Acute anterior uveitis by Dr. Rubana.pptx

Acute presentation of AAU

1. ACUTE ANTERIOR UVEITIS PRESENTER: DR. RUBANA DILAWAR FCPS PART-II STUDENT

2. Chairman:   Prof. Dr. Pankaj Kumar Roy   Department of Vitreo-retina,   NIO & H. Moderator:    Dr. Md. Hafizur Rahman    Assistant Professor    Department of Vitreo-retina,    NIO & H. 2

3. UVEITIS The uvea consists of the middle, pigmented, vascular layer of the eye. Includes the iris, ciliary body, and choroid. Uveitis is broadly defined as inflammation of the uvea. Inflammation of the uvea involve retina, sclera, cornea, vitreous, and optic nerve.  3

4. CLASSIFICATION 4 Anterior Intermediate Posterior Panuveitis Anatomical Infectious Non-infectious Masquerade Aetiological Sudden Insidious Onset Limited Persistent Duration

5. CLASSIFICATION CONT. 5 Acute (Sudden onset, limited duration) Recurrent (Repeated episodes separated by untreated inactive periods) Chronic (Persistent duration with relapse < 3 months after discontinuation of treatment) Remission (Inactivity for 3 months or longer) Clinical Course

6. ANTERIOR UVEITIS Inflammation involving the anterior uveal tract- the iris, anterior part (pars plicata) of the ciliary body is called anterior uveitis. 6

7. CAUSES OF ACUTE ANTERIOR UVEITIS Idiopathic Autoimmune:  HLA-B27 positive  Ankylosing spondylitis  Reactive arthritis (Reiter’s)  Psoriatic arthropathy  Sarcoidosis SLE  Behcet’s disease 7 3. Infective :   Syphilis  HSV 4. Others : Posner- Schlossman Syndrome  Crystalline lens-associated Post-surgical  Trauma  Drug-induced

8. SYMPTOMS Pain Redness Photophobia Watering Blurred vision 8

9. SIGNS 9 Visual acuity : Mildly reduced

10. SIGNS CONT . 10 Ciliary injection

11. SIGNS CONT. 11 Miosis: Occurs due to pupillary sphincter spasm and predisposes to the formation of posterior synechiae

12. SIGNS CONT . 12 Anterior chamber cells and flare: Indicator of inflammatory activity. Haziness of the normally clear fluid in anterior chamber indicates presence of protein due to breakdown of blood-aqueous barrier. The inflammatory cells come out from inflamed blood vessels.

13. SIGNS CONT. 13 Table 4: Grading of anterior chamber flare and AC cells (SUN Workshop) Grade/description of AC Flare Grade of AC cells Cells in field* o- None o- <1 0.5+ 1-5 1+ Faint 1+ 6-15 2+ Moderate (iris and lens details clear) 2+ 16-25 3+ Marked (iris and lens details hazy) 3+ 26-50 4+ Intense (fixed and plastic aqueous) 4+ 50+ *Field size is a 1x1mm slit beam.

14. SIGNS CONT. 14 Hypopyon:  Whitish purulent exudate composed of myriad inflammatory cells in the inferior part of the anterior chamber.

15. SIGNS CONT. 15 Keratic precipitates: These are cellular deposits on the corneal endothelium composed of inflammatory cells such as lymphocytes, plasma cells and macrophages. 

16. SIGNS CONT. 16 Fibrinous exudate in AC: Commonly found in severe acute anterior uveitis with hypopyon in HLA B 27  -related inflammation mostly, such as-    Psoriasis Inflammatory Bowel Disease Reactive arthritis Ankylosing spondylitis

17. SIGNS CONT. 17 Posterior synechiae: Inflammatory adhesions between the pupillary margin and the anterior lens capsule, likely to form at the location of a Koeppe nodule .

18. SIGNS CONT. 18 Iris atrophy:  Patchy or sectoral iris atrophy can occur in herpetic uveitis. 

19. COMPLICATIONS Complicated cataract Secondary glaucoma Cyclitic membrane Choroiditis Retinal detachment Cystoid macular oedema Band keratopathy Phthisis bulbi 19

20. INVESTIGATIONS Situations where investigations are generally required includes- Recurrent AAU. Severe AAU.  Bilateral AAU.  Anterior uveitis that is persistent, chronic or resistant to treatment. Granulomatous inflammatory signs (note that granulomatous conditions may give non-granulomatous AAU). Associated intermediate or posterior uveitis. Ocular or systemic clinical features suggesting underlying disease. 20

21. INVESTIGATIONS CONT. 21 HLA tissue typing: Ankylosing spondylitis Reactive arthritis/ Reiter syndrome Psoriatic arthritis Arthritis in inflammatory bowel disease Syphilis serology: ELISA TPHA VDRL RPR

22. INVESTIGATIONS CONT. 22 Serum ACE: Sarcoidosis Tuberculosis Leprosy Lysozyme: Sarcoidosis ESR & CRP: Systemic inflammatory disorders

