Orals for Eye Care

Consult a definitive reference if you lack experience with a drug or if the patient has serious co-morbidity, reduced liver or renal function, or is pregnant or nursing.

A) Convert lbs to kilograms: (lb. −10%)/2 = kg

B) Antibiotic recommendations: listed in order of preference. See notes and warnings below

1) Lid problems

     · Ocular rosacea

     · Meibomian gland dysfunction

     · Hordeolum

     · Chlamydia

a) Doxycycline: inexpensive, effective, classic

b) Zithromax: moderate price, use if tetracycline problems or you want simple dosing for an acute problem

c) Biaxin: expensive, third choice

d) Tetracycline and erythromycin, inexpensive but not recommended

2) Acute infections with no fever or systemic Sx

· Preseptal cellulitis

· Dacryocystitis

· Hyperacute conjunctivitis

· Sinusitis

· Ear infections

a) Keflex: inexpensive, effective

b) Zithromax: moderate price, use for penicillin allergies

c) Dicloxacillin: moderate price

d) Augmentin: expensive, very effective, may cause diarrhea

e) Ceftin: expensive, good for deep complicated infections with multiple organisms

f ) Penicillin, amoxicillin, ampicillin, Bactrim: inexpensive but less effective

C) Penicillins

1) Dicloxacillin 250 or 500 mg

a) Indications: broad-spectrum bacterial infections, especially cellulitis. Little staph resistance

b) Contraindications: penicillin allergy

c) Adults: 250 – 500 mg qid 1 hr before or 2 hrs after meals

d) Children: 12 – 25 mg/kg daily, divided qid

e) Common side effects: allergy

2) Amoxicillin 250 or 500 mg

a) Indications: non-serious broad-spectrum bacterial infections, especially sinusitis

b) Contraindications: penicillin allergy, resistant staph

c) Adults: 250 – 500 mg qid, OK with meals

d) Children <20 kg: 20 – 40 mg/kg daily, divided qid

e) Common side effects: allergy, occasional GI upset and hyperactivity

3) Augmentin 250 or 500 mg (amoxicillin + clavulanic acid): now also in 200 and 400 mg strengths

a) Indications: serious or resistant broad-spectrum bacterial infections including beta lactamase staph, a more effective drug

b) Contraindications: penicillin allergy

c) Adults and children >40 kg: 500 mg bid

d) Children <40 kg: 20 – 40 mg/kg daily, divided bid

e) Common side effects: GI upset, diarrhea, allergy, rash

4) Penicillin VK 250 or 500 mg

a) Indications: gonorrhea, strep throat

b) Contraindications: penicillin allergy, organisms other than gonorrhea or strep

c) Adults: 500 mg qid, OK with food

d) Children: 15 – 50 mg/kg daily divided qid

e) Common side effects: allergy

D) Cephalosporins

1) Cephalexin (Keflex) 1st generation, 250 or 500 mg

a) Indications: most gram+ bacterial infections, cellulitis

b) Contraindications: 10% cross reaction with penicillin allergy, colitis

c) Adults: 250 – 500 mg qid, OK with food

d) Children: 25 – 50 mg/kg daily, divided qid

e) Common side effects: allergy, rash, polyarthritis, diarrhea

2) Cefuroxime (Ceftin) 2nd generation, 125, 250, 500 mg

a) Indications: deep and complicated infections by multiple organisms such as in sinusitis and ear infections

b) Contraindications: 10% cross reaction with penicillin allergy

c) Adults: 250 – 500 mg bid

d) Children: 250 mg bid with meal

e) Common side effects: diarrhea, nausea, vomiting

E) Sulfa

1) Bactrim (sulfa 400 mg + trimethoprim 80 mg), Bactrim DS (sulfa 800 mg + trimethoprim 160 mg), suspension (sulfa 200 mg + trimethoprim 40 mg, per 5 mL)

a) Indications: bacterial infection, consider if penicillin allergy and erythromycin causes nausea

b) Contraindications: many resistant organisms, sulfa allergies

c) Adults: 2 Bactrim bid or 1 Bactrim DS bid

d) Children: 40 mg/kg of sulfa, divided bid

e) Common side effects: Stevens-Johnson syndrome, colitis (rarely peripheral neuritis, depression, convulsions)

F) Macrolides

1) Zithromax 250 or 500 mg tablets, Z-Pack

a) Indications: broad-spectrum bacterial infections. Especially good as a back up for infected patients with penicillin allergies and ocular rosacea/meibomianitis patients intolerant of doxycycline. Drug of choice for chlamydia, 1, 1000 mg dose

b) Relative contraindications (coordinate with the medical doctor): concurrent use of theophylline, digoxin, warfarin

c) Adults: 500 mg qd first day, then 250 mg qd for 4 days, avoiding antacids, 1 hr before or 2 hrs after meals. Lasts 2 weeks in the body

d) Children >6 months: 10 mg/kg qd first day, then 5 mg/kg qd for 4 days

e) Common side effects: GI upset, abdominal pain, colitis

2) Biaxin 250 or 500 mg tabs

a) Indications: broad-spectrum bacterial infections. For more serious infections than Zithromax

b) Contraindications: concurrent use of theophylline, digoxin, lovastatin, cyclosporine, Norpace

c) Adults: 250 or 500 mg bid

d) Children >20 months:15 mg/kg/day divided bid

e) Common side effects: GI upset, headache, taste changes

3) Erythromycin 250, 333, 500 mg

a) Indications: chlamydia in young and child-bearing women, broad-spectrum infection and rosacea/meibomianitis. Inexpensive alternate drug for penicillin allergy patients and doxycycline intolerant patients

b) Relative contraindications (coordinate with medical doctor): concurrent use of theophylline, digoxin, cyclosporine, Norpace, prednisone

