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Uveitis - A Clinical Approach

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Eric Lukacin

on 14 July 2015

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Transcript of Uveitis - A Clinical Approach

Uveitis - A Clinical Approach
Introduction
Symptoms and Signs of Uveitis
Clinical

Pearls

The uvea of the eye consists of the iris, ciliary body, and choroid, which is the eye’s major blood supply.

Uveitis is broadly defined as an inflammatory condition of the vascular tunic/uvea of the eye.
Pathophysiology
Uveitis results from a breakdown of the blood aqueous barrier, which consists of tight junctions in three locations:

- non-pigmented ciliary body epithelium
- iris vessels
- Schlemm’s canal

This breakdown leads to a process that allows white blood cells and protein to enter the anterior chamber, the hallmark sign of uveitis
Symptoms of Uveitis

- Redness
- Pain
- Photophobia
- Epiphora
- Visual Disturbances – blur, scotoma, floaters
IUSO Presentation
Eric Lukacin
1/3/13
Learning Objectives
The major goals of this presentation are to:

1) Facilitate the process of diagnosing the type of uveitis a patient may have

2) Prepare the optometric clinician to be able to treat and manage uncomplicated cases of
uveitis and make appropriate consultation/referral in cases that require
secondary/tertiary care

3) Increase proficiency for initiating appropriate laboratory analysis, when required
The study of uveitis is complicated and challenging due to the fact that the causes of inflammation of the inner eye can be multiform (infectious, traumatic, neoplastic, or autoimmune)


Eyelid and skin
-Vitiligo
-Nodules

Conjunctiva
-Perilimbal or diffuse injection
-Nodules

Corneal Endothelium
-Keratic Precipitates
-Fibrin
-Pigment

Anterior Chamber
-Inflammatory Cells
-Flare
-Pigment

Iris
-Nodules (Koeppe and Busacca)
-Posterior Synechiae
-Atrophy
-Heterochromia

Angle
-Peripheral Anterior Synechiae
-Nodules
-Vascularization

Intraocular Pressure
-Hypotony
-Secondary Glaucoma
Signs of Uveitis
Intermediate Segment:

Vitreous
-Inflammatory Cells
-Traction Bands

Pars Plana
-Snowbanking

Posterior Chamber
-Inflammatory Cells
-Flare
-Pigment
Anterior Segment
Posterior Segment:

Retina
-Inflammatory Cells
-Inflammatory Cuffing of Blood Vessels
-Edema
-Cystoid Macular Edema
-RPE Hypertrophy/Atrophy
-ERMs

Choroid
-Inflammatory Infiltrate
-Atrophy
-Neovascularization

Optic Nerve
-Edema
-Neovascularization
Anterior
Panuveitis
Classification
of Uveitis
Intermediate
Posterior
iritis/iridocyclitis/cyclitis
Hallmark features: AC Reaction (cells/flare), KPs
Hallmark features: Snow-banking
peripheral inflammation of the pars plana, retina, and choroid
retinitis, choroiditis, retinochoroiditis, chorioretinitis
Hallmark features:
Retinitis – focal, diffuse, and/or occlusive vasculitis Choroiditis – yellow-gray subretinal lestions
can affect the entire inner eye, with inflammation of both the anterior and posterior segments
Gradation of Severity - Structural Changes
Mild:
- low grade cell and flare (Hogan gradation scale)
- keratic precipitates
- lenticular precipitates

Moderate:
- anterior and posterior synechiae
- iris atrophy
- reversible glaucoma
- early lens opacities

Severe:
- irreversible glaucoma
- corneal edema and opacity
- pupillary block
- cataract
- macular edema, cyst, or hole
- RD
- hypotony (ciliary body destruction)
- pthisis bulbi
Associated Factors
- Time course of disease: acute, relapsing, chronic

- Severity: severe, quiescent

- Distribution of uveitis: unilateral, bilateral, focal, diffuse

- Patient demographics: sex, age, race

- Immune system status

- Systemic medications

- Social History: eating habits, pets, sexual practices, occupation, travel
history, drug use
Examples and Review - the "Heavy Hitters" in Anterior and Posterior Uveitis
Anterior Uveitis
Posterior Uveitis

1)acute non-granulomatous
Ankylosing Spondylitis – young males with lower back pain and joint stiffness after inactivity (increased ESR, +HLA-B27)

