10/18/2018. Unraveling Uveitis

Transcription

1 Unraveling Uveitis Trenton Cleghern, OD, FAAO VisionAmerica UAB School of Optometry 11/10/2018 1

2 Disclosure Statement: Nothing to disclose 2

3 Objectives Classify uveitis Current and new therapeutic options Steps to identify systemic or ocular etiologies of the inflammation Discuss when lab testing is needed and which tests are appropriate 3

4 Case 1 40 AA female requests 2 nd opinion for her cataract OS Seen at academic eye center 5 months prior Dx: Neuroretinitis; MRI normal, never went for recommended lab testing Vision significantly blurry OS 4

5 Case 1 Photophobia OU VA sc OD: 20/20 OS: Hand motion (PHNI) Trace cells OD, 2+cells and 3+flare OS Mutton fat KPs OS, iris nodules OS, posterior synechiae OS 5

6 Photo by Trenton Cleghern, OD, FAAO 6

7 Photo by Trenton Cleghern, OD, FAAO 7

8 Image by Trenton Cleghern, OD, FAAO 8

9 Image by Trenton Cleghern, OD, FAAO 9

10 Case 1 Diagnosis: Granulomatous panuveitis OS>OD Difluprednate and atropine Labs ordered Results: elevated ACE and HLA-B27 positive 10

11 Photo by Trenton Cleghern, OD, FAAO 11

12 Photo by Trenton Cleghern, OD, FAAO 12

13 Classification Unilateral vs. bilateral Acute vs. chronic Granulomatous vs. non-granulomatous Location 13

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15 Etiologies Idiopathic HLA-B27 Trauma Herpetic Syphilis Sarcoidosis Lyme Bartonella henselae Behçet s disease VKH Fuch s heterochromic iridocyclitis Multiple sclerosis Lupus Rheumatoid arthritis? Tuberculosis Lens induced Posner-Schlossman Toxoplasmosis Drug induced Juvenile idiopathic arthritis Toxocariasis Cytomegalovirus Tubulointerstitial nephritis and uveitis Masquerade syndromes Leprosy Fungus White dot syndromes Sympathetic ophthalmia 15

16 Rheumatoid Arthritis Uveitis myth Psoriatic, reactive and JIA-actual etiologies Scleritis/episcleritis 16

17 Etiologies of Anterior Uveitis 17

18 Etiologies of AU Idiopathic HLA-B27 Trauma Herpetic Fuch s heterochromic iridocyclitis Behçet s disease Posner Schlossman Lens induced Sarcoidosis Syphilis Juvenile idiopathic arthritis 18

19 Human leukocyte antigen HLA-B27 2-8% of normal population Major histocompatibility complex Role in pathology unclear 19

20 HLA-B27 Related Uveitis Robust inflammation : hypopyon, fibrin, synechiae Major etiology of anterior uveitis Recurrent, bilateral, alternating Associated w/ seronegative spondyloarthropathies Ankylosing spondylitis Reactive arthritis Inflammatory bowel disease Psoriatic arthritis 20

21 Ankylosing Spondylitis 90% are HLA-B27 positive About 25% develop uveitis More common in young white males Lower back and sacroiliac X-ray 21

22 Reactive Arthritis Formerly known as Reiter s Syndrome Follows genitourinary or GI infection More common in men Triad: arthritis, urethritis, conjunctivitis/uveitis 70%-95% HLA-B27+ 22

23 Inflammatory Bowel Disease Ulcerative colitis and Crohn s disease More likely to be bilateral Chronic and low-grade Higher chance of posterior uveitis 23

24 Psoriatic Arthritis About 60% are HLA-B27+ 20% develop uveitis Uveitis more common with arthritis 24

25 Herpetic Uveitis 25

26 Juvenile Idiopathic Arthritis 1-4 years of age ANA positive 3 subtypes Careful monitoring 26

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29 Photo from VisionAmerica 29