23. INVESTIGATIONS CONT. 23 CBC: Infection Malignancy Parasitic infection Serology for: Lyme disease Brucellosis Leptospirosis ANA: Juvenile Idiopathic Arthritis

24. INVESTIGATIONS CONT. ANCA: Wegener granulomatosis QuantiFERON TB Gold test: Tuberculosis HIV Serology Sacroiliac joint X-ray: Ankylosing spondylitis Other seronegative spondyloarthropathies 24

25. INVESTIGATIONS CONT. Chest X-ray: Sarcoidosis Tuberculosis Ocular imaging: B-scan:  Vitreous opacities, choroidal thickening, retinal detachment. OCT: Cystoid macular oedema, epiretinal membrane. FAF: Multiple evanescent white dot syndrome. FFA: Vasculitis, white dot syndromes, macular ischemia. ICGA: Choroidal pathology. UBM: Subtle choroidal effusion, cyclodialysis cleft, cyclitic membrane. 25

26. INVESTIGATIONS CONT. 26 Biopsy: Aqueous tap: Done in unexplained hypertensive uveitis, cases relatively unresponsive to topical steroids. Iris biopsy: Rarely done. Vitreous biopsy: For suspected infectious endophthalmitis. Conjunctival biopsy: For suspected granuloma or infiltrative lesion.

27. INVESTIGATIONS CONT. 27 Other special investigations: High resolution computed tomography chest scan Whole body Gallium scan (sarcoidosis) Purified protein derivative skin test for tuberculosis Bronchoscopy with lavage/ biopsy Cranial MRI Lumbar puncture Endoscopy

28. TREATMENT Goals of treatment include- Preservation of visual acuity Relieving ocular pain Elimination of ocular inflammation Identifying the source of inflammation Prevention of synechiae formation Control of intraocular pressure 28

29. TREATMENT CONT. Non-specific treatment: Local therapy: Cycloplegics Corticosteroids Broad spectrum antibiotics Systemic therapy: Corticosteroids NSAIDS Immunomodulators Specific treatment of the cause Treatment of complications 29

30. TREATMENT CONT. 30 Non-specific treatment: Local therapy: Cycloplegics :  Short-acting: Tropicamide 1% E/D (3 hours) Cyclopentolate 1% E/D (12-24 hours) Long-acting: Homatropine 2% E/D (3 days) Atropine 1% E/D (7-10 days)

31. TREATMENT CONT. Corticosteroids : Long-acting: Dexamethasone Betamethasone Hydrocortisone Prednisolone Triamcinolone 31 Route of administration: Topically as eye drops/ eye ointments Regional steroid injections Broad spectrum antibiotic:   Doesn't have much role in anterior uveitis Short -acting: Fluorometholone Loteprednol ​ Fluocinolone ​

32. TREATMENT CONT. Systemic therapy: Corticosteroids: Systemic corticosteroids are usually not required in anterior uveitis but, may be needed where the response to topical treatment is inadequate. Oral Prednisolone: 1-1.5 mg/kg/day (not more than 60-80 mg/kg/day). Then, gradually tapered every 1-2 weeks according to response. IV Methylprednisolone: Initially 1g/day for 3 days followed by gradual tapering of oral Prednisolone starting at 1-1.5 mg/kg/day. 32

33. TREATMENT CONT. NSAIDS:  Indicated when steroids are contraindicated or not tolerated. Naproxen Tolmetin 33

34. TREATMENT CONT. Immunomodulator therapy: Indicated in- Immediate treatment : Systemic lupus erythematosus with retinal vasculitis. Behçet disease with retinal vasculitis. 34

35. TREATMENT CONT. Early treatment should be considered for: Sympathetic ophthalmitis Vogt– Koyanagi –Harada syndrome Birdshot retinochoroiditis Serpiginous choroidopathy Multifocal choroiditis and  panuveitis  ​ Juvenile inflammatory arthritis 35

36. TREATMENT CONT. As an alternative to steroids: Therapeutic : Inadequate response to topical and periocular steroids or to an oral dose >0.5 mg/kg/day prednisolone; intolerance of systemic steroids or as a steroid-sparing measure. Ocular : Acute disease that is sight threatening or chronic and persistent, exudative retinal detachment or disease involving the macula. 36

37. TREATMENT CONT. Specific treatment of the cause: According to the aetiology. Treatment of complications: Inflammatory glaucoma: Timolol 0.5% twice daily. Tab. Acetazolamide 250mg twice daily. Post-inflammatory glaucoma: LASER iridotomy . Complicated cataract: Cataract surgery after 3 months of quiet period. Retinal detachment: Pars plana vitrectomy . Band keratopathy: Chelation with EDTA. Phthisis bulbi : Enucleation . 37

38. TAKE HOME MESSAGE 38 Uveitis is a sight threatening condition Appropriate diagnosis and proper treatment can save vision and reduce morbidity Details history taking, meticulous ocular and systemic examination is essential for diagnosis of uveitis Treatment should be started as soon as possible to prevent the sight threatening complications of uveitis Causes of infective uveitis must be excluded before starting immunomodulator therapy

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