c) Adults: 1000 mg/day divided bid, tid, or qid, OK with meals

d) Children: 30 – 50 mg/kg daily divided qid

e) Common side effects: nausea is common

G) Tetracyclines

1) Doxycycline 50, 75, 100 mg

a) Indications: use in place of tetracycline for chlamydia, acne rosacea, meibomian gland disease, good broad-spectrum coverage for infections, good for penicillin allergic patients

b) Contraindications: children <age 8, and child-bearing women. Will discolor growing teeth. Avoid with concurrent anticoagulants

c) Adults or >100 lbs: 100 mg bid, avoid milk

d) Children >age 8: day 1, 2 mg/kg divided bid, then 1 mg/kg qd subsequent days

e) Common side effects: GI problems, pseudotumor, rashes, Candida vaginitis overgrowth, nail discoloration, anemia, dizziness, headache, loss of oral contraceptive effectiveness, photosensitivity (cover skin, wear sunglasses)

H) Antivirals

1) Acyclovir (Zovirax) 200 mg

a) Indications: for inexpensive treatment of herpes zoster and herpes simplex infection

b) Contraindications: difficulty with 5x dosing

c) Adults with herpes simplex: initially 200 mg 5x/day for 10 days, then 400 mg bid for up to 12 months

d) Adults with herpes zoster: 800 mg 5x/day for 10 days

e) Children >2 yrs: 20 mg/kg 5x/day up to 800 mg total per day

f ) Common side effects: headache, CNS changes in elderly, GI upset, vertigo, fatigue

2) Valtrex 500 mg caps (pro drug of acyclovir)

a) Indications: more convenient treatment of herpes zoster and herpes simplex infection

b) Contraindications: cost, concurrent use of probenecid (gout Tx), cimetidine (Tagamet)

c) Adults with herpes simplex: 1000 mg bid for 10 days, then 500 mg bid for acute ocular herpes. 500 mg bid for suppression of recurrences

d) Adults with herpes zoster: 1000 mg tid for 7 days

e) Children: not recommended

f ) Common side effects: GI upset, headache, dizziness

3) Famvir 125, 250, 500 mg tabs

a) Indications: more convenient treatment of herpes simplex and herpes zoster infections

b) Contraindications: cost

c) Adults with herpes simplex: 125 mg bid until cleared

d) Adults with herpes zoster: 500 mg tid for 7 days

e) Children: not recommended

f ) Common side effects: GI upset, insomnia, dizziness, nervousness, fatigue

I) Antihistamines

1) Loratadine (Claritin) 10 mg: now over-the-counter (OTC)

a) Indications: non-sedating antihistamine for the relief of seasonal allergic Sx. Onset within 1 hr, lasts 24 hrs

b) Contraindications: non-specific

c) Adults and >age 6: 1, 10 mg tab 1 hr before or 2 hrs after meal qd

d) Children <age 6: not recommended

e) Common side effects: GI upset, mucosal dryness, blur, headache, fatigue, sleepiness, hyperkinesia

2) Loratadine + pseudoephedrine sulfate Claritin-D 24 hr 10/240 mg and Claritin-D 12 hr 5/120 mg)

a) Indications: non-sedating antihistamine and decongestant for the relief of seasonal allergic Sx. If decongestant causes insomnia, use 12 hr version in a.m. and Benadryl in p.m. to aid sleep

b) Relative contraindications: hypertension, diabetes, ischemic heart disease, narrow angle glaucoma, hyperthyroidism, seizures

c) Adults and >age 6: 1 tab, 1 hr before or 2 hrs after meal. Once per day for the 24 hr version and bid for the 12 hr version

d) Children <age 6: not recommended

e) Common side effects: GI upset, mucosal dryness, blur, headache, fatigue, insomnia, sleepiness, hyperkinesia, appetite suppression, bronchospasm

3) Cetirizine hydrochloride (Zyrtec) 5 or 10 mg tablets and syrup

a) Indications: non-sedating antihistamine for the relief of allergic Sx

b) Contraindications: pregnancy, nursing mothers, renal failure

c) Adults: 10 mg qd

d) Children 6 – 11 yrs: 5 –10 mg qd

e) Children 2 – 5 yrs: ½ – 1 teaspoon per day

f ) Common side effects: sleepiness, fatigue, dry mouth

4) Cetirizine hydrochloride 5 mg and pseudoephrine hydrochloride 120 mg (Zyrtec-D 12 hour)

a) Indications: relief of allergic Sx with nasal congestion

b) Contraindications: narrow angle glaucoma, hypertension, use of MAO inhibitors (obsolete antidepressant) within 14 days

c) Adults: 1 tablet bid

d) Children <12: not recommended

e) Common side effects: sleepiness, fatigue, dry mouth

5) Diphenhydramine (Benadryl) caps 25 mg OTC

a) Indications: inexpensive relief of allergic Sx, especially acute and medication induced Sx, sedating

b) Contraindications: respiratory problems, narrow angle glaucoma, hyperthyroidism, hypertension, cardiovascular disease, GI or urinary obstruction

c) Adults: 25 – 50 mg qid

d) Children >6: 25 mg qid

e) Common side effects: sedation, dizziness, excitement, hypotension, GI upset

6) Diphenhydramine + pseudoephedrine (Benadryl allergy/congestion) caps 25 mg OTC

a) Indications: inexpensive relief of allergic Sx with nasal congestion

b) Contraindications: respiratory problems, narrow angle glaucoma, hyperthyroidism, hypertension, cardiovascular disease, GI or urinary obstruction within 2 weeks of MAO inhibitors (obsolete antidepressant)

c) Adults: 2 caps qid

d) Children >6: 1 cap qid

e) Common side effects: sedation, dizziness, excitement, hypotension, rash, GI upset, palpitations

