shibu lijack. speaker: kumar saurabh group of diseases characterized by severe sight threatening...
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Shibu lijack
Shibu lijack Speaker: Kumar Saurabh
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
Uveitis: Definition
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
Problem Statement
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 non-granulomatous 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 HazeDirect Ophthalmoscope
0 : Clear vitreous
+ : Few, normal view ++ : Moderate scattered opacities, obscured view +++ : Many opacities, blurring of view ++++ : Dense opacities, no view
Vitreous HazeIndirect Ophthalmoscope
++++ : 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 striations0 : Nerve fiber layer well defined
Retinal Features
Retinitis
Primary vasculitis
Secondary vasculitis Retinal detachment
Macular oedema
Neovascularization
Active choroiditis
Inactive choroiditis
Choroidal granulomas
Choroidal neovascularization
Choroidal vasculitis
Choroidal Features
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
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
Aims
Laboratory Investigations
Granulomatous uveitis Recurrent uveitis (>3
attacks) Uveitis in a child Positive leads on examination Posterior uveitis Retinal vasculitis Worsening on steroids
Indications
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.Pyrimethamine: 75mg, D125mg/day, 4-6 weeks PLUSSulphadiazine: 2 gm, D11 gm four times daily, 4-6wksPLUSPrednisolone: 40-60 mg/ dayFrom D3-D7, taperedPLUSFolinic Acid: 5mg twice weekly
Regimen 2.Clindamycin 300mg, 4 times Daily, 4-6 weeksPLUSSulphadiazine: 2 gm, D11 gm four times daily, 4-6wksPLUSPrednisolone: 40-60 mg/ dayFrom D3-D7, tapered
Specific Therapy
Peripheral Lesion: Follow up
Posterior Pole Involvement:Prednisolone 40mg/day and
Thiobendazole 20mg/day. 5-7 daysVitrectomy
Ocular Toxocariasis
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 effectsContraindication of steroid therapy
Immunosuppressive Therapy
Absolute Indications: Behcet’s diseaseSympathetic Ophthalmia
Vogt-Koyanagi-Harada Syndrome
Wegener’s Granulomatosis Polyarteritis Nodosa
Nonspecific Therapy: Medical
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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