Although treatment with a topical corticosteroid and an oral NSAID is appropriate to control inflammation and pain in cases of presumed traumatic anterior uveitis, additional diagnostic procedures (see Case Route 2) should be appropriately performed on any eye with hyphema to rule out other possible causes of bleeding. If performing additional diagnostic procedures is not possible, more aggressive treatment, such as a topical corticosteroid with greater intraocular penetration (eg, prednisolone acetate 1%),2 may be more effective in producing a favorable outcome if trauma—or another one-time, controllable condition—is the cause. In addition, because the need for antibiotics is low in patients with intraocular hemorrhage (as represented in the neomycin–polymyxin B–dexamethasone combination), avoiding unnecessary antimicrobial use is recommended. If neomycin–polymyxin B–dexamethasone is the only medication readily available, increasing the frequency of administration (ie, to q6-8h) may be helpful as more aggressive initial treatment. Owner education is also a critical component of the treatment plan, as owners should be aware of the signs (eg, squinting, rubbing, increased cloudiness, increased redness) that would indicate that earlier re-evaluation is necessary.
Treatment with a mydriatic cycloplegic (eg, atropine ophthalmic solution 1%) is indicated in patients with anterior uveitis and low IOP, even if the pupil cannot be visualized due to signs caused by the disease process. Because anterior uveitis produces a miotic, “sticky” pupil, the risk for complete posterior synechiae—and thus secondary glaucoma—is decreased by the use of atropine, which produces pupillary dilation, decreases exudation from the iris, and provides analgesia via cycloplegia. When surgical removal of a globe is advised to treat a painful ocular disease (eg, glaucoma) and the underlying cause of the disease (eg, intraocular tumor) has not been identified, histopathology is appropriate, as the patient’s well-being may be positively impacted if a previously occult disease process is identified.
In this case progression, if additional diagnostics—particularly ocular ultrasonography—had been performed at initial presentation, medical management for the intraocular hemorrhage would have been recognized as ineffective treatment for the underlying cause ultimately identified (ie, intraocular tumor). Because ocular ultrasonography may not be performed on all patients with hyphema for various reasons, it is important to consider that more aggressive medical management is appropriate, in the event that anterior uveitis is medically responsive.