Anterior Uveitis Management

1. Management of Anterior
uveitis

2. • Inflammation of the uveal tissue from iris upto
pars plicata of the ciliary body.
• Subdivided into :
– Iritis – iris
– Iridocyclitis – iris + pars plicata equally
– Anterior cyclitis – pars plicata

3. Investigations
• Thorough ocular examination.
1) Haematological investigations
• TLC and DLC to have a general information about
inflammatory response of body.
• ESR to ascertain existence of any chronic inflammatory
condition in the body.
• Blood sugar levels to rule out diabetes mellitus.
• Blood uric acid in patients suspected of having gout.
• Serological tests for syphilis, toxoplasmosis and
histoplasmosis.
• Tests for antinuclear antibodies, Rh factor, LE cells, C-
reactive proteins antistreptolysin-0, ACE (for
sarcoidosis).

4. • 2) Urine examination for WBCs, pus cells, RBCs and
culture to rule out urinary tract infections.
• 3) Stool examination for cyst and ova to rule out
parasitic infestations.
• 4) Radiological investigations include:
• X-rays of chest, paranasal sinuses, sacroiliac joints
and lumbar spine.
• CT scan high resolution. CT scan of thorax should
be considered for suspected sarcoidosis cases.
• MRI scan of head for suspected sarcoidosis,
demyelination and lymphomas.
• 5) Skin tests. These include tuberculin test, Kveim’s
test for sarcoidosis, toxoplasmin test, lepromin test
and pathergy test for Behcet’s disease.

5. • 6. Biopsy/intraocular fluid samples for
examination
– Aqueous samples for PCR
– Vitreous biopsy for culture and PCR
– Lungs and lymph node biopsy for sarcoidosis

6. Treatment
• I) Non specific treatment
(A) Local therapy
1) Cycloplegic drugs – very effective during acute phase
– Commonly used : 1% atropine sulfate eye ointment or
drops instilled 2-3 times a day
– Atropine allergy - 2% homatropine or 1% cyclopentolate
eyedrops may be instilled 3-4 times a day
– For more powerful cycloplegic effect : a subconjunctival
injection of 0.25 ml in mydricain (a mixture of atropine,
adrenaline and procaine)
– should be continued for at least 2–3 weeks after the eye
becomes quiet, otherwise relapse may occur.

7. • Mode of action :
– (i) gives comfort and rest to the eye by relieving
spasm of iris sphincter and ciliary muscle
–(ii) prevents the formation of synechiae and
may break the already formed synechiae
–(iii) reduces exudation by decreasing
hyperaemia and vascular permeability
–(iv) increases the blood supply to anterior uvea
by relieving pressure on the anterior ciliary
arteries.

8. 2) Corticosteroids
• Commonly used preparations contain - dexamethasone,
betamethasone, hydrocortisone or prednisolone
• Route of administration :
– (i) eye drops 4–6 times a day
– (ii) eye ointment at bed time
– (iii) Anterior sub-Tenon injection is given in severe cases
• Mode of action :
– They reduce inflammation by their anti-inflammatory effect
– Anti-allergic - used in allergic type of uveitis
– Antifibrotic activity - they reduce fibrosis and thus prevent
disorganisation and destruction of the tissues.

9. (B) Systemic therapy
1) Corticosteroids
– a definite role in nongranulomatous iridocyclitis, where
inflammation, most of the times, is due to antigen-antibody
reaction.
– anti-inflammatory and antifibrotic effects
– indicated in intractable anterior uveitis resistant to topical
therapy
• Dosage : Treatment is started with high doses of
prednisolone (60–100 mg) or equivalent quantities of
other steroids (dexamethasone or betamethasone).
– Daily therapy regime is preferred for marked inflammatory
activity for at least 2 weeks.
– In the absence of acute disease, alternate day therapy
regime should be chosen.
– Dose of steroids is decreased by a week’s interval and
tapered completely in about 6–8 weeks in both the regimes

10. 2) NSAIDs
• Can be used where steroids are
contraindicated.
• In uveitis associated with rheumatoid disease
- Phenylbutazone and oxyphenbutazone
• Ankylosing spondylitis - Naproxen

11. 3) Immunosuppressive drugs
• Should be used only in desperate and extremely
serious cases of uveitis, in which vigorous use of
steroids have failed to resolve the inflammation
and there is an imminent danger of blindness.
• Indications : Severe cases of Behcet’s syndrome,
sympathetic ophthalmia, pars planitis and VKH
syndrome.
• Eg : cyclophosphamide, chlorambucil and
methotrexate

12. Azithromycin or tetracycline or
erythromycin
• To treat chlamydial infection in patients and
their sexual partners with Reiter’s syndrome
having urethritis and iritis.

