Good Hope, Heartlands, and Solihull Eye Clinics

Uveitis...some links

David Kinshuck

Uveitis...some links

 

Smoking

Obesity

This probably increases autoimmune disease CMLS16    Increasing asthma   psoriasis   rheumatoid arthritis

 

Low vitamin D

This may contriubte. It contributes to related conditions: asthma   asthma asthma   rheumatoid arthritis

Other

Research

Types of uveitis

Location

  • anterior
  • intermediate
  • posterior   (retina/choroid/vitreous) OII 14
  • panuveitis
  • +/- macular oedema (a secondary response)

Onset etc

  • acute/chronic (several attacks over 3 months is usually a flare up of chronic)
  • acute < 3 months
  • chronic >3 months
  • ?related to CMV
    ' Our results indicate that CMV is a major cause of AU in Thailand and show that FHUS can be caused by both CMV and Rubella virus'.

Acute uveitis..acute anterior uveitis

PDF 

  • hypopyons: generally HLA B27 or Bechets
  • acute: redness around cornea
  • symptoms : red pain photophobia blurred vision floaters, reduced vision 
  • CMV virus OII 13

This may be due to

HLA B27 uveitis

  • acute; hypopyon often; settles with treatment
  • accounts for 50% of acute anterior uveitis (AAU)
  • ankylosing spondylitis/reactive/reiters/enteropathic/?psoriatic

Treatment protocol acute anterior uveitis

  1. Cyclopentolate drops 1% twice daily for 1 week, then
  2. Cyclopentolate drops 1% at night for 1 week, then stop
  3. dexamethasone drops hourly for            hours
  4. dexamethasone drops 2 hourly for         days
  5. dexamethasone drops 4 times a day for 1         week
  6. dexamethasone drops 3 times a day for 1         week
  7. dexamethasone drops 2 times a day for 1         week
  8. dexamethasone drops 1 time a day for 1           week
  9. dexamethasone drops alternate days   for 1         week
  10. then stop dexamethasone
  11. note Cyclopentolate...
    • halves the pain, but blurs sight (poor near vision)
    • prevents the pupil sticking (this is very important)
    • twice a day when eye painful, only at night when no ache
    • not safe/legal to drive when used twice a day in most patients, but safe to drive during the day if used at night
  12. note dexamethasone drops are very important but there are problems; it contributes to cataracts;
  13. they may cause glaucoma..if continues more that 2 weeks an eye pressure check (at optometrist ?) would be helpful
  14. stop smoking as it increases uveitis by 400%
  15. (20% a cigarette; electronic cigarettes much, much safer)
  16. vitamin D supplements (eg multivitamins)
  17. betnesol 4mg/ml (0.5 or 1ml) & mydricaine no 2    0.3ml
  18. or  dexamethasone 3.3 mg/ 1 ml & mydricaine no 2    0.5ml

Consider Cyclosporine see..not in standard use

 

Recurrence

  • Maxidex      hourly, attend Eye Centre A/E
  • 20% may become chronic
  • linked to vitamin d levels 2016

less often, CMV Eye 2012

  • "10 CMV-positive patients, four had endotheliitis, two had Posner–Schlossman syndrome, and one Fuchs heterochromic uveitis syndrome (FHUS). Five out of 21 (24%) samples tested by GWC for Rubella virus were positive, three of which exhibited clinical features of FHUS."
  • Tattoos, particularly with none-recommended inks, may precipitate uveitis.

General health

Genes

  • BJO 2015.... causing a chronic panuveitis

 

Acute macular neuroretinopathy

Acute retinal necrosis

AMPPE 

  • exclude others...steroids if under fovea
  • see

 

Behcets

Birdshot

  • radiating lesions, narrow vessels
  • look at choroid, thickened
  • looks like blobs in choroid
  • treat according to blobs..choroidal thickness
  • Retina 14  steroid implant
  • Multifocal widespread and peripapillary but not under fovea
  • Birdshot hla-a29.2
  • Symptoms
    • blurred vision ,floaters, nyctalopia, good vision, reduced contrast, reduced colour vision, glare and photopsia
  • findings
    • creamy yellow ovoid lesions, radially point to disc, no anterior uveitis, perhaps a little vitreous haze, exclude posterior synechiae, and anterior uveitis
    • FAA, Oct., hla-a29
  • Differential: Amppe serpiginous, sarcoid and lymphoma 
  • Treat
    • 20% don't need
    • 80% systemic Immunosuppression, Cyclosporine, methotrexate, mmf 
    • Rescue...steroids iv or oral, maintenance mycophenolate, tacrolimus, adalimumab Intraocular steroids Monitor
  • http://birdshot.org.uk/, and there is a national birdshot research network

