Disclosure. Urgent care Red Eye referral

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1 2011 Disclosure Speaker s bureau for Allergan, Bausch & Lomb, Carl Zeiss Meditec & Optos Advisory Board: Allergan, Bausch & Lomb, Carl Zeiss Meditec, Sightpath Technologies, Glaxo Smith Kline, Regenero, & Zeavision Like posterior uveitis Inflammation is innate/adaptive These affiliations will have no affect on the content of this lecture I have received lecture honoraria or educational grant support or research funding or serve Most on importantly the advisory boards or speaker s bureaus of: Zeavision, No animals Alcon, were Allergan, harmed B&L, CZM in the preparation of this presentation Urgent care Red Eye referral Red painful eye x2wk despite tx Headache over eyes with eye fatigue Systemically healthy Treated with sulfa antibiotic and Tylenol 2-3+ cells, post synechiae OS, IOP 10 OU, KP s, vitreous and retina normal Overall negative history as pertains to uveitis questions except back pain Ciliary Flush Red eye referral Took pt off of antibiotic Put on PF Q30min x 6hr, then QH, 5% HA*, and 800mg Ibuprofen TID Felt better within 2-3 days Is now on long taper, and doing well No longer has headache Politely thanked urgent care for opportunity to participate in patient s care Uveitis.why do we care Responsible for 10% visual handicaps in Western world Responsible for 15% of cases of total blindness in US Legal blindness develops in 22% of uveitis patients Uveitis related blindness costs US economy over $240 million per year Ending acuity is <20/60 in approx 1/3 OFTEN PRESENT TO OUR OFFICES FOR RED EYE 1

2 Uveitis Encompassed broad range of manifestations affecting the uveal track Iris (as high as 60% 0f cases) CB: intermediate Consider LYME & MS Anterior snowball & snowbanking Retina/choroid: posterior panuveitis Basics of Uveitis Anterior vs Posterior approx 4: per 100,000 depending on study Any age, but primarily Sex: Males more common acute, Females more common chronic Anterior Uveitis May involve other it is (Epi)Scleritis, conjunctivitis, keratitis Common work up Autoimmune JRA (RF) HLA B27 Crohn s (endoscospy), Reiter s(esr/crp), AS (Xray) Infection: HSV, syphillis (VDRL/FTA-ABS), lyme (serological test), TB (PPD/CXR) Inflammatory: sarcodoisis (ACE, CXR) Etiology: Anterior uveitis #1 Etiology: Idiopathic (30-50%) Immunologic: CVD (JRA), IBS, Sarcoid, Ankylosing Spondylitis Infectious Herpetic, Syphilis, CMV, Histo, Toxo, TB, Lyme Non-Infectious: Traumatic Ocular Fuch s Heterochromic iridocyclitis (5%), Glaucomacyclitic crisis, Lens induced Clinical Features: KP s and PS IOP Low: initially High: HSV/steroids/chronic/toxo/ Fuchs heterochromatic Clinical Features: AC reaction Anterior Chamber Cells Flare Cellz n Flare 1 < 5 cells seen Faint haze or not equal bilaterally cells seen at once 3 20 cells Mod. Haze with full iris detail Marked with mild loss of iris detail 4 Dense cells Dense haze, hypopyon 2