J) Carbonic anhydrase inhibitors: (topical Trusopt is usually a better choice)

1) Methazolamide (Neptazane) 25 or 50 mg, 100 per bottle

a) Indications: for reduction of IOP. Fewer side effects than Diamox. Consider Trusopt or Azopt instead

b) Contraindications: sulfa allergy, concurrent steroid or aspirin use

c) Adults: 50 – 100 mg bid or tid

d) Children: not recommended

e) Common side effects: “tingling” of extremities, tinnitus, fatigue, taste change, GI upset

2) Acetazolamide (Diamox) 125 or 250 mg tabs, or 500 mg Diamox Sequels

a) Indications: for IOP reduction. Consider Trusopt or Azopt instead

b) Contraindications: sulfa allergy, chronic obstructive pulmonary disease, diabetes

c) Adults, chronic use: Diamox tablets 125 – 250 mg qid or Diamox Sequels 500 mg bid. In angle closure start with a 500 mg loading dose of Diamox (not Sequels)

d) Children: not recommended

e) Common side effects: drowsiness, fever, diuresis, malaise, paresthesias, tinnitus, GI distress, blood dyscrasias; half of Diamox patients drop out due to side effects. Diamox Sequels better tolerated

K) Osmotics

1) Glycerin (Osmoglyn) 50% solution

a) Indications: urgent relief of angle closure in non-diabetics. Maximum effect in 1 hr. Most effective

b) Contraindications: diabetes

c) Adults: 2 – 3 mL/kg of solution, flavored on ice

d) Children: 2 – 3 mL/kg of solution flavored on ice

e) Common side effects: nausea, diuresis, vomiting

L) Analgesics & anti-inflammatories

1) Ibuprofen (Advil, Medipren, Midol 200, Motrin, Nuprin) 200 mg per tab

a) Indications: relief of pain and inflammation

b) Contraindications: aspirin allergy, alcoholism, gastritis, ulcers, 3rd trimester of pregnancy (use Tylenol instead), concurrent use of other anti-inflammatories such as Celebrex

c) Adults: 600 – 800 mg tid with food

d) Children: 10 – 40 mg/kg tid with food

e) Common side effects: GI upset, dizziness, visual disturbances, photophobia

2) Naproxen (Naprosyn, Naprelan 250 mg, 375 mg, 500 mg) (Aleve 220 mg)

a) Indications: long acting inflammation and arthritis relief. Less effective than ibuprofen for pain

b) Contraindications: aspirin allergy, 3rd trimester of pregnancy (see ibuprofen)

c) Adults: 250 – 500 mg bid, up to 750 mg bid for short term if tolerated

d) Children: 10 mg/kg divided bid (usually ½ of 250 mg tabs)

e) Common side effects: GI upset, headache, dizziness, drowsiness, tinnitus, peptic ulcers and bleeding problems, photophobia, heart disease, stroke

3) Tylenol #3 (30 mg codeine + 325 mg acetaminophen)

a) Indications: inexpensive relief of moderately severe pain

b) Contraindications: drug abuser, concurrent alcohol use, use of MAO inhibitors (obsolete antidepressant) within 14 days

c) Adults: 1 – 2 caps every 4 hrs

d) Children: 0.5 mg/kg of codeine component

e) Common side effects: sedation, drowsiness, vomiting, constipation, respiratory depression, syncope

4) Celebrex 100 or 200 mg

a) Indications: arthritis and relief of acute pain. Similar to NSAIDs without stomach problems

b) Contraindications: sulfa, aspirin, or NSAID allergy

c) Adults: 200 mg bid with initial loading dose of 400 mg

d) Children: not recommended <18 yrs

e) Common side effects: GI upset or pain, blurred vision, increased IOP, cataracts, heart disease, stroke

5) Ultram 50 mg

a) Indications: relief of moderately severe pain. Non-narcotic but works like narcotics with low risk of addiction. Easy on stomach

b) Contraindications: opioid allergy, intoxication

c) Adults 16 – 75 yrs: 50 – 100 mg every 4 – 6 hrs unless liver disease: consider ½ of 50 mg tab for small women and elderly

d) Children: not recommended

e) Common side effects: dizziness, nausea, constipation, headache, somnolence, vomiting

6) Vicodin (5 mg hydrocodone bitartrate and 500 mg acetaminophen)

a) Indications: for relief of moderately severe pain

b) Contraindications: drug abusers, concurrent alcohol use, use of MAO inhibitors (obsolete antidepressant) within 14 days

c) Adults: 1 tab every 4 hrs

d) Children: not approved

e) Common side effects: depression of respiration and cough reflex, sleepiness

Injuries

A) Metallic foreign bodies

1) Subjective

a) Complaints of pain or a foreign body sensation

b) Ask about a high speed projectile history because penetration can be occult and self-sealing

c) Ask if occurred at work and if patient was wearing safety glasses because of possible Worker’s Compensation insurance questions

d) Ask about tetanus shot history. If the wound was dirty and bloody and the last booster >10 yrs ago, or did not receive all of boosters, refer for booster shot

2) Objective

a) VA and pinhole or best corrected VA

b) Pupils

c) External

d) Slit lamp

1) Instill topical anesthetic if necessary in both eyes to facilitate examination

2) Look carefully for penetration, dilate if necessary to look for lens penetration and to look at the retina (no scleral depression)

3) Assessment

a) You must R/O the need for a computerized tomography (CT) or x-ray (no magnetic resonance imaging (MRI))

