Let’s take a venture on the clinical side this month. A few columns back, I had described my interest in ocular inflammation. Dry eye and allergy certainly fit, but the internal inflammation and associated systemic diseases get my motor revving a bit hotter.
We all know that ocular inflammation is often associated with systemic inflammatory disease. At the primary care level, we do a great service to our patients when we can treat ocular inflammation and guide the family doctors and specialists to help with diagnoses that can diminish quality of life. It’s challenging to know that the systemic illness may not manifest itself initially and that there is such a myriad of conditions to consider.
Here are some bullet points on ocular inflammatory disease. For this month’s purpose, we’ll refer to uveitis, scleritis, and episcleritis.
Let’s leave dry eye and allergy for another day.
Avoid the “shotgun” workup, at least in the initial round of testing. Did my homebound 85-year-old patient with granulomatous uveitis need a Lyme titre? Does a patient with no posterior lesions need a toxoplasmosis assay? How about the first time non-granulomatous unilateral uveitis patient who has no systemic symptoms? Does this patient need testing for Wegener’s Midline Granulomatosis, or for scleroderma? That would be a big “NOOOOO” on all counts.
Is it a lifelong study to understand this? It is.
Sure, you can order every test under the sun, but truly graceful practice comes from taking a “most likely” approach. If a systemic condition is unlikely, don’t test for it on the first round. If everyone is stumped, you can always talk to the internist, rheumatologist, etc. and go for Round 2. No one would blame you for missing an early Wegener’s or scleroderma on the first pass. Or, if they DO, have them give me a call.
*QID dosing of Pred Forte for uveitis will get your patient to the ophthalmologist’s chair faster than you can say “1-800.” Q2H dosing for is the bare minimum in our hands, and I honestly have to think of a reason not to go hourly for the first week.
*Soft steroids are touted for episcleritis. Don’t buy it. You never know how a patient will respond, and starting “softly” will often lead to a longer treatment course. You’ll use more steroids than if you had punched hard on the first chance. I often “load” the prednisolone dosage at q2h for a couple of days, and go down to qid then, with a slow taper. Depending on the generic preparation, your mileage may vary.
*Know when you are in trouble. At Q hourly to Q2H dosing, almost no one should get worse in the first week. Durezol has been a strong switch and has saved many patients the required peribulbar steroid injection. But, unremitting anterior chamber reaction, increasing blur, and pain are all signs that it’s not going well, and needs help…..fast.
*Avoid the oral steroids. Yes, we all want to provide quick relief. But, and it’s a BIG but, if you put oral steroids on someone with unknown systemic infection or undiagnosed diabetes, you could literally KILL the patient. Oral steroids require a systemic workup first. Peribulbar injection is the treatment of choice if Durezol fails.
*Taper slowly. All of our uveitis and many episcleritis patients are on a tapering dose of steroids for a month or more. The bounce-back that occurs from tapering too quickly is a source of too much steroid use. Be sure to get a follow-up IOP every 7-10 days. (While a small IOP rise is OK, it does the patient a great service to identify the glaucoma risk associated with being a steroid responder.)
*The diagnosis of “scleritis” is thrown around too loosely. Scleritis patients are usually systemically ill, and don’t present with a big smile. Rheumatoid arthritis is the most common non-infectious cause, while herpes virus is the most common infectious etiology. Scleritis patients ALL require systemic treatment, often in chronic terms. If your patient had this diagnosis and got better on Pred Forte qid for a week, it wasn’t “scleritis.”
Is care of ocular inflammation a great challenge? Yes, it is.
The reward for me is that ocular inflammation patients are some of the most loyal, and they tend to refer their family and friends. These patients should have yearly exams forever, regardless of systemic associations. They understand that you’re rendering care for a condition that is not commonplace or familiar.
I also like the approach that office care of inflammatory conditions is more roll-up-the-sleeves and do some thinking, as opposed to any high-tech panel that could be run. Uveitis takes us out of the pattern recognition approach that we have with things like refractive error and glaucoma. Sherlock Homes’ style deductive reasoning is the rule. Dig in and enjoy these cases!