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Topical treatment of uveitis

Barbara Biziorek, MD, PhD


Department of Ophthalmology
Lublin University School of Medicine, Poland
Mydriatics/cycloplegics
Aim:
to prevent posterior synechiae, pupillary block, iris bomb
to relieve pain and photophobia due to ciliary spasm
Mechanism of action

Cholinergic antagonists atropine, scopolamine, homatropine, cyclopentolate, tropicamide

1-adrenergic agonists phenylephrine


Mydriatic/cycloplegic agents
Tropicamide 0.5%, 1% solution
Cyclopentolate hydrochloride 0.5%, 1%, 2% solution
Homatropine 2.5%,5% solution
Scopolamine 0.25% solution
Atropine 0.5%, 1% solution, ointment
Phenylephrine 2.5%, 10% solution
Side effects and toxicity
Atropine
Systemic fever, tachycardia, dermal flushing, dryness of the mouth, confusional
psychosis, urinary retension, ataxia, convulsions
Ocular-allergic reactions, follicular or papillary conjunctivitis, contact dermatitis, acute
angle-closure glaucoma
Scopolamine
CNS toxicity more often than in atropine, especially in the elderly
Ocular the same as atropine
Homatropine
Systemic and ocular-the same as atropine, but less potent
Cyclopentolate
Systemic-high incidence of CNS side effects, more often in children and the elderly
(ataxia, restlessness, memory loss, visual hallucinations, psychosis, disorientation,
irrelevant speech)
Ocular-transient stinging, other reactions similar to atropine
Tropicamide
Systemic toxicity uncommon

Ocular- hypersensitivity reactions, angle-closure glaucoma in the anatomicaly


predisposed
Treatment of anticholinergic overdosage
Physostigmine salicylate - 0.5 mg in children, 1-4mg in adults
Diazepam in convulsions
Phenylephrine
Systemic-tachycardia, hypertension, ventricular arrhytmia, myocardial infarction
Ocular- allergic dermatoconjunctivitis, keratitis, lacrimation, lid retraction
Corticosteroids
Ophthalmic topical preparations
Dexamethasone sodium phosphate , alcohol 0.1% - solution, suspesion, ointment; the
most potent, increased risk of ocular adverse effects
Prednisolone acetate 0.5%, 1%- suspension
Fluorometholone alcohol 0.1%-suspension, ointment
Rimexolone 1%-suspension
Loteprednol etabonate 0.5%-suspension
Hydrocortisone acetate 1%-ointment
Fludrocortisone acetate 0.1% -ointment
Therapeutic approach
Treat the patient initially aggressively with a potent agent
Dexamethasone alcohol 0.1% or prednisolone acetate 1% hourly or one drop every 5
min during first hour, together with subconjunctival corticosteroids
Ointment at night
Taper according to clinical response
Ocular complications of topical treatment
Allergy to vehicle
Punctate keratopathy
Altered corneal thickness
Susceptibility to infections
Posterior subcapsular cataract
Steroid induced glaucoma
Ptosis
Topical nonsteroidal anti-inflammatory drugs (NSAIDS)
Flurbiprofen 0.03%-solution, diclofenac sodium 0.1%-solution, ketorolac 0.5%-solution,
indomethacin 0.5-1.0%-suspension
Less potent anti-inflammatory proprietes than corticosteroids
Possible role as adjunctive therapy (steroid sparing)
Topical side effects -conjunctival hyperemia, burning, stinging