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,

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ANATOMICAL CLASSIFICATION

ANTERIOR UVEITISANTERIOR UVEITIS IRITISIRITIS IRIDOCYCLITISIRIDOCYCLITIS

INTERMEDIATEINTERMEDIATE UVEITISUVEITIS

POSTERIOR POSTERIOR UVEITISUVEITIS

PANUVEITISPANUVEITIS

POSTERIOR UVEITISPOSTERIOR UVEITIS

Involves the fundus posterior to the Involves the fundus posterior to the

vitreous basevitreous base

- Retinitis - Retinitis

- - Choroiditis Choroiditis

- - Vasculitis Vasculitis

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

TUBERCULOSIS

Anterior segment involvementAnterior segment involvement

Tuberculous uveitisTuberculous uveitis

- Anterior uveitis, - Anterior uveitis,

- Choroiditis - Choroiditis

- Periphlebitis- Periphlebitis

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’)

TOXOPLASMOSISTOXOPLASMOSIS

BEHCET SYNDROME

Recurrent oro-genital ulcerationRecurrent oro-genital ulceration

Ocular featuresOcular features

AAU - cold abscessAAU - cold abscess

RetinitisRetinitis

Retinal vasculitisRetinal vasculitis

Vitritis,Vitritis,

BEHCET SYNDROME

FUNGAL UVIETISFUNGAL UVIETIS

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

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

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.

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

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

SEROLOGYSEROLOGYSYPHILIS

1. Non-treponemal tests

RPR or VDRLRPR or VDRL

Primary infectionPrimary infection

Monitor disease activityMonitor disease activity

Response to therapyResponse to therapy

2. Immunofluorescent antibody test

3. Haemagglutination test

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

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

HLA TISSUE TYPINGHLA TISSUE TYPING

HLA type Associated disease

B27 Spondyloarthropathies

A29 Birdshot chorioretinopathy

B51 Behcet syndrome

HLA-B7 & POHS & APMPPE

HLA-DR2

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

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

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

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

TREATMENT

AIM Prevent vision threatening complications Relieve patients discomfort Treat the underlying cause

FOUR GROUP OF DRUGS Mydriatics Steroids Cyclosporine Cytotoxic agents

TREATMENT

Mydriatics

To give comfort

To prevent formation of posterior synechia

To break down synechia

Drugs (atropine, homatropine, scopolamine,

tropicamide)

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

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

TREATMENT

Side effectsSide effects

Short term Short term

Long termLong term

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.

THANK YOUTHANK YOU