Management of uveitis

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www.ophthalclass.blogspot.com has the complete class on uveitis for undergraduate medical students. This presentation is the fourth in the series and deals with the management of uveitis.

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  • best uueitis lecture till now and more than enough
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  • It was really a good overview of uveitis; I was interested in the topic as I am undergoing treatment for Uveitis with topical Prednisolone;
    Dr>Ramanan Earat
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Management of uveitis

  1. 1. Management of uveitis DR. ANUPAMA KARANTH www.ophthalclass.blogspot.com www.ophthalclass.blogspot.com
  2. 2. Anti-inflammatory agents  ‘-itis’ = inflammation  Treatment : stop inflammation  Use anti-inflammatory drugs  Most potent of such agents : Corticosteroids  Corticosteroids are the mainstay of therapy in uveitis www.ophthalclass.blogspot.com
  3. 3. Complicating the issue  What if the cause is infectious?  Specific anti-infective agent is indicated  Corticosteroids may even worsen the infection when given alone  When the cause is immune related?  Corticosteroids will be effective  Associated side effects maybe significant www.ophthalclass.blogspot.com
  4. 4. Management of uveitis  Finding the etiology  Narrow down list of differentials by history and examination  Appropriate investigations (ocular and systemic)  Referrals for systemic associations  Treating the inflammation  Specific therapy  Non-specific therapy www.ophthalclass.blogspot.com
  5. 5. Few ocular investigations Fundus fluorescein angiogram • Cystoid macular edema (complication) • Serpiginous choroidopathy (pattern of lesion) Ultrasonography • Especially in cases of media opacities Ocular tissue analysis • Aqueous tap • Vitreous tap • Chorioretinal biopsy www.ophthalclass.blogspot.com
  6. 6. Few systemic investigations Sarcoidosis Tuberculosis Toxoplasmosis Syphilis Angiotensin Antitoxoplasma Serology – converting Chest X-ray antibody VDRL, FTA-ABS enzyme Serum calcium Mantoux test Chest X-ray www.ophthalclass.blogspot.com
  7. 7. Commonly ordered tests  Core lab tests  Compete blood count and ESR  Chest X-ray  Serum ACE  VDRL, FTA-ABS  Other tests depending on clinical suspicion www.ophthalclass.blogspot.com
  8. 8. Treatment  Medical  Specific  Non specific  Surgical www.ophthalclass.blogspot.com
  9. 9. Medical therapy  Specific – etiology dependent  ATT – Tuberculosis  Parenteral penicillin – Syphilis  Sulfa and pyrimethamine – Toxoplasmosis  Tetracyclines – Lyme disease  IV Acyclovir –Acute retinal necrosis  IV Ganciclovir – CMV retinitis www.ophthalclass.blogspot.com
  10. 10. Medical therapy  Non-specific  Cycloplegic – mydriatics  Corticosteroids  Immunosuppressives www.ophthalclass.blogspot.com
  11. 11. Cycloplegic mydriatics  To relieve ciliary spasm and pain  To prevent posterior synechiae and break the ones already formed Partly broken posterior synechiae www.ophthalclass.blogspot.com
  12. 12. Cycloplegic mydriatics  Shorter acting  Tropicamide eye drops (effective up to 3 hrs)  Cyclopentolate drops (up to 24 hrs)  Longer acting  Homatropine eye drops (up to 4 days)  Atropine eye drops (up to 7-14 days) Cycloplegia relieves pain and a mobile pupil prevents posterior synechiae www.ophthalclass.blogspot.com
  13. 13. Corticosteroids – the mainstay of therapy  Depending on the site of inflammation and severity  Topical  Periocular  Systemic  Topical drops will not be effective for intermediate, posterior and panuveitis  ‘Use enough soon enough’  To always start with a higher dose and taper before stopping  To investigate before starting www.ophthalclass.blogspot.com
  14. 14. Corticosteroids Topical Periocular Systemic Prednisolone Methylprednisolone Prednisone Dexamethasone Triamcinolone Methylprednisolone Fluoromethalone Betamethasone www.ophthalclass.blogspot.com
