Iritis or Uveitis ?

[82ndtrooper]

I've been treated for Iritis and currently am battling yet another out break of the inflammation. This time the Pred-Forte drops and the dialator drops are not working. Bright lights are extremely painful since I cannot get the right eye to dialate with the Cycligel.

I've been tested for Lyme, communicable, ANA, CBC, chem 7, and a whole host of other blood work for the disease, that is if it's a disease that is produced by an autoimmune disorder (Rheumotology)

Synickii have developed and makes the eye harder and harder to dialate with the cyclegel drops. I fear that both the drops are failing to reduce the inflammation and that if left to the current doctors orders that the synikii are going to cause glaucoma.

Any experience with this in the field ? I relize the disclaimers in the stickies for this forum topic, but would like to see if anyone has treated this, or has had experience with alternative methods of treatments.

Would oral Prednisone be a secondary course of action? or should I just opt for an intro ocular injecton ? I'll be seeing an opthamologic disease specialist on Thursday.

If this is an off topic thread, then I relize the need to shut it down.

Thanks in advance for any experiences related to this in the field by any of the 18D's

[Eagle5US]

I'll be seeing an opthamologic disease specialist on Thursday.

Unfortunately you have passed into the realm of clinical subspecialists. These are the guys who are clinically, legally, and comfortably able to do what all the warning labels and disclaimers warn other practioners about regarding treatment, recommended dosages, and invasive parameters.:(
Do the best you can to hold out until your appointment. Wear the dark glasses and do all of the pupillary rest precautions associated with your standard treatment regimen.
If all else fails and you have reached your threshhold, call his office and ask if he would be willing to meet you at the ED.

Good Luck-
Eagle

[82ndtrooper]

Today I visited with a specialist in ophthamologic disease for acute iritis as described in the first post of this thread.

I've been grappling with the condition for two weeks, although diagnosed some 9 years ago with this condition. It rarely gives me trouble and when it does a couple of day's of diolating drops and Pred-Forte steriodial anti inflammatory drops does the job. Not this time. :(

Since my visit on Saturday the inflammation has cleared up considerably and the adhesions to the iris and the lens are all but practically pulled loose from the diolating drops that relax the iris and pull them apart from the lens. That was the good news, but not without blurred vision and some redness due to the inflammation. Both of which are markedtly improved since Saturday.

Apparently there are some kind of bacteria that adhere to the lens of the eye and are creating the blurred vision. The specialist insisted that I be given an intro ocular injection into the anterior chamber between the iris and the lens to improve the removal of this bacteria. Here's the good part.

He used numbing drops on the eye, 3 drops and a 5 minute wait, then I had to look to the left as he inserted the needle into the eye ball into the anterior chamber to inject the sterioid med. I felt a bit of pressure, but no pain. All was fine and he said "That's it, it's over" Just as he said that my vision began to close in from the periphery and I said "Doc, I think I'm going to lose you"

Next thing I know, I am being cropped up in an ambulance and being IV'd on the way to the ER at St. E's. WTF ?:eek:

I had passed out. Ok, no big deal, but my heart rate had gone down to less than 40 bpm and they were concerned that I was going into heart failure. After being carted into the ER and and EKG hooked up the heart rate was beginning to steady at a rate of 75-80 bpm. All this over an eye that is inflammed. After being monitored for an hour I began to have one of the most painful migraines that I have ever experienced. The ER doc orders 50 mg's of demerol and 25 mg's of the phenagan.....................again my heart rate goes to about 60 bpm once they push the pain meds and they put me on oxygen. Bad call to use an opiod pain med just after I had slow heart rate due to what I would probably call merely shock or psycho trauma after the injection.

Never the less, I'm home and still feeling happy from the demerol in the IV.

I'll never let another doctor put a needle in my eye. And, I dont have any idea why my body responded as it did.

[Eagle5US]

Dude-
Glad you are A-OK. You may have vagal'ed out. There are things we do when people have a "runaway heartbeat" like put there face in cold water, stroke their neck and (you are gonna love this) press on their eyeballs. This slows their heart-as you have experienced with your increase in intraoccular pressure.
I hate that e started you with narcs for your resultant headache....and DEMEROL at that-YIKES- I haven't pushed demerol in years with so many other (better) drugs out there for use. But, medicine being a practice....people practice differently.

Thank you for keeping us posted-let us know how this turns out for you.

Eagle

[82ndtrooper]

EAGLE,

Sincerely thank you for your concern. Your right, the doc at the ER said it was fairly normal to "Vagal" out when given an intro occular injection. I was transported to the ER under federal guidlines for treatment that is considered ordinary and usual.