3 Work-up When to work up anterior uveitis? Bilateral Mutton fat KP > Grade 3+ (or higher) or the presence of hypopyon? Recurrent Work up if > 2 findings above present Dr. Karpecki s clinical pearl of the week Careful history, including very specific questions regarding potential etiologies Careful external examination Pupil testing IOP Cornea Anterior chamber evaluation Iris evaluation for nodules Vitreous evaluation Dilate every patient! Lab Testing What, when, why, who and how? Some basics: CBC, SED, HLA-B27, FTA- ABS, ANA, ACE, Med consult, chest x-ray Also consider: Toxo, Lyme, Histo, TB, Serum lysozyme, other HLA, sacroiliac radiograph BEWARE: Lab tests can be expensive How do you know if in normal range??? Don t forget about Irritable Bowel Syndrome: 5% of Crohn s have uveitis: no specific blood test Herpes ED: up to 85% have uveitis Psoriatic Arthritis: 20% develop uveitis HLA s: A-DR4 VKH, B7 Histo and MS, B51 Bechet s Reiter s syndrome: Urethritis, uveitis and arthritis Anterior Uveitis Treatment BE AGGRESSIVE! Name brand Pred Forte or Econopred No Generic! If mild to mod: q2h If mod to sev: q 1/2 to 1h Long slow lagged taper Consider softer steroid for taper Ointment at night if needed Remember other treatments needed!! Treatment cont. Cycloplegia Either 5%HA OR Atropine 10% Phenylephrine when PS Help restore vasc perm and prevent ache Oral NSAID PO Steroid when posterior Pressure med if needed 3

4 Clinical pearls anterior uveitis When treating a new case of uveitis, what does QID stand for? Quickly Increase the Dose TODAY consider PF vs Durezol Worry more about IOP spikes than cataracts Use steroids often at the beginning Taper once cells are GONE Don t forget cycloplegic But need some iris movement Panuveitis: Barb Posterior uveitis Originally saw 7yrs ago Interoffice referral 4wk h/o iritis on PF QID Treated aggressively Short taper Multiple recurrences Negative labs Long term taper Cataract, glaucoma and CME common Ultimately may cause ON atrophy, RD and scarring Retinal vascular changes Often not responsive to topical meds, even if steroid + NSAID (PO and topical) PO Steroids often needed Intravitreal or subtenons steroid often used Other meds: CSA, COX II, methotrexate, anti TNF and other immunosuppresive agents Side affects Posterior Uveitis Side note on TNF: treatment not only improves uveitis, but MD in animal model 40-80mg PO Be careful: TB DM (hyperglycemia) Peptic Ulcers?affects on HTN BM suppression Oral Steroids Before using it, Dx should be made There is lack of overall consensus Amount use range from 35-60mg 62% of non-infectious uveitis get treated with steroids Olson et al. Ivit Infliximab and CNVM in animal. Arch Ophth 9/07 4

5 Posterior Uveitis treatment cont. Multiple injections usually needed Side affects often necessitate tx cessation Chronic treatment still needed How do you continue to treat without continued systemic affects and inconvenience of repeat injections? Implants Implants will have slow sustained release of medication Retisert approved Others: Posurdex (Solex/Allergan), Medidur (Alimera sciences), I-vation (SurModics/Merck) Other applications being investigated Retisert (B&L) 2005 B&L For non-infectious chronic uveitis Last for ~2.5 yrs Most concerning side effects: Complications of surgery, IOP rise & cataracts fluocinolone acetonide Ozurdex VERY POTENT Short ½ life First drug approved for tx of ME associated with VO (June 2009) Biodegradable dexamethasone (0.7mg) implant injected through 22g applicator last few months Approved in 2010 for chronic non-infectious uveitis 50% of txed grp vs 12% of sham had ZERO V haze Allergan Completely degrades in 6M Haller JA, et al Retina 2009; 29:46-51 Uveitis FACTS Classified based on Anatomic location/structures involved Also Primary or recurrence Acute vs chronic anterior uveitis Acute is abrupt vs Chronic waxes and wanes Symptoms of anterior vs posterior Pain/photophobia: anterior vs Floaters: posterior Granulomatous anterior uveitis KP: often associated with systemic conditions Unilateral vs bilateral anterior uveitis Acute common unilateral and chronic typically bilateral Bilateral more often associated with systemic conditions Accounts for up to 37% of uveitis cases More often idiopathic, and more non-idiopathic causes More likely to have CME and vision loss Includes number of chorio- and neuroretinitis conditions Posterior Uveitis 5

