Investigations in anterior uveitis · 2018-08-11 · Sarcoidosis River water Granuloma Mantoux/HRCT...
Transcript of Investigations in anterior uveitis · 2018-08-11 · Sarcoidosis River water Granuloma Mantoux/HRCT...
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Current approach of Investigations in anterior uveitis
Dr.S.Bala Murugan
Consultant
Aravind Eye Hospital
Pondicherry
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26% of anterior uveitis > systemic disease;
Hence a complete and
thorough evaluation is warranted.
Why investigate anterior uveitis?
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Discern type of anterior uveitis
Non granulomatousGranulomatous
Adult Children
HLA B27HLA B 27
ANA
PPD/ CXR
ACE
VDRL / FTAbs
PPD/ CXR
ACE
Urine: B2 microglobulin
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If you don’t know
what you are looking for,
you may not find an answer
or
worse you may find the
wrong one
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WHY INVESTIGATE
UVEITIS
Provides a 'definitive' etiology
Identify underlying systemic disease
Confirm/ reject a
diagnosis
Helps in the RX
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1. When etiology is clear
2.Traumatic anterior uveitis
3.??Fuch’s anterior uveitis
4. First attack of low grade anterior nongranulomatous uveitis
When is investigations of anterior uveitis
NOT required?
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What happens if you do not order the correct diagnostic tests as required?
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Topical steroids
H/o native t/t for injury
with vegetable
matter
Fungal uveitis
42 year lady C/O Pain, redness,
BCVA 6/36
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Do we need to read articles to investigate
anterior uveitis?
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26 /M with poor personal hygiene presented with….
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Before we investigate….Basics in uveitis
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10 yr old girl
Nil systemic
Recurrent attacks left eye
Transient response to topical
steroids
Tuberculosis
Leprosy
Sarcoidosis
River water Granuloma
Mantoux/HRCT chest-Normal
S,ACE-Normal
No skin changes
History of bathing in pond
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PCR from AC granuloma
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Subtle findings matters! VARIATION IN ANTERIOR CHAMBER DEPTH
Peripherally shallow
Centrally deep
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UBM > CYCLITIC MEMBRANE
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CONFIGURATION OF Keratic precipitates
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Rule out Pseudo FUCH’S:Syphilis, sarcoid
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Immune rings in chronic CMV infections
Perform AC tap for viruses
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Posner schlossman syndrome
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HLA B27 anterior uveitis
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Proven AS / HLA B 27 population
80 to 90% of patients with AS >
positive for HLA-B27
10-15% of people with HLA-B27 gene
End up developing AS /
spondyloarthritis.
10-20% of patients > will test
negative for HLA B27
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Iris nodules gives a wonderful clue
Koeppes = Both granulomatous and non granulomatous
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Bussaca’s indicates granulomatous uveitis
Angle KPs= Berlin’s sign
Order Gonio=
Tent shaped PAS
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Lisch’s nodules> order investigations for NF
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BRUSCH FELD FLECKS> DOWN’S SYNDROME
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To sum up…
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Drug induced anterior uveitisOral Moxifloxacin induced
anterior uveitis!
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BADI vs BAIT
PS smeared on ALC with broad
base
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Drug history is crucial!
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45/ M, acute fibrinous
anterior uveitis
Uveitis work up: not
contributory
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???
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???21/ F NG ANT uveitis+ scleritis
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Anterior endophthalmitis/? TASS
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Masquerades as anterior uveitis
Focus on the atypicality!
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Lens induced anterior uveitis
Courtesy:
Prof.J.Biswas
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49
Following treatment
Lens induced uveitis
Light microscope:
Macrophages laden with lens
matterLucid vitreous in B-Scan
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Investigations guided by findings in anterior exam> Pseudophakia induced uveitis OCT-
CME
AS-OCT > Haptic eroding iris
Gonio: No angle erosion
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51
P’acnes after treatment
Biofilm adherence…
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Clinical pointers to P’ acnes…
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Poor response to topical steroids…
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53
HPE
P’acnes
Lens capsule
Yello tan colonies: Blood agar plate
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Beaded Fibrin
strands
P acnes
Sarcoids
Toxo
plasma
Fungal
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Shifting hypopyon in Behcet’s
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Non shifting hypopyon in infective causes
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EE :Why bother the colour of hypopyon ?
58
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Which presentation in uvea is complete without TB AND SYPHILIS ?
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PPD/ IGRA/PCR/ DIRECT EXAMINATION/Biopsy/Chest
imaging
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JIA associated anterior uveitis
ANA RA FACTORIncreased
ESRPauciarticular
type
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45/F. Defective Vn, Obese,Diffuse Gr STELLATE KPS
Gonio: Tent shaped
PAS
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Biopsy
mandatory?
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LFT not useful outside Japan
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Babu et al. [30] showed hilar lymphadenopathy and fissural nodules were significantly more common inocular sarcoidosis patients compared with ocular tuberculosis on high-resolution chest computerizedtomography.
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HRCT : Tell me a sign that suggests
Sarcoid > TB
Hilar lymphadenopathy / fissural nodules
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TINU : Urinary alpha1- and beta2-macroglobulin!
Krebs von den Lunge-6 (KL-6) is a human glycoprotein ELEVATED
IN TINU/ SARCOID
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HPE-renal biopsy of TINU
H & E stain:
widespread interstitial inflammation with a predominant mononuclear cell infiltrate
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What is the recent advance?Identify the cell type in AC!
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BASELINE WORK UP
Total leukocute
count
Differential count
Erythrocyte sedimentation
rate
PPD/IGRA VDRL/TPHAChest X ray /
Imaging adjuncts
S.ACE / S.Lyzozyme
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Thank you!
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