I spend half my time, willingly, in clinic seeing patients with uveitis. I’ve seen and made some mistakes, and here are some of the lessons I’ve learned along the way.

DILATE

First, anterior uveitis does not preclude other pathologies. All uveitis patients should be dilated, and if you cannot see enough of the posterior segment because of synechiae or vitritis, get an ultrasound. An Optos photo through a small pupil may help reveal peripheral pathology (Figure 1).

If you still cannot get a good view and the diagnosis is unclear, consider a diagnostic vitrectomy.

TREAT AGGRESSIVELY

Topical prednisone 4 times a day is rarely enough to control any inflammation, particularly when used against intermediate, posterior, or panuveitis. Remember, posterior segment inflammation is associated with poor long-term outcomes if only steroids are used.

When treating a patient with severe inflammation, hit hard with steroids and taper slow. Please, do not let the inflammation worsen just to keep the IOP acceptable. If you start your patient on immunosuppressants, like methotrexate, mycophenolate mofetil, or a biologic, make sure to bridge them with steroids.

Once the patient is doing better, you can decrease the steroids slowly while keeping them on the steroid-sparing agent for at least 1 or 2 years, to reduce the chances of a recurrence.

Cycloplegics are used to control pain and prevent or resolve posterior synechiae, but they only work if the adhesion is fresh. For chronic and broad posterior synechiae, cycloplegics will not make a difference. Please, there is no need to keep patients on cycloplegics long-term.

COMPLICATED UNDERLYING CAUSES

There is no standard workup for all uveitis patients. When ordering diagnostic tests, make sure that the results will affect your management. The tests should rule in or rule out a disease.

Consider infections and cancer in your differential diagnoses. For example, to rule out syphilis, get an FTA-ABS, a TPPA, or a syphilis IgG, not just an RPR.

If an older patient develops a new case of vitritis, consider a masquerade syndrome. A vitrectomy with a vitreous biopsy and cytology/flow cytometry analysis may help diagnose lymphoma and save the patient's life.

I caution to avoid intravitreal steroids in a new patient, unless you are 100% sure of the diagnosis. Systemic steroids are preferred because they can be stopped immediately if needed. Once you inject steroids into the eye, there is no way back.

If the underlying cause is an infectious process, then unfortunately you are in big trouble.

COMORBIDITY MANAGEMENT

Glaucoma is present in about 10% of uveitis patients. Not every uveitis patient with high IOP is a steroid responder. Always check the angle for peripheral anterior synechiae. Most uveitis patients respond to topical management, but some patients will need glaucoma surgery, which should not be delayed. When delaying with elective surgery, including cataract surgery or a YAG capsulotomy, wait at least 3 months of quiescent disease to decrease the risk of severe post-op inflammation.

One last plea: Don't mistake endophthalmitis for toxic anterior segment syndrome (TASS). No TASS case has ever gone blind from intravitreal antibiotics. Seriously consider performing a vitreous tap and injecting antibiotics when in doubt. Ask questions later.