Update on Laboratory Testing in Non-infectious Uveitis Arash Maleki, MD Rasool Akram Hospital Iran University of Medical Sciences (IUMS) April 21, 2016

Uveitis Uveitis refers to a collection of about 30 diseases characterized by intraocular inflammation.

The Confusion Uveitis can be the first manifestation of a disease or a diagnosis-clinching disease feature. In one study, only 17% of patients had definitive diagnosis at initial presentation. Ultimately diagnosis or strongly suspected in 65%. 85% of these patients were diagnosed during the longitudinal care based on repeated clinical and laboratory evaluations.

The Frustration Negative work-up, labeled as “Idiopathic Uveitis” has been reported up to 35% in previous studies. Repeated review of medical history, medical symptoms, ocular and systemic examinations, and serologic evaluation can be revealing in these patients.

Systematic Approach Location Course Clinicopathologic characteristics Patient age Social and geographic characteristics Source of inflammation (Host/systemic disease)

Diagnostic approach History taking and RoS Eye examination Extraocular examination Laboratory evaluation

Laboratory Evaluation Screening (syphilis, lyme disease, TB) Versus (toxoplasmosis and HSV) More targeted testing (Bartonella) A key conception for the test is PPV. Two reasons for laboratory testing include: infections and systemic diseases. HLA-B27 and ANA

Laboratory Evaluation Laboratory testing is limited to those studies to be of some reasonable diagnostic value. General battery of tests is inappropriate. Extensive laboratory testing or referral to internists and primary care physicians is not recommended. However, more extensive work-up is recommended in recurrent uveitis (3 or more), granulomatous uveitis, posterior uveitis, and postive RoS.

Laboratory Evaluation When there is no diagnostic clues, no work up is recommended with the first episode of non-granulomatous uveitis in adults. However, these patients should be followed regularly for a positive hint. Basic laboratory studies include: CBC and differentiation, basic metabolic panel, urinalysis, and ESR. Recurrent uveitis in the absence of a clue warrants invetigation that includes: CBC, ESR, PPD or quantiferon gold serum testing, HLA-B27, and FTA-ABS.

Laboratory Evaluation Subsequent testing is based on the results of screening testing.

Common Tests in Non-infectious Uveitis ESR ACE and Lysozyme ANCA (C, P, and atypical) Anti-phospholipid antibodies C3, C4, CH50 Properdin factor B Soluble IL-2 receptor Raji cell assay C1q binding assay C-reactive protein (CRP) α1-acid glycoprotein

Common Tests in Non-infectious Uveitis HLA typing RF and anti-CCP FTA-ABS or MHA-TP ILs levels (IL-6, IL-8, IL-10, and IL-12) especially IL-9, IL-10, and IL-17 Hepatitis serology PCR PPD or QuantiFERON gold

Granulomatous Uveitis CBC and ESR ACE and Lysozyme + work-up for infectious uveitis

Posterior involvement and Retinal Vasculitis CBC and ESR Soluble IL-2 receptor Raji cell assay C1q binding assay + Work-up for infectious uveitis

Genetic advances in Uveitis (GWAS) Genes encoding for HLAs, IL-23R, IL-10, STAT, STAT3, and UBAC2 can be promising testing in the future. (Genome-wide association studies) Hou S, Kijlstra A, Yang P. Molecular Genetic Advances in Uveitis. Prog Mol Biol Transl Sci. 2015;134:283-98. Dunn JP. Uveitis. Prime care. 2015;42(3):305-23. Selmi C. Diagnosis and classification of autoimmune uveitis. Autoimmun Rev. 2014;13(4-5):591-4.  

Conclusion Basic laboratory studies include: CBC and differentiation, basic metabolic panel, urinalysis, and ESR. Laboratory tests should be targeted and battery of tests is not appropriate. Laboratory tests are not only for diagnosis but also for prognosis and treatment.

Thank you for your attention