Cataract surgery

  • Fuchs..good results high %
  • Worse..inflamed eyes at times of surgery
  • certain IOLs

children

Uveitis in children: often no symptoms 

 

CMV retinitis/acute retinal necrosis

  • Eye 2012   Solid organ transplantation 8 months after transplant, HIV infection
    "Pale necrotic retina with focal haemorrhage, in sectors of retina, spreading centrifugally along vascular arcades"  PCR diagnosis. Treat Eye 2012
  • very long interval after initial onset

Chronic anterior

  • HSV/sarcoid/syphilis

Coeliac disease    

Drug induced

  • intravenous biphosphonates
  • etanercept

Episcleritis

Epstein-Barr Uveitis

 

FHUS (Fuchs heterochromic uveitis syndrome)

Glaucoma

'No xalatan if aphakic, or broken capsule' (not all agree)

 

Graft versus host disease

  • vasculitis like picture see

Herpetic  

Heliobacter   

HIV infection

types of uveitis CEO 14

 

Immunosupresison consideration

when using DMARDs (disease modiifying anti-rheumatic drugs)   EyeNews 15

  • rapid or upward change in blood test results (haematology and biochemistry)
  • no live vaccines
  • drug interactions
  • pregnancy..not really safe
  • document toxicity
  • side effects in BNF
  • DMARD booklet
  • self-managment
  • education programme
  • measure outcome
  • MUST trial...systemic versus fluocinole implant AJO 15   OPH 15
    • Implant..more cataract..most, glaucoma.. 30%
    • Systemic treatment...more diabetes, bone problems, etc
    • Implant..better control
    • Quality of life no difference
    • implant: use if unilateral
  • If systemic not working Methotrexate versus mycophenolate=Cellcept trial Methot..slightly superior
  • Viral retinitis and steroids injection
  • Problems can arise after months
  • Cmv 76%..should have given antiviral agent

Plan treatment if immunosuppresion needed

  • systemic steroids
  • assess
  • See patient
    1. How severe
    2. how quickly it responds /came
    3. immunocompetent y,n,
    4. masquerade..infection , malignant
  • If steroids dont work add second line agent
  • Cellcept or tacrolimus
    • second line agents
    • start to work 3 months
    • Both need regular blood tests moorfields pharmacy have a chart
  • if this does not work biologics
  • Slow taper steroids
  • Biologics
    • Infliximab
    • Bechets do very well
    • Etanercept does not work in uveitis
    • May reactivate tb
    • Rituximab fantastic
    • Need special funding
    • Monitoring
    • Safety
      • Clincial handbook of Immunosuppression in uveitis...moorfields
      • Patient getd sresults handbook to complete
    • Cost eg tacrolimus..usegeneric drugs

 

JIA

  • no symptoms
  • arthritis first (1 year before)
  • +ANA, oligo JIA
  • JIA all children must be screen within 6 weeks and every 8 weeks for 6 months
  • Rituximab

Lyme

  • uveitis anterior and intermediate

Lymphoma

  • think of lymphoma in chronic uveitis OI14
  • Undulating rpe when no AMD... Barry
  • Hyper-reflective sub rpe infiltration
  • Hyper-reflective pre rpe infiltration
  • Hyper-reflective choroidal lesions

Macular Oedema

MS

  • intermediate with macular oedema

Multifocal choroiditis

  • choroid OK!!
  • sub rpe space
  • myopic
  • female
  • overlaps with PIC, TB
  • thick choroid, cnv in young girl
  • serpiginous

Neuroretinitis

50% severe hypertension

 

Pars planitis

Perioperative

  • Control uveitis for 3 months; IV methylpred followed by short course of oral steroids

