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Uveitis 2

Dr. Mohammad Shehadeh. Uveitis 2. Special investigations. 1    Not indicated Single attack of mild unilateral AAU without suggestion of a possible underlying disease. A specific uveitis entity such as sympathetic ophthalmitis and Fuchs cyclitis .

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Uveitis 2

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  1. Dr. Mohammad Shehadeh Uveitis 2

  2. Special investigations 1    Not indicated • Single attack of mild unilateral AAU without suggestion of a possible underlying disease. • A specific uveitis entity such as sympathetic ophthalmitis and Fuchs cyclitis. • When a systemic diagnosis compatible with the uveitis is already apparent such as Behçet disease or sarcoidosis.

  3. Indications • Granulomatousinflammation. • Recurrent uveitis. • Bilateral disease. • Systemic manifestations without a specific diagnosis.

  4. Treatment 1- Mydriatics Short-acting a   Tropicamide (0.5% and 1%) has a duration of 6 hours. b    Cyclopentolate (0.5% and 1%) has a duration of 24 hours. c  Phenylephrine (2.5% and 10%) has a duration of 3 hours but no cycloplegia. Long-acting a  Homatropine 2% has a duration of up to 2 days. b   Atropine 1% is the most powerful cycloplegic and mydriatic with a duration of up to 2 weeks.

  5. Indications • To promote comfort by relieving spasm of the ciliary muscle and pupillary sphincter, • To break down recently formed posterior synechiae with intensive topical mydriatics (atropine, phenylephrine) or subconjunctival injection of Mydricaine® (adrenaline, atropine and procaine) in eyes that do not respond to drops • To prevent formation of posterior synechiae following control of acute inflammation by using a short-acting mydriatic that allows some mobility of the pupil but prevents formation of synechiae in the dilated position. • In mild chronic anterior uveitis, the mydriatic can be instilled at bedtime to prevent difficulties with accommodation during the day. • In young children, constant uniocularatropinization may induce amblyopia.

  6. 2- Topical steroids: Indications • Treatment of Acute AU is usually relatively straightforward. • Treatment of Chronic AU is more difficult because long-term therapy is often required with the risk of complications such as cataract and steroid-induced elevation of intraocular pressure

  7. Complications of steroid therapy • 1 -  Elevation of IOP is common in susceptible individuals (‘steroid responders’), but long-term exposure to topical steroids may eventually result in glaucoma in many patients. • 2 - Cataract can be induced by both systemic and, less frequently, topical steroid administration. The risk increases with dose and duration of therapy. • 3 - Corneal complications, which are uncommon, include secondary infection with bacteria and fungi, recrudescence of herpes simplex keratitis, and corneal melting, which may be enhanced by inhibition of collagen synthesis. • 4 - Systemic side-effects are rare, but may occasionally occur following prolonged administration, particularly in children.

  8. 3- Periocularsteroid injection Advantages over topical administration • Therapeutic concentrations behind the lens may be achieved. • Water-soluble drugs, incapable of penetrating the cornea when given topically, can enter the eye trans-sclerally when given by periocular injection. • A prolonged effect can be achieved with ‘depot’ preparation such as triamcinoloneacetonide (Kenalog) or methylprednisolone acetate (Depomedrone).

  9. Indications of periocular steroids • In unilateral or asymmetrical intermediate or posterior uveitis, periocular injections should be considered as first-line therapy to control inflammation and macular oedema. • In bilateral posterior uveitis either to supplement systemic therapy or when systemic steroids are contraindicated. • Poor compliance with topical or systemic medication. • At the time of surgery in eyes with uveitis.

  10. Complications of periocular steroids • Globe penetration. • Elevation of IOP, which with depot preparations may be refractory. • Ptosis. • Subdermal fat atrophy. • Extraocular muscle paresis. • Optic nerve injury. • Retinal and choroidal vascular occlusion. • Cutaneoushypopigmentation.

  11. 4- Intraocular steroids • Triamcinoloneacetonide (4 mg in 0.1 mL) is an option in the treatment of posterior uveitis and CMO unresponsive to other forms of therapy. • It produces rapid resolution of CMO lasting about 4 months and may be used to determine reversibility of visual loss due to CMO. • Injections may be used following surgery on eyes with uveitis when other forms of prophylaxis are not appropriate. • Complications include elevation of IOP, cataract, endophthalmitis (sterile or infectious), haemorrhage and retinal detachment.

