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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

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