Shibu lijack

Shibu lijack Speaker: Kumar Saurabh

Group of diseases characterized by severe sight threatening intraocular inflammation primarily involving the uveal tract which extend occasionally to the contiguous structures like vitreous, optic nerve head, cornea and sclera.*

* International Uveitis Study Group Definition

Uveitis: Definition

Prevalence: 0.73% worldwide Age group: 20-50 years Five to 20% of legal blindness Tedious diagnostic workup Elusive aetiologies Permanent structural damage Low therapeutic index of medications

Problem Statement

Aetiology of Uveitis

Idiopathic Uveitis: 35.7% Uveitis Secondary to Systemic Disease Infectious Uveitis Lens Induced Uveitis Masquerade Syndrome

Goals of Uveitis Management

Reduction of visual morbidity Proper identification of the specific

disease Cost effective utilization of resources

Approach: Ways to achieve that

History Clinical Assessment: Site, stage and vision Differential Diagnosis Tailored Laboratory Tests Correlation with Ancillary Tests Definitive Treatment Control of Adverse Effects

History: Salient Points

Detailed and Suggestive Geographic History Family History Demography: Age, gender, race Personal History: Pets, diet, drugs, sexual Systemic Diseases Ocular History

Ocular History

Onset: Insidious or Sudden Laterality: Unilateral or Bilateral Severity: Mild or Severe Pattern: Single or Multiple Episodes Duration: Acute or Chronic Treatment

Clinical Assessment: Ocular Visual Acuity External : Lids, lacrimal glands

Conjunctiva & Sclera: Congestion, nodules

Cornea: Keratitis, ulceration, keratopathy

Keratic precipitates Anterior chamber: Flare and cells

Iris: Surface, nodules, new vessels

Vitreous: Haze, detachment, hemorrhage

Retina: Retinitis, new vessels, oedema

Choroid: Choroiditis, neovascularization

Keratic Precipitates

Mutton fat keratic precipitates in a case of granulomatous uveitis

Keratic Precipitates

Fine keratic precipitates in a case of non-granulomatous uveitis

Keratic Precipitates

Old keratic precipitates seen in the Arlt’s triangle of corneal endothelium

Keratic Precipitates

Large keratic precipitates seen in case of granulomatous uveitis

Anterior Chamber Reaction

Flare *

0 : Absence + : Barely detectable ++ : Moderate, iris details visible+++ : Marked, iris

details not visible

++++: Intense, fixed fribrinous aqueous

Cell *

0 : Nil 0.5 + : 1-5 cells

+ : 6-15 cells ++ : 16-25 cells +++ : 26-50 cells

++++ : >50 cells

*Standardization of Uveitis Nomenclature (SUN). AJO 2005;140: 509-16

Anterior Chamber Reaction

Cells and flare in uveitic eyes

Iris Nodules

Vitreous HazeDirect Ophthalmoscope

0 : Clear vitreous

+ : Few, normal view ++ : Moderate scattered opacities, obscured view +++ : Many opacities, blurring of view ++++ : Dense opacities, no view

Vitreous HazeIndirect Ophthalmoscope

++++ : Optic nerve head obscured+++ : Optic nerve head visible, blurred border++ : Better view of retinal blood vessels+ : Better view of retinal blood vessels & ONH+ : Blurring of nerve fiber layer striations0 : Nerve fiber layer well defined

Retinal Features

Retinitis

Primary vasculitis

Secondary vasculitis Retinal detachment

Macular oedema

Neovascularization

Active choroiditis

Inactive choroiditis

Choroidal granulomas

Choroidal neovascularization

Choroidal vasculitis

Choroidal Features

Site of Uveitis

Anterior Uveitis: Iritis, iridocyclitis, Anterior cyclitis

Intermediate Uveitis: Posterior cyclitis, Hyalites, Basal Retinochoroiditis

Posterior Uveitis: Chorioretinitis, Retinochoroiditis, Neuroretinitis, Choroiditis