4) Plan

a) For limbal or deep conjunctival foreign bodies, soaking a pledget in topical anesthetic and 2.5% phenylephrine and holding on the affected tissue for 1 min will give deeper anesthesia (cocaine in 4% solution or lidocaine 4% are more effective for painful limbal foreign bodies)

b) Use a foreign body spud, a 1 mm chalazion curette, to remove the foreign body

c) When using a burr to remove a deep rust ring, rinse and clean the bit frequently

d) Remove all rust except the lightest staining

e) Remove all necrotic and edematous material

f ) For stromal wounds, instill 5% homatropine. It relieves ciliary spasm for 2 – 3 days, about as long as it takes to heal

g) Instill Acular or Voltaren for pain

h) Instill Polysporin or Ciloxan ointment for prophylaxis and lubrication

i ) Pressure patching is becoming controversial, but is still a simple way to relieve pain. If you patch in the morning, have the patient remove it before bed. Afternoon patches need to come off by the next morning. Bandage contact lenses are an alternative

j ) Except for non-stromal wounds, prescribe (Rx) Polytrim qid after the patch comes off. If you suspect a contaminated wound, Rx Vigamox or Zymar qid

k) Order a CT whenever an intraocular or orbital foreign body cannot be ruled out (not an MRI)

l ) Refer all intraocular foreign bodies to a retina specialist immediately

5) Return to clinic (RTC) in 2 days

a) Subjective: what % of subjective improvement? Should be at least 50%

b) Objective: visual acuity (VA), pupils, external, slit lamp

c) Assessment

1) Epithelial healing

2) Stromal edema is likely but no infiltrates should be visible

3) Watch striae, may indicate edema or early ulcer

4) Anterior chamber (AC) reaction should be rare cell at most

d) Plan

1) Continue the antibiotic x5d

2) RTC as needed (prn) if Sx worsen or foreign body sensation does not resolve in 3 – 5 days (follow until the epithelium heals)

3) Consider tears prn if a significant foreign body (FB) sensation exists

B) Abrasions, UV burns, welding burns, chemical splashes

1) Subjective

a) Severe pain or foreign body Sx

b) Known history: UV and welding burn symptoms appear several hrs after exposure

2) Objective: (if a chemical burn, irrigate as per Plan below before doing anything else)

a) Instill topical anesthetic for examination comfort

b) VA and pinhole or best corrected VA

c) External

d) Slit lamp with fluorescein

3) Assessment

a) Alkali burns (fertilizer, household bleach) are more persistent and destructive than acidic burns

b) Grade the corneal damage and draw it

4) Plan

a) For chemical splashes, always be sure the patient has 30 min of effective irrigation including that done before patient comes to the office. Be sure the lids are held open, or use a speculum

b) Consider a roll of pH paper. Stop irrigating for 5 min before use. Repeat irrigation until the pH is 7.0

c) 5% homatropine bid for comfort

d) Acular or Voltaren qid for comfort

e) Bacitracin ointment (ung) tid

f ) Pressure patch as needed between ung instillation

g) Alkali burns with epithelial defects may need up to 1 week of steroid to minimize scarring. Refer if severe or central

5) RTC in 2 days

a) Subjective: at least 50% better

b) Objective

1) Re-epithelizing

2) Symblepharon/conjunctival scarring possible with chemical burns

3) Stromal haze possible

4) AC reaction possible

c) Assessment

1) If central scarring, refer or treat with a steroid

2) If AC reaction, cycloplegia, consider steroid

d) Plan: monitor and treat as above until healed

1) Use bacitracin liberally to lubricate and facilitate healing

2) If only stromal haze, monitor

3) If stromal scarring exists after a chemical burn, consider a referral to a cornea specialist or Rx steroids to control

C) Blunt orbital trauma

1) Subjective

a) Known history of blunt trauma

b) Pain?

c) Decreased vision?

d) Diplopia?

e) Flashes or floaters?

2) Objective

a) VA: open lids manually if necessary. Pinhole because the habitual Rx may be wrong now

b) Pupils: afferent pupillary defect (APD) or anisocoria?

c) Extraocular eye movements

1) Any pain on eye movement?

2) Any restrictions, especially in upgaze?

3) If there is an upgaze restriction, do forced ductions with a cotton tipped applicator soaked in anesthetic if the globe is intact

a) No restriction indicates a superior rectus paresis

b) Restriction indicates a trapped inferior rectus secondary to a blow out fracture

d) Confrontation fields

e) Monocular color vision if optic nerve damage suspected

f ) External

1) Draw and document hemorrhage, ecchymosis, and edema. Many of these cases end up in court and drawings are more useful to lay people on juries

2) Look for ptosis and lid lacerations

3) Palpate the orbital rim for step-off fractures and lids for crepitus (crackling sound from trapped air)

4) Check for hypesthesia of the cheek and upper lip on the affected side compared to the unaffected side

5) Compare retropulsion of globes (push gently with thumbs) if you do not suspect a ruptured globe

g) Hertel exophthalmometry: should be £ 21 mm and equal

1) A receded globe may indicate a blow out fracture

2) A proptotic globe resistant to retropulsion may indicate a retrobulbar hemorrhage

h) Slit lamp

1) Cornea: abrasions, lacerations, or striae?

2) AC: hyphema, free red blood cells, inflammatory cell, pigment or flare?

3) Iris: any irregular pupil, anisocoria, iris hemorrhage, iridodialysis, sphincter tears or traumatic mydriasis? Compare angle depth between eyes to find angle recession

4) Lens: subluxation or traumatic cataract? (cataract may take weeks to form)

5) Pigment or RBC in anterior vitreous

i ) IOP: May be low in a traumatized eye. If very low, consider globe rupture. If high, treat with topical glaucoma meds

j ) Dilated fundus examination (DFE)

1) Disk pallor or hemorrhage? (pallor may take weeks to form in optic nerve damage)

2) Retinal hemorrhage or edema from bruising

3) Macular holes, choroidal rupture, or commotio retinae?

4) Vitreous hemorrhage or detachment?