6 Posterior uveitis classification Clinical presentation Focal or Multifocal Choroiditis or Chorioretinitis Retinitis or Retinochoroiditis Neuroretinitis Knowing the clinical presentation helps narrow down the common etiology SUN = Standardization of uveitis nomenclature 2004 Presentation of active inflammation Vitritis &/or panuveitis Vasculitis CME Symptoms vary Complications Chorioretinal atrophy Optic atrophy Cataracts Glaucoma (variable IOP) ERM Occlusive disease Variable Neovascularization/RD Posterior Uveitis Etiologies of vasculitis Vitreous cells seen with or without condensing lens Variety of signs and symptoms Systemic or ocular specific Birdshot RC, Multifocal or Serpiginous C The challenge of posterior uveitis Spelunker: Is HE at risk factor? Encompasses a broad spectrum of diseases In US posterior uveitis is associated with 10% of blindness among 20-50yo (`30yo) Permanent VL if untreated It is likely a manifestation of UNDERLYING systemic disease Many cases require SYSTEMIC tx May affect the host regardless of their immunity 20-50yo More common in whites 6

7 9/29/11 So are the individuals living near the Ohio river valley the only ones that get HISTO? Possible associations May develop Flu like symptoms MOST are asymptomatic Endemic to areas bordering Ohio river valley (Indiana, Ohio, Illinois, Kentucky, Tennessee, and Mississippi) Scarring in lungs; dense nodules with center calcification Dissemination can occur Parts of mid-atlantic (Maryland, W. Virginia & Virginia) 200,000 NEW report/yr Many will lose vision in 1 or both eyes attributed to HISTO 44WM Refer for possible neoplasm nodule in lung Note: calcifications Courtesy Dr. B Sutton (Presumed) Ocular Histoplasmosis Linked to H. capsulatum (A fungi) found in soil with high concentration of fecal material (excrements) from chickens, pigeons and bats GUANO OH MY! Inhale spores Peripapillary atrophy Histo spots maculopathy TRETAD Equatorial streaks Proposed to be the 4th sign Notes in 5% of cases 7

8 Disseminate from lung to choroid Histo Choroid infiltrate Granuloma disrupt RPE CNV Macular involvement may lag behind initial exposure Dx Clinical Dx OCT/FA for CNVM?Histo skin test Treatment CNVM treatment Antifungal used only if concomitant systemic involvement Hazy view = vitritis Histo is the PURESTS form of choroiditis but MULTIFOCAL CHOROIDITIS (a WDS) is NOT! Gass Am J Opthalmol 2003: Jampole AJO 2003; 135: Quillen DA, et al. Am J Ophthalmol 2004;137: Idiopathic variable multiple bilateral WD Outer retina/rpe/choroid Unknown cause Many affects young females & associate with viral prodome But variable symptoms & presentation VL, photopsia, scotoma, floaters Variable inflammation Correct Dx is CRUCIAL idiopathic chorioretinal inflammatory syndromes MEWDS Birdshot Serpeginous AMPPE MFC age young young young laterality unilateral bilateral bilateral bilateral bilateral inflammation mild moderate mild pattern subtle radiating Atrophic around nerve Plaque onset acute acute Others Females Viral prodome Viral prodome Histo-like females recurrence common common 8

9 AMPPE Acute Multifocal Placoid Pigment Epitheliopathy OTHER similarities include: female, viral prodome, diagnostic FA appearance MEWDS Multiple evanescent white dot syndrome OTHER similarities include distribution and more aggressive course Birdshot Chorioretinopathy Serpiginouos Choroiditis (Geographic helicoid peripapillary choroidopathy) Knowing the culprit helps in Dx Non-infectious Immune-related Idiopathic Knowing the culprit helps in Dx Infectious nematode bacteria protozoa fungi viral Sarcoid VKH WDS Pars planitis DUSN Syphilis Toxoplasmosis Histo CMV Toxocariasis Lyme Candida ARN Bechet s Sympathetic ophthalmitis TB PORN Cat scratch Disease Retinitis vs Choroiditis Retinitis Choroiditis Depending upon presentation, specific hx can be elicit and additional labs may be necessary Focal Toxos Multifocal Syphilis Viral Candida Panuveitis Sarcoid Syphilis Focal TB Candida Multifocal Histo WDS Narrow the possible culprits by recognizing the clinical syndrome: medical Hx, SocHx, recent contact, geographic & demographic 9

