Uveitis usually poses a diagnostic dilemma. This is a talk which outlines a clinical approach to reach the correct diagnosis and then it's management.

2. An approach to
management of
Uveitis
Dr Noman Nazir Ahmad
Uveitis and Med Retina Consultant
Eye Deptt. CMH Malir

3. Case 1
● A 32 years old female, doctor by profession, presented to eye department
with a refractory anterior uveitis in her right eye.
● This condition had been persisting despite treatment for at least 3 weeks
causing her blurring of vision, pain, photophobia, watering, and recent
onset of foreign body sensation.
● She was using topical steroids in this eye every 4 hours which initially
resulted in some improvement but this improvement did not last and her
condition worsened despite treatment.
● Her VARE was 6/18 improving to 6/9P with pinhole.
● AC showed +1 to +2 cells. IOP was 26 mmHg
● There was a dendritic ulcer visible at the cornea.

4. ● Topical steroids were reduced and were
changed to a weak steroid ie. FML eye
drops TDS tapering further every 5 days.
● Acyclovir eye ointment was added 5
times a day and reduced according to
response.
● Cyclopen eye drops BD
● She was put on close follow-up
● She steadily improved over next two
weeks and dendritic ulcer disappeared
with decrease in AC inflammation and
normalization of IOP
● After 4 weeks of treatment, her
inflammation had completely resolved
and she was advised to continue the FML
E/D OD and Lovir eye ointment for
another week and then stop.

5. Case 2
● A young lady, 21 years of age presented with recent onset loss of vision in
her right eye. It was painless and progressive.
● VA was HM not improving
● No H/O trauma or surgery or pets.
● Systems review was normal. CXR was normal.
● On exam anterior chmaber exam was normal. Fundus exam showed a
dense vitritis with a central yellowish white lesion about 2 DD in size.
● Her toxoplasma serology was sent but came back negative.

6. ● As toxoplasmosis is a ubiquitous
disease with high rates of ocular
involvement. There was clinical suspicion
of Toxoplasmosis and she was started
on Clindamycin 300 mg QID and
Deltacortil 60 mg tapering to a lower
dose over next 04 weeks.
● She showed regression of the disease
at 4 weeks visit. Her VA improved to 6/60
but did not improve further due to
central involvement.
● Her fundus exam revealed a Toxo scar
involving the fovea. Central involvement
is less common in aquired toxoplasmosis
but it occurs in small number of patients.

7. In a case of Uveitis :
1. Always exclude an infectious cause
2. Look for the site and type of inflammation
3. Do not miss active inflammation
4. Do not forget lymphoma / obtain a biopsy when indicated
5. Do not hesitate to use steroid sparing agents
6. Consider sustained release steroids

8. Correct approach can prevent
permenent vision loss.
● The diagnosis and treatments of intraocular inflammation is often challenging.
Uveitis is a sight-threatening disease entity that can arise from various causes. It
mainly affects working-age individuals and may lead to irreversible visual loss if not
treated properly and in a timely manner. As many as 35% of patients with uveitis
exhibit blindness or visual impairment in at least one eye.
● About at least a third of patients are idiopathic. Others have systemic associations.
● Mainstay of treatment remain the steroids. Steroid sparing drugs help to reduce
unwanted effects of steroids. New immunosuppressive therapies use biological
agents.
● Long acting steroid implants are available with the name Ozurdex and Retisert.

9. Always Exclude an infectious cause
● Many infectious forms can masquerade as noninfectious uveitis. Common infections
include:
○ TB
○ Syphilis
○ Toxoplasmosis
○ Endogenous endophthalmitis
○ HIV/AIDS
○ Candida endophthalmitis

10. Common causes of non-granulomatous anterior inflammation in anterior uveitis or
panuveitis:
● HLA-B27 related uveitis
● Behçet's uveitis
● Juvenile rheumatoid arthritis related uveitis
● Uveitis associated with scleritis
● Uveitis associated with streptococcal infection
● TINU Syndrome
● Juvenile xanthogranuloma
● Multifocal choroiditis
Granulomatous Vs Non-granulomatous