Systemic Examination

Mucocutaneous system

Erythema nodosum Oral ulcerations Kaposi sarcoma Kearatoderama Circinate balanitis Vitiligo Sarcoid granulomas

Musculoskeletal system

Ankylosing spondylitis Rheumatoid arthritis Psoriasis Behcet’s disease Reiter’s syndrome

Differential Diagnosis

Working diagnosis Basis for laboratory investigation Basis for treatment

Laboratory Investigations

To rule out infective etiology To alleviate risks of treatment To find out systemic disease To find out etiology of

masquerade syndrome To come to specific diagnosis Academic purposes

Aims

Laboratory Investigations

Granulomatous uveitis Recurrent uveitis (>3

attacks) Uveitis in a child Positive leads on examination Posterior uveitis Retinal vasculitis Worsening on steroids

Indications

Laboratory Investigations

Complete Blood Count Rheumatoid factor (RA) Antinuclear Antibody (ANA) Anti ds-DNA Antibody Anti Neutrophil Cytoplasmic Antibody (ANCA) Angiotensin Converting Enzyme C- reactive Protein X-ray Chest and Spine Toxoplasma, Rubella, Cytomegalovirus, Herpes

simplex (TORCH) Test Mantoux Test HLA Typing

Ancillary Investigations

Ultrasonography: Media opacity

Fluorescein Angiography: Macular oedema, Chorioretinitis, Disc leakage,

Response

Vitreous Biopsy: Lymphoma, Endophthalmitis

Chorioretinal Biopsy:

Treatment Strategy

Specific Therapy

Ocular Toxoplasmosis

Regimen 1.Pyrimethamine: 75mg, D125mg/day, 4-6 weeks PLUSSulphadiazine: 2 gm, D11 gm four times daily, 4-6wksPLUSPrednisolone: 40-60 mg/ dayFrom D3-D7, taperedPLUSFolinic Acid: 5mg twice weekly

Regimen 2.Clindamycin 300mg, 4 times Daily, 4-6 weeksPLUSSulphadiazine: 2 gm, D11 gm four times daily, 4-6wksPLUSPrednisolone: 40-60 mg/ dayFrom D3-D7, tapered

Specific Therapy

Peripheral Lesion: Follow up

Posterior Pole Involvement:Prednisolone 40mg/day and

Thiobendazole 20mg/day. 5-7 daysVitrectomy

Ocular Toxocariasis

Nonspecific Therapy: Medical

Steroids: Topical, periocular, systemic

Indications: Active Inflammation Prevention and treatment of

complications Infiltration of retina, choroid and optic

nerve

Nonspecific Therapy: Medical

Nonsteroidal Antinflammatory Drugs

Indication: To maintain lower dose of topical steroids

Nonspecific Therapy: Medical

Immunosuppressive Therapy

Vision threatening intraocular inflammation Inadequate response to steroids

Serious steroid induced side effectsContraindication of steroid therapy

Immunosuppressive Therapy

Absolute Indications: Behcet’s diseaseSympathetic Ophthalmia

Vogt-Koyanagi-Harada Syndrome

Wegener’s Granulomatosis Polyarteritis Nodosa

Nonspecific Therapy: Medical

Nonspecific Therapy: Medical

LASER and Cryotherapy

Indications: LASER for choroidal neovascularization

Cryotherapy for refractory pars planitis

Nonspecific Therapy: Surgical

Pars plana Vitrectomy

Indications: Pars planitis Subretinal neovscular membrane

Treatment Response*

Inactive Uveitis : Rare cell in anterior chamber

Improvement : Two step decrease in cells

Reduction in cell count to Grade 0

Worsening : Two step increase in cells

Increase in cell count from 3+ to 4+

Steroid resistance : Two weeks

Immunosuppressive resistance: Three months

*Standardization of Uveitis Nomenclature (SUN). AJO 2005;140: 509-16

Treatment of Complications

Management of cataract Management of glaucoma Management of band shaped keratopathy

and other corneal complications

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