Approach to treating Uveitis.pdf
- 2. An approach to management of Uveitis Dr Noman Nazir Ahmad Uveitis and Med Retina Consultant Eye Deptt. CMH Malir
- 3. Case 1 ● A 32 years old female, doctor by profession, presented to eye department with a refractory anterior uveitis in her right eye. ● This condition had been persisting despite treatment for at least 3 weeks causing her blurring of vision, pain, photophobia, watering, and recent onset of foreign body sensation. ● She was using topical steroids in this eye every 4 hours which initially resulted in some improvement but this improvement did not last and her condition worsened despite treatment. ● Her VARE was 6/18 improving to 6/9P with pinhole. ● AC showed +1 to +2 cells. IOP was 26 mmHg ● There was a dendritic ulcer visible at the cornea.
- 4. ● Topical steroids were reduced and were changed to a weak steroid ie. FML eye drops TDS tapering further every 5 days. ● Acyclovir eye ointment was added 5 times a day and reduced according to response. ● Cyclopen eye drops BD ● She was put on close follow-up ● She steadily improved over next two weeks and dendritic ulcer disappeared with decrease in AC inflammation and normalization of IOP ● After 4 weeks of treatment, her inflammation had completely resolved and she was advised to continue the FML E/D OD and Lovir eye ointment for another week and then stop.
- 5. Case 2 ● A young lady, 21 years of age presented with recent onset loss of vision in her right eye. It was painless and progressive. ● VA was HM not improving ● No H/O trauma or surgery or pets. ● Systems review was normal. CXR was normal. ● On exam anterior chmaber exam was normal. Fundus exam showed a dense vitritis with a central yellowish white lesion about 2 DD in size. ● Her toxoplasma serology was sent but came back negative.
- 6. ● As toxoplasmosis is a ubiquitous disease with high rates of ocular involvement. There was clinical suspicion of Toxoplasmosis and she was started on Clindamycin 300 mg QID and Deltacortil 60 mg tapering to a lower dose over next 04 weeks. ● She showed regression of the disease at 4 weeks visit. Her VA improved to 6/60 but did not improve further due to central involvement. ● Her fundus exam revealed a Toxo scar involving the fovea. Central involvement is less common in aquired toxoplasmosis but it occurs in small number of patients.
- 7. In a case of Uveitis : 1. Always exclude an infectious cause 2. Look for the site and type of inflammation 3. Do not miss active inflammation 4. Do not forget lymphoma / obtain a biopsy when indicated 5. Do not hesitate to use steroid sparing agents 6. Consider sustained release steroids
- 8. Correct approach can prevent permenent vision loss. ● The diagnosis and treatments of intraocular inflammation is often challenging. Uveitis is a sight-threatening disease entity that can arise from various causes. It mainly affects working-age individuals and may lead to irreversible visual loss if not treated properly and in a timely manner. As many as 35% of patients with uveitis exhibit blindness or visual impairment in at least one eye. ● About at least a third of patients are idiopathic. Others have systemic associations. ● Mainstay of treatment remain the steroids. Steroid sparing drugs help to reduce unwanted effects of steroids. New immunosuppressive therapies use biological agents. ● Long acting steroid implants are available with the name Ozurdex and Retisert.
