Samhaa Mohammed, an ophthalmologist, presents an interactive case of a 38-year-old male with sudden decreased vision and eye pain in his left eye. On examination, the patient has ciliary injection, cells and flare in the anterior chamber, and hypopyon. After one week of topical steroids and cycloplegic drops, the patient's vision improved to 6/12 and anterior chamber activity decreased. The doctor considers further assessing the posterior segment and referring the patient to rheumatology for possible systemic treatment to prevent vision loss and other ocular morbidities. The case discusses differentiating diagnoses, management approaches, and long term follow up needs for uveitis.

1. Interactive cases
(uveitis)
Samhaa Mohammed Abd Elmoneim
FRCS Glasgow, Egyptian Fellowship, MSc.
Zagazig Ophthalmic Hospital
(2021)
Samhaa Mohammed

2. Case
Samhaa Mohammed
38 y M, complains of
sudden decrease of
vision, photophopia,
pain of lt eye
Hx of 2 previous
attacks 4 m & 1 y ago
Slit lamp ex. Shows
→
Ciliary injection, AC:
deep , +ve cell/ flare,
hypopyon, IOP 13
mmhg

3. Case
Samhaa Mohammed
Would you like to
assess posterior
segment before
discharge the
patient?
B scan
(Assess posterior
segment
involvement,
Exclude masquerade,
other associations)
B scan free

4. Case
Samhaa Mohammed
What would you like
to ask him also in
Hx?
Trauma (FB), surgery
Travel (CMV, ARN, HIV)
Pets (Toxoplasmosis)
Joint (Behcet, AS,
reactive arthritis)
Skin (Behcet, VKH,
sarcoid, SLE, PAN)
Kidney, GIT (IBS,
interstitial nephritis)
Chest (Sarcoid, WG, TB)
Ear/ CNS (VKH)
No systemic (FHC)

5. Case
Samhaa Mohammed
Does hypopyon
mobility help in
narrowing DD?
Behcet (shifting)
HLA B27 (immobile)
Genital, oral, skin
lesions

6. Case
Samhaa Mohammed
After 1 wk of topical
steroid, cycloplegic
VA 6/12, ↓AC
activity.
What else would you
like to assess?
Fundus shows →
Vasculitis (retinal)
Death
Blindness

7. Case
Samhaa Mohammed
Refer to
rheumatologist
(systemic steroid,
cyclosporine, biologic
Tx) →
(urgent to save life
and vision)
Follow up for life
even with Tx →
(ocular morbidity)

8. Case
Samhaa Mohammed
Ocular morbidities:
Retinal vasculitis
Optic neuropathy/
atrophy
CME
Neovessels/ vit.
haemorhage
RD
glaucoma

9. Case
Samhaa Mohammed
After 4 months, the
patient comes to you
for follow up
complaining of
gradual decrease of
vision secondary to
significant cataract?
Will you perform
phaco? and when if
yes?

10. Case
Samhaa Mohammed
If fundus
examination shows
CME,
Will you inject
intravitreal anti-
VEGF?

11. How will you manage if he has AC
activity without oral/ genital
ulcers?
Samhaa Mohammed

12. Uveitis overview
Samhaa Mohammed

13. When do you need to investigate?
Systemic
features
Recurrent Bilateral Severe Posterior
Young
age
www.slideshare.net/samhaamoh
https://
102559006
-
ammed/uveitis
Samhaa Mohammed

14. When NOT to investigate?
No or
known
Systemic
features
Single
Unilateral
Non gran.
Mild no
hypopyon
Anterior
Specific
(FHU)
www.slideshare.net/samhaamoh
https://
102559006
-
ammed/uveitis
Samhaa Mohammed

15. Uveitis classification
Anatomical
Anterior
(anterior uvea)
Intermediate
(pars planitis)
Posterior
(retina & choroid)
Panuveitis
(all uvea)
Pathological
Granulomatous
Non
granulomatous
Masquerade
(non/ neoplastic)
(V young, old)
Clinical
Infectious (viral,
bacterial, fungal,
parasitic)
Non infectious
(with/out systemic
association)
Samhaa Mohammed
ww
https://
w.slideshar
e.net/samh
aamoham
med/uveiti
-
s
102559006

