Uveitis, Anterior, Granulomatous Treatment & Management

  • Author: Abdullah Al-Fawaz, MD, FRCS; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Feb 25, 2010
 

Medical Care

Treatment of inflammation of the anterior segment is as follows.

  • 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 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 herpetic infection or toxoplasmosis 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 corticosteroids is to be avoided. The goal is 10 mg or less 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.
    • Treat increased intraocular pressure as indicated.
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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

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.

Coauthor(s)

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.

Specialty Editor Board

Andrew A Dahl, MD  Director of Ophthalmology Teaching, Mid-Hudson Family Practice Institute, The Institute for Family Health; Assistant Professor of Surgery (Ophthalmology), New York College of Medicine

Andrew A Dahl, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American College of Surgeons, American Medical Association, American Society of Cataract and Refractive Surgery, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Simon K Law, MD, PharmD  Associate Professor 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, American Glaucoma Society, and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

R Christopher Walton, MD  Professor, Director of Uveitis and Ocular Inflammatory Disease Service, Department of Ophthalmology, Assistant Dean for Graduate Medical Education, University of Tennessee College of Medicine; Consulting Staff, Regional Medical Center, Memphis Veterans Affairs Medical Center, St Jude Children's Research Hospital

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

Disclosure: Nothing to disclose.

Lance L Brown, OD, MD  Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

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, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Roger K George, MD, to the development and writing of this article.

References

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  8. Nussenblatt RB, Whitcup SM. Uveitis. In: Fundamentals and Clinical Practice. 3rd ed. Mosby-Year Book; 2003.

  9. Pepose JS, Holland GN, Wilhelmus KR. Ocular Infection and Immunity. Mosby-Year Book; 1996.

  10. Rao NA, Cousins S, Forster D. Intraocular Inflammation and Uveitis. In: Basic and Clinical Science Course. 1999.

  11. Rosenbaum JT, George RK. Uveitis. In: Current Ocular Therapy 5. 2000:519-21.

  12. [Guideline] Jabs DA, Rosenbaum JT, Foster CS, et al. Guidelines for the use of immunosuppressive drugs in patients with ocular inflammatory disorders: recommendations of an expert panel. Am J Ophthalmol. Oct 2000;130(4):492-513. [Medline].

  13. Jap A, Chee SP. Immunosuppressive therapy for ocular diseases. Curr Opin Ophthalmol. Nov 2008;19(6):535-40. [Medline].

  14. Rodrigues EB, Farah ME, Maia M, Penha FM, Regatieri C, Melo GB. Therapeutic monoclonal antibodies in ophthalmology. Prog Retin Eye Res. Mar 2009;28(2):117-44. [Medline].

 
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Granulomatous anterior uveitis with mutton-fat keratic precipitates and Koeppe and Busacca nodules.
Granulomatous anterior uveitis with numerous Busacca nodules on the iris surface and a few mutton-fat keratic precipitates on the inferior aspect.
 
 
 
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