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Uveitis - Management
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How do I manage a person with suspected uveitis in primary care?
- Refer people with suspected uveitis (new presentations and recurrent) for assessment within 24 hours by an ophthalmologist.
- This includes people who have had uveitis before and feel the symptoms coming on before the signs are present.
- Do not initiate treatment for recurrent uveitis in primary care, unless asked to do so by an ophthalmologist.
Treatment in secondary care
- Non-infectious uveitis
- Corticosteroids are used to reduce inflammation and prevent adhesions in the eye. They may be given topically, orally, intravenously, intramuscularly, or by periocular or intraocular injection, depending on how severe the uveitis is [Gupta and Murray, 2006]. Corticosteroids are tapered slowly (over weeks) because withdrawing them too quickly may lead to rebound inflammation [Gupta and Murray, 2006].
- A cycloplegic-mydriatic drug (for example cyclopentolate 1% or atropine 1%) is also given to paralyse the ciliary body. This relieves pain and prevents adhesions between the iris and lens [Khaw et al, 2004].
- Infectious uveitis
- Infectious uveitis (bacterial, viral, fungal, or parasitic) is treated with an appropriate antimicrobial drug as well as corticosteroids and cycloplegics [Durand, 2005].
- People with severe or chronic uveitis may also be given systemic (non-corticosteroid) immunosuppressive drugs, laser phototherapy, or cryotherapy, or have the vitreous removed surgically (vitrectomy) [Merck, 2008].
Basis for recommendation
Referral is recommended because:
- Uveitis cannot be diagnosed without slit-lamp examination.
- Uveitis usually resolves quickly with treatment; however, if it is not treated or is inadequately treated, it may result in profound and irreversible vision loss [Gupta and Murray, 2006; Merck, 2008].
- Treatment with corticosteroids should not be prescribed before the diagnosis has been confirmed by slit-lamp examination. If the person has herpes simplex virus infection corticosteroids can transform a simple herpetic dendritic ulcer into an extensive amoeboid ulcer involving all layers of the cornea, with resultant corneal scarring and visual loss [Frith et al, 2001].
How do I manage someone with recurrent or chronic uveitis in primary care?
- Refer people with recurrent or chronic uveitis to an ophthalmologist for each episode, to confirm the diagnosis and treatment.
- Do not initiate treatment, unless asked to do so by an ophthalmologist.
- Uveitis should be managed by an ophthalmologist; however, primary healthcare professionals:
- May be asked to monitor the person for adverse effects of long-term oral corticosteroids (continuous or repeated courses).
- May be asked to monitor the use of disease-modifying antirheumatic drugs (DMARDs) or immunosuppressants, depending on locally-agreed shared care guidelines. For more information, see the CKS topic on DMARDs.
- Should ensure that people receiving repeat prescriptions of topical corticosteroids are under the care of an ophthalmologist (to monitor for steroid-induced glaucoma).
Managing the adverse effects of systemic corticosteroids
- Adverse effects of systemic corticosteroids include:
- Gastrointestinal toxicity: consider prescribing gastrointestinal protection. Peptic ulceration with perforation and haemorrhage, dyspepsia, abdominal distention, and oesophageal ulceration have been reported.
- Osteoporosis: see the CKS topic on Osteoporosis - preventing steroid-induced for details on when to prescribe prophylactic bisphosphonate therapy.
- Blood pressure: monitor annually and treat if necessary. See the CKS topic on Hypertension - not diabetic for more information.
- Diabetes mellitus: screen every 6–12 months and treat if necessary. See the CKS topic on Diabetes type 2 for more information.
- Glaucoma: screening is usually conducted within 3 months of starting corticosteroids and annually thereafter.
- Adrenal insufficiency: gradually taper (reduce) the dose after prolonged systemic corticosteroid treatment to prevent potentially fatal acute adrenal insufficiency.
- Immunosuppression: document the person's history of chickenpox or measles. Advise those without a history of chickenpox or measles who are taking systemic prednisolone to avoid close contact with people who have chickenpox, shingles, or measles and to seek urgent medical advice if they are exposed.
- Psychiatric effects (such as mood changes, depression, suicidal thoughts, or feeling high) can occur within a few days or weeks after the start of treatment in up to 5–6% of people. Seek specialist advice if psychiatric adverse effects occur. Most people recover from these reactions after dose reduction or withdrawal, although specific treatment might be necessary.
Basis for recommendation
Referral is recommended because:
- Uveitis cannot be diagnosed without slit-lamp examination.
- Uveitis usually resolves quickly with treatment; however, if it is not treated or is inadequately treated, it may result in profound and irreversible vision loss [Gupta and Murray, 2006; Merck, 2008].
- Treatment with corticosteroids should not be prescribed before the diagnosis has been confirmed by slit-lamp examination. If the person has herpes simplex virus infection corticosteroids can transform a simple herpetic dendritic ulcer into an extensive amoeboid ulcer involving all layers of the cornea, with resultant corneal scarring and visual loss [Frith et al, 2001].
Managing the adverse effects of systemic corticosteroids
- These recommendations are based on published information from manufacturers [ABPI Medicines Compendium, 2009], best medical practice, and advice issued by the Medicines and Healthcare products Regulatory Agency [MHRA, 2007a; MHRA, 2007b].
- The risk and severity of adverse effects with oral corticosteroids increase with the dose and the duration of treatment.
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