What is the appropriate emergency department treatment for a patient presenting with acute uveitis?

Emergency Department Treatment of Acute Uveitis

Immediately initiate topical prednisolone acetate 1% eyedrops at a frequency of every 1-2 hours during the first 24-48 hours for severe inflammation, and arrange urgent ophthalmology referral within 1-2 days. 1

Immediate First-Line Treatment

• Start prednisolone acetate 1% as the preferred topical corticosteroid due to its superior corneal penetration compared to other formulations 2, 1, 3
• For acute anterior uveitis, dosing frequency should be every 1-2 hours while awake for the first 24-48 hours in severe cases, then taper based on response 1
• The FDA-approved dosing is 2 drops four times daily, but this can be increased to every 1-2 hours for acute severe inflammation 4
• Add a cycloplegic agent (such as cyclopentolate or homatropine) to prevent posterior synechiae formation and reduce pain from ciliary spasm 1

Critical Assessment Before Discharge

Grade the severity to determine appropriate referral timing: 1

• Grade 1 (asymptomatic): Routine ophthalmology follow-up
• Grade 2 (anterior uveitis with symptoms): Ophthalmology within 2 days
• Grade 3-4 (posterior/panuveitis or vision-threatening): Same-day urgent ophthalmology consultation

What NOT to Do in the ED

• Avoid difluprednate in the ER setting due to increased risk of corticosteroid-induced intraocular pressure elevation and cataract formation 1
• Do not initiate systemic corticosteroids without ophthalmology consultation - coordinate all treatment decisions with the ophthalmologist 1
• Never start systemic immunosuppression in the ED without first ruling out infectious etiologies 2

Mandatory ED Actions Before Discharge

• Arrange ophthalmology follow-up within 1-2 days for anterior uveitis, or same-day for posterior involvement 1
• Educate patients on warning signs requiring immediate return: worsening pain, decreased vision, increased redness, or new floaters 1
• Emphasize strict adherence to the prescribed drop frequency and the critical importance of ophthalmology follow-up 1
• Provide enough medication to last until the ophthalmology appointment (typically a 5-7 day supply) 3

Special Considerations

• HLA-B27 positive patients with acute anterior uveitis typically have short-lived episodes that respond well to topical corticosteroids alone, but counsel them about high recurrence risk 1
• Pediatric patients require more aggressive monitoring due to higher complication risk - ensure ophthalmology follow-up is confirmed before discharge 1
• Bilateral disease suggests systemic etiology and may require immediate systemic therapy, necessitating same-day ophthalmology consultation 2

Common Pitfalls to Avoid

• Do not discontinue therapy prematurely - if signs and symptoms fail to improve after 2 days, the patient should be re-evaluated by ophthalmology 4
• Do not prescribe topical corticosteroids for longer than 3 months from the ED due to risks of glaucoma and cataract formation 1
• Do not assume all red eyes are simple conjunctivitis - uveitis presents with photophobia, pain, and decreased vision, distinguishing it from conjunctivitis 5
• Do not use topical antibiotics alone - uveitis requires anti-inflammatory treatment, not antimicrobials (unless infectious etiology is confirmed) 6