signs and symptoms of granulomatous uveitis , diagnosis and management in brief.

1. Dr. RAGHAV PREETAM
1ST YEAR RESIDENT ,SRMC

2. A 60 YEAR OLD FEMALE WOMAN ,RESIDENT OF PANYAM PRESENTED TO OPD WITH
C/O
INSIDIOUS ONSET OF DOV SINCE 3 MONTHS ( BOTH EYES )
GRADUALLY PROGRESSIVE
NOT ASS WITH PAIN , PHOTOPHOBIA OR HYPERLACRIMATION.
H/O FLOATERS +
NO H/O METAMORPHOPSIA , MICROPSIA & MACROPSIA.
NO H/O TRAUMA
NO H/O SURGERY
1. Children: Juvenile Rheumatoid Arthritis,
Toxocariasis
2. Young adults: Bechets, Human Leukocyte
Associated antigen B27–
associated uveitis, Fuch’s uveitis.
3. Old age: Vogt Koyanagi Harada syndrome,
Herpes Zoster Ophthalmicus,
Tuberculosis and Leprosy.
1. Males - Ankylosing
spondylitis, Reiters,
Bechet’s, Sympathetic
ophthalmia.
2. Females- Rheumatoid
arthritis, Juvenile
Rheumatoid Arthritis
1. Ankylosing spondylitis, Reiters – Caucausians1.
2. Sarcoid- Blacks
3. Vogt Koyanagi Harada’s syndrome, Bechet’s
syndrome –Orientals1, 8.

3.  PAST ILLNESS :
TB,LEPROSY,SYHILIS
DM,HTN,CVA,CAD
IMMUNOCOMPRIMISED
H/O PREV ATTACKS
ANY OTHER EYE …
 PERSONAL HISTORY :
SMOKER
PETS
DIET
SOCIOECONOMIC STATUS

4.  ARTHRITIS
 URETHRITIS AND CYSTITIS
 NEUROPATHIES & NEPHROPATHIES
 RESIPRATORY ILLNESS ( TB )
 FEVER
 LOSS OF HEARING
 RASH
 STDS
 TRAVEL
 GIT SYMPTOMS
 NEUROLOGICAL MNIFESTATIONS

5. LOOK ENLARGED LACRIMAL GLAND
MADAROSIS & POLIOSIS
CUTANEOUS VESICLES

6. C. NODULE
CILIARY FLUSH

7. BAND
KERATOPATHY
MUTTON FAT
KP`S

8. SPK
GEOGRAPHICCAL ULCERS
SCLEROKERATOUVEITIS

9. MINIMAL AC REACTION
MINIMAL FLARE
HYPHAEMA – HERPES
HYPOPYON – IOP

10. Miotic , festooned
Busacca & koeppe nodules
Sectoral iris atrophy

11. FOREIGN BODY AND NODULES .
ABNORMAL IRIS VESSELS ,
NEOVASCULARIZATION OR FINE BRANCHING
VESSELS – FUCHS

12. PSCC /COMPLICATED
CATRACT
GLAUCOMAFLAKEN

13. SNOW BALLS
LOCAL POCKET – FOCAL
CHORIORETINITS . SNOW
BALLS - SARCOIDOSIS

14. The causes of elevated IOP incude:
[1] Posner-Schlossman’s syndrome
[2] Herpetic uveitis
[3] Toxoplasmosis
[4] Fuchs’ heterochromic iridocyclitis
[5] Sarcoidosis
[6] Iridocyclitis with secondary angle closure glaucoma.

15. RETINAL VASCULITIES - WEGNER’S

16. SARCOIDOSIS & TUMOURS INFILTRATE DISC

17. Chronic inflammation can lead to the following
pathologies at macula
[1] Cystoid Macular Edema (CME)
[2] Macular lamellar holes
[3] Retina Pigment Epithelial clumping
[4] Choroidal Neo-Vascular Membrane (CNVM)
[5] Exudative macular detachment

18. TB & SARCOIDOSIS FOCAL & DIFFUSE

20. Systematic work up
• Descriptive naming Example unilateral/bilateral: granulamatous/
non granulamatous: acute/chronic
• Meshing Comparison with the existing diagnosis
• General and specific lab testing To evaluate the patient for
treatment; To rule in/rule out diagnosis
• Specialist consultation To confirm the systemic disease and start
the treatment
• Therapy General and specific treatment
• Follow up Evaluation for the course of the disease and
effectiveness of treatment

21. Who will need the investigations?
The investigatory work up is needed only for the patients
in whom the investigation,
• Will provide a ‘definitive’ aetiology
• Will confirm or reject a possible diagnosis
• Will identify any underlying systemic disease process or
association
• Will help in the management of the patient
• Will study a possible iatrogenic complication
• Will study the sequela of the disease
• Will play as a prognostic indicator