30 Sarcoidosis Multisystem autoimmune disease Lungs, lymphatics, eyes, skin, nervous system, cardiac, liver, laryngeal Likely multifactorial etiology #2 systemic etiology of uveitis in U.S. 30

31 Sarcoidosis Noncaseating granulomas (non-necrotizing) TNF-alpha Macrophages and T cells produce immune response of cytokines and chemokines Infectious or environmental triggers immune response over-reaction in genetically predisposed individuals 31

32 Sarcoidosis Most prevalent in African American and northern Europeans Women > men Young to middle-aged population Pediatric cases are very rare 32

33 Sarcoidosis Can cause anterior, intermediate, posterior, or panuveitis 25% with presenting symptom of uveitis 30-70% of patients have uveitis Testing: ACE, serum lysozyme or calcium, chest X-ray 33

34 Angiotensin-Converting Enzyme ACE Produced in lung capillaries Also produced in kidneys Major role is renin-angiotensin-aldosterone system 34

35 ACE in Sarcoidosis Produced by granulomas 60% of sarcoid patients Normal under 67 U/L Over 100 U/L = highly suggestive Affected by treatment Sensitivity and specificity only 60% and 70% 35

36 Chest X-ray Electromagnetic waves to create a picture of your bones, blood vessels, organs, and other tissues of the thorax Fast, noninvasive, and inexpensive Abbreviated CXR Bilateral hilar lymphadenopathy Lung parenchymal disease 36

37 Syphilis One of the great masqueraders Standard uveitis treatment + penicillin G Tertiary syphilis Must get partners evaluated! 37

38 Intermediate Uveitis Pars planitis Lyme disease Sarcoidosis Syphilis Multiple sclerosis Cat scratch disease 38

39 Posterior Uveitis Sarcoid, syphilis, tuberculosis Toxoplasmosis/toxocariasis Cat scratch disease Bartonella henselae Lyme Borrelia burgdorferi Herpetic simplex or zoster Cytomegalovirus retinitis Systemic lupus erythematous White dot syndromes VKH 39

40 Photo: Trenton Cleghern, OD FAAO 40

41 Granulomatous Uveitis Sarcoidosis Syphilis Tuberculosis Herpetic Vogt-Koyanagi-Harada syndrome (VKH) Sympathetic ophthalmia 41

42 Masquerade Syndromes Cancer Retinoblastoma Lymphoma Endophthalmitis Ocular ischemia 42

43 Laboratory Testing 43

44 Bilateral When to Test? Recurrent Intermediate, posterior, or panuveitis Obvious systemic complaints Intense inflammation 44

45 ACE: angiotensin converting enzyme (sarcoid) ANA: antinuclear antibody (lupus) ANCA: antineutrophil cytoplasmic antibody (vasculitis) Serum Ca 2+ (sarcoid) Autoimmune Serum lysozyme (sarcoid) HLA: A11, A29, B27, B5, Bw5, DR4 45

46 Infectious FTA-ABS: fluorescent treponemal antibody absorption test (syphilis) RPR: rapid plasma reagin (syphilis) Toxoplasmosis gondii: IgG/IgM antibody titers Bartonella henselae: IgG/IgM antibody titers (cat scratch) Borrelia burgdorferi : IgG/IgM antibody titers (lyme) CMV: polymerase chain reaction (cytomegalovirus) PPD: purified protein derivative (TB) TB quanteferon gold: (TB) 46

47 HLA-B27 ACE Lysozyme FTA-ABS RPR Anterior Uveitis Labs 47

48 Intermediate Uveitis Labs ACE Lysozyme Borrelia burgdorferi IgG/IgM antibodies Consider MS investigation Chest X-ray* 48

49 Posterior Uveitis Labs ACE Lysozyme ANA Borrelia burgdorferi IgG/IgM antibodies Bartonella henselae IgG/IgM antibodies FTA-ABS RPR Toxoplasmosis gondii IgG/IgM antibodies 49

