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Speaker: Kumar Saurabh

Speaker: Kumar Saurabh. Uveitis: Definition. * International Uveitis Study Group Definition.

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Speaker: Kumar Saurabh

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  1. Speaker: Kumar Saurabh

  2. Uveitis: Definition * International Uveitis Study Group Definition 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.*

  3. Problem Statement 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

  4. Aetiology of Uveitis Idiopathic Uveitis: 35.7% Uveitis Secondary to Systemic Disease Infectious Uveitis Lens Induced Uveitis Masquerade Syndrome

  5. Goals of Uveitis Management Reduction of visual morbidity Proper identification of the specific disease Cost effective utilization of resources

  6. 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

  7. History: Salient Points Detailed and Suggestive Geographic History Family History Demography: Age, gender, race Personal History: Pets, diet, drugs, sexual Systemic Diseases Ocular History

  8. Ocular History Onset: Insidious or Sudden Laterality: Unilateral or Bilateral Severity: Mild or Severe Pattern: Single or Multiple Episodes Duration: Acute or Chronic Treatment

  9. 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

  10. Keratic Precipitates Mutton fat keratic precipitates in a case of granulomatous uveitis

  11. Keratic Precipitates Fine keratic precipitates in a case of non-granulomatous uveitis

  12. Keratic Precipitates Old keratic precipitates seen in the Arlt’s triangle of corneal endothelium

  13. Keratic Precipitates Large keratic precipitates seen in case of granulomatous uveitis

  14. 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

  15. Anterior Chamber Reaction Cells and flare in uveitic eyes

  16. Iris Nodules

  17. Vitreous HazeDirect Ophthalmoscope 0 : Clear vitreous + : Few, normal view ++ : Moderate scattered opacities, obscured view +++ : Many opacities, blurring of view ++++ : Dense opacities, no view

  18. 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 striations 0 : Nerve fiber layer well defined

  19. Retinal Features Retinitis Primary vasculitis Secondary vasculitis Retinal detachment Macular oedema Neovascularization

  20. Choroidal Features Active choroiditis Inactive choroiditis Choroidal granulomas Choroidal neovascularization Choroidal vasculitis

  21. Site of Uveitis Anterior Uveitis: Iritis, iridocyclitis, Anterior cyclitis Intermediate Uveitis: Posterior cyclitis, Hyalites, Basal Retinochoroiditis Posterior Uveitis: Chorioretinitis, Retinochoroiditis, Neuroretinitis, Choroiditis

  22. 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

  23. Differential Diagnosis Working diagnosis Basis for laboratory investigation Basis for treatment

  24. 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

  25. Laboratory Investigations • Granulomatous uveitis • Recurrent uveitis (>3 attacks) • Uveitis in a child • Positive leads on examination • Posterior uveitis • Retinal vasculitis • Worsening on steroids Indications

  26. 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

  27. Ancillary Investigations Ultrasonography: Media opacity Fluorescein Angiography: Macular oedema, Chorioretinitis, Disc leakage, Response Vitreous Biopsy: Lymphoma, Endophthalmitis Chorioretinal Biopsy:

  28. Treatment Strategy

  29. Specific Therapy Ocular Toxoplasmosis Regimen 2. Clindamycin 300mg, 4 times Daily, 4-6 weeks PLUS Sulphadiazine: 2 gm, D1 1 gm four times daily, 4-6wks PLUS Prednisolone: 40-60 mg/ day From D3-D7, tapered Regimen 1. Pyrimethamine: 75mg, D1 25mg/day, 4-6 weeks PLUS Sulphadiazine: 2 gm, D1 1 gm four times daily, 4-6wks PLUS Prednisolone: 40-60 mg/ day From D3-D7, tapered PLUS Folinic Acid: 5mg twice weekly

  30. Specific Therapy Ocular Toxocariasis Peripheral Lesion: Follow up Posterior Pole Involvement: Prednisolone 40mg/day and Thiobendazole 20mg/day. 5-7 days Vitrectomy

  31. Nonspecific Therapy: Medical Steroids: Topical, periocular, systemic Indications: Active Inflammation Prevention and treatment of complications Infiltration of retina, choroid and optic nerve

  32. Nonspecific Therapy: Medical Nonsteroidal Antinflammatory Drugs Indication: To maintain lower dose of topical steroids

  33. Nonspecific Therapy: Medical Immunosuppressive Therapy Vision threatening intraocular inflammation Inadequate response to steroids Serious steroid induced side effects Contraindication of steroid therapy

  34. Nonspecific Therapy: Medical • Immunosuppressive Therapy Absolute Indications: Behcet’s disease Sympathetic Ophthalmia Vogt-Koyanagi-Harada Syndrome Wegener’s Granulomatosis Polyarteritis Nodosa

  35. Nonspecific Therapy: Medical LASER and Cryotherapy Indications: LASER for choroidal neovascularization Cryotherapy for refractory pars planitis

  36. Nonspecific Therapy: Surgical Pars plana Vitrectomy Indications: Pars planitis Subretinal neovscular membrane

  37. Treatment Response* *Standardization of Uveitis Nomenclature (SUN). AJO 2005;140: 509-16 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

  38. Treatment of Complications Management of cataract Management of glaucoma Management of band shaped keratopathy and other corneal complications

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