This is appt presentation done by me and my colleagues zakaria Abul-Nasser and Sara Hassan ( agroup of medical undergarduates , school of Medicine, Ain-shams university , Cairo , Egypt ) ... This work was presented at the end of our Ophthalmolgy clinical round .. I Hope every one to get the best out of the presentaion ..Any commentaries are even more appreciated :)

1. New Trends In Management Of
Uveitis

2. Agenda
General Investigations
Considerations
• Classification •Overview
 Anatomical •Differential Diagnosis
Clinical •Lines Of Investigations
Pathological (General & Special :
• Etiology/Pathogenesis Skin tests
•Symptoms  Serology
•Signs Enzyme assay
•Complications  Histopathology
Imaging
HLA typing

3. Management
• Non-specific treatment
mydriatics
Steroids
 Systemic Immunosuppressive agents
Interferons
physical measures
• Specific treatment of the cause
• Treatment of complications :
Inflammatory glaucoma
Post-inflammatory glaucoma
 Complicated cataract
 Retinal detachment of exudative type
Phthisis bulbi
• Surgical management

4. General Considerations
Classification
Anatomical
Anterior Clinical
uveitis
Acute uveitis
Intermediate
uveitis Chronic
uveitis
Posterior
uveitis

5. General Considerations
Classification
Pathological
Suppurative or
purulent uveitis
* Non-granulomatous uveitis
Non-suppurative uveitis
* Granulomatous Uveitis

6. General Considerations
Etiology
Infective
Syndromes of
Non-Infective unknown etiology
Exogenous Endogenous
Allergic or Sympathetic
Traumatic
Autoimmune ophthalmitis

7. General Considerations
Symptoms
Ant. Uveitis Post.Uveitis
( Iridocyclitis ) (Choroiditis )
Acute : Patients are free of pain,
• Dull pain in the eye or forehead although they report
• Impaired vision blurred vision and floaters
• photophobia
•E xcessive tearing (epiphora). Choroiditis is painless, as
the choroid is devoid of
Chronic : sensory nerve fibers.
may exhibit minimal symptoms

8. General Considerations
Signs
Acute Iridocyclitis
 Intense circum-corneal ciliary injection
 small Pupil
 Keratic precipitates (KPs) – endothelium dusting
by myriads of cells
 Flare and cells ( often intense )
 Fibrinous exudate ( if severe )
 Hypopyon ( if very severe )
 The iris is usually unremarkable; occasionally
shows dilated capillaries

10. General Considerations
Signs
Chronic Iridocyclitis
 Injection ……… mild or absent
 Pupil ………. Unremarkable
 KPs........ mutton-fat in granulomatous disease
 Flare and cells …….. Variable
 Fibrinous exudate ……. absent

11. General Considerations
Signs
Post.uveitis (Choroiditis)
 Vasculitis of retinal vessels is possible
 Isolated or multiple choroiditis foci.
 Occasionally the major choroidal vessels will be
visible through the atrophic scars
 No cells will be found in the vitreous body in a
primary choroidal process .However, inflammation
proceeding from the retina (retinochoroiditis) will
exhibit cellular infiltration of the vitreous body

13. General Considerations
Complications
Ant. Uveitis Post.Uveitis
Acute : Depends on the underlying disease and
* Posterior synechiae (PS) …..> rare at severity of the disease
presentation but may form later
* Cataract ….> absent The inflammatory foci will heal within 2–6
Glaucoma …..> rare weeks and form chorioretinal scars.
The scars will result in localized scotomas
Chronic : that will reduce visual acuity if the macula
* PS – common at presentation is affected
* Cataract – rare at presentation but may
develop later
* Glaucoma – rare at presentation but
may develop later

14. Differential Diagnosis
It is important to note that uveitis can be caused or
mimicked by the following :
 “Masquerade Syndromes”- neoplasms mimicking uveitis
 Ocular malignant melanoma
 Retinoblastoma
 Reticulum Cell Sarcoma (Primary Intraocular Lymphoma)
 Leukaemia - Lymphoma - Ocular Metastasis
 Endophthalmitis
 Retinal detachment
 Intraocular foreign body

15. Investigations
General Investigations
 ESR / Plasma Viscosity/ C Reactive Protein
 CXR / FBC /
 Syphilis Serology: TPHA, VDRL
 Urine analysis (Diabetes Mellitus)