50 Topical steroids Oral steroids Injectable steroids NSAIDs Immunosuppressants Treatment 50

51 Hit Hard and Taper Slow! 51

52 Prednisolone acetate 1% Topical Steroids Difluprednate 0.05% Need a 2 grade reduction in activity to taper e.g. improvement from 3+ cell to 1+ cell Weaker steroids possible use as a taper 52

53 Oral Steroids Posterior, pan, or recalcitrant uveitis Must rule out infections, e.g. tuberculosis Side effects Prophylactic acid reducer mg PO per day 53

54 Alternative oral therapy Oral NSAIDs Ibuprofen Indomethacin Naproxen 54

55 Cycloplegia Cycloplegia: 1. Reduce pain (immobilizes inflamed iris) 2. Prevents synechiae 3. Stabilizes leaky blood-aqueous barrier Options: Cyclopentolate short duration of action Homatropine pharmacy availability issues Atropine strongest cycloplegic 55

56 Photo: Trenton Cleghern, OD FAAO 56

57 Breaking Synechiae Cyloplegics + mydriatic drops Can Rx Atropine TID In office concoction soak cotton pledget in: 10% phenylephrine 1% atropine 1% cyclopentolate 57

58 Newer Uveitis Treatment Adalimumab TNF- alpha inhibitor Inflammatory conditions Approved for non-infectious uveitis 58

59 Immunosuppressants Antimetabolites T cell inhibitors Alkylating agents Biologics 59

60 Implants vs Systemic Therapy? MUST Trial 7 year data Systemic therapy>implantable meds 60

61 Final Case 40 YO AA female CC: floaters OD Medical hx: HTN & multiple myeloma VA cc OD: 20/25- OS: 20/20 Stellate keratic precipitates OD 1-2+cell and 1+ flare 61

62 Photo from VisionAmerica 62

63 Photo from VisionAmerica 63

64 Photo from VisionAmerica 64

65 IN SUMMARY HLA-B27-most common in AU Over treating better than under treating DFE! Don t be afraid to order labs 65

66 References 1. Barisani-Asenbauer T., et al. Uveitis a Rare Disease Often Associated With Systemic Diseases and Infections a Systematic Review of 2619 patients. Orphanet J. RareDis. August Waheed, N. HLA-B27 Associated Uveitis. Massachusetts Eye Research and Surgery Institute (MERSI), Harvard Medical School Case Report. November Levine JS, Burakoff R. Extraintestinal Manifestations of Inflammatory Bowel Disease. Gastroenterology & Hepatology. April Kaiser PK, and Friedman NJ. The Massachusetts Eye and Ear Infirmary Illustrated Manual of Ophthalmology. Fourth ed Abdulaal MR, Abiad BH, Hamam RN. Uveitis in the Aging Eye: Incidence, Patters, and Differential Diagnosis. Journal of Ophthalmology. March Sheehan, NJ. HLA-B27: What s New? Rheumatology. Oxford Journals. January Onofrey BE. Ocular Therapeutics Handbook: A Clinical Manual. Third edition Wexler A, Sand T, Elsas TB. Bilateral Macular Thickening in Mild Anterior Uveitis: Is HLA-B27 Involved? BMC Ophthalmology. August Callanan DG. Tailor Uveitis Treatment to Type and Severity. Review of Ophthalmology. August Wakefield D, et al. What is New HLA-B27 Acute Anterior Uveitis? Ocul Immunol Inflamm. April Gerstenblith AT, and Rabinowitz MP. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. Fourth edition Bodh SA, et al. Inflammatory Glaucoma. Oman Journal of Ophthalmology. January Heiligenhaus A, Heinz C, Becker MD. Treatment of Uveitis Cataract. Cataract and Refractive Surgery Essentials in Ophthalmology. Heidelberg: Springer; Uy HS, Christen WG, Foster CS. HLA-B27-Associated Uveitis and Cystoid Macular Edema. Ocul Immunol Inflamm. September Fiorelli VM, Bhat P, Foster CS. Nonsteroidal Anti-inflammatory Therapy and Recurrent Acute Anterior Uveitis. Ocul Immunol Inflamm. April

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