CLINICAL CASE PRESENTATION

Dr. Samten Dorji

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• 38 year old male complained of right eye pain and redness for 5 days duration.

CHIEF COMPLAINT

Personal information

He is from Zhemgang, married with two children and is gardener by profession

• He developed slow onset of pain in his right eye and increase progression of pain. He had associated redness, photophobia, excessive tearing and reduced vision.

HISTORY OF CHIEF COMPLAINT

• No joint pain• No history of asthma or symptoms suggestive of

chest infection• No gastro intestinal symptoms• No history of haematuria or urethral discharge• No skin conditions

SYSTEMIC REVIEW

• Past ocular history/ocular medications/systemic medications/comorbidities/allergies/family history/social history

• No pets in house

HISTORY CONT.

ExaminationRight eye Left eye

Visual acuity 6/60 6/6

With pinhole 6/12 6/6

Color vision Normal Normal

Extraocular movements Normal Normal

Lids and adnexa Normal Normal

Conjunctiva and sclera Circumcorneal congestion Normal

Cornea Clear Clear

Anterior chamber Cells grade +4 and flare grade +3

Normal

Iris and lens Posterior synechia Normal

Pupil Round regular and miotic Round regular and reactive

IOP by Icare 13 mmhg 11 mmhg

Dilated Funduscopy NAD NAD

• 38 year old male presented to eye OPD with right eye pain with redness for 5 days duration with associated photophobia, excessive tearing and reduced vision. On examination there was no significant findings in his left eye. On his right eye his visual acuity was 6/12 with pin hole. He had circumcorneal congestion and had grade +4 cells and grade +3 flare in anterior chamber with posterior synechia and miosis. He doesn’t have any clinical features suggestive of systemic disorder.

CASE SUMMARY

DIAGNOSISAcute anterior uveitis

Supporting points• Unilateral eye pain with

photophobia and redness with excessive tearing for duration of 5 days.

• Circumcorneal congestion with anterior chamber cells and flare with posterior synechia and miosis.

• Fundus appeared normal

Non-Supporting points

• Slow onset

Aetiology

• Idiopathic• HLA-B27 associated uveitis• Behcet disease• Lyme disease

Differential diagnosis• Posterior uveitis with spill over into the anterior chamber• Traumatic iritis• Infectious keratouveitis

Chest X ray PA= NAD

• Cycloplegic drops• Antibiotic drops• Prednisolone drops• Oral prednisolone

MANAGEMENT

SUBJECT REVIEWAcute anterior uveitis

• Introduction • Clinical features• Investigation• Treatment

OUTLINE

• Uveitis is the inflammation of the uveal tract

INTRODUCTION

Clinical course

Acute Chronic Recurrent

Aetiology

Infectious Noninfectious

Histology

Granulomatous Nongranulomatous

Anatomy

Anterior uveitis Intermediate uveitis

Posterior uveitis Panuveitis

• In a large community-based study, the vast majority of uveitis cases were anterior (71%), followed by posterior uveitis (5%) and intermediate and panuveitis (1% each).

• The most common causes of anterior uveitis are idiopathic (38−56%), the seronegative spondyloarthropathies (21−23%), juvenile idiopathic arthritis (JIA; 9−11%), and herpetic keratouveitis (6−10%).

• Presentation: sudden onset of unilateral pain, photophobia and redness, which maybe associated with lacrimation.

• Visual acuity is usually good at presentation except in eyes with severe hypopyon

CLINICAL FEATURES

External examination Miosis

Endothelial dusting Aqueous flare and cells

Cells in field Grade (anterior chamber cells)

<1 0

1-5 +-

6-15 +1

16-25 +2

26-50 +3

>50 +4

Description Grade (aqueous flare)

Nil 0

Just detectable +1

Moderate (iris and lens details clear) +2

Marked (iris and lens detail hazy) +3

Intense(fibrinous exudate) +4

Fibrinous exudate Hypopyon

Posterior synechiae

Low IOP

Investigation INDICATIONS NOT INDICATED

Granulomatous inflammation Single attack of mild unilateral AAU

Recurrent uveitis Sympathetic ophthalmitis and Fuchs cyclitis

Bilateral disease When systemic disease is already apparent

Systemic manifestation

Confirmation

Skin test

Tuberculin test Pathergy test

Lepromin test

1. Non-treponemal test= rapid plasma reagin

2. Treponemal antibody test= fluorescent treponemal antibody absorption test and microhaemagglutination treponema pallidum test

