Download - RED EYE- UVEITIS
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RED EYE- UVEITISRED EYE- UVEITIS
Brig Mazhar IshaqBrig Mazhar Ishaq
Advisor in Ophthalmology,Advisor in Ophthalmology,
Comdt Armed Forces Institute Of Ophthalmology,Comdt Armed Forces Institute Of Ophthalmology,
RwpRwp
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ANATOMICAL CLASSIFICATION
ANTERIOR UVEITISANTERIOR UVEITIS IRITISIRITIS IRIDOCYCLITISIRIDOCYCLITIS
INTERMEDIATEINTERMEDIATE UVEITISUVEITIS
POSTERIOR POSTERIOR UVEITISUVEITIS
PANUVEITISPANUVEITIS
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POSTERIOR UVEITISPOSTERIOR UVEITIS
Involves the fundus posterior to the Involves the fundus posterior to the
vitreous basevitreous base
- Retinitis - Retinitis
- - Choroiditis Choroiditis
- - Vasculitis Vasculitis
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SARCOIDOSIS Presentation Presentation
- Acute - Acute
- Insidious- Insidious
Ocular featuresOcular features
- AAU - AAU - CAU - CAU
- Intermediate- Intermediate
- Candlewax drippings’ - Candlewax drippings’
- Multifocal choroiditis - Multifocal choroiditis
- Retinal granulomas - Retinal granulomas
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TUBERCULOSIS
Anterior segment involvementAnterior segment involvement
Tuberculous uveitisTuberculous uveitis
- Anterior uveitis, - Anterior uveitis,
- Choroiditis - Choroiditis
- Periphlebitis- Periphlebitis
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TOXOPLASMOSISTOXOPLASMOSIS
PresentationPresentation
- Unilateral sudden onset of floaters- Unilateral sudden onset of floaters
SignsSigns
- - Spill-over’ anterior uveitisSpill-over’ anterior uveitis
- - Satellite lesionSatellite lesion
- - Multiple foci are uncommon Multiple foci are uncommon
- - Severe vitritis (‘headlight in the fog’) Severe vitritis (‘headlight in the fog’)
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TOXOPLASMOSISTOXOPLASMOSIS
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BEHCET SYNDROME
Recurrent oro-genital ulcerationRecurrent oro-genital ulceration
Ocular featuresOcular features
AAU - cold abscessAAU - cold abscess
RetinitisRetinitis
Retinal vasculitisRetinal vasculitis
Vitritis,Vitritis,
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BEHCET SYNDROME
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FUNGAL UVIETISFUNGAL UVIETIS
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INVESTIGATIONS
Indications Recurrent granulomatous anterior uveitisRecurrent granulomatous anterior uveitis Bilateral disease Bilateral disease Systemic manifestations with out a specific Systemic manifestations with out a specific
diagnosisdiagnosis Confirmation of suspective ocular picture Confirmation of suspective ocular picture
such as HLA-A29 testing in birdshort such as HLA-A29 testing in birdshort chorioretinopathychorioretinopathy
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NOT NECESSARYNOT NECESSARY
Single attack of mild unilateral acute Single attack of mild unilateral acute
anterior uveitisanterior uveitis
A specific uveitis entityA specific uveitis entity
When a systemic diagnosis compatible When a systemic diagnosis compatible
with the uveitis is already apparentwith the uveitis is already apparent
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INVESTIGATIONSINVESTIGATIONS
Obtain a history, attempting to define the Obtain a history, attempting to define the
etiology.etiology.
Complete ocular examination, including an Complete ocular examination, including an
IOP check and a dilated fundus IOP check and a dilated fundus
examination. examination.
