Imaging in uveitis. Anthony Hall

Transcription

1 Imaging in uveitis Anthony Hall

2 Causes of Vision Loss in Uveitis 1. Cystoid macular oedema 26% 2. Cataract 19% 3. Glaucoma 11% 4. Permanent macular damage 5% Rothova et al BJO 1996; 80:

3 Macular OCT in uveitis CMO 2/3 of uveitis patients The leading cause of visual loss Drives treatment decisions Others Permanent outer retinal damage ERM CNVM

4 Patterns of OCT thickening in uveitis A. Cystic B. Diffuse C. SRF

5 OCT markers of visual prognosis Loss of outer retinal structures EZ Outer limiting membrane

6 Non CMO causes of visual loss ERM CNVM Retinitis

7 CNVM

8 ERM ERM PTMH FTMH

9 Syphilitic placoid

10 Ms GH 26 yr old 6 days of pain redness and photophobia. OH unremarkable GH good OE Left AAU with normal fundus

11 Treatment Investigation

12 Treatment Intensive topical steroids Investigation U&E LFT ACE VDRL HLA B27

13 Review at three weeks Pain and redness resolved but VA 6/12

14

15 Mr DF 21 yr old man JIA and ongoing uveitis Prednisolone, Humira and methotrexate Sec cataract and glaucoma

16 O/E: OD OS 6/9 VA 6/36 18 IOP cells AC ++ cells ++ cells Vitreous ++ cells No MO DFE Apparent MO R>L OCT

17

18 Managed with left intravitreal TA 4 mg/0.1 ml

19

20

21

22

23 RNFL thickness uveitis pts without glaucoma

24 RNFL thickness uveitis pts with glaucoma

25

26 Syphilitic placoid

27 Pre and post treatment OCT ASPPE

28 Mr EW 65M admitted under ID for non-tuberculous mycobacterial (Mycobacterium chimera) sternal wound + aortic graft infection on b/g of sternotomy for Type A aortic dissection in March 2016 Treated with imipenem, clarythromycin, moxifloxacin ID suggest antimicrobial plan: Clarithromycin 500mg BD, moxifloxacin 400mg nocte, rifabutin 300mg mane, Ethambutol 1.2g mane Referred to Ophthalmology OPC with mild floaters in R) eye Nil pain/ LOV

29 O/E: OD OS 6/5 VA 6/4 9 IOP 12 17/17 Ishihara 17/17 D+Q AC D+Q 1+ cells Vitreous Nil cells multifocal deep white lesions in choroid on posterior pole, not affecting macula/disc DFE R>L multifocal deep white lesions in choroid on posterior pole, not affecting macula/disc

30

31

32

33 45 yo man with three days of central visual loss GH URTI 3 weeks prior 6/6 6/60 RE all clear LE vit cells +/- Yellow mac lesion with haemorrhage

34 FA

35

36 1 week

37 6 weeks

38 Mrs FI 59 yr old woman 2 yrs progressive visual loss with floaters OH unremarkable GH good

39 O/E: OD OS 6/18 VA 6/18 9 IOP 12 17/17 Ishihara 17/ cells AC 1 + cells ++ cells Vitreous ++ cells Multiple pale outer retinal choroidal lesions with pigmentation DFE Multiple pale outer retinal choroidal lesions with pigmentation CT

40

41 Mr NK 59 yr old man 10 yrs progressive uveitis and MFC OH unremarkable GH good

42

43

44 Ms FW 28 yr old woman URTI followed by painless paracentral scotoma

45 O/E: OD OS 6/7.5 VA 6/7.5 9 IOP 12 17/17 Ishihara 17/17 + cells AC D+Q 1+ cells Vitreous + cells Confluent pale outer retinal lesions with early pigmentation DFE Confluent pale outer retinal lesions with early pigmentation OCT

46

47 Mr TN 38 yr old Vietnamese man 2 weeks of headache 1 Week bilateral central visual loss

48 O/E: OD OS 6/36 VA 6/60 7 IOP 5 17/17 Ishihara 17/17 ++ cells AC ++ cells ++ cells Vitreous ++ cells Disc swelling Multifocal cloudy serous detachment DFE Disc swelling Multifocal serous detachment OCT

49

50

51 VKH Acute phase Prodrome with HA, meningism, hearing changes then Acute bilat uveitis Serous detachment Disc swelling Acutely steroid responsive Convalescent phase Vitiligo and poliosis Retinal depigmentation Relapsing remitting or chronic uveitis

52 Mrs VH 85 yr old woman presents with 1 week of right sided orbital ache and mild visual loss OH bilat cat ext GH severe RA, treated with MTX and ritux Recent RA related pneumonitis treated with short course of steroids

53 O/E: OD OS 6/7.5 VA 6/7.5 9 IOP 12 17/17 Ishihara 17/17 D+Q AC D+Q 1+ cells Vitreous Nil cells Large single raised mass inferiorly DFE NAD CT

54

55

56

57 Causes of Scleritis (n = 188, Foster et al, 1994) 12% 3% 6% 8% 9% 19% 43% idiopathic RA infections GPA Rel Pol PAN/Hep B Others

58 Scleritis DDx Mild Moderate Episcleritis, atopy (esp limbal), inflamed pingueculum or pterygium HZO, iritis, sinus disease Severe ACG, HZO, uveitis Necrotizing SCC, radionecrosis (+/- infection) Posterior CSR, VKH, uveal effusion syndrome, choroidal primary or secondary, IOI, TED, optic neuritis

59 Mrs CA 31 yr old woman presented with unilateral central distortion

60 O/E: OD OS 6/5 VA 6/18 19 IOP 19 D+Q AC D+Q quiet Vitreous Occ cell only NAD DFE Multiple quiet flat white lesions around posterior pole Single raised lesion with surrounding pigment

61

62

63

64

65 PIC Essex et al 136 patients with PIC 93% female Ave -4 dioptres 46% unilateral 12% recurrent PIC lesions 22% new CNVM Median final VA 6/24

66 Mrs RW 45 yr old woman Referred with long standing R>L intermediate uveitis No longer responding to rpt orbital steroids GH good

67

68 Thank you