PIC Punctate inner choroidopathy

  • PIC Society
  • No cause known
  • look at choroid
  • CNV?
  • young myopic ladies
  • Multiple small lesions, posterior pole, no inflammatory cells, +/- serous detachments
  • Small or larger lesions, flickering lights, scotoma, blurred vision,
  • 2/3 no new lesions over 2y, 12% new lesions ,  1/3 cnv
  • Oct changes ..fluid in suprachoroidal space; also focal choroidal excavation, choroid becomes thickened. Generate choroidal thickness map
  • none cnv lesions may disappear
  • There is no inflammation generally. If there is a hint of inflammation think of...tb, syphilis, sympathetic, etc. Also think of lacquer crack Infection or inflammation
  • Treatment for CNV: Anti-vegf plus steroid, steroids and immunosuppression..adnan tufnail...not routine immunosuppression, needs about 3 injections, about 10 weeks between,
  • If pregnant.....avoid anti-VEGF first trimester, can give it third trimester, but only after full discussion
  • treat cnv and avoid Immunosuppression

Sarcoid

  • subacute/often bilateral/fine or granulomatous KP/choroidal granuloma/exudate around veins
  • SOBOE, tired
  • ACE, Ca++, urine,renal function, LFT, CXR
  • Case...like serpiginous, big black blob in vision
  • Sarcoid: mutton fat kps, white cuffs around vessels, lupus pernio,

Scleritis classification

  • scleritis page
  • Eye 14
  • episcleritis 
    • simple
    • nodular
  • scleritis
    • diffuse
      • anterior
      • posterior
    • nodular
      • necrotising
        • surgical
        • none-surgical
      •  none necrotising

Serpiginous multifocal

  • pcr  50% TB, 25% CMV OII14

Syphilis

  • Becoming more common. Consider in all cases, especially
  • panuveitis and optic neuritis
  • ask/test HIV, rash
  • Methotrexate Retina14

Tattoos

  • Tattoos, particulary with none-reommended inks, may precipitate uveitis.

TINU

  • tubular interstitial nephritis and uveitis; 1% of AAU..sudden bilateral, young patients

Toxoplasmosis

To treat, read this paper. Eye 2012 

  • traditional
    • pyrimethamine, sulphadiazine, folinic acid, (systemic steroids if sight threatened)...details Eye 2012 
    • NOT IF PREGNANT
  • intravitreal clandestine and dexamethasone
  • Secondary prophylaxis:  trimethoprim/sulphmethoxazole once every 3 days. see Eye 2012 
  • Case 1:   thick choroid, nsd, white area next to black scar
  • Case 2:  vitreous cells , given IVT, much worse  (needed vitreous biopsy)
  • treatment BJO 16
  • for acute infection
    • Septrin 160 mg/800 mg Tablets tice day (= 2 tablets twice daily) if not pregnant
    • prednisolone 40mg if..
      • if infection near the macular or threatening vision add prednisolone (about) 40mg a day, reducing the dose over 2 weeks (steroid use: standard precautions, keep away from chickenpox, diabetes and blood pressure checks, etc) see precautions

Tuberculous

  • BJO 2011
  • can be latent of active
  • Quantiferon interferon test, helps a little qfn
  • Tb hypersensitivity or granuloma if tested.
  • Multifocal or vasculitic, occlusive vasculitis. 
  • ? Do you treat eye steroid etc
  • Almost never in lungs
  • Difficult to decide to treat
  • Case:
    • unilateral vitritis and punched out lesions, swollen disc
    • quanitiferon tst
    • T spot blood test
  • review
  • steroids are needed as inflammation can increase with treatment  Eye 2013
  • Methotrexate Retina14
  • Tb retinitis looks like macular serpiginous disease, sympathetic, vkh ,  or Birdshot
  • Tb ..may need 6 m tb treatment and after that can immunosuppress

VKH

  • serous detachments..eptae=VKH (not CSR)
  • thick choroid on oct..and can use this to decide steroid dose
  • looks like CSR
  • VKH bilateral thick choroid
  • follow up for years, may get cnv
  • VKH classification 2014
  • Vkh exudative retinae, a year later vitelligo

