What is the initial treatment for uveitis in the Emergency Room (ER)?

Emergency Room Treatment of Uveitis

For acute uveitis presenting to the ER, initiate topical prednisolone acetate 1% eyedrops immediately (1-2 drops into the affected eye 2-4 times daily, with frequency potentially increased to every 1-2 hours during the first 24-48 hours for severe inflammation), arrange urgent ophthalmology referral within 1-2 days before the patient leaves the ER, and add cycloplegic agents to prevent synechiae formation. 1, 2

Immediate Assessment and Triage

Severity Grading

• Grade 1 (Asymptomatic): Continue with artificial tears and ophthalmology referral within 1 week 1
• Grade 2 (Anterior uveitis with symptoms): Requires urgent ophthalmology referral within 2 days and immediate topical corticosteroid initiation 1
• Grade 3-4 (Posterior/pan-uveitis or vision-threatening): URGENT ophthalmology referral (preferably uveitis specialist) and consider systemic corticosteroids in addition to topical therapy 1

First-Line ER Treatment Protocol

Topical Corticosteroid Therapy

• Prednisolone acetate 1% is the preferred agent due to superior corneal penetration compared to other topical corticosteroids 1, 3, 4
• Initial dosing: 1-2 drops into the conjunctival sac 2-4 times daily, with frequency increased during the first 24-48 hours if necessary 2
• For severe anterior uveitis, dosing may be escalated to every 1-2 hours initially 3, 5
• Avoid difluprednate in the ER setting due to increased risk of corticosteroid-induced intraocular pressure elevation and cataract formation 1

Adjunctive Therapy

• Add cycloplegic agents (coordinated with ophthalmology) to prevent posterior synechiae formation and reduce pain from ciliary spasm 1
• Artificial tears for symptomatic relief in mild cases 1

Critical ER Actions Before Discharge

Ophthalmology Referral Timing

• Grade 2 anterior uveitis: Arrange ophthalmology follow-up within 2 days, prior to patient leaving ER 1
• Grade 3-4 or posterior uveitis: URGENT same-day ophthalmology consultation before initiating treatment 1
• Coordinate all treatment decisions with the ophthalmologist, particularly regarding systemic corticosteroids 1

When to Consider Systemic Corticosteroids

• Posterior or pan-uveitis (Grade 3-4): Consider systemic corticosteroids in addition to topical therapy, but only after ophthalmology consultation 1
• Bilateral severe disease: Systemic therapy may be warranted 3, 5
• In the ER, systemic corticosteroids should generally be deferred to ophthalmology unless vision-threatening complications are present 1

Important Caveats and Pitfalls

Do Not Miss These

• Exclude infectious causes before initiating corticosteroids, particularly in immunocompromised patients or those with history suggesting infection (toxoplasmosis, herpes, tuberculosis, HIV) 3, 6
• Rule out masquerade syndromes (malignancy, intraocular foreign body) that can mimic uveitis 6
• Check for systemic disease associations: Ask about joint pain, back stiffness, skin rashes, or systemic symptoms suggesting spondyloarthritis, inflammatory bowel disease, or other autoimmune conditions 3

Patient Education Before Discharge

• Warning signs requiring immediate return: Worsening pain, decreased vision, increased redness, or new floaters 1, 7
• Compliance is critical: Emphasize the importance of using drops as prescribed and attending ophthalmology follow-up 1
• Do not discontinue therapy prematurely; if no improvement after 2 days, patient must be re-evaluated 2

Contraindications to Immediate Corticosteroid Use

• Suspected infectious uveitis (particularly herpetic or fungal) requires antimicrobial therapy first 3
• Active corneal epithelial defect or ulceration
• Known steroid responders with uncontrolled glaucoma (requires immediate ophthalmology consultation) 4

Special Populations

HLA-B27 Positive Patients with Acute Anterior Uveitis

• These patients typically have short-lived episodes that respond well to topical corticosteroids alone 1
• Educate about recurrence risk and warning signs 1, 7
• If on systemic immunosuppression for spondyloarthritis, continue current therapy and treat the acute episode with topical agents 1

Pediatric Patients

• Require more aggressive monitoring due to risk of complications 1
• Ensure ophthalmology follow-up is arranged before discharge 1
• Consider underlying juvenile idiopathic arthritis in children presenting with chronic anterior uveitis 1

Duration of ER-Initiated Therapy

• Topical corticosteroids should be used as short-term therapy (≤3 months) due to risks of glaucoma and cataract formation 1, 7
• The ophthalmologist will determine the tapering schedule based on clinical response 1, 5
• Systemic therapy is indicated if topical corticosteroids cannot be tapered to ≤2 drops/day within 3 months, but this decision is made by ophthalmology, not in the ER 7