11. Granulomatous Vs Non-granulomatous
Common causes of granulomatous anterior inflammation
1. in anterior uveitis
● Fuchs' uveitis
● Herpetic (herpes simplex, varicella-zoster, Epstein-Barr) uveitis
● CMV anterior uveitis
● Posner-Schlossmann syndrome
● Sarcoidosis
● Tuberculosis
● Syphilis
2. in panuveitis
● Sarcoidosis
● Vogt-Koyanagi -Harada syndrome,
● sympathetic ophthalmia
● Tuberculosis
● Syphilis

12. Granulomatous Vs Non-Granulomatous
● Toxoplasmic retinochoroiditis
● Necrotizing herpetic retinopathies (acute retinal necrosis)
● Post-surgical inflammation (propionibacterium acnes)

13. Do Not Miss Active Inflammation
Many chronic posterior uveitides have subclinical smoldering inflammation which can
lead to these complications and result in irreversible vision loss.:
● Macular edema,
● retinal atrophy
● chorioretinal scarring
Examining borders of the lesions is crucial to determine whether immunosuppression is
adequate. Autofluorescence is valuable for comparing the shape of the lesions, and in
many cases, active borders are hyperautofluorescent.
Prompt treatment has shown to reduce the rate of complications and recurrences in
diseases which run a chronic course like:
● VKH syndrome
● Birdshot chorioretinopathy
● PIC
● Serpiginous chorioretinopathy

14. Do not forget Lymphoma/ Obtain a
biopsy when indicated
When degree of vitreous inflammation is severe but scarring and other
sequelae of inflammation are disproportionately mild, Primary Intraocular
lymphoma should be suspected.
A vitreous biopsy is a useful tool in patients with inflammation
unresponsive to treatment. In these cases a vitreous biopsy has a
diagnostic yield of approximately 60%. Occult infections can also be
identified.

15. Do Not hesitate to use steroid sparing
agents.
Mainstay of therapy for Uveitis remains Corticosteroids. If indicated, a short course of high
dose corticosteroids are given to control acute, severe inflammation or in patients with chronic
inflammation, systemic steroids will be required to control the symptoms followed by long term
steroid sparing immunosuppression.
In acute sight threatening inflammation I/V methyl prednisolone may be used at 500-1000mg/
day for three days, followed by oral corticosteroid therapy.
It is imperative that steroids should be gradually tapered. The taper should not be too quick so
as to prevent rebound inflammation.

16. .... Use of steroid sparing agents
Side effects of steroids should be discussed with the patient. This can improve compliance.
Steroid sparing agents be added to go to a lower dose of systemic steroids.
Immunosuppressive drugs can be indicated at presentation if the disease has a poor
natural history for example in Behcet’s disease with posterior involvement, serpiginous
choroidopathy, sympathetic ophthalmia and birdshot chorioretinopathy.
Additionally, immunosuppressive drugs should be considered if an adequate response is
not seen with two to four weeks of high dose corticosteroids or if after three months of
adequate treatment and taper, the disease is not controlled on less than 10 mg of
prednisone per day.

17. Consider sustained release steroids
in Non-infectious Uveitis.
Intravitreal injection of Triamcinolone acetonide is very important in treatment of
uveitic CME but can cause side effects like cataract, ocular hypertension,
glaucoma, RD, Vitreous Hemorrhage, and endophthalmitis.
Ozurdex is a biodegradable polymer implant that contains 700ug of
dexamethasone, which is to be released in the vitreous cavity over a six months
period. Particularly useful in cases of CME or vasculitis as well as in vitrectomized
eyes in which the effect duration of triamcinolone is significantly decreased.
Retisert is a flucinolone acetonide containing, non-biodegradable implant which
releases the drug for three years. However it has a higher rate of complications.
Can necessitate incisional glaucoma surgery in about 30-40 % eyes - in contrast to
less than 1% in patients with serial Ozurdex injections.
It is very important to rule out infectious causes when intraocular steroids are used.

18. Conclusion
Although uveitis remains a vision threatening disease,more treatment
options are available for its effective treatment in current times.
Prompt diagnosis of infectious causes and control of damaging
inflammation are important steps in it’s management. It is also
important to exclude malignancy.
In non-infectious uveitis, ophthalmologists can consider steroid sparing
treatments, such as Biologics, as well as the newer sustained release
steroid implants.

19. Thank You