16. Uveitis description
Course
Acute (sudden onset,
limited duration)
Recurrent (repeated
episodes separated by
untreated inactive
period)
Relapse (persistent
duration with relapse < 3
m after TTT stop)
Remission (inactivity > 3
m)
Duration
Limited
< 3 m
Persistent
Onset
Sudden
Insidious
www.slideshare.net/samhaamoh
https://
102559006
-
ammed/uveitis
Samhaa Mohammed

17. Causes of post/panuveitis/vasculitis
Granulomatous
Infective
TB, syphilis,
leprosy,
Non infective
VKH, sympathetic
ophthalmia,
sarcoid
Masquerade
metastases,
lyymphoma
Non
granulomatous
Infective
Toxoplasmosis,
endophthalmitis
Non infective
Behcet
Masqerade
RD, lymphoma,
leukemia, OIS
Samhaa Mohammed
www.slide
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share.net/samhaa
mohammed/uveit
102559006
-
is

18. Causes of different uveitis
 Anterior
• HLA B27 spondyloarthropathy
• Fuchs heterochromic uveitis FHU
• Juvenile Idiopathic Arthritis JIA
• Uveitis in inflamatory bowel dis.
• Interstitial nephritis, IgA nephropathy , whipple dis.
• Herpetic
 Intermediate
• Multiple sclerosis MS, Sarcoidosis, Lyme disease, Syphilis,TB
 Posterior
• Non infective:
• Vogt Koyanagi Harada VKH, Sympathetic ophthalmia
• Lens induced uveitis
• Behcet, Sarcoidosis
• MEWDS, APMPPE, Serpingious, AZOOR, birdshot, PIC, MFC
• Infective:
• Toxoplasmosis, toxocariasis (parasitic)
• CMV, ARN, PORN (viral)
• POHS (fungal)
• Syphilis, TB, Cat scratch dis, leprosy, brucellosis (bacterial)
www.slideshare.net/sa
https://
-
mhaamohammed/uveitis
102559006
Samhaa Mohammed

19. C/P of Anterior uveitis
 Symptoms:
• AAU: unilateral photophopia, redness, watery eye
• Recurrent: in HLLAB27, idiopathic.
• CAU: insidious or acute onset. In JIA may be asymptomatic till complication
 Signs:
• VA: according to severity
• Ciliary injection: typically in AAU
• Miosis: spasm of sphincter pupillae → synechia
• AC cells (activity indicator): grading
• Hypopyon: immobile in HLAB27. shifting in Behcet.
• KPS (infl. Cells): arlet Δ (except in FHU is discrete). From fine to mutton fat.
• AC flare (protein): hazy turbid aqeous.
• Fibrinous exudate: in hypopyon of HLAB27
• Iris nodules: koeppe (non g, at pupil), Busacca (g, on surface), Roseola($), Russel(FU)
• Post. synechia: formed rapidly. At koeppe nodules.
• Iris atrophy: diffuse (FHU), sectoral or patchy (herpetiic)
• Heterochromia irides: in daylight difference of both eyes colour.
• NV: twig like vs, amsler sign (FHU), NVI (NOT radial,FFA)
• IOP, post segment (exclude masquerade, CME, spillover)
Samhaa Mohammed
www.slideshar
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med/uveitis
102559006

20. references
• https://www.aao.org/course/core-ophthalmic-
knowledge-uveitis
• https://www.aao.org/diagnose-this-
player/diagnose-this-systemic-symptoms-
associated-with-ch
• http://archopht.jamanetwork.com/article.aspx?arti
cleid=1868368
• https://www.atlasophthalmology.net/photo.jsf;jses
sionid=6AE155C85CEC10DF05D2227D1D5ADD15
?node=9284&locale=es
Samhaa Mohammed

21. Samhaa Mohammed
Thank
you