This document discusses investigations and treatments for uveitis. It begins by outlining general investigations like bloodwork and imaging that can be used to determine the cause of uveitis based on factors like age, ethnicity, type of uveitis, and symptoms. It then discusses specific infectious and non-infectious diseases that can cause uveitis, listing relevant tests and treatments for conditions like tuberculosis, syphilis, sarcoidosis, and more. The document emphasizes that determining the underlying cause of uveitis through appropriate investigations is important for guiding effective treatment.

1. UVEITIS
INVESTIGATIONS
&
TREATMENT

2. References
• AIOS CME Series no. 20 “uveitis made simple work up and
management ” by S.R Rathinam.
• Basic and Clinical Science Course Section 9 intraocular
inflammation and uveitis (AAO).
• Uveitis Fundamentals And Clinical Practice by Robert B.
Nussenblatt & Scott M. Whitcup
• Ophthalmology By Yanoff & Duker
• Postgraduate ophthalmology by Zia Chaudhuri & M Vanithi
• Clinical Review: Investigation and management of uveitis by
Catherine M Guly & John V Forrester
• Principles and Pra/ctice of Ophthalmology by Albert and Jakobiec

3. Uveitis
• Inflammation of the uvea.

4. • To explain cause of poor vision.
• Rule out masquerade
syndromes/infections.
• For academic and research purposes.
INDICATIONS FOR
INVESTIGATIONS

5. Investigations can lead you somewhere, anywhere or nowhere

6. Which INVESTIGATION to do
???
This depends on :
• Age, Sex and ethnicity.
• Type of uveitis
(anterior/intermediate/posterior)
• Associated ocular and extraocular
signs/symptoms.
• Nature of uveitis (acute/chronic;
unilateral/bilateral; active/healed)

7. General Investigations
• Complete Blood count- CBC
• ESR/ C Reactive Protein
• Syphilis Serology- TPHA, VDRL
• Blood sugar & Urine analysis (Diabetes
Mellitus)
• Kidney and Liver function tests

10. Local
• Hot compress – 3-4 times/day :
soothing , increases the circulation
• Use dark glasses

12. Anterior Uveitis:

13. Treatment of Intermediate
Uveitis (IU)

14. Nonsteroidal anti-inflammatory
agents
• Inhibits cyclooxygenase and reduce
prostaglandin synthesis.
• Indicated in
– Postoperative inflammation and CME
– Chronic iridocyclitis of JIA
– Allows maintaining patient on a lower
dose of topical corticosteroid when used
as an adjunct.

15. Infectious Uveitis: Bacterial Diseases
Tuberculosis
• Chest X Ray,
• Mantoux test,
• Acid-fast stain of ocular fluid,
• Culture in LJ media,
• Morning sputum & urine stain &
cultures for M. tuberculosis,

17. • Gamma interferon assays
• Quantiferon TB Gold and
• Enzyme-linked immunospot (ELISPOT)
test.
• PCR

18. • FFA & ICG: CNVM
– Early hypofluorescence, late
hyperfluorescence : active choroiditis
– Ring of fire : sub retinal abscess &
choroidal granuloma
• OCT
• Contact sign & hyper reflective
inflammatory cells
• B scan
• Differentiate subretinal abscess and
neoplasia.

20. Rx

21. Leprosy
• Slit smear test or other tissue biopsy
Corneal scraping
acid-fast bacilli
AC tap acid-fast
bacilli globi
skin biopsy Fite stain

22. Rx
• Multidrug treatment including rifampicin,
dapsone, and clofazimine for a period of
6–12 months.
• Topical corticosteroids and oral
corticosteroids.
• Phenylepherine is the drug of choice to
keep pupils mobile in leprosy patients

23. Syphilis
• Dark-field
microscopy/immunofluorescent staining
• Nontreponemal tests: (detect antibody to
cardiolipin cholesterol antigen)
– Venereal Disease Research Laboratory
(VDRL)
– Rapid plasma reagin (RPR)
– (CSF)-VDRL

24. • Treponemal tests:(detect antibodies
against treponemal antigens)
– Treponema pallidum immobilization test
– Fluorescent treponemal antibody
absorption tests (FTA-ABS)
– Hemagglutination treponemal test for
syphilis
– Hemagglutination assay for T. pallidum
– Microhemagglutination tests

25. Syphilis

26. Leptospirosis
• Microagglutination test
• ELISA for Leptospira antigens
• PCR

27. Rx

28. Lyme disease
• Borrelia burgdorferi by ELISA and
Western blot
• Culture from peripheral blood, skin rash,
and CSF.
• PCR
• ELISA and indirect immunofluorescent
antibody (IFA) can detect IgM & IgG.
• Lymphocyte antigen stimulation,
antibody capture enzyme immunoassay,
and detection of antibodies in urine

