ANTERIOR SEGMENT DISORDERS
| DIAGNOSIS AND MANAGEMENT OF ANTERIOR UVEITIS —Allan R. Rutzen, MD, Associate Professor of
Ophthalmology and Visual Sciences, University of Maryland School of Medicine, Baltimore
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| Introduction: anterior uveitis more common than posterior uveitis; cells in anterior chamber of eye first sign (not
associated with vision loss); long-term sequelae include glaucoma, cataract formation, and macular edema (all
associated with vision loss)
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| Diagnosis: systemic conditions (eg, syphilis, ankylosing spondylitis, juvenile rheumatoid arthritis, multiple sclerosis
[MS], and sarcoidosis) can present with ocular manifestations that precede systemic manifestations; ocular
findings sometimes diagnostic feature of certain diseases (eg, Reiter syndrome, Behçet’s syndrome, Vogt-Koyanagi-Harada
[VKH] syndrome) and can help establish diagnosis
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 | Medical history: makes diagnosis in 90% of cases; consider patient’s demographics, acute presentation or chronic
condition, uni- or bilateral inflammation, associated systemic symptoms, and response to previous therapy; consider
using uveitis questionnaire to obtain information about patient’s medical history
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| Physical examination: examine patient in full light to determine whether corporeal features present that may aid in
diagnosis (eg, characteristic posture of ankylosing spondylitis, hand manifestations of rheumatoid arthritis); examine
patient’s skin and joints; consider limited neurologic examination in patients suspected of Behçet’s syndrome
or MS
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| Distinguishing forms: non-granulomatous—characterized by small or fine keratic precipitates (KP); features not
helpful diagnostically in some patients (eg, if mild inflammation present); indicative of HLA-B27–linked disorders,
Fuchs heterochromic iridocyclitis, and juvenile rheumatoid arthritis (JRA); granulomatous form—
characterized by large, greasy KP, iris nodules, and choroidal granulomas; indicative of sarcoidosis, tuberculosis
(TB), toxoplasmosis, and VKH syndrome
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| Considerations: infectious vs inflammatory causes; consider masquerade syndromes and potential for malignancy;
work-up—obtain targeted diagnostic work-up to establish specific diagnosis if possible
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| Other associated diseases: syphilis—recommend testing in patients with anterior uveitis because disease easily
treatable, but outcome poor if untreated; use fluorescent treponemal antibody (FTA) absorption test or microhemagglutination
assay (MHA) for Treponema pallidum (highly sensitive and specific tests; moderate cost and low
risk); Lyme disease—transmitted through infected deer tick; somewhat common along East coast of United
States; fairly easy to treat; low risk associated with test; low incidence in Western states and low diagnostic yield
for testing in these areas; consider likelihood of positive test when deciding whether to test; tuberculosis (TB)—
Centers for Disease Control and Prevention (CDC) geographic distribution of data on TB case rates shows prevalence
according to state; consider prevalence when deciding whether to test for TB using purified protein derivative
(PPD; tuberculin) skin test; if ordering PPD skin test, also consider performing skin tests for other
antigens, eg, mumps, candida, tetanus; placement of several antigens in skin test can help to show anergy or failure
to respond to skin test, which may support diagnosis of sarcoidosis; test patients at high risk for exposure
(eg, health care professionals); PPD test associated with low risk and low cost; also useful if contemplating use
of immunosuppressive agents
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| Radiologic tests: also helpful in making diagnosis; hilar adenopathy seen on chest x-ray indicative of sarcoidosis;
chest x-ray diagnostic tool in cases of suspected TB; gallium scan used to evaluate patient for sarcoidosis; spinal or
sacroiliac x-ray used in cases of suspected ankylosing spondylitis
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| Steroids: mainstay of treatment; begin with ocular steroid drops; prednisolone most effective agent; potency of
steroid associated with greater increase in intraocular pressure (IOP); site-active corticosteroids, eg, loteprednol
and rimexolone, less likely to increase IOP, but also less effective in controlling uveitis; considerations—
treatment should focus on eliminating inflammation; recommend aggressive treatment to control (and maintain
control of) inflammation; initial therapy—prednisolone 1% every hour; consider dilating drops in patients
at risk for development of posterior synechiae; begin tapering drug therapy when cells ≤1+; posterior synechiae
formation—consider breaking up synechiae (fresh and not firmly adherent) in patients with first episode of
uveitis; can use pledget with dilators to break synechiae
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| Periocular steroids: consider if topical steroids insufficient in patient with unilateral uveitis; may use subconjunctival
or subtenon injections; consider subtenon injections in cases with posterior segment involvement or if macular
edema present
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| Systemic agents: eg, oral steroids; consider in patient unresponsive to topical steroids, with posterior segment involvement,
or systemic involvement; consider immunosuppressive agent if inflammation persists >4 wk
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| Antimicrobial agents: use intravenous (IV) penicillin for syphilis; consider doxycycline or amoxicillin in Lyme disease;
treat TB with anti-TB agents; use intraocular antibiotics and capsulectomy in patients with post-cataract–
surgery inflammation
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| Steroid delivery implant: fluocinolone acetonide intravitreal implant (Retisert) associated with long duration of effect,
but significant cost; also associated with risk for development of cataracts and glaucoma
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| CHRONIC CONJUNCTIVITIS —Todd P. Margolis, MD, PhD, Professor of Ophthalmology and Director, Francis I.