16. Investigations
Special Investigations
Skin Tests:
Tuberclin skin tests
pathergy test : for diagnosis of Behcet's syndrome
Serology:
Syphilis Toxoplasmosis
*Dye test (Sabin-Feldeman)
* Non treponemal :RPR & VDRL * Immunoflurescent antibody
* Treponemal : FTA-ABS & MHA- * Heamagglutination tests
TP
*ELISA

17. Investigations
Special Investigations
Enzyme assay Imaging Biopsy:
Ocular biopsies :
* (ACE) * Flurescin angiography
*Lysozyme has good * Conjunctiva and
* Iodocyanine green lacrimal gland
sensitivity but less angiography
specificity than ACE * Aqueous sample
* Ultrasonography (US) * Vitreous biopsy
* Optical coherence * Retinal and
tornography (OCT) Choroidal biopsies.

18. Investigations
Special Investigations
Radiology:
1. Chest radiographs are to exclude tuberculosis and sarcoidosis.
2. Sacroiliac joint x ray is helpful in the presence of a spondyloarthropathy in
the presence of symptoms of low back pain and uveitis.
3- CT and MRI of the brain and thorax are useful in sarcoidosis , multiple
sclerosis and primary intraocular lymphoma
HLA typing:
HLA type Associated disease
B27 Ankylosing
A29 spondylitis
B51 Bircishot
HLA - B7& DR2 chorioretinopathy

19. Management
 Non-specific treatment
mydriatics
Steroids
 Systemic Immunosuppressive agents
Antimetabolites
Interferons
physical measures
 Specific treatment of the cause
 Treatment of complications :
Inflammatory glaucoma
Post-inflammatory glaucoma
 Complicated cataract
 Retinal detachment of exudative type
Phthisis bulbi
 Surgical management

20. I.Non-specific treatment
Mydriatics
Steroids
Systemic Immunosuppressive Agents
Interferons
Physical measures

21. Mydriatics
Short-acting Long –acting
Tropicamide (0. 5% and 1 %)..> 6h Atropine 1%
 Cyclopentolate (0. 5% and 1 %)..>24 h is the most powerful
cycloplegic and mydriatic
 Phenylephrine (2.5% and l0%) ..> 3h with a duration of action
‘’ but no cycloplegic effects ‘’ lasting up to 2 weeks

22. Mydriatics
Indications
To relieving spasm of the ciliary muscle and
pupillary sphincter ( usually with atropine )
To reduce exudation by decreasing hyperaemia and vascular
permeability
To increases the blood supply to anterior uvea
To prevent formation of posterior synechiae by using a short-acting
mydriatic which keeps the pupil mobile.
To break down recently formed synechiae with intensive topical
mydriatics (atropine. phenylephrine) or subconjunctival injections of
Mydricaine

23. Steroids
periocular
injection Intravitreal
injection
Topical
eyedrops Systemic
or
ointment Route of
administration

24. Steroids
Topical Steroids
Indications
Treatment of acute anterior uveitis
Frequently then gradually tapered . Often discontinued by 5-6 weeks
Treatment of chronic anterior uveitis
is more difficult because the inflammation may last for months and even
Complications
Corneal systemic side
Glaucoma Cataract
complications effects

25. Steroids
Periocular injections
Advantages over topical steroids
Therapeutic concentrations behind the lens may be achieved.
water-soluble drugs incapable of penetrating the cornea when
given topically, can enter the eye trans-sclerally. when given by
periocular injection
along-lasting effect can be achieved with depot preparations such
as (methylprednisolone acetate " Depomedrone" ).

26. Steroids
Periocular injections
Indications
Severe acute anterior uveitis
Intermediate uveitis
As an adjunct to topical or systemic therapy in resistant chronic anterior
uveitis
Poor patient compliance with topical or systemic medication
At the time of surgery in eyes with uveitis

27. Steroids
Intravitreal injection
* Intravitreal steroid injection of is currently
under evaluation.
* It has been used successfully in resistant
uveitic chronic cystoid macular oedema.

28. Steroids
Systemic therapy
Preparations Indications
1- Oral prednisolone • Intractable anterior uveitis
resistant to topical therapy and
* 5 mg is the main preparation. anterior sub-Tenon injections.
* Enteric coated tablets are useful in
patients with acidpeptic disease. • Intermediate uveitis unresponsive
to posterior subTenon injections.
2. Injections of (ACTH]
* Useful in patients intolerant to oral • Certain types of posterior or
steroids. panuveitis, particularly with severe
bilateral involvement.

