Tailored+Investigations+for+Uveitis.pptx

Uveitis

1. Tailored Investigations for Uveitis

2. Objectives We will discuss Definition of uveitis Diagnostic approach to uveitis How to tailor investigations to a case of uveitis

3. Condition in which all or part of the uvea (middle layer of the wall of the eye) becomes inflamed. The uvea includes the choroid, the ciliary body, and the iris . Uveitis may also affect the lens, retina, optic nerve, and vitreous humor

4. Pathway to diagnosis Pattern recognition: Detailed history + Ophthalmic examination Recognize patterns that indicate particular conditions

5. Pathway to diagnosis Probabilistic method: Differential diagnoses based on intuition guided by clinical experience

6. Medical history Present illness and course Past history of similar episodes Systemic comorbidities Systemic diseases Pets, environment, sexual history Past history of treatment and response to treatment

7. Ocular examination - Anterior segment

8. Anterior chamber cells

9. Anterior chamber flare

10. Ocular examination - Posterior segment

11. Vitreous cells

12. Vitreous flare

13. Anatomical classification The Standardization of Uveitis Nomenclature (SUN) Working Group guidance on uveitis terminology, endorsed by the International Uveitis Study Group (IUSG), categorizes uveitis anatomically: ★ Anterior: the anterior chamber is the primary site of inflammation. ★ Intermediate: primarily vitreous inflammation including pars planitis. ★ Posterior: retina and/or choroid. ★ Panuveitis: all uveal structures are involved

14. Diagnostic questions

15. Causes of granulomatous uveitis

16. Causes of unilateral uveitis

17. Anterior uveitis - causes Idiopathic Ankylosing spondylitis Reiter syndrome Inflammatory bowel disease Psoriatic arthritis Behcet disease Juvenile rheumatoid arthritis Fuch’s heterochromic iridocyclitis Sarcoidosis Syphilis Glaucomatocyclitic crisis Masquerade syndrome

18. Intermediate uveitis - causes Sarcoidosis Inflammatory bowel disease Multiple sclerosis Lyme disease

19. Posterior uveitis - causes Focal retinitis Focal choroiditis Toxoplasmosis Toxocariasis Onchocerciasis Tuberculosis Cysticercosis Nocardiosis Masquerade syndrome Masquerade syndrome

20. Posterior uveitis - causes Multifocal retinitis Multifocal choroiditis Syphilis Histoplasmosis Herpes simplex virus Sympathetic ophthalmia Cytomegalovirus Vogt-Koyanagi- Harada syndrome Sarcoidosis Sarcoidosis Candidiasis Serpiginous choroidopathy Meningococcus Birdshot choroidopathy Masquerade syndromes Masquerade syndromes

21. Panuveitis - causes Syphilis Sarcoidosis Vogt- Koyanagi- Harada syndrome Infectious endophthalmitis Behcet disease

22. Post- test probability Posttest probability = Pretest probability × sensitivity (Pretest probability × sensitivity) +(1 − Pretest probability)(1 − specificity) >1%

23. When investigations are not indicated? A single episode of unilateral mild/moderate (no hypopyon) non- granulomatous AAU with no ocular or systemic suggestion of underlying disease. Typical clinical features of a specific entity for which investigation is not usually indicated (e.g. Fuchs uveitis syndrome). A systemic diagnosis compatible with the clinical features (e.g. Sarcoidosis) has already been confirmed.

24. Indications of investigations Recurrent uveitis Severe AAU Bilateral AAU Anterior uveitis - persistent, chronic or resistant to rx Granulomatous inflammatory signs Associated intermediate or posterior uveitis Ocular or systemic clinical features that indicate systemic disease

25. Step 1: Routine investigations CBC Chest X- ray ESR CRP RBS, RFT, LFT

26. Step 2 Investigations guided by Anatomical classification Clinical and pre- clinical findings Medical history

27. HHH CMV, VZV, HSV, Rubella titres Syphilis serology Toxoplasma serology Tuberculin test HLA B27 typing ANA, ANCA, Anti- phospholipid antibody X- ray sacroiliac joint

28. Step 3: Further investigations Radiological: Brain MRI CT chest PET CT entire body

29. Step 3: Further investigations Histopathological: Bronchial lavage Conjunctival / lacrimal gland biopsy Skin granuloma biopsy Ocular lymphoma - diagnostic vitrectomy

30. 42 y/o female presents with a 10 year history of uveitis, intermittently treated with systemic and topical corticosteroids, with chief c/o blurring of vision [LE > RE] No rash / joint findings RE LE V/A 6/15 6/36 SLE WNL Mutton fat KPs Vitreous Trace vitreous cells, trace vitreous haze +2 vitreous cells and +2 vitreous haze Retina Peripheral retinal vasculitis and cystoid macular edema Peripheral retinal vasculitis and cystoid macular edema

31. Specific investigations Chest x- ray ANCA ACE levels CT scan of sinuses MRI brain Multiple sclerosis

32. 73 y/o woman presented with B/L blurred vision since 1 year. The patient first noticed floaters in the left eye a year ago, did not see an ophthalmologist until months ago, when she was found to have B/L mild vitritis. Over the next 3 months, her vision decreased in both eyes. H/O type 2 diabetes mellitus - controlled with oral hypoglycemic agents Childhood h/o rheumatic fever Also complaints of weight loss and unsteady gait

33. RE LE V/A 6/15 6/36 Anterior segment WNL WNL Vitreous +2 vitreous cells, +2 vitreous haze +2 vitreous cells and +2 vitreous haze Retina Punctate yellow subretinal infiltrates Punctate yellow subretinal infiltrates, retinal hemorrhage, edema Physical examination: ataxia

34. Specific investigations Chest x- ray ANCA ACE levels Vitrectomy - negative for ocular lymphoma Systemic evaluation for malignancy Sarcoidosis

35. A 21- year- old male patient presented with on and off blurring of vision in right eye during last 2 years. RE LE V/A 1 MFC 6/12 PHI 6/9 Color vision Red desaturation NAD Anterior segment Quiet AC, no hypopyon, open angles (Shaffer 4) Quiet AC, no hypopyon, open angles (Shaffer 4) Vitreous +2 vitreous cells WNL Fundoscopy Hazy WNL B- scan Diffuse hyperechogenic pattern WNL

36. ★ Multiple nodular pyoderma gangrenosum ulcers noticed on ventral and dorsal surface of left leg ★ Multiple, round, whitish aphthous ulcers in oral cavity ★ Scrotal swelling Pathergy test positive

37. Specific investigations ESR HLA typing Behcet’s disease

38. 35 y/o male presents with loss of vision in LE since 1 year and blurred vision in RE since 2 weeks. H/O episode of congestion in LE before 1 year with sequential vision loss H/O 1 episode of congestion and blurred vision in LE that was treated by topical medications [patient does not have documentation] H/O TB 15 years ago, pt completed ATT

39. RE LE V/A 6/24 HM+ PL+ PR4+ Color vision Defective NAD Anterior segment Pigment dispersion over ALC, mutton fat appearing keratic precipitates, round non- reactive pupil Early posterior subcapsular cataract, round non- reactive pupil Vitreous +1 vitreous cells, +1 vitreous haze WNL

40. RE LE Fundoscopy Patches of retinitis at posterior pole with inflammatory vascular sheathing, mild disc edema, disc pallor Patches of chorioretinal atrophy at posterior pole and mid periphery s/o inactive healed lesions, disc pallor

41. Specific investigations HHH IgG titres for CMV, HSV, HZV CD4 count Chest X- ray CMV retinitis