Proctor Foundation for Research in Ophthalmology, University of California, San Francisco, School of Medicine
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| Diagnosis: medical history—ask about use of contact lenses, history of itching or rubbing (allergies), use of eye drops or
washes, new personal care products, sexually transmitted diseases, and presence of pets, eg, kittens, birds; physical
examination—look for presence of follicles; determine type and quality of papillary reaction and type of staining pattern;
look for punctal plugs and conjunctival scarring
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| Chronic follicles: consider medication toxicity, staphyloccocus-associated immune reaction, molluscum contagiosum,
and chlamydia; look at superior tarsal conjunctiva and flip eyelid when looking for follicles (useful for diagnosis)
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| Papillary reaction: note presence of fine velvety reaction and pale white reaction; look for giant papillary conjunctivitis
(GPC) of classic or cobblestone appearance; degree of papillary reaction unimportant diagnostically (quality
important); fine velvety papillae indicate rubbing; pale white papillae indicative of allergic reaction;
cobblestone GPC characteristic of allergy or atopic disease; classic GPC tends toward smaller size and can produce
scarring on apices; focal GPC caused by irritation from foreign body
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| Conjunctival scarring: look for subconjunctival fibrosis, shortening of fornix, blepharon formation, and entropion
with trichiasis; consider postsurgical scarring, postviral conjunctivitis, atopic disease, and ocular cicatricial pemphigoid
(OCP)
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| Eyelids: examine lids for evidence of blepharitis, molluscum, trichiasis, and exposure (commonly missed)
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| Nasolacrimal system: examine for punctal plugs and dacryocystitis
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| Staining tests: rose bengal/lissamine green—helpful evaluation tool; helps identify exposure, medication toxicity,
trauma, immune-mediated disease, and keratinization (superior limbic keratoconjunctivitis [SLK] and OCP); superior
bulbar—evaluate for SLK and retained foreign body; diffuse—pattern indicative of medication or contact
lens solution toxicity, overwear of contact lenses, or molluscum contagiosum; inferior corneal—results from staphyloccocus-mediated
immune reaction, incomplete blink, nocturnal lagophthalmos, or inferior exposure; inferior/nasal
—allows evaluation for medication toxicity, trauma, and (rarely) redundant conjunctiva; nasal
bulbar—usually due to trauma (punctal plugs, fingers, tissues, or eye-dropper tips)
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| Testing: microbiologic studies—use chocolate agar plate; moisten swab for microbial cultures; avoid calcium alginate
swab and rose bengal/lissamine green staining if considering polymerase chain reaction (PCR) testing;
cytology—consider Giemsa stain for eosinophils and direct fluorescent antibody (DFA) test for chlamydia, and look
at Giemsa stain for evidence of malignant transformation
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| Management: discontinue all medications; remove punctal plugs; discontinue contact lens use; epilate lashes;
avoid trauma-inducing tools (eg, fingers, facial tissue); use directed therapy based on examination and testing
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| CAN FUNGAL KERATITIS BE PREVENTED? —John P. Whitcher, MD, MPH, Clinical Professor of Ophthalmology,
Francis I. Proctor Foundation for Research in Ophthalmology, University of California, San Francisco, School
of Medicine
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| Corneal ulceration: World Health Organization (WHO) study—found 6 million new corneal ulcers occur each year
in 10 Southeast Asian countries (grouped near India) with combined population of 1.6 billion; corneal abrasion
main risk factor; treatment often ineffective; in these countries, corneal ulceration results in blindness (often from
eye perforation) in 25% of patients and visual disability (from corneal scarring) in 75% of patients; cases often unreported
(“silent epidemic” in developing world); WHO recommended series of studies to look at efficacy of village-level
prevention of corneal ulceration using Bhaktapur eye study model; Bhaktapur eye study—442 patients
with corneal abrasions; all patients treated with chloramphenicol ointment 1% (most widely used eye antibiotic in
world, except for Europe and United States) tid for 3 days; 96% of abrasions healed without sequelae; however, 18