The eye feels much better, the adhesions seems to be breaking off due to a larger diameter of the pupil from the diolating drops and the redness and inflammation seem to be disapearing, albeit, slower than I would like.

The ER doc took mercy on me and prescribed a few 5/500 Vicodin for early morning pain since the mornings are when the eye has not received it's required drops during sleep. Honestly, I dont even like the idea of using an opiod pain killer for pain that can be managed by a couple of extra strength Tylenol. I did ask as to why he ordered Demerol for a migraine and he said that most triptans have proven unreliable for immediate abortive migraine pain. At least in his years of ER practice. He also pushed an non sterioidal anti inflammatory to reduce the chance of a rebound migraine. The Demerol certainly puts you in a good mood, but he actually said that 50 mg's is a fairly small dose compared to other doses for more injurious pain.

Thanks for your follow up post and your concern.

[jasonglh]

Damn my eyes are watering just thinking about that. Glad to hear you are doing better though.

Eagle5US

I think drug choice is a hospital thing. In my wifes ICU they use morphine but where I work its usually demerol or dilaudid. Didn't know you could vagal someone down by eye pressure I learn something every day here.

[Eagle5US]

EAGLE,
I did ask as to why he ordered Demerol for a migraine and he said that most triptans have proven unreliable for immediate abortive migraine pain. At least in his years of ER practice.
He is absolutely correct (and backed by the literature) in knowing that triptans are relatively ineffective after the spasm / pain cycle has been initiated. Without getting into the pharmacokinetics of it, a successful initial "migraine pharmacotherapy" consists of Compazine, Phenergan and Benedryl and some add Toradol (the NSAID you probably received) pushed IV. This combination has been shown to have a higher efficacy in relieveing migraine headaches than narcotic therapy as it works on the cause of the HA itself, not the pain receptors associated with it. HA's that are refractory to this coctail and have entered the pain cycle do then need narcotherapy for patient comfort until the HA resolves.
Demerol has a VERY hgh side effect rate, but is dirt cheap and has been around long enough for many folks to be very comfrortable prescribing it. Though I have had tremendous success with it 10 years ago, with the advent of medications such as fentanyl and dilauded, most practioners I have worked with in Emergency Departments and Trauma Centers rarely utilize it today.

Not gospel-only my opinion and the way I practice.

Eagle

[82ndtrooper]

He is absolutely correct (and backed by the literature) in knowing that triptans are relatively ineffective after the spasm / pain cycle has been initiated. Without getting into the pharmacokinetics of it, a successful initial "migraine pharmacotherapy" consists of Compazine, Phenergan and Benedryl and some add Toradol (the NSAID you probably received) pushed IV. This combination has been shown to have a higher efficacy in relieveing migraine headaches than narcotic therapy as it works on the cause of the HA itself, not the pain receptors associated with it. HA's that are refractory to this coctail and have entered the pain cycle do then need narcotherapy for patient comfort until the HA resolves.
Demerol has a VERY hgh side effect rate, but is dirt cheap and has been around long enough for many folks to be very comfrortable prescribing it. Though I have had tremendous success with it 10 years ago, with the advent of medications such as fentanyl and dilauded, most practioners I have worked with in Emergency Departments and Trauma Centers rarely utilize it today.

Not gospel-only my opinion and the way I practice.







Eagle



The only side effects, other than the obvious opiate uphoria, were an itchy nose and funny enough, constipation. I remember reading somewhere that in India the children are given small doses of pure opium orally to stave off diareah and the resulting dehydration. :munchin

Actually isn't Dilauded a much stronger opiate than Demerol ? I would probably only expect that if I had a more serious injury than a severe migraine. I've had various pain meds for dislocated shoulders for the reduction where I believe I was also alway's given Versid (spelling?) and then woke up an hour later wondering when they were going to reduce the shoulder. Of course by the that time I had been to post reduction X-ray and had a sling and swath on the arm. Funny Bones medication. :D I've dislocated both shoulders and one actually had reduced more than 10 times at the ER. I finally got smart and decided to have Cincinnati Sports Medicine due surgery. Since the two surgery's at Womack Army Hospital, Ft. Bragg N.C. and the one here in Cincinnati, neither has dislocated since.

Back to putting drops in the eye.

Thanks for the responses EAGLE.

[Eagle5US]

LOL...