  15. 15. Complications of corticosteroids Topical Periocular Systemic As for topical As for topical Cataract Weight gain Peptic ulcer Ptosis Osteoporosis Glaucoma Diabetes Scleral perforation Hypertension www.ophthalclass.blogspot.com
  16. 16. Immunosuppressives  In corticosteroid resistant or intolerant cases  In vision threatening inflammations - as first line  Specific cases  Beh et’s syndrome  Sympathetic ophthalmitis  VKH syndrome  Necrotizing sclerouveitis  Adverse reactions can be severe and life threatening www.ophthalclass.blogspot.com
  17. 17. Immunosuppressives Alkylating Antimetabolites T-cell inhibitors agents Methotrexate Cyclophosphamide Cyclosporine Azathioprine Chlorambucil Tacrolimus Watch out for nephrotoxicity, hepatotoxicity and marrow toxicity www.ophthalclass.blogspot.com
  18. 18. Surgery in uveitis  Diagnostic  AC tap  Vitreous biopsy  Chorioretinal biopsy  Therapeutic  Cataract  Glaucoma  Retinal detachment  Vitrectomy www.ophthalclass.blogspot.com
  19. 19. Complicated cataract Polychromatic lustre and breadcrumb appearance www.ophthalclass.blogspot.com
  20. 20. Management of complications  Cataract surgery  If no active inflammation for at least 3 months  Perioperative steroids  Heparin surface modified IOLs  Glaucoma  Anti-glaucoma topical medication  Peripheral iridotomy / iridectomy in iris bombé  Trabeculectomy with mitomycin C or 5 fluorouracil www.ophthalclass.blogspot.com
  21. 21. Management of complications  Cystoid macular edema  Control of inflammation - corticosteroids  NSAIDs  Pars plana vitrectomy if persistent vitritis  Hypotony  Intensive corticosteroids and cycloplegia  Pars plana membranectomy for cyclitic membrane  Vitreous opacification  Pars plana vitrectomy www.ophthalclass.blogspot.com
  22. 22. Management of uveitis … …a few examples www.ophthalclass.blogspot.com
  23. 23. Anterior uveitis  35 yr old male  Ciliary congestion, fine KPs, AC flare, posterior synechiae and hypopyon in RE  Similar history of redness a year ago www.ophthalclass.blogspot.com
  24. 24. Anterior uveitis… Posterior synechiae, pupil bound down Hypopyon www.ophthalclass.blogspot.com
  25. 25. Anterior uveitis…  Management  History and examination to narrow the differentials – nothing significant  The core lab tests – Mantoux highly significant  Referral to pulmonologist – confirm diagnosis of tuberculosis  Co-management www.ophthalclass.blogspot.com
  26. 26. Anterior uveitis…  Ocular management  Topical corticosteroids  Prednisolone eye drops hourly, tapered as per response  Homatropine eye drops 3 times a day  Follow up for  Inflammation  Intraocular pressure  Complications  Systemic management  Anti-tuberculosis therapy www.ophthalclass.blogspot.com
  27. 27. Intermediate uveitis  13 year old girl  Fever of unknown origin, 1 month  Redness both eyes, 1 week  Eye examination  Spill-over anterior uveitis  Anterior vitreous exudates / snowballs  Systemic examination  Lymphadenopathy www.ophthalclass.blogspot.com
  28. 28. Intermediate uveitis… Cells and exudates in the anterior vitreous www.ophthalclass.blogspot.com
  29. 29. Intermediate uveitis… Management  Lymph node biopsy  Caseating granulomatous lesions  Physician diagnosis - tuberculosis  Systemic management  ATT – fever responded within 4 days  Ocular management  On 1 week follow up, vision drop of 2 lines  Systemic corticosteroids under cover of ATT for short period (1mg/kg body wt of prednisone, tapered and stopped within 4 weeks) www.ophthalclass.blogspot.com
  30. 30. Posterior uveitis  35 year old, HIV positive female  Sudden painless loss of vision RE  Ocular examination  Spill over fine KPs  CMV retinitis in the fundus  CD4 count – 50 www.ophthalclass.blogspot.com
  31. 31. Posterior uveitis… CMV retinitis – granular retinal necrosis, frosted branch angiitis www.ophthalclass.blogspot.com
  32. 32. CMV retinitis  Management  Antiretroviral therapy  IV Ganciclovir 5mg / kg body wt bid – induction course 2 weeks  Maintenance – 5mg / kg body wt od www.ophthalclass.blogspot.com

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