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SKIN TESTSSKIN TESTS
1. Tuberculin skin test (montoux & Heaf) Intradermal inj of purified proteinIntradermal inj of purified protein PositivePositive
Induration of 5-14 mm with in 48 hoursInduration of 5-14 mm with in 48 hours
NegativeNegative Excludes TBExcludes TB May occure in advanced diseaseMay occure in advanced disease
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PATHERGY TESTPATHERGY TEST
Increased dermal sensitivity to needle traumaIncreased dermal sensitivity to needle trauma
Behcet syndromeBehcet syndrome
Rarely positive in absence of systemic activityRarely positive in absence of systemic activity
Pustule formationPustule formation
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SEROLOGYSEROLOGYSYPHILIS
1. Non-treponemal tests
RPR or VDRLRPR or VDRL
Primary infectionPrimary infection
Monitor disease activityMonitor disease activity
Response to therapyResponse to therapy
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2. Immunofluorescent antibody test
3. Haemagglutination test
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Enzyme-linked Immunosorbent Assay Enzyme-linked Immunosorbent Assay (ELISA(ELISA)
Antibodies in aqueous (more specific)Antibodies in aqueous (more specific)
Other conditions (cat-scratch fever & toxocariasisOther conditions (cat-scratch fever & toxocariasis
Antinuclear Antibody (ANA) In children with JIA who are at high risk of
developing ant uveitis
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ENZYME ASSAY
1.1. Angiotensin converting enzyme (ACE)Angiotensin converting enzyme (ACE) Nonspecific test Nonspecific test Granulomatous disease like Granulomatous disease like
- Sarcoidosis (elevated in 80% & in acute)- Sarcoidosis (elevated in 80% & in acute)
- TB- TB
- Leprosy- Leprosy
2. Lysozyme Good sensitivity but less speceficity for Good sensitivity but less speceficity for
sarcoidosissarcoidosis
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HLA TISSUE TYPINGHLA TISSUE TYPING
HLA type Associated disease
B27 Spondyloarthropathies
A29 Birdshot chorioretinopathy
B51 Behcet syndrome
HLA-B7 & POHS & APMPPE
HLA-DR2
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IMAGINGIMAGING
1. Fluorescein angiography (FA) Retinal vasculitisRetinal vasculitis CMOCMO
2.2. Indocyanine angiography (ICG)Indocyanine angiography (ICG) Better for choroidal disease Better for choroidal disease
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3. Ultrasonography (US) It is useful in opaque media especially in
excluding a RD or intraocular mass
4. Optical coherence tomography(OCT) Detecting CMO Identify vitreoretinal traction as a mechanism
of CMO
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BIOPSY Histopathology still remains the gold-standard
1.conjunctiva And Lacrimal gland
- Sarcoidosis
2.Aqueous samples
- For (polymerase chain reaction) PCR
- Viral retinitis (occasionally)
3.Vitreous biopsy
- Infectious endophthalmitis
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RADIOLOGY1. Chest X-rays
- To exclude TB and Sarcoidosis
2. Sacro-illiac joint X-Rays- Diagnosis of spondyloarthropathy
3. CT & MRI - Sarcoidosis
- Multiple sclerosis
- Primary intraocular lymphoma
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TREATMENT
AIM Prevent vision threatening complications Relieve patients discomfort Treat the underlying cause
FOUR GROUP OF DRUGS Mydriatics Steroids Cyclosporine Cytotoxic agents
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TREATMENT
Mydriatics
To give comfort
To prevent formation of posterior synechia
To break down synechia
Drugs (atropine, homatropine, scopolamine,
tropicamide)
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TREATMENT
Steroids (mainstay of treatment)Steroids (mainstay of treatment)
Topical administration
Complications (glaucoma, posterior sub capsular cataract,
corneal complications, systemic side effects)
Periocular injections
Severe acute anterior uveitis
Adjuvant to topical/systemic
Poor compliance
Pre op
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TREATMENT
Systemic therapy PreparationsPreparations
Prednisolone 5mgPrednisolone 5mg
IndicationsIndications RulesRules
Start with large dose then reduceStart with large dose then reduce Initial dose 1-1.5 mg/kg BWInitial dose 1-1.5 mg/kg BW Before breakfastBefore breakfast Taper offTaper off Less than 2 weeks abrupt stop Less than 2 weeks abrupt stop
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TREATMENT
Side effectsSide effects
Short term Short term
Long termLong term
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TREATMENT
CyclosporinCyclosporin
Steroid sparing agentSteroid sparing agent
Complications are hypertension and nephrotoxicityComplications are hypertension and nephrotoxicity
Cytotoxic drugs Cytotoxic drugs
Potentially blinding bilateral reversible uveitisPotentially blinding bilateral reversible uveitis
Intolerable side effects from systemic steroids Intolerable side effects from systemic steroids
therapy.therapy.
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THANK YOUTHANK YOU