RED EYE- UVEITIS Brig Mazhar Ishaq Advisor in Ophthalmology, Comdt Armed Forces Institute Of Ophthalmology, Rwp

ANATOMICAL CLASSIFICATION ANTERIOR UVEITIS IRITIS IRIDOCYCLITIS INTERMEDIATE UVEITIS POSTERIOR UVEITIS PANUVEITIS

POSTERIOR UVEITIS Involves the fundus posterior to the vitreous base - Retinitis - Choroiditis - Vasculitis

SARCOIDOSIS Presentation - Acute - Insidious Ocular features - AAU - CAU - Intermediate - Candlewax drippings’ - Multifocal choroiditis - Retinal granulomas

TUBERCULOSIS Anterior segment involvement Tuberculous uveitis - Anterior uveitis, - Choroiditis - Periphlebitis

TOXOPLASMOSIS Presentation - Unilateral sudden onset of floaters Signs - Spill-over’ anterior uveitis - Satellite lesion - Multiple foci are uncommon - Severe vitritis (‘headlight in the fog’)

TOXOPLASMOSIS

BEHCET SYNDROME Recurrent oro-genital ulceration Ocular features AAU - cold abscess Retinitis Retinal vasculitis Vitritis,

BEHCET SYNDROME

FUNGAL UVIETIS

INVESTIGATIONS Recurrent granulomatous anterior uveitis Indications Recurrent granulomatous anterior uveitis Bilateral disease Systemic manifestations with out a specific diagnosis Confirmation of suspective ocular picture such as HLA-A29 testing in birdshort chorioretinopathy

NOT NECESSARY Single attack of mild unilateral acute anterior uveitis A specific uveitis entity When a systemic diagnosis compatible with the uveitis is already apparent

INVESTIGATIONS Obtain a history, attempting to define the etiology. Complete ocular examination, including an IOP check and a dilated fundus examination.

SKIN TESTS Tuberculin skin test (montoux & Heaf) Positive Negative Intradermal inj of purified protein Positive Induration of 5-14 mm with in 48 hours Negative Excludes TB May occure in advanced disease

PATHERGY TEST Increased dermal sensitivity to needle trauma Behcet syndrome Rarely positive in absence of systemic activity Pustule formation

SEROLOGY SYPHILIS Non-treponemal tests RPR or VDRL Primary infection Monitor disease activity Response to therapy

Immunofluorescent antibody test Haemagglutination test

Enzyme-linked Immunosorbent Assay (ELISA) Antibodies in aqueous (more specific) Other conditions (cat-scratch fever & toxocariasis Antinuclear Antibody (ANA) In children with JIA who are at high risk of developing ant uveitis

ENZYME ASSAY Angiotensin converting enzyme (ACE) Lysozyme Nonspecific test Granulomatous disease like - Sarcoidosis (elevated in 80% & in acute) - TB - Leprosy Lysozyme Good sensitivity but less speceficity for sarcoidosis

HLA TISSUE TYPING HLA type Associated disease B27 Spondyloarthropathies A29 Birdshot chorioretinopathy B51 Behcet syndrome HLA-B7 & POHS & APMPPE HLA-DR2

IMAGING Fluorescein angiography (FA) Retinal vasculitis CMO Indocyanine angiography (ICG) Better for choroidal disease

Optical coherence tomography(OCT) Ultrasonography (US) It is useful in opaque media especially in excluding a RD or intraocular mass Optical coherence tomography(OCT) Detecting CMO Identify vitreoretinal traction as a mechanism of CMO

BIOPSY Histopathology still remains the gold-standard conjunctiva And Lacrimal gland - Sarcoidosis Aqueous samples - For (polymerase chain reaction) PCR - Viral retinitis (occasionally) Vitreous biopsy - Infectious endophthalmitis

RADIOLOGY Chest X-rays Sacro-illiac joint X-Rays CT & MRI - To exclude TB and Sarcoidosis Sacro-illiac joint X-Rays - Diagnosis of spondyloarthropathy CT & MRI - Sarcoidosis - Multiple sclerosis - Primary intraocular lymphoma

TREATMENT AIM FOUR GROUP OF DRUGS Prevent vision threatening complications Relieve patients discomfort Treat the underlying cause FOUR GROUP OF DRUGS Mydriatics Steroids Cyclosporine Cytotoxic agents

TREATMENT Mydriatics To give comfort To prevent formation of posterior synechia To break down synechia Drugs (atropine, homatropine, scopolamine, tropicamide)

TREATMENT Steroids (mainstay of treatment) Topical administration Complications (glaucoma, posterior sub capsular cataract, corneal complications, systemic side effects) Periocular injections Severe acute anterior uveitis Adjuvant to topical/systemic Poor compliance Pre op

TREATMENT Systemic therapy Preparations Indications Rules Prednisolone 5mg Indications Rules Start with large dose then reduce Initial dose 1-1.5 mg/kg BW Before breakfast Taper off Less than 2 weeks abrupt stop

TREATMENT Side effects Short term Long term

TREATMENT Cyclosporin Steroid sparing agent Complications are hypertension and nephrotoxicity Cytotoxic drugs Potentially blinding bilateral reversible uveitis Intolerable side effects from systemic steroids therapy.

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