Transcript ANIMATED TATE - Dr. Kumar Saurabh

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Speaker: Kumar Saurabh
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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
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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
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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
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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
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Detailed and Suggestive
Geographic History
Family History
Demography: Age, gender, race
Personal History: Pets, diet, drugs, sexual
Systemic Diseases
Ocular History
Ocular History
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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
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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
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 Haze
Direct Ophthalmoscope
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: Clear vitreous
: Few, normal view
: Moderate scattered opacities, obscured view
: Many opacities, blurring of view
: Dense opacities, no view
Vitreous Haze
Indirect Ophthalmoscope
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: 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 striations
: Nerve fiber layer well defined
Retinal Features
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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
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Erythema nodosum
Oral ulcerations
Kaposi sarcoma
Kearatoderama
Circinate balanitis
Vitiligo
Sarcoid granulomas
Musculoskeletal system
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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
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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
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Indications
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Granulomatous uveitis
Recurrent uveitis (>3 attacks)
Uveitis in a child
Positive leads on examination
Posterior uveitis
Retinal vasculitis
Worsening on steroids
Laboratory Investigations
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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: 75mg, D1
25mg/day, 4-6 weeks
PLUS
Sulphadiazine: 2 gm, D1
1 gm four times daily, 4-6wks
PLUS
Prednisolone: 40-60 mg/ day
From D3-D7, tapered
PLUS
Folinic Acid: 5mg twice weekly
Clindamycin 300mg, 4 times
Daily, 4-6 weeks
PLUS
Sulphadiazine: 2 gm, D1
1 gm four times daily, 4-6wks
PLUS
Prednisolone: 40-60 mg/ day
From D3-D7, tapered
Specific Therapy
Ocular Toxocariasis
 Peripheral Lesion: Follow up
 Posterior Pole Involvement:
Prednisolone 40mg/day and
Thiobendazole 20mg/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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