29. Rx

30. B. Parasitic Diseases
Toxoplasmosis
• ELISA for Toxoplasmosis Serum anti-
Toxoplasma IgG and IgM,
• Toxoplasmosis: IgM is important in neonates,
while it is rising IgG in adults
• Skull X Ray for calcification, if congenital
Toxoplasmosis,
• HIV if bilateral Toxoplasmosis,
• CT/MRI if HIV positive and symptomatic
Toxoplasmosis

31. Goldmann-Witmer (GW)
coefficient
• Compares the levels of intraocular
antibody production to that of serum,
as measured by ELISA.
• GW ratio > 4 is diagnostic of local
antibody production to a specific
microbial pathogen.

32. Ophthalmology 2005 Nov;112(11):1876-82

33. • Clindamycin
• Subconjunctival injection 50mg
• Intravitreal, +/- systemic Rx
– Weekly (or monthly in pregnancy) til quiet
• Lasave et al, Ophth 2010;117:1831-1838

34. Cysticercosis
• B-scan ultrasound (USG), ultrasound Bio
Microscope (UBM) of eye to distinguish
from choroidal melanoma.
• CT and MRI of body tissues of brain,
muscle

35. Rx
• Vitrectomy to remove larva from vitreous.
• In subretinal lesions via sclerotomy site,
and repair of detachment with scleral
buckling.
• Albendazole can be used.

36. Toxocariasis
• ELISA for Serum anti-Toxocara canis
IgG and IgM
• Eosinophils in aqueous/vitreous

38. Viral diseases : HIV
• Tridot
• Western blot
• ELISA

39. Rx
• HAART is a combination of two drug
categories: two or more reverse
transcriptase inhibitors, such as
zidovudine (a nucleoside analog) or
nevirapine (a non-nucleoside reverse
transcriptase inhibitor)
• With one or more viral protease inhibitor,
such as indinavir or ritonavir

40. Herpes simplex virus &
Herpes varicella-zoster virus
• Aqueous and vitreous fluid for PCR
(polymerase chain reaction),
• Goldmann-Witmer quotient

41. Rx
• Intravenous acyclovir is given at 1500
mg/m2 every 8 hours for about 7 days.
• Followed by several weeks of oral
acyclovir.
• Retinal detachment: prophylactic laser
demarcation
• ARN-associated retinal detachments:
vitrectomy, endolaser, and silicone oil
techniques.

42. Cytomegalovirus
• Congenital
• Viral inclusion bodies in urine, saliva,
intraocular fluid
• Complement fixation test useful @ 5-24
mos
– after loss of maternal antibodies

43. • Acquired: Usually clinical diagnosis
– PCR of aqueous/vitreous
– Culture urine, saliva, lymphocytes
– Giant cells with inclusions - retina, RPE
• Nuclear inclusions eosinophilic
• Cytoplasmic inclusions basophilic

45. Disease HLA Typing
Tubulointerstitial nephritis and uveitis
syndrome
DRB1
Birdshot retinochoroidopathy A29
Behcet’s disease B51, B5
Reactive arthritis B27
Anterior uveitis (AS) B27, DR8
Vogt-Koyanagi-Harada disease DR4
Sympathetic ophthalmia DR4
Panuveitis DR4
Intermediate uveitis B8, B51, DR3; DR2
Chronic iridocyclitis (IJA) DR5; DQ3 (7.5)
Retinal vasculitis B44
Multiple sclerosis B7, -DR2
Sarcoidosis B8, B13
JIA B27, A2,DR5, DR 8, DR 11
HLA ASSOCIATION

46. Juvenile idiopathic arthritis
• ANA
• RA factor
• X Ray
II. Non Infectious Uveitis

47. • Treatment
– AC cells (do not treat flare):
– Topical or periocular steroids
– NSAIDS
– Immunosuppressives
• Methotrexate
• Biologics: Infliximab; Adalimumab
• Band keratopathy: EDTA chelation
• Glaucoma: meds/surgery
• Cataracts: quiet 3 months
– anterior vs. pars plana approach

48. HLA-B27 related
Anterior Uveitis
• HLA-B27 typing
• X-ray sacroiliac joints (2 yearly
Sacroiliac joint X rays in males if initial
X ray normal)

49. • Definitive diagnosis: biopsy
– Non-caseating epithelioid granulomas
– Conjunctiva, lacrimal gland, skin,
transbronchial,mediastinal
Sarcoidosis

