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22/08/2012 Introduction
Differential Diagnosis of
Posterior Uveitis
Philip I. Murray
Birmingham and Midland Eye Centre
University of Birmingham
UK
Anatomical Classification
v Classification of uveitis
v Common causes of posterior uveitis
v Clinical clues
v History
v Examination
v White dot syndromes
v Management
v Investigation
v Treatment
v Assessment
Clinical Classification
Deschenes J, Murray PI, Rao NA, Nussenblatt RB.
International Uveitis Study Group (IUSG): clinical
classification of uveitis. Ocul Immunol Inflamm
2008;16:1-2.
Posterior uveitis
v Isolated posterior uveitis relatively uncommon
v Often associated with retinal vasculitis
v Symptoms include floaters and loss of vision
v Idiopathic
v Part of a systemic disease process
v Specific syndromes (including white dot
syndromes)
v Very important as frequently results in loss of
vision
v Systemic therapy is usually required
Common ‘causes’ of noninfectious posterior uveitis
v Idiopathic
v Sarcoidosis
v Multiple sclerosis
v 
v 
v 
v 
v 
v 
“White dot” syndromes
Multifocal choroiditis
V-K-H syndrome
Behçet’s disease
Birdshot
Masquerade (primary NHL-CNS)
1 22/08/2012 Common ‘causes’ of infectious
posterior uveitis
v Toxoplasmosis
v Herpes viruses
v VZV
v HSV 1 and 2
v CMV
v TB
v Syphilis
v Fungi
History - clues
MUST exclude infection
Don’t forget about
masquerade
Ocular examination - clues
v Unilateral / bilateral
v AC / vitreous inflammation
v Granulomatous / non-granulomatous
v Retinal / choroidal
v “White dot” syndromes
v Optic nerve involvement
v Sudden / Insidious
v Unilateral / Bilateral
v Age
v Ethnicity
v Family history
v Systems enquiry e.g. oro-genital ulcers, CNS
symptoms, preceding viral illness
v Colour vision
v Dark adaption
v Immunocompromised
White Dot Syndromes
v A group of disorders characterized by multiple
whitish-yellow inflammatory lesions located at
the level of the outer retina, retinal pigment
epithelium, and choroid
v Frequently includes anything that gives white
‘dots’ in the fundus
v They present important diagnostic and
therapeutic challenges
v History and examination findings extremely
important
v Look for the clues
2 22/08/2012 Acute posterior multifocal placoid pigment epitheliopathy (APMPPE)
Vogt-Koyanagi-Harada syndrome (V-K-H)
Birdshot chorioretinopathy
Punctate inner choroiditis (PIC)
Viral retinitis
Retinal pigment epithelialitis
Diffuse subacute unilateral retinitis (DUSN)
Sarcoidosis
Acute zonal occult outer retinopathy (AZOOR)
Syphilis
Intraocular lymphoma
Multiple evanescent white dot syndrome (MEWDS)
Toxoplasmosis
Histoplasmosis
Am J Ophthalmol 2004;137:538-50
Multifocal choroiditis with panuveitis (MFC)
Behçet’s disease
Serpiginous choroiditis
Sympathetic ophthalmia
Acute macular neuroretinopathy (AMN)
Pneumocystis choroidopathy
Associated Features
v Ocular and non-ocular
v Ocular include:
v Uveitis (or absence of)
v Vitreous cells / abnormalities
v Retinal vascular changes
v Macular changes
v Disc changes
v Non-ocular
v e.g. CNS signs and symptoms
The Dots
v Unilateral / bilateral
v Single / few / multiple / confluent
v Depigmented/pigmented
v Size
v Shape
v Natural history
v Acute vs. chronic
v Evanescent / persistent
v Response to treatment
v Fundal distribution
v Level
3 22/08/2012 Management - Investigation
v Serological (don’t forget TB - IGRAs)
v Radiological
v Intraocular fluid analysis – infectious agent,
NHL
v Imaging
v OCT
v Angiography - FFA, ICG
v Visual Fields
v Electrodiagnostics
v OCT
v B scan ultrasound
AC tap – what to look for
v Herpesviruses
v HSV, VZV, CMV, EBV
v Toxoplasmosis
v 16S rRNA gene
v 18S rRNA gene
v Mycobacteria TB
v Syphilis
v IL-10/IL-6 ratio
AC Tap – How I do it
v Informed consent
v Cornea, iris, lens damage
v Hyphaema
v Infection
v Frequent topical LA
v Topical povidone iodine 5% to conjunctival
sac
v Position patient on slit-lamp
v Assistant to lift up upper lid
4 22/08/2012 AC taps at the slit lamp
v Retrospective study of 560 uveitis patients
who underwent AC paracentesis at the slit
lamp in the out-patient setting
v 510/560 paracenteses performed were
undertaken using a 27-gauge needle
attached to an insulin syringe, and an
O’Rourke aqueous pipette was used for the
rest
v Patients with undilated and dilated pupils
were included
Trivedi D, Denniston AKO, Murray PI.
