Management of uveitis
DR. ANUPAMA KARANTH
www.ophthalclass.blogspot.com
www.ophthalclass.blogspot.com

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
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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
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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
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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
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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
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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
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Treatment
 Medical
 Specific
 Non specific
 Surgical
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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
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Medical therapy
 Non-specific
 Cycloplegic – mydriatics
 Corticosteroids
 Immunosuppressives
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Cycloplegic mydriatics
 To relieve ciliary spasm and pain
 To prevent posterior synechiae and break the ones already
formed
Partly broken posterior synechiae
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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

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
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Corticosteroids
Topical Periocular Systemic
Prednisolone Methylprednisolone Prednisone
Dexamethasone Triamcinolone Methylprednisolone
Fluoromethalone Betamethasone
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Complications of corticosteroids
Topical Periocular Systemic
As for topical
As for topical
Cataract Weight gain
Peptic ulcer
Ptosis
Osteoporosis
Glaucoma Diabetes
Scleral perforation
Hypertension
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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
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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

Surgery in uveitis
 Diagnostic
 AC tap
 Vitreous biopsy
 Chorioretinal biopsy
 Therapeutic
 Cataract
 Glaucoma
 Retinal detachment
 Vitrectomy
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Complicated cataract
Polychromatic lustre and breadcrumb appearance www.ophthalclass.blogspot.com

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
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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
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Management of uveitis …
…a few examples
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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
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Anterior uveitis…
Posterior
synechiae, pupil bound
down
Hypopyon
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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
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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
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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
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Intermediate uveitis…
Cells and exudates in the anterior vitreous www.ophthalclass.blogspot.com

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)
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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
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Posterior uveitis…
CMV retinitis – granular retinal necrosis, frosted branch angiitis
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CMV retinitis
 Management
 Antiretroviral therapy
 IV Ganciclovir 5mg / kg body wt bid – induction course 2
weeks
 Maintenance – 5mg / kg body wt od
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