Shibu lijack Speaker Kumar Saurabh Shibu lijack Uveitis

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Speaker: Kumar Saurabh Shibu lijack

Uveitis: Definition § 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

Problem Statement § § § § 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

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 nongranulomatous 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 *Standardization of Uveitis Nomenclature (SUN). AJO 2005; 140: 509 -16 Cell * 0 : Nil 0. 5 + : 1 -5 cells + : 6 -15 cells ++ : 16 -25 cells +++ : 26 -50 cells ++++ : >50 cells

Anterior Chamber Reaction Cells and flare in uveitic eyes

Iris Nodules

Vitreous Haze Direct Ophthalmoscope 0 : Clear vitreous + : Few, normal view ++ : Moderate scattered opacities, obscured view +++ : Many opacities, blurring of view ++++ : Dense opacities, no view

Vitreous Haze Indirect Ophthalmoscope ++++ : Optic nerve head obscured +++ : Optic nerve head visible, blurred border ++ : Better view of retinal blood vessels & ONH + : Blurring of nerve fiber layer striations 0 : Nerve fiber layer well defined

Retinal Features § Retinitis § Primary vasculitis § Secondary vasculitis § Retinal detachment § Macular oedema § Neovascularization

Choroidal Features §Active choroiditis §Inactive choroiditis §Choroidal granulomas §Choroidal neovascularization §Choroidal vasculitis

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 Aims § § 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

Laboratory Investigations Indications § § § § Granulomatous uveitis Recurrent uveitis (>3 attacks) Uveitis in a child Positive leads on examination Posterior uveitis Retinal vasculitis Worsening on steroids

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. Regimen 2. Pyrimethamine: 75 mg, D 1 25 mg/day, 4 -6 weeks PLUS Sulphadiazine: 2 gm, D 1 1 gm four times daily, 4 -6 wks PLUS Prednisolone: 40 -60 mg/ day From D 3 -D 7, tapered PLUS Folinic Acid: 5 mg twice weekly Clindamycin 300 mg, 4 times Daily, 4 -6 weeks PLUS Sulphadiazine: 2 gm, D 1 1 gm four times daily, 4 -6 wks PLUS Prednisolone: 40 -60 mg/ day From D 3 -D 7, tapered

Specific Therapy Ocular Toxocariasis § Peripheral Lesion: Follow up § Posterior Pole Involvement: Prednisolone 40 mg/day and Thiobendazole 20 mg/day. 5 -7 days Vitrectomy

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 effects Contraindication of steroid therapy

Nonspecific Therapy: Medical § Immunosuppressive Therapy Absolute Indications: Behcet’s disease Sympathetic Ophthalmia Vogt-Koyanagi-Harada Syndrome Wegener’s Granulomatosis Polyarteritis Nodosa

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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