Uveitis, management

Alkylating agents interfere with DNA replication and transcription, resulting in depression of T- and/or B-cell populations. The most commonly used alkylating agents in uveitis management include cyclophosphamide (Cytoxan ) and chlorambucil (Leukeran ). 

Thrombolytic agents a need for improvement Thyroid preparations Trace minerals essential for health Traveler s diarrhea prevention of Tuberculosis treatment of Upper respiratory tract infection treatment of Urinary tract infections treatment of Uveitis management of Vaginal candidiasis treatment of Vasodilators effects on cardiac output (CO)... 

Smith, R.E. and Nozik, R.A. (1989). Cystoid macular oedema and uveitis. In Uveitis A Clinical Approach to Diagnosis and Management , 2nd edn. pp. 108-119. Williams and Wilkins, Baltimore. 

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. 

Management of the ocular aspects of Reiter s syndrome is directed toward control of inflammation.The uveitis can be fairly severe and resistant to therapy. In most instances such topical steroids as 1% prednisolone acetate or 0.1% dexamethasone are recommended. Dosage is variable but in severe cases should be administered initially every 1 to 2 hours and accompanied by such cycloplegic agents as 5% homatropine or 0.25% scopolamine two to three times daily. Aggressive treatment reduces formation of synechiae and subsequent secondary glaucoma. In patients who have severe uveitis, either sub-Tenon s capsule or oral steroids may be used in conjimction with topical management. 

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. 

Uveitis, by definition, describes an inflammatory state affecting the uveal tissues of the eye these include the iris, ciliary body, and choroid. Any or all of these structures may be involved in uveitis, a potentially blinding disorder that has great potential impact from both a medical and socioeconomic standpoint. This chapter reviews the classification, pathophysiology, epidemiology, diagnostic considerations, and medical management of uveitis. 

The measurement of intraocular pressure (lOP) is essential in the initial assessment and ongoing management of uveitis. In the early stages of uveitis the lOP is typically low, due to secretory hypotony within the ciliary body. Over time, however, the lOP may normalize or rise to abnormal levels due to numerous mechanisms, including trabecular blockage by inflammatory debris and synechia formation. Elevated lOP usually indicates a more chronic condition. 

The frequency of corticosteroid administration varies with the intensity of the reaction. For mild anterior uveitis (1-1- cells and flare), dosing every 4 hours may be sufficient. Moderately severe anterior uveitis may be managed with 1% prednisolone acetate or similar medication every 2 to 3 hours. In severe cases steroids may be dosed hourly or even more frequently. Corticosteroid ointments may be used at bedtime, though the duration of this drug modality only extends the medication s efficacy for perhaps an additional hour or 2. In the case of severe anterior uveitis, it is probably better to have the patient awaken every 2 to 3 hours and instill another drop. 

Unfortunately, most of the current management strategies for uveitis are borne out of anecdotal and/or empirical approaches. Few if any randomized, controlled, clinical trials exist regarding conventional therapy for uveitis indeed, only a handful of such trials have been identified in the current literature, and most of those focus on the use of systemic cyclosporine. 

Essentially, the four goals for the medical management of uveitis are (1) preservation of vision, (2) relief of ocular pain, (3) amelioration of ocular inflammation, and (4) prevention of pathologic sequelae, including synechia... 

Another relatively recent development for the management of intermediate and/or posterior uveitis is the sustained-release intravitreal corticosteroid implant, for example, Retisert (fluocinolone acetonide 0.59 mg Bausch Lomb, Rochester, NY, USA). Retisert is indicated fc)r the treatment of chronic noninfectious uveitis affecting the posterior segment of the eye. An intravitreal dexamethasone implant is also currently luider investigation. 

Figure 29-1 Flow chart for management of patient with anterior uveitis. (Reprinted with permission from Alexander KL. Optometric clinical practice guidelines care of the patient with anterior uveitis. St. Louis, MO American Optometric Association, 1994.)...

Intermediate uveitis may not warrant any therapeutic intervention in mild cases where the visual acuity is 20/40 or better. However, medical therapy is required for most patients. Macular edema is a frequent complication and requires prompt management to prevent permanent vision loss. In general, topical steroids are minimally effective in intermediate uveitis, except in those patients who are aphakic. Periocular and systemic steroids are substantially more efficacious. Periocular steroid injections are preferable in unilateral presentations and in children, whereas oral or other systemic routes are required for bilateral cases. For steroid-resistant intermediate uveitis, immunosuppressive therapy or surgery (cryotherapy and vitrectomy) may be necessary. Complications associated with intermediate uveitis include persistent CME,... 

A number of laboratory tests and ancillary studies may aid in the management of uveitis. Such testing is indicated when the patient presents with any of the following conditions (1) recurrent uveitis or uveitis unresponsive to treatment, (2) bilateral uveitis, (3) uveitis with posterior involvement, or (4) uveitis associated with signs or symptoms suggestive of systemic disease. 

Smith JR. Management of uveitis. Chn Exp Med 2004 3 21-29. Wade NK. Diagnostic testing in patients with ocular inflammation. Int Ophthalmol Chn 2000 40 37-54. 

Anonymous. Drug-induced uveitis can usually be easily managed. Drugs Ther Perspect 1998 11 11-14. 

Injection of hydrophilic drugs under the bulbar conjunctiva results in direct diffusion of relatively high levels of the drug into the anterior chamber, comeal stroma, posterior chamber and anterior vitreous. In the horse, the route is used most frequently to manage acute anterior segment disease or, using depot corticosteroid preparations, in the management of anterior uveitis uncomplicated by comeal ulceration. 

Intravitreal implants impregnated with ciclo-sporin (cyclosporin A, cyclosporine) deliver protracted and controlled intraocular drug release and have been successfully used in the management of some cases of equine recurrent uveitis (ERU) (Gilger Allen 1998, Gilger et al 2000). 

Pilocarpine-induced miosis has very little value in managing glaucoma in the horse and may increase lOP (van der Woerdt et al 1998). Miotics may also potentiate the clinical signs of uveitis where these are present. 

This reference studies the most recent advances in the development of ocular drug delivery systems. Covering methods to treat or prevent ocular inflammation, retinal vascular disease, retinal degeneration, and proliferative eye disease, this source covers breakthroughs in the management of endophthalmitis, uveitis, diabetic macular edema, and age-related macular degeneration. 

Viral endophthalmitis has become a major concern in AIE management, and some of uveitis are shown to arise from viral origin (e.g. acute retinal necrosis). Intravitreal antiviral therapy is surely one of the crucial modalities. The b-wave, the c-wave, the oscillatory potentials and the VEP remained unchanged after 5 repetitive weekly (once a week) intravitreal injections of 200 pig ganciclovir. 

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