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Uveitis, Anterior, Granulomatous Treatment & Management

  • Author: Andrew A Dahl, MD, FACS; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: May 09, 2016
 

Medical Care

Treatment of inflammation of the anterior segment is discussed below.

Cycloplegia

Use a long-acting cycloplegic agent, such as cyclopentolate or homatropine, to relieve both pain and photophobia (if present) and to prevent the formation of posterior synechiae. However, this may not always be necessary in chronic disease, especially if the inflammation is well controlled. In any case, allowing for some pupil movement is helpful to prevent posterior synechiae formation in the dilated position.

Corticosteroids

Topical corticosteroids are the mainstay of therapy and should be used aggressively during the initial phases of therapy.

If the patient poorly complies with topical therapy or if the iritis is not responding to topical corticosteroids, a subconjunctival injection of shorter-acting or depot steroids may be used. Betamethasone (Celestone) is short and intermediate acting and can be used for exacerbations, whereas triamcinolone acetate is longer acting and is used more often for associated cystoid macular edema or vitritis.

Depot steroids should be avoided in cases of uveitis secondary to any suspected infectious process because of their potentially severe adverse effects.

In severe cases of iritis, oral corticosteroids may be added to the treatment regimen (after ruling out the infectious etiology or after under coverage of medication, which treats the infectious etiology).

Prolonged use of systemic corticosteroids is to be avoided. The goal is less than 10 mg of prednisone per day by 6 months. In severe disease or if prolonged corticosteroids are being used, systemic corticosteroid-sparing immunomodulatory agents are used in chronic noninfectious uveitis. If evidence shows involvement of the posterior uvea by noninfectious uveitis, intravitreal steroids can be used via intravitreal injection or insertion of a steroid-eluting delivery system (eg, Retisert, Iluvien, Ozurdex).

Treat increased intraocular pressure as indicated.

Systemic immunomodulating agents

Systemic immunomodulating agents may be used in patients in whom regional or systemic corticosteroids are not responding or in patients who have the potential for steroid side effects. Systemic immunomodulating agents work by selectively blocking steps in the inflammatory and immune cascades. For example, abatacept and alefacept dampen the immune response by interfering with the activation of T cells, while adalimumab, etanercept, and infliximab target the inflammatory mediator TNF-alpha.

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Surgical Care

Glaucoma surgery can be performed if medical treatment fails to control the intraocular pressure and after quieting the eye from inflammation. In case of cataract, the eye must be free of inflammation at least 3 months before the surgery. A peripheral iridectomy may be indicated for iris bombe; however, if the pupil is not entirely occluded or secluded, an iridectomy can precipitate iris bombe by diverting flow from the small area of the pupil that is not occluded. In that case, if there is an exacerbation of inflammation, the pupil can close as there is no flow and the iridectomy may become occluded as well.

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Consultations

If a specific systemic diagnosis is suspected or is confirmed on the basis of laboratory and/or radiographic investigation, consultation with a subspecialist may be indicated.

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Contributor Information and Disclosures
Author

Andrew A Dahl, MD, FACS Assistant Professor of Surgery (Ophthalmology), New York College of Medicine (NYCOM); Director of Residency Ophthalmology Training, The Institute for Family Health and Mid-Hudson Family Practice Residency Program; Staff Ophthalmologist, Telluride Medical Center

Andrew A Dahl, MD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, American Intraocular Lens Society, American Medical Association, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Medical Society of the State of New York, New York State Ophthalmological Society, Outpatient Ophthalmic Surgery Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, American Glaucoma Society

Disclosure: Nothing to disclose.

R Christopher Walton, MD Professor, Director of Uveitis and Ocular Inflammatory Disease Service, Department of Ophthalmology, University of Tennessee College of Medicine

R Christopher Walton, MD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, Retina Society, American College of Healthcare Executives, American Uveitis Society

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy, Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

Andrew A Dahl, MD, FACS Assistant Professor of Surgery (Ophthalmology), New York College of Medicine (NYCOM); Director of Residency Ophthalmology Training, The Institute for Family Health and Mid-Hudson Family Practice Residency Program; Staff Ophthalmologist, Telluride Medical Center

Andrew A Dahl, MD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, American Intraocular Lens Society, American Medical Association, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Medical Society of the State of New York, New York State Ophthalmological Society, Outpatient Ophthalmic Surgery Society

Disclosure: Nothing to disclose.

Acknowledgements

Abdullah Al-Fawaz, MD, FRCS Assistant Professor, Cornea and Uveitis Department, King Abdulaziz University Hospital, Department of Ophthalmology, King Saud University, Riyadh, Saudi Arabia

Abdullah Al-Fawaz, MD, FRCS is a member of the following medical societies: American Academy of Ophthalmology and Royal College of Physicians and Surgeons of Glasgow

Disclosure: Nothing to disclose.

Roger K George, MD, Director of Uveitis Service, Madigan Army Medical Center; Clinical Instructor, Department of Ophthalmology, Oregon Health and Sciences University

Disclosure: Nothing to disclose.

Ralph D Levinson, MD Associate Professor of Ophthalmology, Jules Stein Eye Institute at the David Geffen School of Medicine at UCLA

Ralph D Levinson, MD is a member of the following medical societies: American Academy of Ophthalmology, American Uveitis Society, Association for Research in Vision and Ophthalmology, and International Ocular Inflammation Society

Disclosure: Nothing to disclose.

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Granulomatous anterior uveitis with mutton-fat keratic precipitates on posterior corneal surface and Koeppe and Busacca nodules of the iris.
Granulomatous anterior uveitis with numerous Busacca nodules on the iris surface and a few mutton-fat keratic precipitates on the inferior aspect of the cornea.
Mutton-fat keratic precipitates in sarcoidosis.
 
 
 
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