51. • Gallium scan:
– Increased uptake in lacrimal & salivary
glands (panda sign), lungs
• Pulmonary Function Tests
• Diffusing capacity of the lung for
carbon monoxide (DLCO)
• Skin testing
– Anergy
– Kveim test

52. Rx
• Indications:
– Uveitis
– Symptomatic pulmonary disease
• Corticosteroids
– Local
• Topical, periocular, intravitreal (injection / implant)
– Systemic
• Other immunosuppressives
– Cyclosporine, methotrexate, chlorambucil,
azathioprine, mycophenolate mofetil

53. • Cataract surgery
– Eye quiet 3 mos pre-op
– High doses systemic steroids perioperatively
– Pars plana vs. anterior approach

54. Wegener’s granulomatosis
• Chest radiography,
• Sinus x-ray film,
• cANCA (antinuclear cytoplasmic
antibodies),
• Urinalysis,
• Tissue biopsy

55. Rx
• Treatment: corticosteroids,
• cyclophosphamide
– Decreases 1-year mortality from 90% to
10%

56. Polyarteritis nodosa (PAN)
• Serum eosinophils,
• p ANCA,
• Angiography

57. Rx
• Treatment: corticosteroids,
cyclophosphamide
– Decreases 5-year mortality from 90% to
20%

58. Behcet’s syndrome
• Fundus Fluorescein Angiography (FFA)
– Capillary dropout, vascular remodeling
– Vascular & disc leakage, NV
• HLA-B51 and B52,
• Pathergy on skin testing

59. Rx

60. Vogt-Koyanagi-Harada
syndrome (VKH)
• USG, (ultrasonogram)
• FFA
– Early phase numerous hyperfluorescent dots at level of RPE.
gradually enlarge & accumulates in the subretinal space
– Chronic phase, diffusely scattered dots of hyperfluorescence
due to the window defects at evel of the RPE.

61. Rx
Steroids Oral or
IVPrednisone 1.5-2
mg/kg With tropical
steroids and
cycloplegics
Cytotoxic and/or
immunosuppres
sive eg.
azathioprine,
mycophenolate
mofetil,
cyclophosphami
de, and
ciclosporin
Chronic phase
require both
cytotoxic agents
and
corticosteroids

62. Sympathetic ophthalmia
• USG, ( ultrasonogram)
• FFA
• Enucleation of the blind eye and
histopathology

63. Enucleation
of the injured
eye within 2
weeks of
injury
Rx
Steroids
Prednisone
1.5-2 mg/kg
Cytotoxic and/or
immunosuppressive eg.
azathioprine,
mycophenolate mofetil,
cyclophosphamide, and
ciclosporin

64. Fuchs’ heterochromic
iridocyclitis
• Based on the clinical presentation

65. • Treatment
– Topical steroids (often unnecessary)
– Cataract surgery – usually do well
– Glaucoma may be difficult to control

66. Birdshot
• FA & ICG
• Retinal lesions often silent on FA
– Hypofluorescent lesions early
– Hyperfluorescent late
• Hyperpermeability of retinal capillaries
• CME
• Disc hyperfluorescence/leakage
• Hypofluorescent lesions on ICG

67. • HLA-A29
– 7% population
– 50-80% birdshot
• Strongest association of all HLA associated
diseases
• Response to retinal S Antigen
(arrestin) in 90%
• Abnormal dark adaptation
• Chronic visual field loss and
progressive nyctalopia

68. • ERG may be reduced
– 30 Hz flicker implicit time
– Bright scotopic response amplitude
• Useful for monitoring treatment
response

69. Rx
• Corticosteroids – may help in ~ 50%
• Other immunosuppressives
• Kiss et al, Ophth 2005 112: 1066-1071
– Mycophenolate (start 1g/d to 3g/d)
– Cyclosporine (start 3mg/kg to 5mg/kg/d)
– Monitor ERG q 6 mos
– Quiescent 2 yrs then slow taper

70. • 5 year follow-up
• 50% maintained 20/50 or better
• Visual acuity loss due to CME (63%)
• Other causes of decreased vision: ERM,
CNV, macular scars, cataract

71. Intraocular lymphoma
• Vitreous biopsy for cytology, immuno
histochemist(CD-20 cells)
• MRI,
• lumbar puncture,
• CSF cytology

73. OZURDEX®
• Dexamethasone 0.7mg intravitreal
implant
• Indicated in macular edema following
branch retinal vein occlusion (BRVO)
or central retinal vein occlusion
(CRVO) and non-infectious uveitis.