5) Peripheral holes or tears? Do scleral indentation if feasible and no globe penetration or hyphema is present

k) Gonioscopy: defer for 2 weeks if RBC are present in the AC

3) Assessment

a) Identify the affected tissues

b) If there is decreased vision or color vision without corresponding visible tissue damage, consider traumatic optic neuropathy

c) If a retinal detachment cannot be ruled out due to a hyphema or vitreous hemorrhage, a B-scan ultrasound should be performed

4) Plan and follow up

a) Traumatic iritis: 1% cyclopentolate qid or 5% homatropine bid and Pred Forte qid, RTC in 2 days

b) Hyphema and micro hyphema

1) Strict bed rest with head elevated 30°

2) No aspirin or blood thinners

3) Atropine 1% qid

4) Pred Forte qid

5) No reading (too many saccadic eye movements)

6) TV is good

7) Treat elevated IOP if necessary

8) Use a shield on the affected eye

9) Consider bilateral patching to stop saccades

10) No strenuous activity or lifting for 2 – 4 weeks

11) Monitor vision at home and RTC in 1 – 2 days

a) Monitor fundus as it becomes visible

b) Do gonioscopy and scleral depression 2 – 4 weeks later

c) Commotio retinae: monitor weekly, repeat scleral depression

d) Choroidal rupture: retinal consult, then monitor weekly, then monthly for neovascular membrane formation

e) Orbital blow out, superior rectus paresis, crepitus, rim fracture, hypesthesia, exophthalmos resistant to retropulsion

1) Instruct not to blow nose

2) Immediately (STAT) CT

3) Referral to oculoplastics ophthalmologist, or ENT if CT is positive

4) Start broad-spectrum antibiotics and a nasal decongestant

f ) Traumatic optic neuropathy: STAT referral for CT and possible steroids and optic nerve sheath fenestration

g) Laceration, penetration, or rupture of globe or cornea: STAT referral to appropriate sub specialist, usually retina or cornea, depending on location of injury

Diagnosis and Management of Uveitis

A) Subjective: diagnose by the classic history

1) Acute iritis or uveitis causes a red painful photophobic eye

2) Ask, “Is it an itchy scratchy pain (cornea or external disease), or deep and achy (uveitis)?”

3) Acute uveitis pain is invariably deep and achy, usually intense and debilitating

4) The affected eye has a photophobic reaction when light is shone in the contralateral eye

5) Chronic smoldering uveitis may have no pain and a white eye

6) Juvenile uveitis is more likely to be severe and chronic

B) Objective

1) VA (corrected) and pinhole VA if necessary (grade II+ – IV+ cells may cause complaints of hazy vision)

2) Pupils: may be miotic from ciliary spasm. R/O APD

3) External: blepharospasm and deep conjunctival injection (red-purple color) and ciliary flush. Look for herpes simplex or zoster vesicles. Look for subtle sarcoid nodules in the lid margin and on the conjunctiva

4) Slit lamp: use a good slit lamp

a) Cornea

1) Epithelium: use stain to R/O any HSV dendrite or bacterial ulcer as a precipitating factor. Remember we will be using steroids

2) Stroma: clear and compact unless other problems

3) Endothelium: look for KPs

a) Draw: note

1) Number

2) Size

3) Distribution: (superior KPs usually are herpes simplex)

b) Type

1) Granulomatous (mutton fat) KPs

2) Non-granulomatous

3) Fine dusting: (too fine to see except in retroillumination)

c) Age (difficult judgment)

1) New: appears wet or cheesy

2) Old: dry, dusty, pigmented, involuted

b) AC reaction: qualify and quantify

1) Look for cell and flare before using any drops

2) Use brightest parallelepiped about the size of the pupil to find cell and flare. Back-scattered light from the iris will wash out view if the beam is too large

3) Look in front of black pupil, but search the entire chamber

4) Grade cell (looks like small white spheres), flare (looks like smoke or white lint), and pigment individually with a 1 mm2 spot beam directed from as far to side as possible

5) Iritis grading system: cell is diagnostic for follow up as the iritis resolves

a) Rare: 1 or less cell in 1 mm2 beam

b) Occasional: 3 cells in 1 mm2 beam

c) ½+: 5 cells in a 1 mm2 beam

d) I+: 10 cells in a 1 mm2 beam

e) II+: 20 cells in a 1 mm2 beam

f ) III+: 30 cells in a 1 mm2 beam

g) IV+: 40 cells in a 1 mm2 beam (driving through blizzard with headlights on)

6) Grade pigment and flare with the same scale

7) Is the aqueous plasmoid? Do the cells circulate or are they fixed? If plasmoid, the increased fibrin levels indicate a more severe iritis and cause an increased risk of synechiae. A plasmoid aqueous may also indicate ciliary body shut-down

8) Is there a hypopyon or individual red blood cells? Indicates human leukocyte antigens (HLA)-B27 or possibly Behcet’s or an endogenous endophthalmitis

9) Is the chamber deep, no peripheral anterior synechiae?

c) Iris

1) Look for posterior synechiae, but can’t tell for sure until dilate

2) Look for iris nodules (granulomatous)

3) Look for iris atrophy or color change (Fuch’s heterochromic iridocyclitis). Sector atrophy and transillumination defects are probably herpes simplex

d) Lens

1) Not diagnostic unless hypermature cataract causing inflammation, trauma, or posterior synechiae

2) If pseudophakic, R/O UGH (uveitis, glaucoma, hyphema)

5) IOP

1) Usually low: OK

2) If high: treat, avoid prostaglandins. Do not use optipranolol or pilocarpine. Do not do argon laser trabeculoplasty (ALT)

