REFRESHER: ANTERIOR UVEITIS

Transcription

1 REFRESHER: ANTERIOR UVEITIS 2. SAoO Kongress Messe Luzern Dr. med. Christian Böni Augenklinik Universitätsspital Zürich Christian Böni Seite 1

2 Anterior Uveitis: Clinical Issues Diagnostics: yes or no? Which tests should be ordered in which situation? Which form of treatment? When drops? Periocular injektions? Systemic therapy? Christian Böni Seite 2

3 Definitions AU SUN Classification: Iritis and Iridocyclitis 30% Acute: sudden onset and <3 months duration Recurrent: repeated episodes, periods of inactivity Chronic: persistent, relapse <3 months after discontinuing treatment AC Cells: 0, 0.5+, 1+, 2+, 3+, 4+ AC Flare: 0-4+ Precipitates: descriptive Iris nodules, iris transillumination Christian Böni Seite 3

4 Classification and Etiology Idiopathic / not classifiable 50% Non-infectious systemic disease - HLA B27 related -Sarcoid - JIA related -TINU - Behcet Infectious cause - Viral: HSV / VZV / CMV related - Lues, Borreliose, Tbc Christian Böni Seite 4

5 Diagnostic work-up Mythos first episode doesn t need work-up Criteria: History and ocular findings Suspected disease entity Test order according to suspicion: HLA B27 Rx Thorax, (ACE, Lysozym, IL 2 Rec) CBC, CRP, BSR, ANA, (ANCA,) Crea, Liver enzymes Serology: Lues, (Borrelia, Quantiferon), (U-Status) See rheumatology or other specialists Anterior chamber tap Christian Böni Seite 5

6 Treatment of Anterior Uveitis Goals: Inactivate inflammation Prevent complications and control IOP Prevent recurrence Anti-inflammatory stepladder: Topical potent steroid drops high frequency / every hour: Prednisolon Acetat 1%, Dexamethason, Ultracortenol AS (Hydrocortison, Rimexolon, Loteprednol, Fluorometholon) Cycloplegia, Sprengspritze Subconjunctival, periocular, intravitreal steroids (for CME) Systemic steroids for severe or bilateral AU Immunosuppressive therapy for chronic or recurrent AU Christian Böni Seite 6

7 History: CASE 1-27y old male Recurrent episodes of inflammation since 2 months No joint / gastrointestinal / pulmonary / cutaneous / neurological complaints No medication Findings: BCVA OD 0.4, OS 0.3 IOP OU 17mmHg Anterior Segment OU AC cells 3+, posterior synechia Posterior segment OU quiet Christian Böni Seite 7

8 CASE 1 Bilateral anterior uveitis with synechia Which tests do you perform? A. No tests, because they are always negative B. CBC, CRP, Borrelia, Lues, Brain MRI C. CBC, CRP, HLA B27, ANA, Borrelia, Lues, Chest X Ray Christian Böni Seite 8

9 CASE 1 Bilateral anterior uveitis with synechia Diagnostic tests CBC, CRP, HLA B27, ANA, Borrelia, Lues Chest X Ray All results negativ Rheumatologic evaluation: no signs of systemic disease Treatment Pred Forte every hour, systemic PDN 1mg/kg Taper Inflammation quiet, <0.5+ cells Christian Böni Seite 9

10 CASE 1 Bilateral anterior uveitis with synechia Bilateral recurrence 2 months later while on PDN 7.5mg/d and PF 2x/d. And now? A. Increase systemic Prednison to 1mg/kg B. Periocular steroid injections C. Add immunosuppressive treatment and increase topical and systemic Prednison to 0.5mg/kg Christian Böni Seite 10

11 CASE 1 - Reminder Local / systemic steroids act quickly, generally good response BUT high risk of side effects: IOP problems, cataract development, bone density, weight gain, metabolism, mental/psychological disorder For chronic anterior uveitis: consider steroidsparing immunosuppressive treatment Christian Böni Seite 11

12 History: CASE 2 63y old female recurrent hypertensive uveitis since 15 years Current treatment: Valacyclovir 3x500mg, Glaupax 3x250mg, Cosopt 2x, Latanoprost 1x, Maxidex 3x Findings: BCVA OD 0.3, OS 1.0 IOP OD 25mmHg, OS 18mmHg Anterior segment OD AC 0.5+, no posterior synechia. OS quiet Posterior segment OD disc exc 0.8, OS 0.3. OU retina attached, unremarkable Christian Böni Seite 12

13 CASE 2 Unilateral hypertensive AU Which tests do you order? A. This is Fuchs Uveitis Syndrom, I don t order tests B. This is Posner Schlossmann Syndrom, I don t order tests C. CBC, viral serology, anterior chamber tap D. CBC, ACE, IL 2 receptor, Borrelia, Bartonella Christian Böni Seite 13

14 CASE 2 Unilateral hypertensive AU Diagnostic tests: CBC, viral serology, anterior chamber tap Results: PCR positive for Cytomegalie Virus, negative for HSV/VZV Treatment with Ganciclovir local (or systemic) and topical steroids not responsive to Aciclovir! Christian Böni Seite 14

15 Hypertensive anterior uveitis Fuchs Uveitis Syndrom unilateral (15% bilateral), diffuse small stellate KP, minimal AC reaction, no synechia, iris heterochromia diffuse atrophy, iris paler, fine angel vessels Poor response to steroids Complication: glaucoma 30-50%, cataract 50% Posner Schlossman Syndrome Recurrent anterior uveitis and high IOP, mild AC reaction, no or few KPs Aetiology: idiopathic, CMV anterior uveitis Viral uveitis Sarcoid uveitis Christian Böni Seite 15

16 Anterior Uveitis take home Test according your suspicion Consider benefits and risks of treatment, discuss them with patients Refer if non-responsive, unclear, mysterious or severe Christian Böni Seite 16

17 Vielen Dank für Ihre Aufmerksamkeit Christian Böni Seite 17