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