COMANAGEMENT Q&A

Put Out the Fire of Iritis

Edited by Paul C. Ajamian, O.D.

Question: Should O.D.s always comanage iritis?

Answer:   Many optometrists don't feel comfortable managing iritis themselves, yet they should. In most cases optometrists can manage this disease well on their own. Treat these patients aggressively, but then know to refer when the eye is not responding to topical therapy.

Case in point: A 52-year-old white female presented with severe iritis and a history of three other episodes of iritis in the past decade, always in the left eye. In this latest instance, she had seen an optometrist who noted that she had 4+ cells and flare and early posterior synechia. The doctor assumed that the patient needed to see an ophthalmologist. This second doctor put the patient on an insufficient topical steroid regimen of Pred Forte QID and Cyclogyl BID to dilate the pupil.

The patient then came to us a week later. The eye was not responding and was in fact getting worse. Now the iris had revealed 360 degrees of synechia, and there was evidence of significant cells and flare in the anterior chamber.

The bottom line is that this patient needed to be treated very aggressively from day one, and she wasn't. In a case like this, use an aggressive course of treatment: For moderate to severe iritis, prescribe prednisolone at least every hour, or even every half-hour or 15 minutes.

Here's a pearl for compliance: The heavy dose of the drug partially drains to the nose, leaving a very bitter taste. Try punctal occlusion, either by inserting temporary plugs or by teaching the patient digital occlusion.

If there's evidence of synechia, you also have to dilate the pupil aggressively. Cyclopentolate or even homatropine often does not dilate the pupil enough to break or prevent synechia. I use 1 percent atropine drops and 10 percent phenylephrine drops QID. Pharmacists rarely have those in stock, so keep a few bottles of each to dispense directly to patients and to prevent a delay in treatment.

Since patients can't instill drops every hour while they sleep, prescribe a steroid ointment for night. We have our pharmacist mix up dexamethasone ointment in batches of 10 or 12 tubes, which serves our demands for about a year. Or you can use commercially-available TobraDex, which has dexamethasone in it.

See iritis patients frequently, and don't be in a rush to taper the drops. Rather, lag the tapering behind the improvement. So if a patient with advanced iritis shows significant improvement by day three, maintain the same initial regimen until you notice even more improvement. Then taper gradually. Advise these patients that they're going to be on drops for a fairly long period of time, often four weeks or more.

Also, beware of substituting the generic steroid for the brand name. I recently had a case where the iritis improved over a period of a week or two and then actually got worse. It turned out that the patient had run out of Pred Forte and was switched to a generic. Generic topical prednisolone just doesn't seem as efficacious as the brand name.

Question: At what point do you refer the iritis patient for further treatment?

Answer: If you're treating the patient aggressively with the brand-name steroid as well as dilating agents, and yet the inflammation and symptoms are not improving—and even if some other clinical signs like elevated pressures appear—then get another opinion from an anterior segment specialist, preferably one who understands uveitis. The specialist may put the patient on an oral regimen of prednisone or may give a local steroid injection.  

While optometrists can most often treat iritis without referring, there are certainly some cases where you must recognize that the patient isn't improving and will need some other treatment modality.

Send comanagement questions to Review of Optometry, 201 King of Prussia Road, Radnor, PA 19089.