This guideline last updated 11/05/2022 12:14:43

 ​Differential diagnosis

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

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 keratitic 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 on already 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