3) If dangerously high, consider Fuch’s or glaucomatocyclitic crisis (Posner-Schlossman)

a) IOP may be 40 – 60

b) Mild AC reaction

c) Mild, fine KPs on cornea or in trabecular meshwork

d) Start glaucoma meds and topical steroid

6) Dilated fundus examination: cycloplegia causes dramatic relief of pain. If necessary, do this earlier to facilitate other examination

a) Check for synechiae: break if present

1) Tropicamide 1% and 2.5% phenylephrine, wait ½ hr

2) Try Tropicamide 1% and 10% phenylephrine, wait ½ hr

3) Soak a pledget with Tropicamide 1% and 10% phenylephrine and insert under lower lid while looking up with topical anesthesia for 5 – 10 min if necessary. Alternatively, use 5 doses of 10% phenylephrine 5 min apart. Punctal occlude and monitor BP and pulse for systemic reaction, especially if cardiac risk factors

4) Many will break later at home

b) Do DFE if feasible, R/O rare but dangerous problems that require a STAT retina consult. If photophobia is too intense, do it at the next visit

1) Intermediate uveitis: cells in anterior vitreous, unknown origin, may spill over into or from the AC. Consult

2) Pars planitis: the most missed diagnosis. You must scleral depress at least inferiorly. Look for snowballs/snowbanks especially at inferior equator. Often indicates Lyme disease. Retina consult

3) Histo or toxo scars: inspect closely for fluffy lesions at the edge of an old scar. Consult (STAT if near macula)

4) Look for exudation from vessels or disk. STAT consult

5) Look for cystoid macular edema (CME), especially if VA is down. Retinal inflammation can cause epiretinal membranes after time. Retina consult

6) Look for an exudative choroiditis or acute retinal necrosis. STAT consult

C) Assessment: these conditions are easier to treat

1) Subclinical iritis: mild to moderate classic Sx, but no objective signs

2) Anterior uveitis or iritis vs. intermediate uveitis vs. pars planitis vs. pan uveitis

a) 95% of uveitis is anterior

b) Intermediate uveitis: inflammation affecting the ciliary body, vitreous, and peripheral retina

c) Pars planitis is a subset of intermediate uveitis characterized by inflammation at the pars plana

3) Unilateral vs. bilateral: bilaterality indicates a systemic cause that will need a laboratory workup. Expect the uveitis to be harder to treat

4) Initial or recurrent? (3rd or greater occurrence) 50% of recurrent uveitis has a systemic cause

5) Idiopathic (50%) vs. systemic cause

D) Plan

1) Cycloplegia

a) 1 drop of atropine in office

1) Use only if a low risk of synechiae such as in traumatic or post surgical iritis

2) With any other iritis it may get much worse before you get it under control. Avoid synechiae in an 8 mm pupil. They are usually not breakable

3) Lasts about 1 week: inexpensive

b) 1 drop of 5% homatropine in office: only if low risk of synechiae, lasts 1 – 3 days

1) Subclinical iritis

2) Traumatic iritis

3) Post-surgical iritis

4) Staph marginal infiltrates causing ciliary spasm or AC reaction

5) Post foreign body removal ciliary spasm or AC reaction

c) Cyclopentolate 1% bid – tid for all other uveitis: preferred, mobility prevents synechiae. Pharmacy may not carry; dose in-office to start

d) Tropicamide 1% tid also OK

2) Steroid: Pred Forte is preferred. Inflamase Forte has a better, inexpensive generic and patients do not have to remember to shake. Use only Pred Forte for III+ or greater iritis. This is an initial dosing plan. The most common mistake is under-treatment. Dark irides need more steroids

a) Grade occasional cell, or traumatic, or subclinical iritis: Rx qid

b) Grade I+ – II+ cell: Rx q2h (waking)

c) Grade III cell: Rx q1h

d) Grade IV cell and plasmoid aqueous: q30 min. Consider adding FML or Tobradex ung hs

e) Granulomatous: consider sending out for a conjunctival biopsy before using steroids

1) Ocular sarcoidosis affects only the eye, blood tests will not detect unless lung involvement

2) Later, if the treatment is not working and you are trying to R/O ocular sarcoid, a biopsy will not help because topical steroids will have melted the sarcoid nodules

3) RTC in 2 days, nothing will change sooner for up to grade III cell. RTC in 1 day for grade IV cell or plasmoid aqueous

E) 2 day follow up

1) Subjective: ask how much improvement of symptoms in percentage. Expect about 50% from cycloplegia, even if AC is no better

2) Objective: VA, IOP, slit lamp. Do DFE if not done yet

3) Assessment/Plan: is it improving?

a) Improving: continue cycloplegia and steroid according to the above guidelines. RTC in 2 days

b) Unchanged: increase meds 1 step. RTC in 2 days

c) Worse: repeat DFE, increase to max meds. RTC in 1 day

d) If still synechiae, repeat pledget, monitor BP

F) Continuing follow up

1) Long term steroid can cause IOP rise (usually after 3 – 8 weeks) and posterior subcapsular cataracts, but there is no alternative here. Watch for side effects and treat as needed

2) If still worsening, still grade IV+, hypopyon, or any posterior chamber involvement: get consult urgently

3) If unchanged (and does not meet criterion in F2) with controllable IOP, do uveitis questionnaire (see end of chapter) and lab testing (section J below). Sit tight for 2 weeks at max topical meds. Then consider consultation and oral prednisone or Kenalog injection

4) If improving

a) Continue Pred dosing until only rare or occasional cells in AC

b) Simple, acute iritis that responds quickly: taper with 2 day steps

1) Example taper steps: q30 min, q1h, q2h, qid, tid, bid, qd

c) Chronic, recurrent, systemic, slow responding cases need 1 week – 1 month steps

d) Be prepared to medicate for months in stubborn cases but do not under medicate. Always monitor IOP and watch for CME

e) A damaged blood aqueous barrier in the ciliary body can leak protein flare permanently. Only treat cell

f ) Long standing trace cell can eventually cause CME

g) Lotemax can be substituted if necessary for steroid responders after you achieve control. Increase Lotemax dosage 1 level if substituted for Pred Forte. Using the same dosage counts as a taper step because Lotemax is less potent

5) Get a consult if indicated

6) Fuch’s heterochromic iridocyclitis etiology may be viral. Steroids are of limited help. Refer

7) Use topical Acular and Pred Forte with Indocin 25 mg tid po (or ibuprofen 600 mg tid po) for CME. Discontinue topical epinephrine, Propine, Xalatan, which can cause CME

8) Bilateral scleritis is a very serious problem: REFER!

