eMedicine Specialties > Ophthalmology > Iris & Ciliary Body

Uveitis, Anterior, Granulomatous: Treatment & Medication

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

Updated: Sep 5, 2007

Treatment

Medical Care

Treatment for 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.
  • 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 (eg, Celestone) may be used.
    • Depot steroids should be avoided in cases of uveitis secondary to herpetic or toxoplasmosis because of their potentially severe adverse effects.
    • In severe cases of iritis, oral corticosteroids may be added to the treatment regimen.
  • Aqueous suppressant: If the IOP is elevated, a topical aqueous suppressant should be used.

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.

Medication

Topical corticosteroids and a cycloplegic agent should be started immediately. If the eye does not adequately respond to topical therapy within 1 week or so, oral corticosteroids or a periocular injection of corticosteroids may be added to the treatment regimen.

Oral corticosteroids may be particularly useful in cases of bilateral noninfectious granulomatous iritis. Routine use of depot steroids in infectious uveitis, in known steroid responders, or in patients with a glaucoma or already elevated IOP should be considered carefully because of potential for severe or sight-threatening adverse effects.

In cases of severe granulomatous iritis, the treating clinician may elect to begin therapy with topical and oral corticosteroids. The tapering of steroid therapy is guided by the clinical response on follow-up examination. Topical or systemic nonsteroidal anti-inflammatory drugs (NSAIDs) are of little or no benefit in the treatment of granulomatous iritis.

Corticosteroids

These agents are the mainstays of therapy for iritis, and they help to stabilize blood-aqueous barrier.


Prednisolone acetate 1% (Pred Forte, Econopred)

Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and by reversing increased capillary permeability.

Adult

1 gtt q1-2h initially; frequency based on severity of iritis

Pediatric

Administer as in adults

Documented hypersensitivity; viral, fungal, or tubercular infections

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hypertension; known to cause cataract formation with long-term use; suspect fungal invasion in any persistent corneal ulceration where a corticosteroid has been used or is in use (obtain fungal cultures when appropriate)


Prednisone (Meticorten, Deltasone, Orasone)

Can be used if topical therapy inadequate to treat iritis (especially if bilateral). Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and by reversing increased capillary permeability.

Adult

40-60 mg PO qd; taper over 2-4 wk after satisfactory response

Pediatric

0.5-1 mg/kg PO qd

When used with digoxin may increase risk of digitalis toxicity; monitor for hypokalemia in patients taking diuretics

Documented hypersensitivity; avoid use in viral, fungal, or tubercular processes

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use

Cycloplegia

These agents are used to help prevent or break posterior synechiae and to reduce ciliary body–induced pain.


Cyclopentolate hydrochloride 1% (AK-Pentolate, Cyclogyl)

Prevents muscle of ciliary body, and sphincter muscle of iris, from responding to cholinergic stimulation. Induces mydriasis in 30-60 min and cycloplegia in 25-75 min.

Adult

1 gtt qd/tid

Pediatric

Administer as in adults

May antagonize antiglaucoma effects of ophthalmic cholinesterase inhibitors

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

May cause psychotic reaction in children; may produce reactions similar to those of other anticholinergics

More on Uveitis, Anterior, Granulomatous

Overview: Uveitis, Anterior, Granulomatous
Differential Diagnoses & Workup: Uveitis, Anterior, Granulomatous
Treatment & Medication: Uveitis, Anterior, Granulomatous
Follow-up: Uveitis, Anterior, Granulomatous
Multimedia: Uveitis, Anterior, Granulomatous
References
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References

  1. Lobo A, Barton K, Minassian D, du Bois RM, Lightman S. Visual loss in sarcoid-related uveitis. Clin Experiment Ophthalmol. Aug 2003;31(4):310-6. [Medline].

  2. McCannel CA, Holland GN, Helm CJ, Cornell PJ, Winston JV, Rimmer TG. Causes of uveitis in the general practice of ophthalmology. UCLA Community-Based Uveitis Study Group. Am J Ophthalmol. Jan 1996;121(1):35-46. [Medline].

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

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

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

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

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Further Reading

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Keywords

iritis, iridocyclitis

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Contributor Information and Disclosures

Author

Roger K George, MD, Director of Uveitis Service, Madigan Army Medical Center; Clinical Instructor, Department of Ophthalmology, Oregon Health and Sciences University
Roger K George, MD is a member of the following medical societies: American Uveitis Society
Disclosure: Nothing to disclose.

Medical Editor

Andrew A Dahl, MD, Residency Director, Ophthalmology, Kingston Hospital, Department of Ophthalmology, Assistant Professor of Surgery (Ophthalmology), Mid Hudson Family Practice Institute
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.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
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.

Managing Editor

R Christopher Walton, MD, Director of Uveitis and Ocular Inflammatory Diseases Service, Associate Professor, 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 and American Medical Association
Disclosure: Nothing to disclose.

CME Editor

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.

 
 
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