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Uveitis
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.
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Uveitis
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- 2. References • AIOS CMESeries 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 ofthe uvea.
- 4. • To explaincause of poor vision. • Rule out masquerade syndromes/infections. • For academic and research purposes. INDICATIONS FOR INVESTIGATIONS
- 5. Investigations can leadyou somewhere, anywhere or nowhere
- 6. Which INVESTIGATION todo ??? 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 • CompleteBlood 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
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- 14. Nonsteroidal anti-inflammatory agents • Inhibitscyclooxygenase 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: BacterialDiseases 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 interferonassays • 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.
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- 21. Leprosy • Slit smeartest or other tissue biopsy Corneal scraping acid-fast bacilli AC tap acid-fast bacilli globi skin biopsy Fite stain
- 22. Rx • Multidrug treatmentincluding 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:(detectantibodies 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
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- 26. Leptospirosis • Microagglutination test •ELISA for Leptospira antigens • PCR
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- 28. Lyme disease • Borreliaburgdorferi 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
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- 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 • Comparesthe 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.
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- 33. • Clindamycin • Subconjunctivalinjection 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 toremove larva from vitreous. • In subretinal lesions via sclerotomy site, and repair of detachment with scleral buckling. • Albendazole can be used.
- 36. Toxocariasis • ELISA forSerum anti-Toxocara canis IgG and IgM • Eosinophils in aqueous/vitreous
- 38. Viral diseases :HIV • Tridot • Western blot • ELISA
- 39. Rx • HAART isa 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 acycloviris 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 • Viralinclusion bodies in urine, saliva, intraocular fluid • Complement fixation test useful @ 5-24 mos – after loss of maternal antibodies
- 43. • Acquired: Usuallyclinical 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 Tubulointerstitialnephritis 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 – ACcells (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 • Chestradiography, • 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 • FundusFluorescein Angiography (FFA) – Capillary dropout, vascular remodeling – Vascular & disc leakage, NV • HLA-B51 and B52, • Pathergy on skin testing
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- 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 IVPrednisone1.5-2 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 eyewithin 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 • Basedon the clinical presentation
- 65. • Treatment – Topicalsteroids (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 maybe 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 yearfollow-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 • Vitreousbiopsy for cytology, immuno histochemist(CD-20 cells) • MRI, • lumbar puncture, • CSF cytology
- 73. OZURDEX® • Dexamethasone 0.7mgintravitreal implant • Indicated in macular edema following branch retinal vein occlusion (BRVO) or central retinal vein occlusion (CRVO) and non-infectious uveitis.
Editor's Notes
- #16 unifocal or multifocal choroiditis
- #57 Small vessel vasculitis
- #61 :(A) Fundus fluorescein angiography of the right eye showing staining of the optic disc in the early arteriovenous phase with multiple pinpoint hyperfluorescence. (B) Fundus fluorescein angiography of the right eye showing staining of the optic disc with pooling of dye in the subretinal space in the late arteriovenous phase