22.  TB
 SARCOIDOSIS
 SYPHILIS
 LEPROSY
 HERPES SIMPLEX AND HERPES ZOSTER
 MASQUERADE SYNDROME
 VKH
 SYMPATHETIC OPHTHALMIA

23.  CBC WITH DIFFERENTIAL
 CHEST XRAY FOR SARCOID & TB
 FTA-ABS FOR SYPHILIS
 MONTOUX TEST
 ACE TEST FOR SARCOID
GALLIUM TEST FOR SARCOID
TOXOPLASMOSIS (ELISA)
LYME SEROLOGY

25. Chronic inflammation
Infiltration with lymphocytes , plasma cells and with
mobilisation & proliferation of large monocular cells which
eventually become epithelioid & giant cells & aggregate
into nodules
Necrosis in adjacent structures leads to a reparative
process resulting in fibrosis & gliosis of involved area.

27.  Mycobacterium tuberculosis or bovis
 1-2% ocular involvement in known TB patients
 Chronic smoldering granulomatous infection involving any part of
uvea .
 Signs :
Mutton fat kps
Koeppe and busacca nodules
Retinal vascular periplebhitits
Choroiditis unifocal or multifocal
Serpiginous choriditis
Single solitary choroidal granuloma

28.  Investigations :
 CXR ( does not rule out)
 Mantoux test
 TS SPOT & QUANITFERON TB
SPOT TEST


29. Mode of presentation
Acute (3rd decade)
Lofgren
syndrome
Heerfordt
syndrome
Insidious ( 5th
decade )
7th nerve palsyFever ,
E.Nodosum ,
BiHLN ,
artharlgia
Fever + parotid
Uveoparotid fever
Neurological
Fever , arthralgia ,dysnoea

30.  SYSTEMIC :
Lungs 95 % - bilateral hilar
lymphadenopathy , pulm fibrosis ,
bronchiectasis
Skin – Erythema Nodosum , lupus
Perini , skin granuloma
 OCULAR :
Lacrimal enlargement
Conjunctival granuloma
Dry eye
Chr ant uveitis
Subtle periplebitis , candle wax
drippings ,snow balls & vitritis ,
NVE
Fundus granulomata
?pappilitis

31. Chest xray – 95% positive
Elevated ACE :
Normal 12 -68U /L
If on steroid false negative
Rises in DM ,leprosy , hyperthyroidism , CRF
Galium scan
Skin test

32. Treponema pallidum ( spirochaete )
Uveitis in secondary or terititary stages
Uncommon ,Bilateral ( 50% of cases )

34. Non treponemal tests
(cardiolipin antigen )
VDRL & RPR
Treponemal tests
(Treponemal antigens)
FTA – ABS , Heamagglutin
Less specific
Monitor Rx effectiveness
Equally sensitive &
more specific
investigations

35. Mycobacterium leprae
Lepromatous & tuberculoid types
Skin, nerves ,eye

37. Slit skin smear test
9 banded armadillo – experimental
No culture conclusive
Clinical correlation most imp

38. Vitiligo ,
poliosis
alopecia
Ant uveitis
VOGT KOYANAGI SYNDROME
Exudative
RD
pappilitis
Multifocal
choroiditis
Csf pleocytosis
HARADA SYNDROME

39. FFA
multiple
hyperfluroscent dots
which increase
gradually at level of
RPE
USG
Serous RD , diffuse
thickening of post
choroid ,vitreous
opacities & post scleral
thickening
CSF
pleocystosis

40.  Herpes simplex & herpes zoster
 Ocular signs :
Decreased
corneal
sensations
Central kps
Sectoral iris
atrophy
Secondary
glaucoma
Hutchinson`s
sign
Trabeculitis&
outflow block
Tip of nose
,inc risk of
uveitits
Sensitive to
topical
steroids

41.  The term masquerade syndrome encompasses a group of disorders that mimic
clinical presentations of ocular inflammation .
MALIGNANT DISORDERS NON MALIGNANT DISORDERS
Intraocular lymphoma Intraocular FB
Leukaemia RD
Carcinoma metastasis Myopic degeneration
Uveal melanoma Pigment dispersion syndrome
Childhood malignancies Post op inf
Cancer associated retinopathy Post vaccination disorders
Melanoma associated retinopathy Rifabutin , didanosine reactions

43. Topical steroids Cyclplegics
Antibiotics Immunotherapy
Rx

44. Predinsolone
Biphasic solubility ,penetrates lipids & aqueous layers
No effect
Inc frequency +bed time ointment
Periocular inj
Systemic therapy
Effective
Taper
dose
Loteprednol & Rimexolone
Lesser chance of inc IOP

45. Pred 1mg/kg/day
Consider AC tap
Rule out infection and masquerade syndrome
Antibiotics /+immunosupressive