breakthrough ulcers (culture-positive for bacteria); no fungal ulcers found in breakthrough group, despite previous
study in Nepal showing 20% of corneal ulcers caused by fungus (fungal keratitis responsible for 20%-66% of corneal
ulcers in many developing countries)
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| Prevention of corneal ulcers in Bhutan, India: study followed 55 villages with combined population of 10,000
for 18 mo; 115 patients with corneal abrasions treated with chloramphenicol ointment 1% tid for 3 days; all patients
healed without sequelae; in 2 districts in study area (Paro and Punakha), no corneal ulcers reported during
study period, but incidence of corneal ulcers held constant at 340 per 100,000 annually in 3 surrounding districts;
study concluded that village-level methods effective in preventing corneal ulcers in this population
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| Prevention of corneal ulcers in Myanmar (formerly Burma): study followed 3 villages with combined population
of 17,000 for 1 yr; 126 patients with corneal abrasion given chloramphenicol ointment 1% tid for 3 days
and clotrimazole ointment 1% tid for 3 days; no patient treated with study regimen developed corneal ulcer; study
treatments effective in preventing fungal corneal ulceration in this population
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| Prevention of corneal ulcers in South India: study followed combined population of 48,000 for 18 mo; 374
patients with corneal abrasions randomized to receive either chlorampenicol ointment 1% and clotrimazole
ointment 1% tid for 3 days, or chlorampenicol ointment 1% and placebo ointment tid for 3 days; previous study
found incidence of corneal ulcers 113 per 100,000 in this region; 368 or 98.5% of abrasions healed without
complications
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| Prevention of fungal keratitis: 4 separate studies show prevention of fungal keratitis can occur in developing
countries at village level; most cost-effective medication currently unknown; studies suggest antifungal prophylaxis
unnecessary to prevent fungal ulceration; antibiotics alone probably effective
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Educational Objectives
| The goal of this activity is to obtain a greater understanding of anterior uveitis, chronic conjunctivitis, and fungal
keratitis. After hearing and assimilating this program, the clinician will be better able to:
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| 1. Discuss the diagnosis of anterior uveitis.
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| 2. Describe the management of anterior uveitis.
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| 3. Evaluate a patient for chronic conjunctivitis.
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| 4. Manage a patient with chronic conjunctivitis.
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| 5. Describe methods to prevent fungal keratitis.
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Suggested Reading
Biswas J et al: Efficacy and safety of 1% rimexolone versus 1% prednisolone acetate in the treatment of anterior
uveitis--a randomized triple masked study. Int Ophthalmol 25:147, 2004; Butrus S et al: Ocular allergy: diagnosis
and treatment. Ophthalmol Clin North Am 18:485, 2005; Chang JH et al: Ocular cicatricial pemphigoid: manifestations
and management. Curr Allergy Asthma Rep 5:333, 2005; Curi A et al: Acute anterior uveitis. Clin Evid 14:739,
2005; Gritz DC et al: Topical issues in the treatment of bacterial keratitis. Int Ophthalmol Clin 38:107, 1998; Leonardi
A: In-vivo diagnostic measurements of ocular inflammation. Curr Opin Allergy Clin Immunol 5:464, 2005;
Ono SJ et al: Allergic conjunctivitis: update on pathophysiology and prospects for future treatment. J Allergy Clin
Immunol 115:118, 2005; Whitcher JP et al: Prevention of corneal ulceration in the developing world. Int Ophthalmol
Clin 42:71, 2002.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue there
is nothing to report.
Drs. Margolis and Whitcher were recorded December 1-2, 2006, in San Francisco, CA, at Ophthalmology 2007: Takes
and Outtakes, sponsored by the University of California, San Francisco, School of Medicine. Dr. Rutzen was recorded
September 15-17, 2006, in Cambridge, MA, at What’s New in Anterior Segment Disorders, the First Annual Ocular Immunology
and Uveitis Foundation Physician Education Conference, sponsored by the Ocular Immunology and Uveitis
Foundation at the Massachusetts Eye Research and Surgery Institute. The Audio-Digest Foundation thanks the
speakers and the sponsors for their cooperation in the production of this program.
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