10 General Erythrocyte sedimentation rate (ESR) C-reactive protein (CRP) VDRL/FTA-ABS Chest X-ray (CXR) Angiotensin converting enzyme (ACE) ANA (antinuclear antibody) CBC (cell blood count) Mantoux test: Purified Protein Derivative (PPD) Lyme titer (depending on area) Specific Toxo Elisa titers Western blot CSF (cerebrospinal fluid) DNA polymerase chain reaction Keep in mind PRICE I.E. ANA + RF + LYME + CBC = $300 Management Test to consider ELISA toxo titers DDx test to consider: FTA-ABS/VDRL PPD Chest x-ray Toxocara ELISA HIV testing if patient is at high risk EDUCATE EXPECTING MOMs: special avoidance of cat litter and undercooked meat Pts with inactive scar: should be aware of si/s associated with reactivation/complications Ocular Toxoplasmosis Some studies suggest that HALF of all fundus posterior uveitis are due to toxoplasmosis Toxoplasmosis gondii Obligate intracellular protozoa It is the common infectious retinitis In the US, represents 3-70% of the cases 1 bill infected worldwide (most common posterior) uveitis It usually presents as SYSTEMICALLY asymptomatic Tx is the same for systemic and/or ocular manifestations of Toxoplasmosis Toxoplasmosis retinochoroiditis MOST COMMON Tx Uveitis: PF + cycloplegic The classic TRIPLE therapy (4-6 wk course) 1. Daraprim (Pyrimethamine): Two 50mg tablets (100mg) loading dose, followed by 50mg QD (may be divided BID) BM suppression & liver toxicity 2. Sulfadiazine: 2g loading dose, followed by 1g QID Initial loading dose ranges from 2-4mg BM suppression & hypersensitivity 3. STEROIDS MUST ADD: Folinic acid 3-5mg 2-3x/week to the above regiment to avoid BM depression The truth about steroids You should CONFIRM the Dx prior to its use Generally started hrs after antibiosis, followed by slow taper Calms the associated inflammation moderate-severe vitritis 10

11 Condition is self-limited & meds may be toxic Resolution ~4wks Treatment recommendations Depends on location, size or complications Active for > 1M Lesion in HIV pt Regardless of location or presentation Macular/ON involvement or threaten Moderate-severe vitritis associated VL Tx is also consider for LARGE active lesions (>1DD) MONOCULAR Small peripheral lesions (outside the posterior arcades) TYPICALLY observed Contemporary tx Bactrim DS (Co-trimoxazole) 800/160 1 double strength (DS) QD 800mg sulfamethoxaloze+160mg trimethoprim Use for 4-6wks ASK PT ABOUT SULFA ALLERGIES Cheaper, better compliance & safer profile than CLASSIC tx Opermcak et al, Ophthalmology 1992 (safety and efficacy), Rothova et al, Am J Ophthalmol 1993 (comparison to classic and clindamycin regimens) 1990 Am Uveitis Soc had NO consensus of most appropriate tx Treatment does NOT eliminate tissue cyst, thus cannot PREVENT recurrence. Transplacental Avoid uncooked food Wash V/F Hiatus from cat litter duties Intermediate Host Definitive Host No clinical trial has demonstrated that one antibiotic is superior to another Gilbert 2002 (review of current research in toxo) Note when using steroids Prior to initiating therapy CBC and TB test are needed Do not Rx oral steroid w/o antibiotics Sabates 1981 When tapering corticosteroids, REMEMBER that antimicrobial agent are continued until corticosteroids are STOPPED! Medical Treatment Options Corticosteroids (systemic/periocular) Moderate-severe or visual threatening presentations 0.5mg-1mg/kg QD for wks-month with taper Treatment is designed to minimize host defense system Antihelmenthics If used, it is in Combo with steroids if: Ocular dz not responding to steroids alone Systemic disease is present Variable choices X 7-10d Thiabendazole (Mintezole) Albendazole (Albenza) Diethylcarbamazine citrate (Hetrazan) Mebendazole Concomitant OLM and VLM is rare 11