White dot syndromes Eye News 2015

  • Birdshot
    • creamy yellow spots, like shotgun pellets
    • HLA-A29
  • serpiginous
    • snake like lesions from disc
  • apmppe
    • leaves scars
    • whites spots, younger patients, prodromal illness, auditory symptoms, meningism, bowel, lymphadenopathy; self limiting
  • aibse acute idiopathic blind spot enlargement syndrome 
    • apd, disc not swollen, unilateral, fluctuates
  • azoor
    • acute zonal outer retinopathy
    • bilateral, intrusive photopsia, enlarged blind spot, later RPE depigmentation and bone spicules, later: differentiate from RP
  • AAOR
    • acute annular outer retinopathy
    • like azoor but damage seen years later
  • MEWDS
    • unilateral, APD, enlarged blind spot, prodromal viral illness, photopsia, 100 micron white spots that disappear, no scars unlike apmpee
  • AMN
    • acute macular neuroretinopathy
    • scotoma
    • BJO 15 
    • new associations BJO16
  • MCP
    • bilateral inflammation creamy yellow lesions, vitreous cells and debris, cme, periphlebitis
  • PIC
    • fewer lesions centered around fovea, ?subset of MCP
  • Peripheral multifocal chorioretinitis
  • Progressive subretinal fibrosis and uveitis syndrome
  • Retinal pigment epitheliitis (Krill's disease)
    • distorted vision in young people after a viral infection
    • very small dark spots in outer retina, surrounded by yellow halo. Neurosensory fluid accumulation that resolves
  • Susac Retina16
  • Unilateral acute idiopathic maculopathy
    • recent flu-like illness, RPE disruption and central elevation, similar to Bests, vitreous sells, resolves may be leaving a Bulls eye lesion.

Blood tests in rheumatic dieases

  • Rhf +ve 75% rheumatoid arthritis and 10% healthy
  • CRP most specifiic ~70% for rheumatoid arthritis
  • antiphospholipid 33% SLE
  • HLA b27 90% ankylosing spondylitis

Diagnosis

  • very helpful Eye 16
  • HLA b27 (acute anterior)
  • HLA B61 Birdshot
  • hypopyons: generally HLA B27 or Bechets
  • acute: redness around cornea
  • symptoms : red pain photophobia blurred vision floaters, reduced vision 
  • side
  • KPs, cells, flare, granulomatous KPs
  • flare >3+ hypopyon
  • angle new vessels
  • conjunctivitis
  • Herpetic only affects one eye
  • keratitis
  • scleritis
  • panuveitis
  • chorioretinitis
  • vitritis: vitreous haze = cells
  • retinal vasculitis
  • papillitis
  • secondary glaucoma
  • IOP >26
  • If HZV/shingles:
    • sometimes there is no rash
    • often IOP 50, treat, better, returns
  • cataract
  • posterior synechiae
  • band keratopathy
  • VA < 6/60
  • mouth ulcers
  • temperature >380
  • weight loss
  • gender
  • heterochromia
  • oligoarthritis
  • inflammatory back pain
  • chronic diarrhoea
  • deep vein thrombosis
  • erythematous skin plaques
  • itching
  • nail pitting
  • urethritis
  • coughing
  • hemoptysis
  • good response to NSAI
  • Mantoux >10mm
  • iris nodules
  • macular oedema
  • papulopustular rash
  • erythema nodosum
  • rectal bleeding
  • ANAs
  • sacroileitis
  • patergy
  • joint pain 
  • vitreous haemorrhage
  • Uveitis in children: often no symptoms 

 

Uveitic glaucoma

  • Fuchs fhc vessels cross angle , nodules on pupil margin, floaters,
  • Protglandins may not work 

 

 

