Uveitis

Prescribing Notes:

• Antimuscarinics dilate the pupil (mydriasis) and paralyse the ciliary muscle (cycloplegia). They are used in the treatment of anterior uveitis.
• Atropine is the most potent and has the longest duration of action (7 days or more).
• Cyclopentolate is less potent and of shorter duration (up to 24 hours).
• Phenylephrine may be used to supplement the mydriatic effect of these.
• Contact dermatitis may occur relatively frequently if atropine is used long term.
• Phenylephrine is used as a mydriatic prior to ophthalmic procedures. Its effect lasts up to seven hours.
• Toxic systemic reactions to atropine and cyclopentolate in the very young and very old are possible.
• Patients should be warned not to drive for several hours after mydriasis.

Prescribing Notes:

• The first line treatment of anterior uveitis is corticosteroid drops – see the ‘Treatment with corticosteroids’ pathway within Inflammatory eye conditions page.
• A minority of patients require systemic therapy for sight threatening disease. Treatment of sight threatening disease is managed by an ophthalmologist experienced in the management of uveitis. For more information refer to Scottish Uveitis Network guidelines.
• Systemic corticosteroids may be used for management of sight threatening disease, immunosuppressive therapies are used for their steroid sparing effect or to induce remission of disease. For more information on use of systemic corticosteroids refer to Scottish Uveitis Network guidelines. For formulary choices of corticosteroids refer to formulary recommendations for treatment with corticosteroids.
• There is limited evidence of comparative efficacy to choose between conventional non-biologic steroid sparing agents. Locally preferred options include mycofenolate mofetil, mycophenolic acid or tacrolimus in preference to other alternative options due to the favourable tolerability and side-effect profiles. Mycofenolate mofetil, mycophenolic acid or tacrolimus are appropriate for shared care, refer to local board policies.
• Mycophenolic acid 720mg is approximately equivalent to mycophenolate mofetil 1g but the two should not be considered interchangeable.
• Adalimumab is recommended as an option for treating non-infectious uveitis in the posterior segment of the eye in adults with inadequate response to corticosteroids, only if there is:

• • active disease (that is, current inflammation in the eye) and
  • inadequate response or intolerance to immunosuppressants and
  • systemic disease or both eyes are affected (or 1 eye is affected if the second eye has poor visual acuity) and
  • worsening vision with a high risk of blindness (for example, risk of blindness that is similar to that seen in people with macular oedema).

• For intravitreal steroid implants see the ‘Treatment with corticosteroids’ pathway within Inflammatory eye conditions page.

Prescribing Notes:

• Antimuscarinics dilate the pupil (mydriasis) and paralyse the ciliary muscle (cycloplegia). They are used in the treatment of anterior uveitis.
• Antimuscarinics may be prescribed for one week following cataract surgery. Children receiving antimuscarinics long-term for iritis should be reviewed after a month.
• Atropine is the most potent and has the longest duration of action (7 days or more).
• Atropine 1% eye drops are used for refraction and fundus examination in children with darkly pigmented irises. One drop is instilled once on the night before examination and once on the morning of the visit. Systemic absorption, particularly in children under 3 years, may occasionally lead to facial flushing. Contact dermatitis occurs relatively frequently when it is used in the long term.
• Atropine 1% eye drops may be used once daily or on alternate days in the “good” eye in patients with a lazy eye (as an alternative to wearing an eye patch) for 1-3 months according to response. Treatment should be reviewed regularly.
• Cyclopentolate is less potent and of shorter duration (up to 24 hours). It is used for refraction and fundus examination in children.
• Phenylephrine may be used to supplement the mydriatic effect of these.