12 Determine weight of patient (in Kg) Determine total amount of med per day based on mg/kg/day Determine frequency of dosing Determine amount of med to administer at each dosing total amount drug per day number of doses per day Total drug per dose Available concentration 200 mg or 400 mg Recommended dose is mg/kg/day SO. 60 lb = 27 kg 60/2.2 Dosage = mg (recommended)/kg/day 30 mg X 27 kg= 810 mg/day Dosing interval (what s available) 810 mg / 4 doses = mg Rx: 200 mg QID Oops, I should have not eaten DIRT! In children there is a 3X greater risk of medication error & related injury Use hourly dosing rather than number of times per day Q 6 hours in lieu of QID Decide on proper administration Be careful with similar names TobraDex and Tobrex PUPPY s feces (+) VITRITIS Papillitis Granoloma Vitritis Dragging retina/vessels Fibrotic band May remain in soil Encysted larvae 12

13 Ocular Syphilis Surgical Intervention Vitrectomy: TRD or ERM present Extensive fibrosis Photocoagulation is another tx option but Direct invasion of Treponema pallidum Spirochete (gram negative bacteria) Congenital form Acquired form Don t forget to recommend animal de-worming Primary At inoculation site Chancre: Round, firm & painless ULCER Few wks after inoculation Secondary Systemic treponemal spread RASH (maculopapular) Rough, red & diffuse Palms of hands and soles of the feet Ocular manifestations Syphilis/ Lyme conjunctivitis/(epi) scleritis interstitial keratitis BILATERAL uveitis Iris roseolae (rare) cataract/secondary glaucoma posterior uveitis pupillary abnormalities/optic neuropathies Tonic Argyll Robertson pupil Latent (hidden) Can last yrs (+) blood tests without si/s Tertiary (3 rd stage) : 1-10yrs after exposure Neurosyphilis (10% of cases) Paresis & meningitis Neuro-ophthalmic Si/s Cardiovascular syphilis Affects coronary or aorta Gumma Soft non-cancerous growth Benign T-cell response to the bacteria 13

14 What questions should you consider asking? Posterior findings (50% bilateral) Retinitis Focal or Diffuse multifocal chorioretinitis Inactive: Salt & pepper Fundus (DDx) But normal ERG Vitritis CME Vasculitis Vein occlusion Optic neuropathy Neovascularization Red Atlas Elicit sexual history Sexually active? Multiple partners? Ask about specific rashes Ask about ulcers Hx of HIV IV drug user How do you address these questions? Reviewing tests & importance to ODs Possible cause? If suspect syphilitic posterior uveitis Use a non-treponemal test (i.e. VDRL) to screen for the disease Obtain quantitative measurement of antb production, which can be used later to determine if tx is affective Use the treponemal test (FTA-ABS) to confirm the (+) screening test can also help determine the presence of the ANY stage (including LATENT stage) Cat Scratch Disease Lyme Disease Syphilis Viral (HSV, mumps) Toxoplasmosis NOT AION MORE Treatment? Doxycycline 100mg PO BID He adds the fact that he was hunting recently & thought he got poison IVY likely culprit? Lyme disease Most common arthropod-borne disease Endemic to N.A., Europe & northern Asia 1 st report in Lyme, Connecticut (1975) Like syphilis, it is a spirochete illness (Borrelia burgdorferi) gram (-) bacteria TICKS are the carriers White tail deer is the most common host Prevalence in summer months Arthropod: invertebrate animal having an exoskeleton (external skeleton) Systemic clinical manifestations Stage 1: RASH (Erythema migrans) Flu like symptoms: Fever, headache, aches/fatigue, joint pain Stage 2 Neurological manifestations Bell s palsy & peripheral neuropathy & optic neuropathy Stage 3 Associated ocular signs Posterior uveitis Carditis (heart inflammation) Arthritis chronic/relapse (rheumatologic) knee Just like syphilis 14