Safety of anterior chamber paracentesis
performed at the slit lamp. Clin Exp
Ophthalmol 2011;39:725-8.
Results
v Two patients had an inadvertent injection of air
into the AC using the pipette, with spontaneous
resolution and no adverse outcome
v One patient had an allergic reaction to povidone
iodine
v One patient had anterior lens capsule touch that
was self-sealing but resulted in a tiny localised
opacity. This was due to eye movement because
of language difficulties. There were no long-term
sequelae and visual acuity was not affected
v No patient had wound leak, hypotony, hyphaema
or endophthalmitis
Management - Treatment
v Appropriate anti-infective agent
v Corticosteroid – dose, route
v Immunosuppressants including biologicals
(evidence base)
v Anti-VEGF
Management - Treatment
v What are we trying to achieve?
v To improve vision?
v To prevent further loss of vision?
v To prevent any loss of vision?
v Treatment or cure?
v Need to understand the underlying
pathogenetic mechanisms
v Are they the same at the beginning of the disease
as compared to later on?
Why determine disease activity
and damage?
v  Important when progression of disease is considered
v  Uveitis is often relapsing with recurrent episodes of potentially
reversible disease activity
v  Effective therapy can limit the development of irreversible organ
damage resulting from:
v  The disease process or
v  Secondary to drug toxicity or co-morbid conditions
v  In view of the repeated episodes of activity that patients may
suffer during the course of their disease, it is important to have
measures of activity that allow the disease to:
v  Be monitored
v  Assess the response to therapy
v  Determine the need for further therapy
5 22/08/2012 v The routine use of activity and damage indices allows
the clinician to account formally for each clinical
feature, thus improving his treatment decisions
v They provide a mechanism by which disease
progression can be monitored
v Index-generated scores may be a component of
prognostic and outcome measures
v Facilitates standardization of research, allows better
comparison of data between centres and facilitate
multi-centre trials
v Outcome measures should include the patient's
perspective of the effect of the disease and its
therapy on physical and emotional function as well as
financial status
Assessing disease activity in uveitis
v Activity vs damage
v What are we treating?
v Cystoid macular oedema, macular ischaemia, new
vessels, optic disc disease, vitritis
v Is it treatable?
v If so, how do we quantify an improvement?
v What parameters should we measure?
Assessment of activity - response
to therapy
v Clinical (SUN)
v Acuity – BCVA, Snellen, logMAR, pinhole, near
v Slit-lamp - AC activity, vitreous cells
v Hand held lenses - CMO, retinal vasculitis
v BIO - vitreous haze
v Imaging
v OCT
v FFA / ICG
v Electrodiagnostics
v (B-scan ultrasound)
v Quality of life
6 22/08/2012 What impact does uveitis make
on activities of daily living?
v Quality of life affected by:
v Visual impairment
v Any associated disease
v Therapy - response, side-effects
v Visual function does NOT = reading a Snellen
chart at 6 metres using one eye at a time
v Visual quality of life
v VCM1 of VR-QOL (UK)
v VFQ-25 / VF-14 (USA)
v General health quality of life
v SF-36/EQ-5D-5L
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