29. Steroids
Systemic therapy
General rules of administration
• Start with a large dose and then reduce .
• A reasonable starting dose of prednisolone is 1mg/kg per
day given in a single morning dose.
• Once the inflammation is brought under control , reduce
the dose gradually over several weeks.
• If steroids aregiven for less than 2weeks , there is no need
for gradual reduction.

30. Steroids
Systemic therapy
Side effects
• Dyspepsia
• Mental changes
short term • Electrolye imbalance
• Aseptic necrosis of the head of the
therapy femur , and very rarely
• Hyperosmolar , Hyperglycemic non-
ketotic coma
• A Cushngoid state
Long term •
•
Osteoporosis
Reactivation of infections such as TB
therapy • Cataract
• Limitation of growth in children

31. Systemic Immunosuppressive agents
Antimetabolites T-cell inhibitors
Indications of Immunsuppressives:
1. Sight-threatening uveitis. Which is usually bilateral , non-
infectious , reversible and has failed to respond to adequate
steroid therapy.
2. Steroid-sparing therapy in patients with intolerable side effects
from systemic steroids.

32. Azathioprine Methotrexate Mycophenolate
Systemic Immunosuppressive mofetil
agents
Antimetabolites
Indications mainly Behçet disease include variety of alternative to other
chronic non-infectious anti- metabolites
uveitis
Dose 1-3 mg/kg per day (50 mg is 7.5-25mg in a single 1 g per day
tabletet) orally once daily or dose once weekly
in divided doses.
Side effects • bone marrow suppression •bone marrow •gastrointestinal
• gastrointestinal suppression disturbance
disturbances and •hepatotoxicity and • bone marrow
hepatotoxicity. •Pneumonitis suppression.
are serious but rarely
occur with low-dose
administration. The
most common side
effects are
gastrointestinal.
Monitoring complete blood count every full blood counts and full blood counts and
4-6 weeks and liver function liver function tests liver function tests
tests every 12 weeks every 1-2 months. every 1-2 months

33. Interferons
Indications Routes of administration &
Dose
recombinant human IFN-α has • Interferon-α is given by subcutaneous
been used with success to treat injection
a variety of posterior uveitides,
including those associated with • started as a high dose of daily
injections then tapered to lower-dose
intermittent injections
•Behçet
• Vogt-Koyanagi-Harada • With this regimen, corticosteroids are
disease tapered to as low doses as possible,
and other immunosuppressants are
•sympathetic ophthalmia and discontinued prior to initiation of IFN-α
idiopathic causes. therapy

34. Interferons
Side effects
•The most common side effect of IFN-α therapy is flu-like symptom
Significant adverse effects
•leukopenia,
• alopecia,
•elevated hepatic enzymes,
•depression, and other central nervous system (CNS) effects
• Drug-induced lupus

35. Physical measures
1-Hot fomentation
It is very soothing
diminishes pain and increases circulation, and thus
 reduces the venous stasis.
As a result more antibodies are brought and toxins are
rained. Hot fomentation can be done by dry heat or wet
heat.
2- Dark goggles These give a feeling of comfort, by
reducing photophobia, lacrimation and blepharospasm.

36. II. Specific treatment of the cause
• Unfortunately, in spite of the advanced diagnostic tests,
still it is not possible to ascertain the cause in a large
number of cases.
• So a full course of antitubercular drugs for underlying
Koch’s disease, adequate treatment for syphilis,
toxoplasmosis etc…, when detected should be carried out.
• When no cause is ascertained, a full course of broad
spectrum antibiotics may be helpful by eradicating some
masked focus of infection in patients with non-
granulomatous uveitis.

37. III. Treatment of complications
Inflammatory glaucoma Post-inflammatory Complicated cataract
(hypertensive uveitis) glaucoma

38. III. Treatment of complications
Retinal detachment of Phthisis bulbi
exudative type

39. IV. surgical management of patient with uveitis
Surgical indications in the management of uveitis include
visual rehabilitation
 diagnostic biopsy when findings may change the treatment plan
 removal of media opacities to monitor the posterior segment
Despite advances in anti-inflammatory and immunomodulatory
therapy, permanent structural changes can occur in the eye that are
best managed with surgery (e.g. cataract formation, secondary
glaucoma, retinal detachment)
In preparing the eye for surgery, medical treatment should be
intensified for a minimum of 3 months to achieve complete quiescence
of inflammation (i.e. complete eradication of anterior chamber cells,
active vitreous cells).