3. Dark ground microscopy

Serology Syphilis Toxoplasmosis

1. Dye test(Sabin-Feldman)= gold standard2. Immunofluorescent antibody test3. Haemagglutination tests4. Enzyme linked immunosorbent assay (ELISA)

Enzyme assay Sarcoidosis

Tuberculosis

Leprosy

Serum angiotensin converting enzyme

Lysozyme assay

HLA tissue typingHLA type Associated disease

B27 spondyloarthropathies

A29 Birdshot chorioretinopathy

B51 Behcet syndrome

Optical coherence tomography

Radiology

Chest X ray Sacro iliac joint X ray

CT and MR

1. Conjunctival and lacrimal gland biopsy

BIOPSY

Treatment Mydriatics

Short acting Long acting

Tropicamide (6 hours) Homatropine (2 days)

Cyclopentolate(24 hours) Atropine(2 weeks)

Phenylephrine(3 hours)

Promote comfort

Break down recently formed

posterior synechiae

Prevent formation of posterior synechiae

Topical steroids

AAU CAU

• Frequent instillation of drops at first

• The frequency is tapered off once the inflammation gets controlled

• Exacerbations treated as AAU

• The intensity of flare can also indicate an active process

• Follow up of patient regularly

Complication

Elevation of IOP

Periocular steroid injection

Advantages

• Therapeutic concentrations behind the lens may be achieved

• Trans-sclerally entrance• Prolonged effect

Indications

• First line therapy in unilateral intermediate or posterior uveitis

• Supplement systemic therapy or when systemic steroids are contraindicated

• Poor compliance• At time of surgery

Complication

Globe penetration

Increased IOP

Ptosis

Sub dermal fat atrophy

Extraocular muscle paresis

Optic nerve injury

Retinal and choroidal vascular occlusion

Cutaneous hypopigmentation

Systemic steroids• Oral prednisolone and intravenous infusion of methylprednisolone

Indications

• Intermediate uveitis unresponsive to posterior sub tenon injection

• Posterior or panuveitis, particularly with bilateral involvement

• Prior to intraocular surgery• Anterior uveitis resistant to topical.

Contraindications

• Poorly controlled diabetes• Peptic ulceration• Osteoporosis• Active systemic infection• Psychosis on previous exposure to

steroids

Short term side effects Long term side effects• Dyspepsia• Mental changes• Electrolyte imbalance• Aseptic necrosis of the head of the

femur

• Cushingoid state• Osteoporosis• Limitation of growth• TB reactivation• Cataract• Diabetes and myopathy

Antimetabolites Azathioprine Methotrexate Mycophenolate mofetil

Indications Behcet syndromeVogt-Koyanagi-Harada syndrome

Uveitis associated with sarcoidosis and Juvenile idiopathic arthritis

Alternative to azathioprine

Dose and route

Starting dose=1-3mg/kgAfter 1-2 weeks dose is doubledStopped only after disease has been inactive for over 1 year and the daily steroid dose is under 7.5mg

Adult:10-25mg weeklyChildren:30mgFolic acid 2.5-5mg/ day

1-2 g daily orally

Side effects Bone marrow suppression, hepatotoxicity and nausea

+ acute pneumonitis Gastrointestinal disturbance and bone marrow supression

Monitoring CBC and LFT CBC and LFT CBC

Calcineurin inhibitorsCiclosporin Tacrolimus

Indications Behcet syndrome, intermediate uveitis, birdshot choroidopathy, Vogt-Koyanagi-Harada syndrome, sympathetic ophthalmitis and idiopathic retinal vasculitis

Alternative to Ciclosporin

Dose and route 2.5-7.5mg/kg daily orally 1-0.25mg/kg daily orally

Side effects Nephrotoxicity, hyperlipidaemia, hepatotoxicity, hypertension, hirsutism and gingival hyperplasia

Hyperglycaemia, neurotoxicity and nephrotoxicity

monitoring Blood pressure, RFT and LFT + blood glucose

Biological blockersInterleukin receptor antagonists Tumour necrosis factor alpha antagonist

Daclizumab and anakinra Infliximab and adalimumab

• Introduction • Clinical features• Investigation• Treatment

SUMMARY

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