Uveitis anterior

Manczak M, Jiang S, Orzechowska B, Adamus G (2002) Crucial role of CCL3/MIP-1 alpha in the recurrence of autoimmune anterior uveitis induced with myelin basic protein in Lewis rats. J Autoimmun 18 259-270... 

Figure 9.7 Mild anterior uveitis. Collections of macrophages (keratic precipitates) can be seen on the endothelial surface of the cornea (arrowheads).

Carbachol stimulates the same muscarinic receptor as pilocarpine and also inhibits acetylcholinesterase, the enzyme that metabolizes acetylcholine. Carbachol is more potent than pilocarpine, but it causes more accommodation spasm and brow ache and may also cause anterior uveitis. Carbachol is rarely used today because of the side-effect profile. 

Hypersensitivity to any component of the formulation where constriction is undesirable (eg, acute iritis, acute or anterior uveitis, some forms of secondary glaucoma, pupillary block glaucoma, acute inflammatory disease of the anterior chamber). 

Inflammatory conditions Treatment of steroid-responsive inflammatory conditions of the palpebral and bulbar conjunctiva, lid, sclera, cornea, and anterior segment of the globe, such as Allergic conjunctivitis acne rosacea superficial punctate keratitis herpes zoster keratitis iritis cyclitis and selected infective conjunctivitis (when the inherent hazard of steroid use is accepted to obtain an advisable diminution in edema and inflammation [prednisolone]) vernal conjunctivitis episcleritis epinephrine sensitivity and anterior uveitis. 

Anterior uveitis - Apply 1 to 2 drops into the conjunctival sac of the affected eye every hour during waking hours for the first week, 1 drop every 2 hours during waking hours of the second week, and then taper until uveitis is resolved. 

The autoimmune rheumatic diseases consists of Rheumatoid Arthritis (RA), Spondylarthritis (SpA), Systemic Lupus Erythematosus (SLE), Polymyositis, Dermatomyositis, Polymyalgia Rheumatica, Acute Temporal Arteritis, Giant Cell Arteritis, Behcet s Disease, Sjorgren s Syndrome, Felty s Syndrome and Mixed Connective Tissue Disease (MCTD). Spondylarthritis (SpA) can be subdivided in Reactive Arthritis (ReA), Ankylosing Spondylitis (AS), Psoriatic Arthritis (PsA), Arthritis associated with the inflammatory bowel diseases are Crohn s disease and Ulcerative Colitis (IBD), Undifferentiated SpA (UspA) and Sacro-ilitis, Juvenile SpA and Acute Anterior Uveitis (AAU). 

There is comparative effectiveness of anti TNF-a modalities in the treatment of patients with RA and AS (see Canete et al., 2004). This would apply to all the disease entities of SpA such as, PsA, ReA, Crohn s disease. Ulcerative Colitis, Acute Anterior Uveitis (AAU), and Undifferentiated Spondylarthritis (UspA). 

The adverse effects that most frequently result in discontinuation of rifabutin include GI intolerance, rash, and neutropenia. Rifabutin levels will be increased with concurrent administration of fluconazole and clarithromycin, resulting in anterior uveitis, polymyalgia syndrome, and a yellowish-tan discoloration of the skin (pseudojaundice). Other adverse reactions are similar to those of rifampin, such as hepatitis, red-orange discoloration of body fluids, and drug interactions due to effects on the hepatic P450 cytochrome enzyme system. 

Anterior uveitis and neutropenia are fairly common side effects of cidofovir therapy. Ocular hypotony and metabolic acidosis are rare. Exposure to therapeutic levels of cidofovir causes cancer in rats therefore, this drug should be considered a potential human carcinogen. Animal studies have also shown cidofovir to produce embryotoxic and teratogenic effects and to impair fertility. 

The ocular adverse effects of latanoprost include conjunctival hyperemia, iris pigmentation, periocular skin color changes, anterior uveitis, and cystoid macular edema in pseudophakic patients (77,78). H. simplex dendritic keratitis has been reported after treatment with latanoprost (79). In patients with uveitic glaucoma, latanoprost can cause increased intraocular pressure and recurrence of inflammation (80). 

Fechtner RD, Khouri AS, Zimmerman TJ, Bullock J, Feldman R, Kulkarni P, Michael AJ, Realini T, Warwar R. Anterior uveitis associated with latanoprost. Am J Ophthalmol 1998 126(1) 37-41. 

Dapiprazole is contraindicated in circumstances in which pupillary constriction is imdesitable, such as acute anterior uveitis, and for patients having hypersensitivity to any component of the preparation. 

Because of its prolonged mydriatic and cycloplegic effect and relatively weak cycloplegic action, particularly in darkly pigmented irides, homatropine is not a drug of choice for fundus examination or cycloplegic refraction. Homatropine is primarily used in the treatment of anterior uveitis, in which its effects are similar to those of atropine. 

Cyclopentolate is also useful in the treatment of anterior uveitis, particularly in patients sensitive to atropine. If the inflammation is severe, more frequent instillations may be necessary, because its duration of action is less than that of atropine. 

Cystoid macular edema Anterior uveitis Punctate corneal erosions Corneal pseudodendrites... 

Similar to CME, a number of cases have been reported alleging an association between latanoprost therapy and the development of anterior uveitis. Although prostaglandins play an important role in the development of vascular permeability associated with uveitis, disruption of the blood-aqueous barrier associated with latanoprost can be small, transient, and sometimes reversible despite continued latanoprost therapy. 