G) Kenalog injections: for powerful long term control with few systemic side effects

1) Used for

a) Any anterior uveitis that cannot be controlled topically

b) Any posterior uveitis

2) 10 – 40 mg injected sub-tenon superior and/or inferior

3) Lasts about 2 months. You can see the off-white cheesy deposits under the conjunctiva

4) Can also be injected retrobulbar with the same effectiveness. Less discomfort? Most ophthalmologists are more familiar with doing this procedure

5) Monitor IOP for several months; if severe steroid response, the deposit may need to be excised or a trabeculectomy performed. ⅓ have an IOP rise

H) Oral prednisolone: (10 – 60 mg) alternative to Kenalog; do not want to use for a chronic iritis with systemic cause because of systemic side effects

1) Be sure no diabetes. Monitor glucose weekly

2) If diabetic, monitor glucose daily and only with an internist’s help

3) Be sure no stomach ulcer Hx

4) Taper orals first, then topicals

I) Methotrexate and cyclosporine: antimetabolites used for chemotherapy. Low doses are used for chronic uveitis and other connective tissue disorders

1) Only used by uveitis expert or in conjunction with an experienced internist

2) Can be very effective in reducing the need for steroid or in getting recalcitrant, chronic cases under control

3) Good for rheumatoid and juvenile rheumatoid arthritis-related uveitis

J) Laboratory testing for uveitis/iritis: iritis is often a sign and symptom of systemic disease

1) Consider laboratory investigation when

a) Third or greater occurrence

b) Bilateral

c) Granulomatous (larger, white KPs)

d) Slow resolving (>6 weeks) or flaring iritis

e) Significant positive uveitis questionnaire results (see end of chapter)

f ) Posterior or intermediate uveitis (also order a retina/uveitis consult)

2) Sources of privileges

a) Local hospital

b) Local for profit lab

c) Local friendly medical doctor

3) Write out requested tests with diagnosis on your Rx pad and send with the patient

4) If no privileges are possible, phone the patient’s medical doctor, give the differential diagnosis and what you need to R/O and the indicated lab tests. Do not insult him/her, but some tests are better for our purposes than others

5) Order lab tests to R/O systemic conditions. Refer to an internist as necessary for systemic treatment. Expect slow resolution and recurrences if a systemic factor identified. Use 1 week – 1 month per step taper

6) A basic limited screen recommended for all uveitis patients

a) Complete blood count (CBC) with platelet and differential: good overall health screening. Normals are listed on the lab report

1) A high platelet count with chronic bilateral uveitis indicates a lymphoma

2) A high white blood cell count indicates a systemic infection

b) Westergren erythrocyte sedimentation rate (sed rate): non-specific, indicates systemic inflammation, infection, malignancy, or collagen vascular disorder versus local inflammation (i.e., idiopathic uveitis). Maximum normal values for males are age ¸2. For females (age +10)¸2

c) Fluorescent treponemal antibody absorption (FTA-ABS): best syphilis test. You are not assuming anything about the patient’s personal life. It is just another indicated test

d) HLA-B27 antibody test

1) Recurrent non-granulomatous iritis with episodes of complete resolution in an otherwise healthy eye, and hyperacute iritis, are likely to be caused by HLA-B27

2) A positive result explains the uveitis and changes your management by warning you to treat vigorously, taper slowly and expect recurrences

3) It also indicates an inherited, non-specific predisposition to

a) Uveitis

b) Ankylosing spondylitis (lower back stiffness)

c) Arthritis and juvenile rheumatoid arthritis

d) Inflammatory bowel and Crohn’s disease

e) Psoriatic arthritis, psoriasis

f ) Other collagen vascular disorders

e) Angiotensin converting enzyme (ACE): indicates pulmonary sarcoid only. Sarcoid is the leading cause of granulomatous iritis, especially in blacks and females

f ) Serum lysozyme: indicates non-pulmonary sarcoid. Localized inflammatory nodules can be found anywhere, including the uvea and conjunctiva; especially associated with granulomatous iritis, blacks, and females

g) Antinuclear antibody (ANA): an autoimmune collagen vascular screen

1) A positive result in a child probably indicates juvenile rheumatoid arthritis

2) In an adult it probably indicates systemic lupus erythematosus

h) Chest x-ray: to R/O pulmonary tuberculosis (TB) and sarcoid (ask about a persistent cough)

1) Pulmonary TB lesions are necessary to cause uveitis

2) Pulmonary sarcoid lesions are not necessary to cause uveitis

3) Purified protein derivative (PPD) with anergy panel will test positive if there has ever been TB exposure, but if there are no lung lesions, it is not the cause of the uveitis

4) TB usually causes granulomatous KPs, but it may be difficult to determine

7) Expand the laboratory search based on uveitis questionnaire (see end of chapter) and exam findings

a) Rheumatoid factor: rheumatoid arthritis is usually diagnosed long before it causes iritis. Order if

