Uveitis

This presentation gives a brief notes about Uveal tract inflammation and its treatment in this first part presentation.

1. Uveitis. Part 1 Dr. Amr Mounir.MD Lecturer of Ophthalmology Sohag University

2. Background

3. Definition Uveitis: Inflammation of uveal tract (iris, ciliary body & choroid ) Types: 1- Anterior uveitis 2-Intermediate uveitis 3- Posterior uveitis

4. Anterior uveitis :Includes   iridocyclitis  and  iritis . Iritis is the inflammation of the  anterior chamber  and  iris . Iridocyclitis presents the same symptoms as iritis, but also includes inflammation in the  ciliary body

5. Intermediate uveitis

6. Intermediate uveitis   also known as  pars planitis , consists of vitritis —which is inflammation of cells in the vitreous cavity, sometimes with  snowbanking , or deposition of inflammatory material on the  pars plana . There are also "snowballs," which are inflammatory cells in the vitreous .

7. Posterior uveitis - Posterior uveitis: Chorioretinitis  is the inflammation of the   retina  and  choroid . - Pan-uveitis  is the inflammation of all layers of the uvea

8. Clinical picture Respiratory symptoms …….. TB, Sarcoidosis. Skin problems accompanied by uveitis erythema nodosum (arms +chin) >>>> Sarcoid & Bechet oral & genital ulcers >> Bechet Joint disease AS……….20% ant.uveitis juvenile chronic arthritis Reiter syndrome ……….. Bowel problems

9. Signs Visual acuity may reduced ciliary injection Anterior uveitis: Keratitic precipitates Inflam . Cells maybe visible as clumps on endothelial of cornea (mostly Inferior) On slit lamp exam. Flare & hypopyon in severe inflammation. Posterior synechia

10. Signs

11. Intermediate and posterior uveitis Cells in the vitreous Macular edema

12. Grading of aqueous cells Slit-lamp grading of aqueous cells (1 mm × 3–4 mm beam) Trace ……………… 1-5 cells +1 …………………. 6-15 +2 …………………. 16-25 +3 ……………………. 26-50 +4 …………………….. >50

13. Etiology Idiopathic Infections Systemic immune-mediated disease (40%) Syndromes confined primarily to the eye Masquerade syndromes 30% of patients don’t fit an well-defined disease category

14. Investigations Main aim : determine systemic association Investigation should be guided by medical History & General Examination : Pt with first episode of non granulomatous iritis with no past medical History & no systemic signs…so investigations are not indicated Recurrent persistent iritis with unusual severity, not responsive to medical therapy or bilateral……….so here investigation is needed

15. Ancillary tests 1- Ultrasound biomicroscopy (UBM ): Ciliary body involvement can best be confirmed by ultrasound biomicroscopy (UBM ). 2- Fundus fluorescein angiography (FA):  is mandatory for retinal and choroidal lesions . The FA allows identification of active inflammation of the retinal vessels as seen in vasculitis.  The pattern of staining and leakage provides diagnostic clues. Vascular occlusions can also be detected Complications of uveitis that are best studied on FA include cystoid macular edema (CME), neovascularization of retina 3- Indocyanine green angiography (ICGA ): is the technique of choice for imaging the choroid. 

16. 4- Optical coherence tomography (OCT ): CME, neovascularization of retina, epiretinal membrane, or Vitreomacular traction syndrome can be demonstrated well

17. Lab. Investigations CBC count Erythrocyte sedimentation rate ( ESR) Antinuclear antibody (ANA) Rapid plasma reagin (RPR) Venereal disease research laboratory (VDRL) Purified protein derivative (PPD) Lyme titer HLA-B27 Urinalysis HIV test

18. Imaging studies Chest X ray to rule out sarcoidosis & TB Chest CT done if we have –ve chest X ray but sarcoidosis still highly suspected 3 . Sacroiliac radiograph , if AS is suspected

19. 10 Clinical Pearls for Treating Uveitis By American A.O 1- Anatomical location of the inflammation . 2- Patient’s current treatments and medications . 3- A targeted review of systems . 4- A careful examination for depth of inflammation. 5- The workup . 6- Corticosteroids are the mainstay of therapy . 7- Prolonged therapy with prednisone, especially at doses greater than 10 mg daily, can have significant side effects . 8- Uveitis patients are frequently steroid responders . 9- New approaches in immunotherapy involve more cellular-specific targeting, such as T-cells.

