitoring at regular interval = increasing the frequency up to 15 minutes interval Periocular corticosteroid injection + Tapering of topicals Oral corticosteroid in tapering schedule along with topical therapy
Oral Steroid Indication of Oral steroid in Anterior Uveitis: Not responding to topical periocular steroid Bilateral, severe anterior chamber inflammation Associated complications such as hypotony, exudative retinal detachment
Case scenario A 34 years lady Known patient of HLA B27 uveitis Third attack in one year Oral Methotrexate 10mg/week OD: Severe AC reaction IOP 04 mm of Hg BCVA 6/60
USG B-scan Started on frequent topicals IVMP 3 doses followed by Oral steroid 60mg/day
Lesson learnt Fundus examination is a must ( Incase of hazy view, obtain an USG B-scan) Associated complications with anterior uveitis should be treated aggressively
High Index of Suspicion Diffuse Anterior Infiltrating Retinoblastoma
Case Scenario A 6-year-old emmetropic boy Known patient of JIA OS: Redness, ocular pain with mild diminution of vision (6/7.5) Recurrent attacks of anterior uveitis three months back On oral methotrexate 7.5 mg/week No H/O posterior Segment Involvement OCT of the left eye showed a CNVM with retinal thickening and subretinal fluid
Hiked up the dose of oral methotrexate Intravitreal injection of anti VEGF (Ranibizumab) @1-Month follow-up 6/6
Corticosteroid & IOP Hydrocortisone Fluorometholone Rimexolone Prednisolone Dexamethasone / Betamethasone (in ascending order) Systemic Topical Subtenon (depot preparation) Subconjunctival (depot preparation) Intravitreal (depot preparation) (in ascending order) LeHoang P. The gold standard of noninfectious uveitis: corticosteroids. Dev Ophthalmol. 2012;51:7-28.
Rise in IOP Topical use : 4 7 weeks ; Systemic use: months or years The risk is found to increase with subsequent periocular / intravitreal injections Monitoring IOP in all patients receiving steroids is necessary Children Old age Myopia Diabetes Family History High baseline IOP
Immunosuppressive Non-infectious etiology Recurrent attacks of anterior uveitis Resistant to corticosteroid
Biologicals Is there any role of drugs like biologicals in the management of anterior uveitis?
42-year-old male, Known patient of HLA B27 associated Uveitis OD: cells 0.5+, and flare 1+ in Anterior Chamber IOP 4 mm of Hg Received a periocular steroid injection and on frequent topical steroid Backache and stiffness of knee joints Examination by rheumatologist revealed painful intersegmental restrictions in movement of the cervical and lumbar vertebra, effusion of the knee joints and a positive Schober s test He was subsequently administered subcutaneous Golimumab the injection was repeated every 4 weeks 50 mg and
UBM showed significant resolution of ciliary body edema with resolved supraciliary effusion Marked improvement in his backache, joint stiffness. IOP improved to 16 mm of Hg
Iontophoresis It is a non-invasive technique that involves the application of a small electric current to enhance the penetration of an ionized drug into the tissue.
To Conclude. Detailed examination of fundus is a must in a case of anterior uveitis Monitoring the degree of inflammation at frequent interval is the important step in management of anterior uveitis High-Index of suspicion is required in treatment of pediatric & geriatric anterior uveitis
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