In 1990 approximately 50 cases of anterior uveitis were reported in the United Kingdom, where metipranolol had been available since 1986. At one hospital the incidence of uveitis in patients using 0.6% metipranolol was 14% (15 of 109). All cases resolved with appropriate management. Drug-induced anterior uveitis has also been reported as a rare event in the United States, but a true causal relationship has not been definitely established. 

Patel NP, Patel KH, Moster MR, Spaeth GL. Metipranolol-associated nongranulomatous anterior uveitis. Am J Ophthalmol 1997 123 843-844. 

Ideally the effective dose should be used for the shortest time necessary to secure the desired clinical response. The dosage should be individualized as much as possible to the patient and the severity of the condition. The patient s general health must be considered and close supervision maintained to assess the effects of steroid therapy on the course of the disease and possible adverse effects. With ocular disease the route of steroid administration is an important determinant of the pharmacologic and therapeutic effects observed. Topical ocular therapy is usually satisfectory for inflammatory disorders of the eyelids, conjimctiva, cornea, iris, and ciliary body. In severe fiarms of anterior uveitis, topical therapy may require supplementation with systemic or periocular (local injection) steroids. Chorioretinitis and optic neuritis are most often treated with systemic steroids. 

Anterior uveitis Posterior uveitis Sympathetic ophthalmia Sclera Scleritis Episcleritis Retina... 

The main side effect associated with oral acyclovir, valacyclovir, and femciclovir is intestinal disturbance such as nausea and vomiting. Acyclovir is available in an 800-mg tablet that does not contain lactose therefore it is less likely to cause lactose-related diarrhea. Lower dosages are recommended for treatment of elderly patients with impaired creatinine clearance. Perhaps the most significant factor in fevor of antivirals is that they minimize the common complications of the disease, including dendriform keratopathy, stromal keratitis, and anterior uveitis. 

Band keratopathy was first described in 1848 and is a chronic degenerative condition characterized by the deposition of calcium carbonate salts in the superficial corneal layers, most frequently in the interpalpebral area. Although there are many reported cases of idiopathic band keratopathy, some of which seem to have a hereditary component, the most common causes are associated with chronic ocular inflammation and systemic conditions resulting in altered calcium metabolism. Band keratopathy is typically seen in eyes with chronic uveitis, severe superficial keratitis, corneal ulcers, chemical burns, interstitial keratitis (IK), trachoma, phthisis bulbi, and prolonged glaucoma. The chronic anterior uveitis of juvenile idiopathic arthritis is frequently associated with band keratopathy, with one study reporting its development in 66% of patients with juvenile idiopathic arthritis. 

During corneal healing it is important to monitor for any signs of corneal infiltrate or anterior uveitis. Although most corneal infiltrates associated with RCE have been shown to be sterile, the clinical appearance of these infiltrates is not definitive in differentiating infectious from immune causes. For this reason any infiltrates that develop should initially be treated with antibiotic drops as if they were infectious. 

The patient is followed daily until the corneal injury resolves. Unless an anterior uveitis is present, the cyclo-plegic, steroid, and antibiotic can be discontinued once the epithelium has healed. If healing of the mild alkali burn does not proceed as expected, it is possible that ischemia is present, necessitating reevaluation of the treatment. 

Additional findings in EKC can include pseudomembrane formation (Figure 26-46) and corneal epithelial sloughing. Symblepharon, scleritis, and anterior uveitis rarely develop. Nasolacrimal system obstruction due to inflammation or adhesion of opposing surfaces, as occurs in symblepharon formation, also is a rare complication. 

Varicella-zoster virus is a member of the Herpesviridae femily. The viral contagion is transmitted via aerosolized water droplets or close physical contact with infected lesions. The primary infection results in varicella or chickenpox. The varicella infection can have potentially devastating ocular sequelae the most common is anterior uveitis followed by SPK. After the primary infection, latent infection occurs in multiple ganglia throughout the body. Herpes zoster is the resultant reactivation of the latent varicella-zoster virus and most often occurs in elderly and immunocompromised patients. Factors such as physical and emotional trauma, immunosuppressive medications, irradiation, cancer, tuberculosis, malaria, and syphilis are known to reactivate the virus. 

Deep corneal edema with folds in Descemet s membrane, in the presence of an intact epithelium, can develop from 3 to 4 months after acute HZO. This disciform keratitis may involve the full thickness of the cornea and may be surrounded by a ring-like cellular infiltrate called a Wessley ring. It is considered to be an immune response to viral antigens and responds quickly to topical steroids, especially when initiated early. Unfortunately, it is common to have recurrences when steroids are tapered or discontinued and can lead to corneal scarring or, more seriously, corneal melt.There is often an associated anterior uveitis with keratic precipitates as well as diffuse corneal edema, endothelial cell loss, and increased lOP secondary to trabeculitis. 

Systemic antiviral therapy promotes resolution of HZO skin lesions and reduces the incidence and severity of dendriform keratopathy, anterior uveitis, and stromal keratitis by decreasing the rate of virus replication. All patients with acute HZO should receive antiviral therapy with the goal of minimizing ocular complications. Acyclovir, valacyclovir, and femciclovir are FDA approved for management of herpes zoster. Acyclovir usually is administered orally in dosages of 800 mg five times per day far 7 days. Valacyclovir has better bioavailability when taken orally and can be used with a recommended dosage of 1 g three times a day for 7 days. Famciclovir, which has bioavailability similar to valacyclovir, has an increased half-life and also has the advantage of less frequent administration than acyclovir 500 mg three times a day for 7 days. 

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