13. (C) Physical measures
• 1. Hot fomentation. It is very soothing,
diminishes pain and increases circulation, and
thus reduces the venous stasis. As a result, more
antibodies are brought and toxins are drained.
Hot fomentation can be done by dry heat or wet
heat.
• 2. Dark goggles. These give a feeling of comfort,
especially when used in sunlight, by reducing
photophobia, lacrimation and blepharospasm

14. II) Specific treatment of the cause
• Nonspecific treatment is very effective and usually
controls the uveal inflammation, in most of the cases,
but it does not cure the disease, resulting in relapses
• All possible efforts should be made to find out and
treat the underlying cause
• Eg : a full course of antitubercular drugs for underlying
Koch’s disease, adequate treatment for syphilis,
toxoplasmosis
• When no cause is ascertained, a full course of broad
spectrum antibiotics may be helpful by eradicating
some masked focus of infection in patients with
nongranulomatous uveitis.

15. III) Treatment of complications
• 1. Inflammatory glaucoma
– Drugs to lower intraocular pressure such as 0.5%
timolol maleate eyedrops twice a day and tablet
acetazolamide (250 mg thrice a day)
– Pilocarpine and latanoprost eye drops are
contraindicated in inflammatory glaucoma
• 2. Post inflammatory glaucoma
– Treated by laser iridotomy
– Surgical iridectomy may be done when laser is not
available

16. • 3. Complicated cataract requires lens
extraction. Presence of fresh KPs is considered
a contraindication for intraocular surgery
• 4.Retinal detachment of exudative type
usually settles itself if uveitis is treated
aggressively. A tractional detachment requires
vitrectomy and management of complicated
retinal detachment, with poor visual
prognosis.
• 5. Phthisis bulbi especially when painful,
requires removal by enucleation operation

17. Hypopyon :A hypopyon consists of polymorphonuclear
leucocytes which accumulate in the lower angle of the
anterior chamber and eventually become enmeshed in
a network of fibrin

18. Causes:
• Corneal ulcer
• Iridocyclitis
• Toxic anterior segment syndrome
• Retinoblastoma (pseudohypopyon)
• Endophthalmitis
• Panophthalmitis

19. Mechanism of development
• Diffusion of bacterial toxins results in iritis
• When iritis is severe, massive outpouring of
leucocytes from the vessels occurs – the cells
gravitate to the bottom of the anterior
chamber
• Pseudohypopyon – due to collection of tumor
cells

20. • The development of a hypopyon depends on two
factors: (i) the virulence of the infecting organism
and (ii) resistance of the tissues.
• Hypopyon ulcers are much more common in old,
debilitated or alcoholic subjects.
• Hypopyon is usually sterile – the leucocytosis is
due to toxins and not due to actual invasion by
bacteria
• Descemet’s membrane is impermeable to
bacteria and leucocytes – this accounts for the
ease and rapidity with which it is often absorbed

21. Grading
• H0 – Absent
• + - less than 2mm
• ++ - less than 5mm (filling up to half of
anterior chamber
• +++ - 5mm or more (filling more than half of
anterior chamber)

22. Management
• It may develop in an hour or two,rapidy
disappear and readily reappear
• It is usually unnecessary to remove the pus; if
ulcerative process is controlled, it will be
absorbed
• In some cases of recalcitrant fungal ulcers, an
anterior chamber tap to test the hypopyon for
fungal invasion , followed by an anterior chamber
wash with antifungals may be required

23. • Hypopyon can cause secondary glaucoma –
treated with 0.5% timolol maleate, bid eye
drops and oral acetazolamide
• If source of infection is dacryocystitis –
dacryocystectomy