Management of Uveitis

Overview

• Anterior uveitis is an intraocular inflammation of the uveal structures anterior to the middle of the vitreous cavity.
• Along with conjunctivitis, keratitis, and acute glaucoma, it is one of a group of ocular conditions commonly termed "red-eye." 
• This disease is associated with ocular trauma as well as many systemic diseases, including juvenile rheumatoid arthritis, ankylosing spondylitis, Reiter's syndrome, sarcoidosis, herpes zoster, and syphilis

Management

• The treatment of anterior uveitis is nonspecific, usually involving topical therapy with corticosteroids and cycloplegics. 
• Occasionally oral steroids or nonsteroidal anti-inflammatory drugs (NSAIDs) may be prescribed.
• The general goals for therapy in anterior uveitis are: 
• To preserve visual acuity
• To relieve ocular pain
• To eliminate the ocular inflammation or identify the source of inflammation
• To prevent formation of synechiae
• To manage intraocular pressure

Corticosteroids

• to decrease inflammation by reducing the production of exudates, stabilizing cell membranes, inhibiting the release of lysozyme by granulocytes, and suppressing the circulation of lymphocytes
• Depending on the severity of the inflammation being treated, the frequency can range from hourly to every other day. 
• Prednisolone acetate 1% is preferred
• Sometimes, steroids can cause ocular hypertension; therefore, patients must be monitored at 4- to 6-week intervals.

Cycloplegic and Mydiatrics

• cholinergic antagonists which work by blocking neurotransmission at the receptor site of the iris sphincter and ciliary muscle. 
• To relieve pain by immobilizing the iris
• To prevent adhesion of the iris to the anterior lens capsule (posterior synechia), which can lead to iris bombe and elevated IOP
• To stabilize the blood-aqueous barrier and help prevent further protein leakage (flare)

Oral Steroids / NSAIDS

• Oral prednisone may be utilized in recalcitrant cases of anterior uveitis in which topical steroids have produced little response
• As prostaglandin inhibitors, NSAIDs (particularly aspirin and ibuprofen) reduce inflammation, thus are sometimes useful

Others

• Therapy for increased IOP is as indicated

Initial Treatment

1. Cycloplegic agents: Cyclopentolate, 1%, may be used three times per day (t.i.d.) for mild anterior uveitis; or homatropine, 5%, may be used twice daily (b.i.d.) or t.i.d. for moderate anterior uveitis; or atropine, 1%, may be used b.i.d. or t.i.d. for severe anterior uveitis.
2. Topical steroids: Prednisolone acetate, 1%, every 1-6 hours depending on severity; the more severe the inflammation, the more frequent the dosage. 
3. Topical beta blocker: Timolol maleate, 0.5%, or betaxolol may be used b.i.d. if inflammatory glaucoma is present and there are no contraindications to beta blockers

References:

1. http://emedicine.medscape.com/article/1209595-treatment
2. http://emedicine.medscape.com/article/1209123-overview#a6
3. http://www.aoa.org/documents/optometrists/CPG-7
4. Clinical Management Guideline. Uveitis (anterior, acute and recurrent). College Of Optometrist, Version 3 22.07.13.