7.1 Acute Anterior Uveitis

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Eyecare Guidelines/
Section 7 - Uvea/
7.1 Acute Anterior Uveitis

Date of last review: Due to be updated

Differential diagnosis

Acute angle closure glaucoma
Lens-induced uveitis
Intraocular foreign body
Intermediate uveitis
Posterior uveitis
Panuveitis

Possible management by Optometrist

Treatment

Check the following
- IOP
- Anterior Chamber
  - Always dilate pupil to look for anterior chamber cells
- Dilated fundus examination
- Exclude herpes simplex keratitis

If no reason to refer to the Ophthalmology department, and if there are no contraindications, prescribe

PoM Prednisolone 1% eye drops every waking hour
Cyclopentolate 1% eye drops 3 times daily

Instruct the patient to re-attend for review next day

Day Two

Re-examine the patient
Check the IOP (looking for steroid response)

If no better

Phone ophthalmology to discuss next steps
At the request of Ophthalmology, you may be asked to prescribe or co-prescribe

Omeprazole 20mg daily for gastric protection
POM Prednisolone 30mg daily for one week, 20mg daily one week, 15mg daily one week, 10mg daily one week, 5mg daily then stop

If better

Continue Cyclopentolate 1% eye drops 3 times daily for 7 days and then stop
Reduce POM Prednisolone 1% eye drops as follows:

Every second waking hour for 1 week
Then 6 times a day for the next 1 week
Then 4 times a day for the next 1 week
Then 3 times a day for the next 1 week
Then 2 times a day for the next 1 week
Then 1 times a day for the next 1 week, then stop

One week after stopping Prednisolone 1% eye drops

Re-examine the patient
Check the IOP
If no better, phone ophthalmology to arrange for an urgent appointment
If better, first, and even recurrent cases, if responsive to treatment, do not need to be referred for further investigation by ophthalmology

Some Boards, however, may wish you to contact ophthalmology regarding second or subsequent presentations to discuss whether further assessment and/or investigation may be indicated, even if patient better

Advice

Most cases of anterior uveitis are autoimmune where the immune system (spleen, bone marrow, glands) mistakenly thinks there is infection when there is none
Autoimmune conditions relapse and remit, so may recur in the future in either eye

Patients with one autoimmune condition in the form of anterior uveitis are more likely to have other autoimmune conditions particularly

Ankylosing spondylitis
Inflammatory bowel disease

However, no additional treatment or investigation is required, if there are no corresponding symptoms
Patients with bilateral anterior uveitis or granulomatous keratic precipitates may have sarcoidosis

Multisystem inflammatory disease of unknown aetiology
Lung involvement common and diagnosed with a Chest X-ray

A minority develop progressive lung disease requiring oral steroids

Apart from herpes, infection is a rare cause of anterior uveitis

Treatment failure or specific features may suggest:

Syphilis
Tuberculosis
Lyme disease

Management Category

Refer same day if:

Patient is a child
Patient is already on systemic treatment for uveitis (oral steroids, immunosuppressants, biologics or similar)

Patients on systemic treatment for non-ocular reasons do not need to be referred

Bilateral involvement
New posterior synechiae or non-dilating pupil
IOP > 30 mmHg
Hypopyon or vitritis
Macular oedema
Choroiditis
Vasculitis
You cannot see anterior chamber cells, but symptoms or other signs point to anterior uveitis

Possible management by Ophthalmologist

As above
Systemic steroids for recalcitrant cases
Investigation, guided by symptoms and signs

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