Posterior uveitis by Dr. VIJAY PRATAP VIPSY

CONTAIN ONLY INTERMEDIATE AND POST. UVEITIS

1. BY DR. VIJAY PRATAP SINGH MLB MC , JHANSI

2. Uveitis Term uveitis strictly means inflammation of uveal tissue only. However, clinically there is always some associated inflammation of the adjacent structure such as Retina Vitreous Sclera Cornea

3. CLASSIFICATION OF UVEITIS

4. Infective uveitis Immune related uveitis Toxic uveitis Traumatic uveitis Uveitis a/w non-infective systemic diseases. Idiopathic uveitis

5. Intermediate uveitis Inflamation of pars plana ,peripheral retina, choroid and vitreous base. -Account for 10% of all uveitis -Bimodal distribution Etiology – -Idiopathic (HLA-DR2) 85% -Known cause(15%) TB, Syphilis, Sarcoidosis and Lyme disease.

6. Sign Ant. Segment sign- looks normal but may be show - Low grade flare and cell - Few KP’s d/t spill over ant. Uveitis - Late stage- lens show complicated cataract. Post. Segment sign.- - Vitreouse cell - Snow ball or cotton ball opacities near ora serrate - Sever vitreouse opacification – may be leucocoria

7. Complication Complicated cataract CME Secondary glaucoma Vitreouse haemorrhage . Tractional RD Band keratopathy Tx - Periocular or systemic steroid Immunosuppressive drugs Cryotherapy or indirect laser photocoagulation Pars plana vitrectomy

8. POSTERIOR UVEITIS is Inflammation of retina or choroid posterior to vitreous base .  Choroiditis  Chorioretinitis  Retinochoroiditis  Retinal vasculitis  Neuroretinitis

9. Infective causes

10. Non infective causes

11. Symptoms CHOROIDITIS is a painless condition but visual symptoms d/t vitreouse haze and retinal involvement Visual symptoms Defective vision Photopsia Floaters Metamorphosia Micropsia Macropsia Positive scotoma

12. Sign Ant. Segment sign- Usually there is no external sign, however fine KP’s may be seen Vitreouse opacities- It is mainly d/t choroiditis Choroiditis may be Focal Diffuse and Multifocal

13. Choroidal patches Active patches Pale yellow or dirty white raised area with ill-defined edge. Healed patches- Sharply defined from the rest of normal area d/t atrophy of choroidal tissue

14. Approch to uveitis

15. SLE Diagnostic criteria- Malar rash Serositis Arthritis etc. Choroidopathy : Fundus examination may reveal multiple serous retinal detachments, retinal pigment epithelium detachments and a central serous chorioretinopathy Retinopathy : It typically occurs bilaterally but may be unilateral or asymmetric. The most common findings include cotton-wool spots and hemorrhages. Less common findings include hard exudates, retinal edema, visual acuity loss or metamorphopsia , and vascular tortuosity . Specific tests- Anti nuclear Ab Assay.

16. SARCOIDOSIS Ant seg - sarcoid granulomas , iris nodules Post seg - vitritis , periphlebitis , snow balls Diagnosis- X-ray chest Hypercalcemia Serum ACE Ga scan Biopsy

17. Ocular sarcoidosis (A) Large iris nodules; (B) nodular involvement of the trabecular meshwork (C) snowballs Periphlebitis in sarcoidosis . (D) Periphlebitis with involvement of the optic nerve head (E) occlusive periphlebitis and disc oedema ; (F) ‘ candlewax ’ drippings

18. Choroidal and retinal involvement in sarcoidosis . (A) Small peripheral choroidal granulomas ; (B) confluent choroidal infiltrates; (C) multifocal choroiditis ; (D) multiple small retinal granulomas . Dx - CXR, Serum ACE, Biopsy. Tx - Depend on severity, topical/ periocular /systemic steroid can be used.

19. HSV, VZV Immunosuppressed patients Hutchinson’s sign. Reduced corneal sensations Sectoral atrophy of iris. Peripheral retinal periarteritis . ARN- retinal necrosis in periphery which rapidly spreads. PORN- rapidly progressive visual loss. Full thickness necrosis and early macular involvement. PCR based assay.

20. CMV Retinitis Usually a/w Pt. suffuering from AIDS, on cytotoxic chemotherapy or long term immunosuppression . Ant. Segment sign- KP’s may be seen. Post. Segment sign- Haemorragic retinitis Granular retinitis Tx - -HAART. - Ganciclovir , valaganciclovir , foscarnet and cidofovir

21. TOXOPLASMOSIS Congenital toxoplasmosis. Acquired toxoplasmosis. Toxoplasmosis in the immunocompromised host. Ocular toxoplasmosis.

