Diagnosis and treatment of anterior uveitis: optometric management

Figures & data

Table 1 Review of systems to be included with any patient that presents with uveitis

System	Review of systems: questions to ask	Condition(s) to rule out
Joints	Pain or stiffness of hands, wrists, fingers, toes, lower back, spine, other weight-bearing joints?	JIA, HLA-B27-associated disorders, RA, SLE, other collagen vascular disorders
Skin	Rash?	Syphilis, SLE, sarcoidosis, Behcet’s disease, Kawasaki disease, Lyme disease, drug reactions
Gastrointestinal	Abdominal discomfort, nausea, vomiting, diarrhea, or melena?	IBD (Crohn’s disease or ulcerative colitis)
Oral	Oral ulcers?	SLE, Behcet’s disease, IBD
Genital	Genital ulcers?	Behcet’s disease, syphilis
Neurologic	Headache?	Behcet’s disease, VKH syndrome, multiple sclerosis
	Peripheral weakness or paresthesia?
Pulmonary	Cough?	Sarcoidosis, tuberculosis, Wegener granulomatosis, systemic fungal infections

Note: Data from previous studies.^{2–4,9–13,16–19,23}

Abbreviations: JIA, juvenile idiopathic arthritis; HLA-B27, human leukocyte antigen B27; RA, rheumatoid arthritis; SLE, systemic lupus erythematous; IBD, inflammatory bowel disease; VKH, Vogt–Koyanagi–Harada.

Table 2 Review of systems and appropriate laboratory testing

Condition	Clinical signs and symptoms	Ancillary testing
Ankylosing spondylitis	Young male, chronic lower back pain, chest pain, muscle pain in the morning, or sitting for prolonged periods	HLA-B27, sacroiliac X-ray
Reactive arthritis (Reiter’s syndrome)	Young male, arthritis, urethritis	HLA-B27, ESR, CRP
Juvenile idiopathic arthritis	Sacroiliitis	ANA, RF, knee radiograph
Inflammatory bowel disease (Crohn’s or ulcerative colitis)	Abdominal cramps, chronic diarrhea (more than three loose bowel movements a day, lasting more than 3 months)	HLA-B27, GI referral for endoscopy
Sarcoidosis	African American female predilection, posterior uveitis, pulmonary issues	ACE, chest X-ray, or CT scan
Tuberculosis	Prolonged cough, fever, chills, night sweats, weight loss	PPD, chest X-ray, quantiferon gold
Syphilis	History of sexually transmitted infection	FTA-ABS, RPR, or VDRL
	Primary: single chancre (painless ulceration of genitals)
	Secondary: rash on palms of hands and soles of feet
	Latent: no signs or symptoms
	Tertiary: fever, malaise, headache, joint pain
	Recall, this has been known as the “great imitator”
Toxoplasmosis	Immunocompromised, exposure to cats, history of eating raw meat	Toxoplasma IgG or IgM for acute acquired cases
Lyme disease	Recent tick bite	Lyme Western blot
Wegener’s granulomatosis	Sinus, pulmonary, kidney disease, scleritis	Antineutrophil cytoplasmic antibody, sinus films, chest X-ray, serum creatinine
Psoriatic arthritis	Psoriasis with arthritis
Behcet’s disease	Oral and/or genital ulcers	HLA-B51
Juvenile idiopathic arthritis	Children, mostly girls, may be asymptomatic	ANA, RF
Herpes simplex virus 1 and 2	History of vesicular rash(es) with dermatomal distribution	HSV IgG and IgM antibody titers (poor sensitivity)
HIV	Any unusual presentation of uveitis	Tridot analysis for HIV

Note: Data from previous studies.^{2–4,9–13,16–19,23–56}

Abbreviations: HLA-B27, human leukocyte antigen B27; ESR, erythrocyte sedimentation rate; CRP, C-reactive protein; ANA, antinuclear antibody; RF, rheumatoid factor; GI, gastrointestinal; ACE, angiotensin-converting enzyme; CT, computed tomography; PPD, purified protein derivative; FTA-ABS, fluorescent treponemal antibody absorption; RPR, rapid plasma regain; VDRL, venereal disease research laboratory; IgG, immunoglobulin G; IgM, immunoglobulin M; HSV, herpes simplex virus.

Table 3 Blood work

Abbreviation of test name	Complete name of test	Use
CBC with diff	Complete blood count with differential	Underlying bacterial or viral etiology, WBC malignancy (leukemia or lymphoma)
CMP	Comprehensive metabolic panel	Kidney function, liver function, electrolyte and fluid balance
ESR	Erythrocyte sedimentation rate	Generalized inflammation
CRP	C-reactive protein	Inflammation
ANA	Antinuclear antibody	SLE or JIA
RF	Rheumatoid factor	RA
HLA-B27	Human leukocyte antigen B27	IBD (Crohn’s or ulcerative colitis), ankylosing spondylitis, reactive arthritis (Reiter’s), psoriatic arthritis, Behcet’s disease
FTA-ABS	Fluorescent treponemal antibody absorption	Syphilis (infected)
RPR and VDRL	Rapid plasma regain and venereal disease research laboratory	Syphilis (screening)
Lyme titers		Lyme disease
ELISA	Enzyme-linked immunosorbent assay	Lyme disease
ACE	Angiotensin-converting enzyme	Sarcoidosis
Serum lysozyme	Serum lysozyme	Sarcoidosis
Quantiferon gold	Quantiferon gold	TB
PPD skin test	Purified protein derivative	TB
CXR	Chest X-ray	TB, sarcoidosis

Note: Data from references.^{2–4,9–13,16–19,23–56}

Abbreviations: WBC, white blood cells; SLE, systemic lupus erythematous; JIA, juvenile idiopathic arthritis; RA, rheumatoid arthritis; IBD, inflammatory bowel disease; TB, tuberculosis.

Table 4 Most commonly prescribed topical ophthalmic corticosteroids

Drug/preparation	Common trade name (manufacturer)	Formulation
Difluprednate	Durezol (Alcon)	0.05% emulsion
Dexamethasone	Dexamethasone sodium phosphate (Bausch + Lomb)	0.1% suspension
	Maxidex (Alcon)	0.1% suspension
		0.1% ointment
Prednisolone acetate	Pred Forte (Allergan)	1.0% suspension
	Econopred Plus (Alcon)	0.12% suspension
	Pred Mild (Allergan)	0.12% suspension
Fluoromethalone	FML (Allergan)	0.1% suspension
Loteprednol etabonate	Lotemax (Bausch + Lomb)	0.5% suspension
		0.5% gel
		0.5% ointment
	Alrex (Bausch + Lomb)	0.2% suspension

Note: Data from Foster and Vitale⁴ and Jabs et al.¹²

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