  12. 5- Systemic steroids • Preparations A- Oral prednisolone 5 or 25 mg tablets are the main preparations. B- Intravenous infusion of methylprednisolone 1 g/day, repeated for 2 to 3 days is an option in severe disease.

  13. Indications of systemic steroids • Intermediate uveitis unresponsive to posterior sub-Tenon injections. • Sight-threatening posterior or panuveitis, particularly with bilateral involvement. • Rarely, anterior uveitis resistant to topical therapy. • Occasionally prior to intraocular surgery as prophylaxis against worsening inflammation.

  14. Contraindications of systemic steroids • Poorly controlled diabetes is a relative contraindication. • Peptic ulceration. • Osteoporosis. • Active systemic infection. • Psychosis on previous exposure to steroids.

  15. Side-effects of systemic steroids • Short-term therapy may cause dyspepsia, mental changes, electrolyte imbalance, aseptic necrosis of the head of the femur • Long-term therapy may cause a Cushingoid state, osteoporosis, limitation of growth in children, reactivation of infections such as TB, cataract and exacerbation of pre-existing conditions such as diabetes and myopathy.

  16. 6- Antimetabolites • A substance that closely resembles an essential metabolite and competes with, interferes with, or replaces the metabolite in physiological reactions. • It interferes with a cell's growth or ability to multiply

  17. Indications • Sight-threatening uveitis, which is usually bilateral, non-infectious, reversible and has failed to respond to adequate steroid therapy. • Steroid-sparing therapy in patients with intolerable side-effects from systemic steroids or those with chronic relapsing disease requiring a daily dose of prednisolone of more than 10 mg

  18. Examples of antimetabolites • Azathioprine: Side-effects include bone marrow suppression, hepatotoxicity and nausea • Methotrexate:Side-effects including bone marrow suppression, hepatotoxicity, acute pneumonitis (weekly administration)

  19. Intermediate uveitis • Intermediate uveitis (IU) is an insidious, chronic, relapsing disease in which the vitreous is the major site of inflammatory signs. • The condition may be idiopathic or associated with a systemic disease . • Pars planitis (PP) is a subset of IU in which there is ‘snowbanking’ and/or ‘snowball’ formation. • IU accounts for up to 15% of all uveitis cases and about 20% of paediatricuveitis. • The diagnosis is essentially clinical, and investigations are carried out to exclude a systemic association, especially in the presence of suggestive findings and in older individuals. • The exact age of onset of IU may be difficult to determine, since an extended period may elapse before patients become symptomatic.

  20. Diagnosis Presentation: • is with the insidious onset of blurred vision often accompanied by vitreous floaters. • The initial symptoms are usually unilateral, but the condition is typically bilateral and often asymmetrical.

  21. Signs of iintermediateuveitis • Anterior uveitis • Vitreous cells with anterior predominance are universal. • Vitreous condensation and haze in more severe cases. Table shows the grading of vitreous haze. • Vitreous snowballs are usually most numerous in the inferior peripheral vitreous (see Fig.

  22.  Grading of vitreous haze Haze severity Grading • Good view of nerve fibre layer (NFL) 0 • Clear disc and vessels but hazy NFL +1 • Disc and vessels hazy +2 • Only disc visible +3 • Disc not visible +4

  23. Course • A minority of patients have a benign course, which may not require treatment, with spontaneous resolution within several years. • In other patients the disease is more severe and prolonged with episodes of exacerbations that tend to become progressively worse. • IU associated with systemic diseases has a variable course depending on the disease and its severity. • The disease may last as long as 15 years and preservation of vision will depend on control of macular disease. In follow-up of up to 4 years, 75% of patients have a visual acuity of 6/12 or better.

  24. Complications • CMO occurs in 30% of cases and is the major cause of impaired visual acuity. • Macular epiretinal formation is common. • Cataract and glaucoma may occur in eyes with prolonged inflammation, particularly if requiring long-term steroid therapy. • Peripheral retinal vasoproliferativetumours are uncommon. • Retinal detachment is uncommon, but may occur in advanced cases (see Fig.).. • Vitreous haemorrhage may occur from the snowbank or disc new vessels, particularly in children with PP.

  25. Treatment • Initial treatment involves topical steroids or posterior periocular steroid injections. Further options in unresponsive cases include systemic steroids and immunosuppressive agent

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