Anterior Uveitis Treatment Concerns and Implications

Educational Objectives

The goal of this program is to improve diagnosis and management of anterior uveitis. After hearing and assimilating this program, the clinician will be better able to:

1. Identify the most common cause of noninfectious anterior uveitis.

Summary

Patient case: 18-yr-old man presented 2 wk after sudden onset of redness, blurring, and irritation in left eye; patient reported occasional low back pain; vision and eye pressure within normal limits; posterior examination normal; acute posterior synechiae noted; differential diagnosis includes idiopathic, HLA-B27, juvenile idiopathic arthritis (JIA), infection, and sarcoidosis; noninfectious etiology suspected; treated with 1 g methylprednisolone (Depo-Medrol, Medrol, Solu-Medrol) and mixture of atropine, epinephrine, and 4% cocaine to break posterior synechiae; patient improved over next 2 wk; test for HLA-B27 positive

Anterior uveitis: consequences include significant vision loss, medication-associated comorbidities, increased health care costs, decreased quality of life, lost productivity, and emotional distress; anterior is most common type of uveitis (estimated 70%-90% of cases); requires aggressive treatment; may be associated with other ocular and systemic problems

Posterior synechiae: major problem in anterior uveitis; cataract surgery in these patients difficult; precludes use of femtosecond laser for cataract extraction; pupillary irregularities remain after surgical manipulation of iris; aggressive postcataract inflammation occurs and challenging to manage; patients at risk for hypotony; scarring can disrupt aqueous outflow and lead to glaucoma; breaking posterior synechiae can resolve glaucoma without additional therapy; however, chronic synechiae do not respond to acute medical therapy (surgical excision required)

HLA-B27: most common cause of noninfectious anterior uveitis (30%-50% of cases); 8% to 10% of white population has this genotype; only 1% of population positive for HLA-B27 develops uveitis; some patients with HLA-B27 genotype present with mild asymptomatic anterior segment flare but progress to severe inflammation in 1 to 2 wk; this delayed severity not understood; unique to individuals with HLA-B27; possibly avoided by treating mild flare aggressively

Other eye manifestations of anterior uveitis: scleritis; retinal vasculitis; corneal involvement; optic nerve inflammation, vitritis; papillitis; macular edema; glaucoma; cataract; these complications typical in patients positive for HLA-B27; study found 88% of eyes with cystoid macular edema have peripheral leakage (indicating active disease)

Monotherapy vs multitherapy: some patients do not respond to monotherapy; medications having different mechanisms of action can be combined; case example — woman with JIA-induced anterior uveitis had complete resolution of symptoms after treatment with combination of azathioprine, cyclosporine, and celecoxib (Celebrex)

New treatments: iontophoresis (electrochemical delivery of medications into eye); aldehyde trap (delivers nonsteroidal anti-inflammatory medications to eye; shows promise for allergic conjunctivitis, dry eye, and noninfectious anterior uveitis); innovations aimed at reducing dependence on steroids; although iontophoresis used for steroid treatment, it also aids delivery of medication in patients who find use of eyedrops difficult; cataract and glaucoma surgery common in these (usually young) patients; consider diagnostic and therapeutic anterior chamber paracentesis, especially when patient not responding to treatment

Readings

Gonzales JA et al: Combination nivolumab- and cabiralizumab-associated acute bilateral anterior and posterior scleritis and anterior uveitis. Am J Ophthalmol Case Rep 2018 Feb 8;10:117-8; Invernizzi A et al: Objective quantification of anterior chamber inflammation: measuring cells and flare by anterior segment optical coherence tomography. Ophthalmology 2017 Nov; 124(11):1670-7; Maya JR et al: Emerging therapies for noninfectious uveitis: what may be coming to the clinics. J Ophthalmol 2014;2014:310329 doi: 10.1155/2014/310329; Myles ME et al: Recent progress in ocular drug delivery for posterior segment disease: emphasis on transscleral iontophoresis. Adv Drug Deliv Rev 2005 Dec 13;57(14):2063-79; Parker DM et al: Chronic anterior uveitis in children: psychosocial challenges for patients and their families.[published online ahead of print March 28, 2018]. Am J Ophthalmol pii: S0002-9394(18)30133-8. doi: 10.1016/j.ajo.2018.03.028; Pathanapitoon K et al: Clinical spectrum of HLA-B27-associated ocular inflammation. Ocul Immunol Inflamm 2017 Aug;25(4):569-76.

Disclosures

For this program, Dr. Anesi and the planning committee reported nothing relevant to disclose. In his lectures, Dr. Anesi presents information that is related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Anesi was recorded at the 2018 Preventable Blindness Hot Topics Crash Course, presented by the Ocular Immunology and Uveitis Foundation, on April 21, 2018, in Cambridge, MA. To learn about upcoming CME activities from the Ocular Immunology and Uveitis Foundation, please visit www.uveitis.org. The Audio Digest Foundation thanks Dr. Anesi and the Ocular Immunology and Uveitis Foundation for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OP561402

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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