Reiter’s Syndrome/Reactive Arthritis – young males with urethritis, polyarthritis, and iritis (increased ESR, +HLA-B27)
Inflammatory Bowel Disease – includes Crohn’s disease and ulcerative colitis (lower colon vs full colon affected; +HLA-B27)

Bechet’s Disease – young adults (Asian/Middle Eastern most common) with acute recurrent hypopyon, iritis, and mouth and genital ulcers (+HLA-B27)

Lyme Disease – may have tick bite history, skin rash, and/or arthritis (ELISA/Lyme Titer)

Glaucomatocyclitic Crisis – mild iritis with recurrent, self-limiting episodes of elevated IOP (30’s-40’s), fine KPs, and open angle via gonioscopy

2)chronic non-granulomatous

Juvenile Rheumatoid Arthritis (JRA) – most common cause of uveitis in children; classic presentation if bilateral, young girls, +ANA, -RF; three subtypes (pauciarticular (1-4 joints – most commonly associated with uveitis), polyarticular (5 or more joints), and systemic (Still’s disease)

Fuch’s heterochromic iridocyclitis – unilateral mild uveitis; iris colour changes

3)chronic granulomatous

Sarcoidosis – African American, bilateral, more common in females; abnormal chest radiography with increased ACE levels (may have posterior uveitis)

Tuberculosis – Positive PPD test, abnormal chest x-ray, night sweats (may have posterior uveitis)

Herpes Simplex/Herpes Zoster – associated with increased IOP in involved eye

Syphilis – maculopapular rash on palms/soles, instersitial keratitis, + RPR or VDRL (active syphilis) and + FTA-ABS (latent syphilis)

1)Acute non-granulomatous

Ankylosing Spondylitis
Reiter’s Syndrome/Reactive Arthritis
Inflammatory Bowel Disease – includes Crohn’s disease and ulcerative colitis
Bechet’s Disease
Lyme Disease
Glaucomatocyclitic Crisis

2) Chronic non-granulomatous

Juvenile Rheumatoid Arthritis (JRA)
Fuch’s heterochromic iridocyclitis

3) Chronic granulomatous

Sarcoidosis
Tuberculosis
Herpes Simplex/Herpes Zoster
Syphilis

Toxoplasmosis

Histoplasmosis

Sarcoidosis

Syphilis

Pars Planitis

Cytomegalovirus
Anterior Uveitis
Intermediate Uveitis
Posterior Uveitis
Panuveitis
R/O Systemic Disease
Management
Consult
Treat
Unilateral, non-granulomatous
Bilateral, granulomatous, or recurrent
Therapeutic Regimen and Follow-up
Supplemental Testing
- Labs
- Imaging
Topical:
1) Corticosteroids
2) Cycloplegics and Mydriatics
3) Glaucoma medications for IOP reduction
Follow-up:
- Initial follow-up within 1-7 days
depending on severity
- Reduce/taper medications based
on response to treatment
1) Need an accurate and extensive History and ROS

--> this may evolve throughout your examination!
2) Remember the Associated Factors that can affect and influence uveitis

--> age, sex, race, etc.
3) Supplemental testing is your friend and can aid in your diagnosis when warranted

--> Labs, Imaging
4) Management - when to treat and when to refer

--> Treat - anterior uveitis
--> Obtain Consultation - all other types
Summary
1) Brief overview on the anatomy and pathophysiology of uveitis
2) Covered the hallmark symptoms and signs of uveitis
3) Discussed a classification system for uveitis based on location of involved structures
4) Identified associated risk factors of uveitis
5) Reviewed some of the common forms of anterior and posterior uveitis seen by
optometric clinicians
6) Established clinical pearls for determining when to treat, when to consult/refer, and
when to order supplemental testing for uveitis
7) Outlined standard of care treatment and follow-up of anterior uveitis with topical
medications
Literature Cited
Alexander, K., Dul, M., Lalle, P., Magnus, D., Onofrey, B. (1994). Optometric Clinical
Practice Guideline – Care of the Patient with Anterior Uveitis. American
Optometric Association.

Cheatham, K., Cheatham, M., Wood, K. (2010). KMK Part I – Applied Science Review
Guide. 5th edition, Vol. 1. KMK Education Services, LLC.