Versed is one of my favorite drugs in the world.
Patient: Damn Doc, this friggin HURTS!!!
Me: I know, I'm sorry....here is something for the pain now....but I'm gonna give you something so you won't remember it.
an hour later
Patient: Man, I remember injuring myself, but I really thought it would hurt more...when you gonna fix it?
Me: Here is your discharge papers....see ortho in the morning:D

The main badness with demerol is the nausea and vomiting. Whats worse than being in pain? Being in pain and pukeing your guts out.
Dilauded is a VERY powerful drug....hence my love of it. .5 to 2 mg of Dilauded can cure many ills for folks with significant pain. If you need IV pain medicine, I will give you something that works quickly and effectively the first time.
I hate being in pain, I hate my patients being in pain. People come see me because they hurt. I can fix that most of the time.

Add to that, people who are victims of multisystem trauma needn't remember the experience for the rest of their lives either....let me introduce you to my leetle friend....Senor Versed.:cool:

Nearly all opiates cause constipation as they slow your digestive tract. Increase your roughage and clear fluids, add a stool softener (over the counter is fine) if you need it.

I am glad you are feeling better......try and keep in perspective that there are many any ways to do the same thing in medicine...treat folks, diagnose stuff, learn things.....it really is generally based on the practitioner's preference. I am by no means saying your physician was incorrect in any way in your management. I just wanted to make certain that was crystal clear.

Eagle

[82ndtrooper]

That's funny !

I suppose I'm not the only person that had a lapse in memory when Versed is pushed then. Every time I had a reduction of the shoulder I came to some level of conciousness and wondered when in the hell they were going to put my shoulder back into place. Only to find the girl friend or nurse commenting on what I have said under the influence after reduction of the shoulder. Pretty damn good stuff.

Your analogy is spot on ! But I suppose you've done that a thousand times.

As to your use of opiods, I was never under the impression that you disagreed with the pain management, merely under a different practice, most of the time with the treatment and abortive measures for severe migraines.

Back to the drops in the eye.

Thanks again for your responses EAGLE5US.

[82ndtrooper]

Yesterday was the second intro occular injection into the right eye. I gagled out again but for only a few seconds and the doc was taking my radial pulse as I gain conciousness. I ask "did I lose time again" and he replied "yes Scott, but only a few seconds this time"


As if any time is a good thing. :rolleyes:

it's actually clearing up after yesterdays injection and is requiring less and less diolating drops for pain. Maybe the second injection is the charm. Still a bit fuzzy though on the sight picture when tested prior to the doc coming into the room. I'll hope this sight improves with this injection.

[Gypsy]

:eek:

Hope you'll be good to go in short order, 82ndtrooper.

[CoLawman]

I swear on everything holy. I will not ever let someone give me a shot in the eyeball, NEVER................unless Eagle is there with some mystery meds!

[82ndtrooper]

I swear on everything holy. I will not ever let someone give me a shot in the eyeball, NEVER................unless Eagle is there with some mystery meds!


It's actually painless and rather uneventuful, except for the passing out part:eek:

The Wiley-X Romers with the dark lenses have been getting their use though this last couple of weeks. :)

[82ndtrooper]

Ok, for three weeks now I've been putting silly drops in my eye, I've two injections of steroids in the eyeball, and could not see with a static diolated eye with the diolater drops. Itching, tearing, and generally loss of total vision.

Last night I hit my threshold limit and decided to drive accompanied to the VA Medical Center ER in Cincinnati, Ohio. The wait was 3 hours to be seen by a doc and not without having to wear the Wiley's and a full pack of Kleenex to wipe the tearing. Enough already eh?

I finally get called to the ER by the Doc. He heres my story about the treatment and the drops and the injections. He locates my medical history in the VA system computer and see's that this has been going on since the diagnosis in 1991.

We both agree that treatment is not agressive enough even with two injections of steroids in the eye. He say's to me "Why didnt the O.D. put you on oral steroids (Prednisone)?" I discussed the admition that I had expressed concern for the injections and that oral steriods had worked in the first time that I had the condition.

He orders a weeks worth of 20mg's of Prednisone and instucts me to go to the in patient pharmacy and take two tablets as soon I return home with food to soften the stomach side effects.

I wake up this morning and the condition is almost completley gone !!!! :lifter

I begged for oral Prednisone and was diverted to intraoccular injections instead. Now my eye is feeling like a normal person with only the one dose of Prednisone. I went to a privat O.D/M.D and here I go to the VA and the intern doing his ER rotation gives one dose of tablets and it's gone. It may be the total sum of the injections and the drop and the oral dose, but I'm sticking with the VA for all and everything I do to my body now.

By the way, the Cincinnati VA is clean, no mold, and has tv's in every room with phones.

[Gypsy]

Great news all around, glad to hear the VA Doc squared you away!

[82ndtrooper]

Never mind. It was a long winded post anyway.