22. Congenital toxoplasmosis. The classic clinical triad Retinochoroiditis . Cerebral calcifications. Convulsions.

23. OCULAR TOXOPLASMOSIS Ocular Toxoplasmosis is the most common cause of Posterior uveitis , The lesions develop in deep retina, few to no vitreous cells may be present (Headlight in fog) It frequently presents as a focal necrotizing retinitis, adjacent to a larger, atrophic chorioretinal scar,often located in macula in congenital cases.

24. The hallmark of the disease is a necrotizing Retinochoroiditis , which may be Primary or Recurrent - In primary ocular toxoplasmosis , a unilateral focus of necrotizing retinitis is present at the posterior pole in more than 50% of cases -The area of necrosis usually involves the inner layers of the retina and is described as a whitish fluffy lesion surrounded by retinal edema

25. Recurrent ocular toxoplasmosis TOXOPLASMOSIS With reactivation of live tissue cysts ,the areas of newly active necrotizing retinitis are usually adjacent to old scars ( so-called satellite lesions ). In some patients, multiple grayish white dots at the level of the retinal pigment epithelium (RPE) appear. No associated vitreous reaction occurs with this manifestation. Macular edema may be seen.

26. Complication of ocular Toxoplsmosis Optic neuritis or papallitis a/w edema k/a Jensen disease. PVD & Tractional RD. Retinal vasculitis . Granulomatous or Nongranulomatous anterior uveitis . Retinal ischemia Neovascularization of the retina & Optic disc. Secondary glaucoma.  Optic atrophy. BRVO & BRAO CME or CNVM (rare & late sequel).

27. Investigation LABORATORY STUDIES- Serology  Serum antitoxoplasma antibody titers Enzyme-linked immunosorbent assay (ELISA) Indirect fluorescent antibody test Indirect hemagglutination test Complement fixation Sabin-Feldman dye test IMAGING STUDIES- Fluorescein angiography (FFA) Indocyanine green (ICG) B-SCAN

28. Treatment- TRIMETHOPRIM AND SULFAMETHOXAZOLE with Para- aminobenzoic acid (PABA). Pyrimethamine ( Daraprim ) with oral folinic acid. Clindamycin , spiramycin , tetracyclines , atovaquone , azithromycin and clarithromycin . Topical steroids Photocoagulation or cryotherapy & Pars plana vitrectomy are surgical option

29. OCULAR TOXOCARIASIS Intestinal roundworm. Young children Almost U/L Clinically p/w- - Chronic toxocara endophthalmitis ( leucocoria ) - Post pole / peripheral granuloma Dx -ELISA, USG, CT scan. Tx - Sub- Tenon steroid, pars plana vitrectomy

30. Syphilitic uveitis It may occur disseminated, peripheral or diffuse choroiditis . Dx - Confirmed by FTA-ABS blood test TPI test VDRL tes Tx - usual uveitic Tx + Systemic penicillin or other antisyhilitic drugs

31. Tubecular uveitis Common cause in developing countries. Clinical presentations- A) Ant. Uveitis B) Post. Uveitis -Multiple miliary tubercal in choroid -Douse or multifocal choroiditis . - Choroidal garanuloma . C) Vasculitis ( Eales ’ disease). Dx - Clinical based + skin test + Isoniazid response test Tx - Chemotherapy with ( R+Z )+ Usual Tx of uveitis

32. Fungal uveitis PRESUMED OCULAR HISTOPLASMOSIS SYNDROME   More common in endemic area Clinical features- Histospot - Atrophic scar scattered in mid-retinal periphery Macular histospot - Atrophic macular scar f/b a hole in Bruch’s membrane Tx - a) Systemic steroids in active macular lesions b) Laser photocoagulation in subretinal neovacular membrane c) Anti-VEGF

33. Ocular candidiasis Opportunistic infection in pt. suffering from AIDS Cause multifocal chorioretinits . Multiple small, round, whitish area a/w area of haemorrages with pale center( Roth’s spot ). Tx - Topical cycloplegics & antifungal Systemic antifungal. Pars plana vitrectomy

34. HLA associated uveitis Behcet’s Disease- A/w HLA-B51 B/L ,acute recurrent iridocyclitis a/w hypopyon Also a/w post. Uveitis , vitritis , periphlebitis retinae and retinitis . Tx - Corticosteroid Immunosuppressive drugs

35. Vogt– Koyanagi –Harada syndrome VKH syndrome is an idiopathic multisystem autoimmune disease featuring inflammation of melanocyte -containing tissues such as the uvea , ear and meninges . a/w HLA-DR4/DW15 Post. Uveitis lesion includes - Multifocal choroidits - Exudative RD - Choroidal depigmentation (sun glow fundus ) - Dalen- fuch’s nodules - Peripheral choroidal granuloma Tx -Corticosteroid and immunosuppressive drugs