15 Variable ocular manifestations Just like syphilis Anterior segment uveitis IK Conjunctivitis/scleritis Optic neuritis Chorioretinitis Pars planitis Vitritis Pigmentary changes Vasculitis Dx criteria Classic skin rash +Hx of exposure within the month Hx of a bite Visited in endemic area Been in the woods If no rash, then Hx of exposure + an organ involvement CDC NE, upper Midwest Cali, RI, NY, NJ, PN, Conn, MA, Wisconsin Blue present & red future Brownstein et al.ecohealth2005;2:38-46 Dx criteria If no hx of exposure (unaware of bite or has not visit endemic area): Involvement of 2 organs + classic rash Serological testing help in Dx but ELISA titers & Western blot for B. burgdorferi (IgG and IgM) (+) rash may still be a necessity Endemic areas Lyme pts may have a (-) serological test International Lyme & Associated Diseases Society Fosters care for Lyme disease pts through physician training Emphasis on how to properly diagnose the disease Current treatment Set up today s guidelines in 2006 Advancements in research CDC Lyme disease treatment 14d course Sarcoid Work-up 1 st line of treatment Doxycycline 100mg PO BID or Tetracycline 500mg QID Amoxicillin 500mg PO TID or PNC 500mg QID Allergies to 1 st line treatment Erythromycin 250mg PO QID Cefuroxime axetil 500mg PO BID Neurological involvement PNC G intravenous JUST like! Best efficacy following treatment within 72hrs Chest X-ray: abnormal 90% Accuracy Lungs 76-94% Mediastinal lymphnodes 96% Other findings Peripheral lymph nodes 59-82% Conjunctiva 25-57% accuracy BIOPSY 15

16 Sarcoid: More work-up Angiotension converting enzyme (ACE) Reflective of complete body activity Could be negative if only eye involvement 70% sensitive & 80% specific Gallium scan: Nonspecific Tests level of gallium actively accumulated in granulomas Head (face), neck & chest Can also be (+) in lymphoma Acute Sarcoidosis Levels Abrupt, explosive onset in young pts Spontaneous remission w/i 2 yrs after initial Dx Iritis more common ocular manifestation Responds well to corticosteroids Long term complications minimal Sarcoid Sarcoidosis Levels Chronic: Disease continues for over 2 yrs More insidious onset More intrapulmonary involvement More chronic lung disease Retinal findings 16

17 Multi-Systemic Disease Lungs (95%) May be the related cause of death unknown etiology characterized by intrathoracic involvement Ocular system 25-60% have ocular manifestations Lymph nodes CNS Salivary glands Liver/spleen/heart erythematous papules Anterior Uveitis Chronic, mutton fat (granulomatous), iris nodules Lid /iris/pupils nodules Lacrimal gland infiltration Band keratopathy Orbital granuloma proptosis Neurological involvement Optic nerve edema (direct infiltration or compression) Ocular Manifestations Most common cause of fungal infection CANDIDA Endogenous endophthalmitis Disseminated from systemic fungal disease IV drug users (heroin addict) AIDS pts or other debilitating dzs (DM, alcoholism, cancer, transplantation) Other intra-ocular hematogenous spread recent major surgery (abdominal), bacterial sepsis, indwelling intravenous catheters/placement of central venous device Exogenous endophthalmitis Organism enter eye s/p ocular trauma or surgery The paradox Candida endophthalmitis Although immunosuppresion is a risk factor for fungal infections, candidal endophthalmitis is NOT common in AIDS pts Immune response is necessary Chorioretinitis Creamy whitish chorioretinal granuloma Single or multiple Isolated or confluent Progress to scars Vitreous involvement More pronounce in advance stage of the dz vitreal pearl puff ball 17