Some cases

  1. 66y female
    • Bilateral blurred floaters, right vitreous cells, and vitritis, and large retinal lesion
    • Got worse next day
    • Vitreous tap, arn suspected, foscarnet, maxidex, but his did not work, so azithromycin in case toxo...probably was toxo
    • Pcr negative..more retinitis
    • Declined biopsy vit,retina
    • Treatment stopped not much worse, agreed for biopsy,
    • udden rapidly progressing vitritis...often ARN: hsv hzv cmv
  2. 64y male
    • Left blurred, pain. 4 weeks
    • previously treated for TB and sarcoid for right vasculitis swollen disc, steroid granuloma, treated with steroids, recurrent anterior uveitis, right
    • Peripheral choroidal effusion, ?sclerits.
    • Got better with steroids orally
    • Was this sarcoid?
  3. 28y male
    • Uveitis bilateral anterior, left posterior, left disc swelling
    • Ffa papillitis phlebitis, peripheral retinitis
    • Had painful lumps on legs, mouth ulcers, epididymitis= bechet's
    • Negative interferon test..quantiferon (for TB), wr, etc
    • Prednisolone, azathiaprin
  4. 37y waiter Rumanian, left uveitis, hiv status negative.
    • Left eye lots of retinal exudate tap blood cxr: foscarnet valcicloiir, pcr neg Cmv +, wr positive, hiv + Doxycycline.. Got better= syphylis
  5. 40y Female asian
    • Bilateral ant post serous detachment, headaches
    • treatment: iv methypred cellsept
    • vkh diagnosed
    • Ace 75
    • Recurred: cellsept increased again, steroid,
    • Recurrent aau, thought to have been vkh,
    • Ace >100 is sarcoid, comes down with treatment, useful for monitoring
    • Ace high in all uveitis, but 75 is not sarcoid
  6. Case 40 y lady
    • Recent blurred and photopsia
    • Lots of phlebitis...multifocal retina...icg showed birdshot
    • mycophenylate started; will add tacrolimus if response poor
  7. Case
    • ffa leopard spots, cant see in dark
    • Shallow detachment 
    • Bloods syphilis tb negative
    • .?lymphoma
  8. Case
    • Not vkh, not typical birdshot, ? Ipcvcnv ..no polyps
    • Csr? ?eplerenone
  9. Case
    • Tired,memory,various problems, ex alcohol,
    • Hep bc, hiv, ebvcmv lyme syphylis
    • Leopard spots..uveal effusion,nh lymph,csr, diffuse mela..., 
    • Silver poisoning 
  10. Case
    • Multiple retinal aneurysms, ?coats
    • Treatment ..laser to ischaemic zones and may be antivegf
    • Laser whilst not leaking too much, may be antivegf first 
  11. Case
    • Melanoma treated with pembrolizumab, melanoma associated retinopathy
    • Retina autoantibodies 
    • Retinitis and vitritis and reduced sight,ac signs of fhc,
    • pigmentation of retina And later cnv = Mar retinopathy 
  12. Case
    • Blurred sight bmt, (=bone marrow transplant)
    • Retina lots haemorrhages, cws
    • Hsv, cmv, hzv, systemic steroids, ? Bmt retinopathy 
  13. Case
    • 74 lady
    • tia symptoms, breast ca metastasis
    • Recent bellspalsy
    • Left panuveitis and secondary glaucoma
    • 2 d later white lesions periphery
    • arn/ (acute retinal necrosis)
    • treated: Iv acyclovir, vit tap iv gancyclovir,
    • steroids..not at very beginning
    • then valacyclovir
    • Later foscarnet x 3 ..given weekly
    • Confirmed Resistant hzv...thymidine kinase resistance 
    • Result...acyclovir resistant hzv acute retinal necrosis
    • Foscarnet not oral and toxic intravenous, OK intravitreal
    • Department liaised with moorfields, parvesio
  14. Case
    • 74y
    • Optic atrophy cupped with shunt and a few haemorrhages
    • Optos ..lots of leakages, ffa, nve, masses of peripheral none perfusion
    • Bilateral prp and glaucona rx
    • optos useful to demonstrate peripheral retina)
  15. Case
    • 2013 left strvo
    • 2015 a second strvo
    • Cmo, lucenti sx 4
    • Localised laser and peripheral
    • 2016 recurrent vitreous haemorrhages
    • optos Ffa identified more areas of none perfusion then lasered
  16. Case
    • Rvo,  5 injections, had a lot of ischaemia but this improved without laser
    • Suggest widefield ffa For all vascular
    • Amd only not widefield 
  17. Case 17-19 aflibercept deposits
    • Aflibercept brvo 63 m, 
    • Seagull like floaters Seen on red free
    • On posterior vitreous face, white quiet eye
  18. Case
    • Wet armd aflibercept, 
    • Refractile floaters in posterior vitreous face
  19. Case
    • Anterior vitreous floaters, again after aflibercept 
  20. Case
    • 11 y f
    • Difficult seeing blackboard 
    • 4 m loss of sight both, 6/36 both
    • Macular scars bilaterally
    • Oct...scarred cnv...,
    • Family history bests, treated with antiVEGF both, one eye did not improve, one did
    • Bests, Best vitelliform macular dystrophy,
    • Best 1. Gene
    • Egg yolk lesion Eog to diagnose
  21. Case
    • 7y f
    • Bilateral cnv, treated as bests, in family..edts etc7
  22. Case
    • 20y male, known bests,  presented with cnv
    • Bests...more cnv with trauma
  23. Case
    • 60y f dm...not known diabetic 
    • Presented with corneal abscess and hypopyon , pain free, other eye fine
    • Cef and gent, iop 40
    • Other eye...hba1c 140, proliferative retinopathy
    • ...always look at other eye! 

Treatment