Good Hope Eye Clinic

Uveitis...some links

David Kinshuck

Uveitis...some links

 

Smoking

Obesity

This probably increases autoimmune disease CMLS16

 

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  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. betnesol 4mg/ml (0.5 or 1ml) & mydricaine no 2    0.3ml
  17. 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

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

Birdshot

  • radiating lesions
  • 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

Behcets

Cataract surgery

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

 

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)

  • 24% rubella Eye 2012
  • 42% CMV cyctomegalovirus

Glaucoma

 

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

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,
  • ? 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

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

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
  • HlAb27 (acute anterior)
  • HLA B61 Birdshot
  • acute
  • side
  • KPs
  • granulomatous KPs
  • flare >3+ hypopyon
  • angle new vessels
  • conjunctivitis
  • keratitis
  • scleritis
  • panuveitis
  • chorioretinitis
  • vitritis
  • retinal vasculitis
  • papillitis
  • secondary glaucoma
  • IOP >26
  • 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

 

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! 
  24. Case
    • 74y
  25. Case
    • 74y
  26. Case
    • 74y
  27. Case
    • 74y
  28.