Implementing advanced concepts in the management of uveitis
Whether you are practicing in a referral-based clinic, primary-care office, or commercial setting, we will all encounter patients with uveitis. There are a wealth of articles, studies, and lectures on how to diagnose, treat, and manage uveitis. Instead of reiterating the typical discussion of uveitis, we present a few not-so-common pointers that will greatly enhance your ability to manage this disorder.
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Use an in-office pledget
Posterior synechiae can put patients at risk for intraocular hypertension and glaucoma, so it’s best to be aggressive and break synechiae as soon as they form. If not treated quickly and appropriately, a firm scar between the iris and lens will form, making it very difficult to break. In order to prevent posterior synechiae, cycloplegic agents are prescribed to keep the pupil dilated. However, in cases where patients present with an already densely formed synechia, it can be much more challenging to break just by prescribing cycloplegics.
By utilizing a pledget, a small wad of cotton, we can administer a large, sustained dose of dilating agents to break the synechia.
The procedure is as follows:
• Break off a small amount of cotton from cotton swab and firmly roll it around your fingers to make a dense circle
• Instill an equal amount of 1% atropine, 2% cyclopentolate, and 10% phenylephrine into a bottle cap and shake around to mix (check the patient’s blood pressure due to the higher concentration of phenylephrine being used)
• Put the cotton into the bottle cap to absorb the mixture
• Instill proparacaine into the eye and insert the pledget into the lower lateral cul-de-sac with forceps
• Leave the pledget in place for approximately 30 minutes, checking on the patient periodically
After the pledget is removed, re-evaluate the pupil and synechia. Upon discharge, patients are prescribed the appropriate anti-inflammatory agents as well as a cycloplegic agent. If there is still a significant amount of posterior synechia remaining, the patient should return in one or two days to administer another pledget.