1) Bad arthritis

2) Scleritis

3) Peripheral corneal thinning diseases. Also order anti-neutrophil cytoplasmic antibody (ANCA) test

b) Conjunctival biopsy of nodules in recurrent granulomatous iritis: the only way to prove purely ocular sarcoid. Recommended for all granulomatous iritis, especially in blacks and females. Must be done before any systemic steroid use

c) HLA-B5, another rare marker for a predisposition to iritis

d) Behcet’s skin puncture test: R/O Behcet’s disease if Japanese or Mediterranean descent, hypopyon, retinal vasculitis, or bilateral with a history of mouth and urogenital sores. Get retina and internal medicine consults for this

e) Crohn’s or inflammatory bowel disease — recurrent diarrhea: no easy lab test, 10 – 20% have + HLA-B27, refer to family medical doctor or GI specialist for GI workup to R/O inflammatory bowel or Crohn’s disease. You can manage the iritis conventionally

f ) Lyme titer and erythrocyte sedimentation rate (sed rate) and enzyme linked immuno absorbent assay (ELISA): if a history of a tick bite, fever, or rashes. Also order if pars planitis is present

g) MRI of brain and orbits with thin sections through orbits to R/O demyelination from multiple sclerosis (MS): consider in females with paresthesia and a Hx of retrobulbar neuritis

h) Juvenile rheumatoid arthritis: ANA and HLA-B8

i ) Reiter’s syndrome: mostly a clinical diagnosis by an internist. Urethritis and uveitis followed by arthritis. May feature elevated HLA-B27 and various infectious diseases

j ) Tubulointerstitial nephritis and uveitis syndrome (TINU): an autoimmune disease causing kidney disease and usually bilateral, non-granulomatous anterior uveitis. The uveitis responds well to steroid therapy, though it may be recurrent or chronic. Order blood urea nitrogen (BUN), serum creatinine levels, sed rate, and urinalysis. Manage with a nephrologist

8) Iritis/uveitis syndromes that you should refer to a uveitis or retina specialist and the tests they may order

a) Retinal vasculitis with oral or genital ulcers: HLA-B5,
HLA-B57, HLA-B27 to R/O Behcet’s (retina consult)

b) Chorio-retinitis (if active, get a STAT retina consult): anti-toxoplasma, IgG, IgM to R/O toxo or histoplasmosis

c) Retinal vasculitis and subacute sinus problems: ANCA test, chest x-ray, sinus CT, R/O Wegener’s granulomatosis (retina consult)

d) Choroiditis, exudative retinal detachment, tinnitus: fluorescein angiogram (FANG), audio testing, lumbar puncture, MRI, to R/O Harada’s disease

e) Vitritis in elderly female: vitreous biopsy to R/O lymphoma or infection

f ) Multifocal choroiditis of posterior pole in middle age males: HLA-A29 to R/O birdshot choroiditis

9) All of these tests are interpreted for you. The report will show the normal range and indicate your results. Abnormal results will be flagged

10) If history and exam results do not help focus your lab search, and the case meets criteria for further investigation, order a “shotgun panel”

Uveitis Questionnaire

Used with permission of F. Mitchel Opremcak, MD, The Ohio State University, Department of Ophthalmology

Family History

These questions refer to your grandparents, parents, aunts, uncles, brothers, sisters, children or grandchildren.

Has anyone in your family ever had

Tuberculosis                                                                        yes no

Syphilis                                                                               yes no

Arthritis or rheumatism                                                         yes no

Diabetes                                                                             yes no

Allergies                                                                              yes no

Gout                                                                                   yes no

Has anyone in your family had medical problems of the

Eyes                                                                                   yes no

Skin                                                                                    yes no

Kidneys                                                                              yes no

Lungs                                                                                 yes no

Intestines                                                                            yes no

Brain                                                                                   yes no

Social History

Have you lived out of the U.S.A.?                                         yes no

            Where?

Have you lived in other states?                                             yes no

            Where?

Is your job harmful to your eyes?                                          yes no

            How?

Have you ever owned a puppy?                                             yes no

Have you ever owned a cat?                                                 yes no

Have you ever eaten raw meat or hamburger?                        yes no

Do you drink untreated stream, well or lake water?                  yes no

Have you ever been exposed to sick animals?                       yes no

Do you smoke cigarettes?                                                    yes no

Have you ever used IV drugs?                                              yes no

Have you ever had bisexual or homosexual relationships?       yes no

Have you ever taken birth control pills?                                  yes no

Personal Medical History

Have you ever had the following diseases?

Anemia                                                                               yes no

Cancer                                                                                yes no

Diabetes                                                                             yes no

Hepatitis                                                                             yes no

High BP                                                                              yes no

Pleurisy                                                                              yes no

Pneumonia                                                                          yes no

Ulcers                                                                                 yes no

Herpes                                                                                yes no

Chicken pox                                                                        yes no

Shingles or Zoster                                                                yes no

German measles or Rubella                                                  yes no

Mumps                                                                               yes no

Chlamydia or Trachoma                                                        yes no

Syphilis                                                                               yes no

Gonorrhea                                                                           yes no

Tuberculosis (TB)                                                                yes no

Leprosy                                                                               yes no

Leptospirosis                                                                       yes no

Histoplasmosis                                                                    yes no

Candida or Moniliasis fungal infection                                    yes no

Coccidiomycosis                                                                 yes no

Sporotrichosis                                                                     yes no

Cryptococcal infection                                                          yes no

Toxoplasmosis                                                                    yes no

Amoeba infection                                                                 yes no

Giardiasis                                                                            yes no

Toxocariasis                                                                        yes no

Cysticercosis                                                                      yes no

Trichinosis                                                                          yes no

Whipple’s disease                                                                yes no

Hay fever                                                                            yes no

Allergies                                                                              yes no

Pemphigoid                                                                         yes no

Vasculitis               