New trends in management of uveitis


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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 :)

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New trends in management of uveitis

  1. 1. New Trends In Management Of Uveitis
  2. 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. 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. 4. General Considerations ClassificationAnatomical Anterior Clinical uveitis Acute uveitis Intermediate uveitis Chronic uveitis Posterior uveitis
  5. 5. General Considerations ClassificationPathological Suppurative or purulent uveitis * Non-granulomatous uveitis Non-suppurative uveitis * Granulomatous Uveitis
  6. 6. General Considerations Etiology Infective Syndromes of Non-Infective unknown etiologyExogenous Endogenous Allergic or Sympathetic Traumatic Autoimmune ophthalmitis
  7. 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 ofChronic : sensory nerve fibers.may exhibit minimal symptoms
  8. 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
  9. 9. General Considerations Signs Chronic Iridocyclitis Injection ……… mild or absent Pupil ………. Unremarkable KPs........ mutton-fat in granulomatous disease Flare and cells …….. Variable Fibrinous exudate ……. absent
  10. 10. 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
  11. 11. General Considerations Complications Ant. Uveitis Post.UveitisAcute : Depends on the underlying disease and* Posterior synechiae (PS) …..> rare at severity of the diseasepresentation but may form later* Cataract ….> absent The inflammatory foci will heal within 2–6Glaucoma …..> rare weeks and form chorioretinal scars. The scars will result in localized scotomasChronic : that will reduce visual acuity if the macula* PS – common at presentation is affected* Cataract – rare at presentation but maydevelop later* Glaucoma – rare at presentation butmay develop later
  12. 12. 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
  13. 13. Investigations General Investigations ESR / Plasma Viscosity/ C Reactive Protein CXR / FBC / Syphilis Serology: TPHA, VDRL Urine analysis (Diabetes Mellitus)
  14. 14. Investigations Special InvestigationsSkin Tests:Tuberclin skin testspathergy test : for diagnosis of Behcets syndromeSerology: Syphilis Toxoplasmosis *Dye test (Sabin-Feldeman)* Non treponemal :RPR & VDRL * Immunoflurescent antibody* Treponemal : FTA-ABS & MHA- * Heamagglutination testsTP *ELISA
  15. 15. Investigations Special InvestigationsEnzyme assay Imaging Biopsy: Ocular biopsies :* (ACE) * Flurescin angiography*Lysozyme has good * Conjunctiva and * Iodocyanine green lacrimal glandsensitivity but less angiographyspecificity than ACE * Aqueous sample * Ultrasonography (US) * Vitreous biopsy * Optical coherence * Retinal and tornography (OCT) Choroidal biopsies.
  16. 16. Investigations Special InvestigationsRadiology:1. Chest radiographs are to exclude tuberculosis and sarcoidosis.2. Sacroiliac joint x ray is helpful in the presence of a spondyloarthropathy inthe presence of symptoms of low back pain and uveitis.3- CT and MRI of the brain and thorax are useful in sarcoidosis , multiplesclerosis and primary intraocular lymphomaHLA typing: HLA type Associated disease B27 Ankylosing A29 spondylitis B51 Bircishot HLA - B7& DR2 chorioretinopathy
  17. 17. 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
  18. 18. I.Non-specific treatment Mydriatics SteroidsSystemic Immunosuppressive Agents Interferons Physical measures
  19. 19. 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
  20. 20. MydriaticsIndications 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
  21. 21. Steroids periocular injection Intravitreal injection Topicaleyedrops Systemic orointment Route of administration
  22. 22. 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 sideGlaucoma Cataract complications effects
  23. 23. Steroids Periocular injectionsAdvantages 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" ).
  24. 24. Steroids Periocular injectionsIndications 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
  25. 25. Steroids Intravitreal injection* Intravitreal steroid injection of is currentlyunder evaluation.* It has been used successfully in resistantuveitic chronic cystoid macular oedema.
  26. 26. Steroids Systemic therapy Preparations Indications1- 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 inpatients with acidpeptic disease. • Intermediate uveitis unresponsive to posterior subTenon injections.2. Injections of (ACTH]* Useful in patients intolerant to oral • Certain types of posterior orsteroids. panuveitis, particularly with severe bilateral involvement.
  27. 27. Steroids Systemic therapy General rules of administration• Start with a large dose and then reduce .• A reasonable starting dose of prednisolone is 1mg/kg perday given in a single morning dose.• Once the inflammation is brought under control , reducethe dose gradually over several weeks.• If steroids aregiven for less than 2weeks , there is no needfor gradual reduction.
  28. 28. Steroids Systemic therapy Side effects • Dyspepsia • Mental changesshort term • Electrolye imbalance • Aseptic necrosis of the head of the therapy femur , and very rarely • Hyperosmolar , Hyperglycemic non- ketotic coma • A Cushngoid stateLong term • • Osteoporosis Reactivation of infections such as TB therapy • Cataract • Limitation of growth in children
  29. 29. Systemic Immunosuppressive agents Antimetabolites T-cell inhibitorsIndications 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 effectsfrom systemic steroids.
  30. 30. Azathioprine Methotrexate Mycophenolate Systemic Immunosuppressive mofetil agents AntimetabolitesIndications mainly Behçet disease include variety of alternative to other chronic non-infectious anti- metabolites uveitisDose 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
  31. 31. Interferons Indications Routes of administration & Doserecombinant human IFN-α has • Interferon-α is given by subcutaneousbeen used with success to treat injectiona 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 aredisease tapered to as low doses as possible, and other immunosuppressants are•sympathetic ophthalmia and discontinued prior to initiation of IFN-αidiopathic causes. therapy
  32. 32. Interferons Side effects•The most common side effect of IFN-α therapy is flu-like symptomSignificant adverse effects•leukopenia,• alopecia,•elevated hepatic enzymes,•depression, and other central nervous system (CNS) effects• Drug-induced lupus
  33. 33. Physical measures1-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, byreducing photophobia, lacrimation and blepharospasm.
  34. 34. 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.
  35. 35. III. Treatment of complicationsInflammatory glaucoma Post-inflammatory Complicated cataract(hypertensive uveitis) glaucoma
  36. 36. III. Treatment of complicationsRetinal detachment of Phthisis bulbi exudative type
  37. 37. IV. surgical management of patient with uveitisSurgical 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 immunomodulatorytherapy, permanent structural changes can occur in the eye that arebest managed with surgery (e.g. cataract formation, secondaryglaucoma, retinal detachment)In preparing the eye for surgery, medical treatment should beintensified for a minimum of 3 months to achieve complete quiescenceof inflammation (i.e. complete eradication of anterior chamber cells,active vitreous cells).