Cheatham, K., Wood, S. (2011). KMK Part II – Diagnosis and Treatment Board Review
Guide Guide. 2nd edition.KMK Education Services, LLC.

Ehlers, J., Shah, C. (2008). The Wills Eye Manual. 5th edition. Lippincott Williams and
Wilkins.

Friedman, N., Kaiser, P., Pineda, R. (2009). The Massachusetts Eye and Ear Infirmary –
Illustrated Manual of Ophthalmology. 3rd edition. Saunders Elsevier, Inc.

Opremcak, E., Cunningham, E., Foster, C., Forster, D., Moorthy, R., Lopatynsky, M.
(2004). Basic and Clinical Science Course – Intraocular Inflammation and
Uveitis. Section 9, 2004-2005 edition. American Academy of Ophthalmology

Sleight, W. (2011). Advanced Ocular Disease II Course Notes – Uveitis. New England
College of Optometry
Case Report
Demographics:
53 y/o African American Female presents for evaluation 11/5/12

Chief Complaint:
Patient presented for examination due to:
- blurred vision at N>D, OS>OD
- black spots/floaters, OS - most prominent with near tasks
- mild photophobia for past 1 month, OU
- mild eye pain for past 1 month, OU
- patient had not had a recent eye exam and thought she needed new reading glasses

Patient Ocular Hx:
- LEE ~1.5 yrs ago
- (-) for Flashes/Floaters/Injury/Surgery/Patching/Eye Turn/Eye Disease
- (+) Refractive Error (patient wears OTC readers only)

Family Ocular Hx:
- (-) for Glaucoma, ARMD, Cataracts, Blindness

Patient Medical Hx:
- LPE 6 months ago
- (+) Hypertension and Hyperlipidemia

Medications taken by patient:
- HTN and Hyperlipidemia meds (patient could not remember names of meds)
- Multivitamins

Patient Allergy History:
-NKDA, no food/environmental sensitivities

Review of Systems:
Unremarkable, except for conditions noted above
DDx?
Clinical Findings:

Entrance Acuities:
DVA: sc OD: 20/25
OS: 20/50- (slow)
OU: 20/25-1

NVA: cc OD: 20/20
OS: 20/20
OU: 20/20

* Patient wears OTC readers only (+2.00)

Entrance Tests:
EOMS: FESA
Pupils: PERRL (–)APD
FCF: Full, OD and OS

Anterior Segment Evaluation:
Lids/Lashes/Adnexa: Mild MGD, OU
Conjunctiva: Trace injection, OS>OD
Cornea: Trace SPK OD; multiple large KPs, edema, striae OS
Anterior Chamber: Deep and quiet OD; prominent AC Rxn OS (3+ cell, 2+ flare)
Iris: Flat, OU
Lens: 1+ NSC OU, 1+ ACC, OU
Vitreous: Clear, no cells/flare, OU

IOPs: 18 mmHg OD, 19 mmHg OS @ 1:40pm with GAT

Posterior Segment Evaluation:
Dilation with 1% Tropicamide and 2.5% Phenylephrine, OU
C/D: 0.35 H/V, OU
Margins: Distinct, healthy
Vessels: 2/3 with age appropriate crossings/changes, OU
Macula: Clear and flat, OU
Vitreous: Syneresis, no cells/flare, OU
Posterior Pole and Periphery: No holes/breaks, OU; (-) snow-banking, OU
Assessment:
1) Unilateral anterior uveitis with likely granulomatous etiology, OS

Plan:
1) RTC 3 days for f/up - Rx PF q2H and HA BID OS


F/up:

11/8/12:
- Stable clinical presentation - continue PF q2H and HA BID OS.
- Ordered labs (ACE, CBC, ESR), Chest X-ray, and Tb PPD
- RTC 4 days for f/up

11/12/12:
- Improving clinical presentation - PF to q3H and HA BID OS
- lab results all negative
- RTC 4 days for f/up

11/16/12:
- Improving clinical presentation - PF to QID and HA BID OS
- RTC 10 days for f/up

11/28/12:
- Improving clinical presentation - Start PF taper, d/c HA OS
- RTC 1 month for f/up

12/20/12:
- patient completed PF taper at this time
- Recheck one month
Full transcript