- 9. Always Exclude an infectious cause ● Many infectious forms can masquerade as noninfectious uveitis. Common infections include: ○ TB ○ Syphilis ○ Toxoplasmosis ○ Endogenous endophthalmitis ○ HIV/AIDS ○ Candida endophthalmitis
- 10. Common causes of non-granulomatous anterior inflammation in anterior uveitis or panuveitis: ● HLA-B27 related uveitis ● Behçet's uveitis ● Juvenile rheumatoid arthritis related uveitis ● Uveitis associated with scleritis ● Uveitis associated with streptococcal infection ● TINU Syndrome ● Juvenile xanthogranuloma ● Multifocal choroiditis Granulomatous Vs Non-granulomatous
- 11. Granulomatous Vs Non-granulomatous Common causes of granulomatous anterior inflammation 1. in anterior uveitis ● Fuchs' uveitis ● Herpetic (herpes simplex, varicella-zoster, Epstein-Barr) uveitis ● CMV anterior uveitis ● Posner-Schlossmann syndrome ● Sarcoidosis ● Tuberculosis ● Syphilis 2. in panuveitis ● Sarcoidosis ● Vogt-Koyanagi -Harada syndrome, ● sympathetic ophthalmia ● Tuberculosis ● Syphilis
- 12. Granulomatous Vs Non-Granulomatous ● Toxoplasmic retinochoroiditis ● Necrotizing herpetic retinopathies (acute retinal necrosis) ● Post-surgical inflammation (propionibacterium acnes)
- 13. Do Not Miss Active Inflammation Many chronic posterior uveitides have subclinical smoldering inflammation which can lead to these complications and result in irreversible vision loss.: ● Macular edema, ● retinal atrophy ● chorioretinal scarring Examining borders of the lesions is crucial to determine whether immunosuppression is adequate. Autofluorescence is valuable for comparing the shape of the lesions, and in many cases, active borders are hyperautofluorescent. Prompt treatment has shown to reduce the rate of complications and recurrences in diseases which run a chronic course like: ● VKH syndrome ● Birdshot chorioretinopathy ● PIC ● Serpiginous chorioretinopathy
- 14. Do not forget Lymphoma/ Obtain a biopsy when indicated When degree of vitreous inflammation is severe but scarring and other sequelae of inflammation are disproportionately mild, Primary Intraocular lymphoma should be suspected. A vitreous biopsy is a useful tool in patients with inflammation unresponsive to treatment. In these cases a vitreous biopsy has a diagnostic yield of approximately 60%. Occult infections can also be identified.
- 15. Do Not hesitate to use steroid sparing agents. Mainstay of therapy for Uveitis remains Corticosteroids. If indicated, a short course of high dose corticosteroids are given to control acute, severe inflammation or in patients with chronic inflammation, systemic steroids will be required to control the symptoms followed by long term steroid sparing immunosuppression. In acute sight threatening inflammation I/V methyl prednisolone may be used at 500-1000mg/ day for three days, followed by oral corticosteroid therapy. It is imperative that steroids should be gradually tapered. The taper should not be too quick so as to prevent rebound inflammation.
- 16. .... Use of steroid sparing agents Side effects of steroids should be discussed with the patient. This can improve compliance. Steroid sparing agents be added to go to a lower dose of systemic steroids. Immunosuppressive drugs can be indicated at presentation if the disease has a poor natural history for example in Behcet’s disease with posterior involvement, serpiginous choroidopathy, sympathetic ophthalmia and birdshot chorioretinopathy. Additionally, immunosuppressive drugs should be considered if an adequate response is not seen with two to four weeks of high dose corticosteroids or if after three months of adequate treatment and taper, the disease is not controlled on less than 10 mg of prednisone per day.
- 17. Consider sustained release steroids in Non-infectious Uveitis. Intravitreal injection of Triamcinolone acetonide is very important in treatment of uveitic CME but can cause side effects like cataract, ocular hypertension, glaucoma, RD, Vitreous Hemorrhage, and endophthalmitis. Ozurdex is a biodegradable polymer implant that contains 700ug of dexamethasone, which is to be released in the vitreous cavity over a six months period. Particularly useful in cases of CME or vasculitis as well as in vitrectomized eyes in which the effect duration of triamcinolone is significantly decreased. Retisert is a flucinolone acetonide containing, non-biodegradable implant which releases the drug for three years. However it has a higher rate of complications. Can necessitate incisional glaucoma surgery in about 30-40 % eyes - in contrast to less than 1% in patients with serial Ozurdex injections. It is very important to rule out infectious causes when intraocular steroids are used.
- 18. Conclusion Although uveitis remains a vision threatening disease,more treatment options are available for its effective treatment in current times. Prompt diagnosis of infectious causes and control of damaging inflammation are important steps in it’s management. It is also important to exclude malignancy. In non-infectious uveitis, ophthalmologists can consider steroid sparing treatments, such as Biologics, as well as the newer sustained release steroid implants.
- 19. Thank You