20. Lastly: 10-Helpful reference articles   include: 1- Guidelines for the use of immunosuppressive drugs in patients with ocular inflammatory disorders.  Am J Ophthalmol.  2000; 130:492-513. 2- The Standardization of Uveitis Nomenclature (SUN) Working Group.  Am J Ophthalmol.  2005; 140:509-516.

21. Aims: 1. relief pain & inflammation 2. prevent ocular structural damage 3. prevent visual loss & retinal or optic damage Include : Cycloplegia Long acting cycloplegic agents (cyclopentolate , hematropine )used to relief pain& photophobia by mydriasis

22. I. Corticosteroids: A. Local delivery of corticosteroids: Topical corticosteroids: Iontophoresis Periocular injections Intravitreal injections and inserts B. Systemic oral steroids (oral and intravenous )

23. II. Immunosuppressants III. Biologics IV. Adjuvant therapy : Cycloplegic Newer nonsteroidal anti-inflammatory agents Anti-vascular endothelial growth factor (anti-VEGF) therapy bevacizumab , ranibizumab V. Current concepts in infectious uveitis management

24. Corticosteroids 1. Topical , is the mainstays of therapy used aggressively esp. in initial phases of therapy , - “ soft steroids ” eg: fluorometholone , rimexolone , and loteprednol etabonate difluprednate (0.05%) (difluoroprednisolone butyrate acetate) has greater glucocorticosteroid receptor binding 2. Subconjunctival injection , used if patient poorly complies to topical type or iritis not respond to topical ttt alone 3. Oral corticosteroid maybe necessary in severe cases of iritis and post uveitis

25. Topical steroids

26. Systemic steroids

27. Immunosuppressive agents Immunosuppressive drugs can be classified as antimetabolites , T cell inhibitors , and alkylating agents . These drugs take many weeks to have an effect, so initial therapy of ocular inflammation typically include high dose of systemic steroids. Immunosuppressive therapy can be started simultaneously with corticosteroids in severe cases or during the tapering of oral corticosteroids 4–8 weeks later in cases of chronic uveitis.

28. Biologics Anti-tumor Necrosis Factor-alpha (Anti TNFα) Therapies: etanercept, infliximab, and adalimumab Interferons (IFN ) Intravenous Immunoglobulin Anti-interleukin Therapies: Daclizumab is a humanized monoclonal antibody against the interleukin (IL)-2 receptor . Biologic therapy provides new options for the treatment of refractory uveitis, showing a favorable safety and efficacy profile .

29. Adjuvant Therapy To provide symptomatic relief for pain and discomfort and break the posterior synechiae, the following cycloplegics can be used : Short acting cycloplegics : Tropicamide (0.5 and 1%) has a duration of 6 hours Cyclopentolate (0.5 and 1%) has a duration of 24 hours Long acting cycloplegics : Homatropine 2% has a duration of up to 2 days Atropine 1% is the most powerful cycloplegic and mydriatic with duration of up to 2 weeks.

30. NSAIDs Newer Nonsteroidal Anti-Inflammatory Agents: Bromfenac, Nepafenac They are used for reduction of ocular pain and inflammation following cataract surgery and in scleral inflammation . Bromfenac ophthalmic solution 0.09 % Nepafenac 0.1%

31. Vitrectomy

32. Vitrectomy 1- Diagnostic vitrectomy combined with PCR in idiopathic uveitis 2- Therapeutic vitrectomy: Indications : 1) Uveitis persists despite maximum tolerable medical treatment 2) In complications of long standing inflammations, a densely opacified vitreous, scar tissue pulling on the ciliary body causing hypotony, cystoid macular edema, an epiretinal membrane, a dense posterior lens capsule opacification or a Tractional retinal detachment 3) Vitrectomy removes the lodged lymphocytes in the vitreous, inflammatory debris, immune complexes and autoantigens. 

33. Thank you