Management of uveitis

Transcription

1 Management of uveitis DR. ANUPAMA KARANTH

2 Anti-inflammatory agents -itis = inflammation Treatment : stop inflammation Use anti-inflammatory drugs Most potent of such agents : Corticosteroids Corticosteroids are the mainstay of therapy in uveitis

3 Complicating the issue What if the cause is infectious? Specific anti-infective agent is indicated Corticosteroids may even worsen the infection when given alone When the cause is immune related? Corticosteroids will be effective Associated side effects maybe significant

4 Management of uveitis Finding the etiology Narrow down list of differentials by history and examination Appropriate investigations (ocular and systemic) Referrals for systemic associations Treating the inflammation Specific therapy Non-specific therapy

5 Few ocular investigations Fundus fluorescein angiogram Cystoid macular edema (complication) Serpiginous choroidopathy (pattern of lesion) Ultrasonography Especially in cases of media opacities Ocular tissue analysis Aqueous tap Vitreous tap Chorioretinal biopsy

6 Few systemic investigations Sarcoidosis Tuberculosis Toxoplasmosis Syphilis Angiotensin converting enzyme Chest X-ray Antitoxoplasma antibody Serology VDRL, FTA-ABS Serum calcium Mantoux test Chest X-ray

7 Commonly ordered tests Core lab tests Compete blood count and ESR Chest X-ray Serum ACE VDRL, FTA-ABS Other tests depending on clinical suspicion

8 Treatment Medical Specific Non specific Surgical

9 Medical therapy Specific etiology dependent ATT Tuberculosis Parenteral penicillin Syphilis Sulfa and pyrimethamine Toxoplasmosis Tetracyclines Lyme disease IV Acyclovir Acute retinal necrosis IV Ganciclovir CMV retinitis

10 Medical therapy Non-specific Cycloplegic mydriatics Corticosteroids Immunosuppressives

11 Cycloplegic mydriatics To relieve ciliary spasm and pain To prevent posterior synechiae and break the ones already formed Partly broken posterior synechiae

12 Cycloplegic mydriatics Shorter acting Tropicamide eye drops (effective up to 3 hrs) Cyclopentolate drops (up to 24 hrs) Longer acting Homatropine eye drops (up to 4 days) Atropine eye drops (up to 7-14 days) Cycloplegia relieves pain and a mobile pupil prevents posterior synechiae

13 Corticosteroids the mainstay of therapy Depending on the site of inflammation and severity Topical Periocular Systemic Topical drops will not be effective for intermediate, posterior and panuveitis Use enough soon enough To always start with a higher dose and taper before stopping To investigate before starting

14 Corticosteroids Topical Periocular Systemic Prednisolone Methylprednisolone Prednisone Dexamethasone Triamcinolone Methylprednisolone Fluoromethalone Betamethasone

15 Complications of corticosteroids Topical Periocular Systemic Cataract Glaucoma As for topical Ptosis Scleral perforation As for topical Weight gain Peptic ulcer Osteoporosis Diabetes Hypertension

16 Immunosuppressives In corticosteroid resistant or intolerant cases In vision threatening inflammations - as first line Specific cases Behςet s syndrome Sympathetic ophthalmitis VKH syndrome Necrotizing sclerouveitis Adverse reactions can be severe and life threatening

17 Immunosuppressives Antimetabolites Alkylating agents T-cell inhibitors Methotrexate Cyclophosphamide Cyclosporine Azathioprine Chlorambucil Tacrolimus Watch out for nephrotoxicity, hepatotoxicity and marrow toxicity

18 Surgery in uveitis Diagnostic AC tap Vitreous biopsy Chorioretinal biopsy Therapeutic Cataract Glaucoma Retinal detachment Vitrectomy

19 Complicated cataract Polychromatic lustre and breadcrumb appearance

20 Management of complications Cataract surgery If no active inflammation for at least 3 months Perioperative steroids Heparin surface modified IOLs Glaucoma Anti-glaucoma topical medication Peripheral iridotomy / iridectomy in iris bombé Trabeculectomy with mitomycin C or 5 fluorouracil

21 Management of complications Cystoid macular edema Control of inflammation - corticosteroids NSAIDs Pars plana vitrectomy if persistent vitritis Hypotony Intensive corticosteroids and cycloplegia Pars plana membranectomy for cyclitic membrane Vitreous opacification Pars plana vitrectomy

22 Management of uveitis a few examples

23 Anterior uveitis 35 yr old male Ciliary congestion, fine KPs, AC flare, posterior synechiae and hypopyon in RE Similar history of redness a year ago

24 Anterior uveitis Posterior synechiae, pupil bound down Hypopyon

25 Anterior uveitis Management History and examination to narrow the differentials nothing significant The core lab tests Mantoux highly significant Referral to pulmonologist confirm diagnosis of tuberculosis Co-management

26 Anterior uveitis Ocular management Topical corticosteroids Prednisolone eye drops hourly, tapered as per response Homatropine eye drops 3 times a day Follow up for Inflammation Intraocular pressure Complications Systemic management Anti-tuberculosis therapy

27 Intermediate uveitis 13 year old girl Fever of unknown origin, 1 month Redness both eyes, 1 week Eye examination Spill-over anterior uveitis Anterior vitreous exudates / snowballs Systemic examination Lymphadenopathy

28 Intermediate uveitis Cells and exudates in the anterior vitreous

29 Intermediate uveitis Management Lymph node biopsy Caseating granulomatous lesions Physician diagnosis - tuberculosis Systemic management ATT fever responded within 4 days Ocular management On 1 week follow up, vision drop of 2 lines Systemic corticosteroids under cover of ATT for short period (1mg/kg body wt of prednisone, tapered and stopped within 4 weeks)

30 Posterior uveitis 35 year old, HIV positive female Sudden painless loss of vision RE Ocular examination Spill over fine KPs CMV retinitis in the fundus CD4 count 50

31 Posterior uveitis CMV retinitis granular retinal necrosis, frosted branch angiitis

32 CMV retinitis Management Antiretroviral therapy IV Ganciclovir 5mg / kg body wt bid induction course 2 weeks Maintenance 5mg / kg body wt od