18 Candida endophthalmitis How is the DIAGNOSIS confirmed? CLINICAL APPEARANCE AND A (+) FUNGAL CULTURE BLOOD CULTURES VITREAL BIOPSY By the time it becomes symptomatic 2/3 rd are bilateral & ½ have multiple lesions But this is challenging Zone 1 Pizza Fundus Minimal, IF ANY vitritis satellite Inactive CMV-R Pt was asymptomatic and NEVER treated before for CMV-R but had been taking HAART cocktail X 2 yrs WHAT HAPPENED? Zone 2 (to VV) Zone 3 (to ora) Granular look with satelite lesions Viral load undetectable & CBC was relatively HIGH CMV-R Tx in the Era of HAART PIOL range in appearance Currently, according to U.S. Public Health Service (USPHS) and the Infectious Diseases Society of America (IDSA) guidelines: HAART may be safely used as a maintenance therapy Pt can D/c anti-cmv drug if: CD4+ cell count >200 cells/mm 3 (s/p 3-6 months) X 3M Maintained a relative undetectable viral load CONTINOUS MONITOR IS STILL IMPORTANT 1999, the USPHS/IDSA guidelines revised in 2001 Primary uveal lymphoma Diffuse/mul2focal creamy yellow DEEP subre2nalrpe infiltra2ve lesions with VITREOUS CELL More likely a variant of ocular adnexa lymphoma Primary vitreore+nal lymphoma A SUBre2nal infiltra2ve described as low lying mass More closely associated to a Variant of PCNSL Vitreal biopsy confirms Dx Yanoff & Duker Ophthalmology 18

19 NEED to r/o CNS involvement (primary CNS lymphoma PCNSL ) with MRI & LP Primary intraocular lymphoma (PIOL) pt s are in their late 50 s & mid 60 s. PIOL is a subset of PCNSL American uveitis society criteria for Dx of ARN Rapid circumferential progression. Eventually leads to necrosis if untx Prominent a/c rxn & vitritis >1 foci of retinal necrosis Occlusive vasculitis Distinguishing our pt from PORN PORN ARN Posterior segment findings of ocular TB NOT a common cause of uveitis in US Multifocal choroiditis Unilateral or bilateral May resemble WDS DEEP Gray-yellow nodules Granuloma Can become necrotic with time POSTERIOR POLE 2 involvement Retinitis Serous retinal detachment Vasculitis/periphlebitis Vitreous involvement Varma Eye 2005 Clinical Picture 1-3 weeks after inoculation Infection Bartonella henselae (1985) Gram (-) bacteria Cat s scratch is principal RESOVOIR Cat-Flea vector Lymphadenopathy Flu like prodome (fever) Regional swollen lymph 19

20 A. Rash B. Swollen lymph nodes C. Nausea/GI problems D. Flu-like symptoms PARINAUD'S OCULOGLANDULAR SYNDROME CONJUNCTIVITIS + PAN + FEVER Most common finding Parinaud s oculoglandular syndrome Vitritis/uveitis Focal Chororetinitis With or with associated optic nerve swelling AND the most common Courtesy Drs. J Sowka & L. Alexander Regional Lymphadenopathy (+) ELISA/EIA Bartonella titers Known cat contact (+) Lymph node biopsy of bacilli Treatment Options: Bartonella susceptible to a # of antimicrobial Macrolide Azithromicyn 250mg PO Erythromycin 500mg QD Bactrim QD Ciprofloxacin mg/kg BID Rifampin mg PO QD Doxycycline mg BID Can t use in pt < 8yo 20

21 Treating remains controversial Neuroretinitis is a self-limited disease Palliative management Tx efficacy has been difficult to establish Treatment is considered In more severe presentations Immunocompromised To speed-up recovery 21