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Intraocular Inflammation and Uveitis > Clinical Approach to Uveitis > Flashcards

Clinical Approach to Uveitis Flashcards

1
Q

band keratopathy commonly seen in which uveitis?

A

JIA

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2
Q

heterochromia and unilateral stellate KP?

A

Fuch’s heterochromic iridocyclitis

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3
Q

retinal perivasculitis with candlewax drippings

A

sarcoidosis

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4
Q

DDx unilateral uveitis

A

HLA B27, herpes, Fuch’s, infectious/parasitic, IOFB, post-surgical (less commonly Behcet’s, sarcoidosis, pars planitis)

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5
Q

Classifications of uveitis w/ involved tissues

A

anterior (AC): iritis, iridocyclitis, anterior cyclitis

intermediate (vitreous): pars planitis, posterior cyclitis, hyalitis

posterior uveitis (retina or choroid): focal/multiforcal/ diffuse choroiditis, chorioretinitis, retinochoroiditis, retinitis, neuroretinitis

panuveitis: AC + vit + retina or choroid

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6
Q

Which of the following is not appropriate for treatment of uveitis?
PF, durezol, loteprednol, FML

A

loteprednol (does not penetrate eye)

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7
Q

causes of uveitis with retinal arteritis?

A

syphilis, HSV (ARN/BARN), VZV (PORN), SLE, PAN, IRVAN, Churg-Strauss

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8
Q

causes of uveitis with retinal phlebitis?

A

sarcoid, Eales, Behcet’s, MS, Birdshot, HIV

smart eagles bypass multiple bee hives

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9
Q

causes of uveitis with retinal arteritis and phlebitis?

A

Wegener’s (granulomatosis w/ polyangiitis), toxoplasmosis, Crohn’s, relapsing polychondritis, frosted branch angiitis

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10
Q

time course of acute uveitis?

A

resolved by 3 months

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11
Q

examples of diffuse v discrete granulomatous uveitis?

A

diffuse: VHK and sympathetic ophthalmia
discrete: sarcoidosis

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12
Q

when to perform surgery for uveitis?

A

controlled immunosupression for at least 3 months

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13
Q

Diagnosis and w/u of acute, severe anterior uveitis with:

  1. arthritis, back pain, GI/GU symptoms
  2. aphthous ulcers
  3. febrile illness with flank pain
  4. no other symptoms
A
  1. seronegative spondyloarthropathies (sacroiliitis, . HLA-B27, sacroiliac films, rheum and GI referrals as needed
  2. Behcet’s: HLA B-51 (rarely obtained)
  3. TINU: renal panel, urine beta2-microglobulin, nephrology referral
  4. Idiopathic. HLA-B27
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14
Q

Diagnosis and w/u of acute, moderate-severity anterior uveitis with:

  1. dyspnea
  2. increased IOP
  3. poor response to steroids
A
  1. sarcoid. ACE, lysozyme, CXR, chest CT, biopsy
  2. glaucomatocyclitic crisis (Posner-Schlossman syndrome), herpetic iritis. PCR of aqueous (optional)
  3. syphillis: RPR or VRDL, syphilis IgG or FTA-ABS or MHA-TP
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15
Q

Diagnosis and w/u of chronic, mild anterior uveitis with:

  1. pediatric patient with arthritis
  2. heterochromia, diffuse KP, unilateral
  3. post-surgical
A
  1. JIA. ANA, ESR, rheumatoid factor
  2. Fuchs. none
  3. P. acnes or other low-grade endophthalmitis. consider vitrectomy, capsulectomy w/ culture
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16
Q

Diagnosis and w/u of mild-moderate intermediate uveitis with:

  1. SOB
  2. tick exposure, erythema migrans
  3. neurologic symptoms
  4. Over age of 50
  5. None
A
  1. sarcoid. ACE, lysozyme, CXR, CT chest, biopsy
  2. lyme. ELISA, western blot for conformation
  3. MS. MRI brain
  4. Intraocular lymphoma. vitreous biopsy
  5. pars planitis. none
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17
Q

Diagnosis and w/u of focal chorioretinitis with vitritis with:

  1. adjacent scar, raw meat ingestion
  2. child, h/o geophagia
  3. HIV
A
  1. toxoplasmosis. serology for toxo or PCR
  2. toxocara. ELISA, CBC
  3. CMV retinitis. none
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18
Q

Diagnosis and w/u of multifocal chorioretinitis with vitritis with:

  1. SOB
  2. peripheral retinal necrosis
  3. AIDS (2 answers)
  4. IV drug use (2 answers)
  5. visible intraocular parasite, from Africa or Central/South America (2 answers)
  6. Over age of 50
  7. None (2 answers)
A
  1. sarcoid. ACE, lysozyme, CXR, CT chest, biopsy
  2. ARN. VZV and HSV titers (ELISA), PCR of ocular fluids, possible vitrectomy/retinal biopsy
  3. syphilis, toxoplasmosis. RPR or VRDL, Syphilis IgG or FTA-ABS or MHA-TP; ELISA for toxo
  4. Candida or Aspergillus. blood, vitreous cultures
  5. cysticercosis (ELISA, MRI), onchocerciasis (skin snip).
  6. primary intraocular lymphoma. vit biopsy
  7. birdshot (HLA-A29, FA), MFCPU (rule out TB, sarcoid, syphilis)
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19
Q

Diagnosis and w/u of diffuse chorioretinitis with vitritis with:

  1. dermatologic/CNS symptoms, serous RD
  2. post- surgery or trauma bilateral
  3. post- surgery or trauma unilateral
  4. Child, h/o geophagia
A
  1. VKH. FA, B-scan, LP for CSF pleocytosis
  2. SO. FA
  3. endophthalmitis. consider vitrectomy, culture
  4. toxocara.
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20
Q

Diagnosis and w/u of focal chorioretinitis without vitritis with no symptoms but h/o carcinoma

A

neoplastic. metastatic w/u

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21
Q

Diagnosis and w/u of multifocal chorioretinitis without vitritis with:

  1. Ohio/Miss Valley
  2. Lesions confined to posterior pole
  3. Geographic/maplike pattern of scar
A
  1. POHS. FA if macular involvement
  2. white dot syndrome (MEWDS, PIC, APMPPE). FA
  3. serpiginous choroiditis. FA, PPD or quantiferon, CXR
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22
Q

Diagnosis and w/u of diffuse chorioretinitis without vitritis from Africa or South/Central America?

A

onchocerciasis. skin biopsy

23
Q

Diagnosis and w/u of retinal vasculitis with:

  1. aphthous ulcers, hypopyon
  2. malar rash, female, arthralgias
  3. chronic sinusitis w/ hemorrhagic rhinorrhea, dyspnea, renal insufficiency, purpura
A
  1. Behcet. HLA-B5 and -B51
  2. SLE. ANA, anti-ds DNA, C3, C4
  3. Wegener’s (granulomatosis with polyangiitis). c-ANCA
24
Q

w/u for scleritis

A

ANA, ANCA, ESR, CRP, CXR, UA, uric acid, HLA B27, infectious causes as indicated

25
Q

differential for panuveitis

A

SO, VKH, endophthalmitis, sarcoid, toxocara, toxoplasmosis, syphilis, cysticercosis

26
Q

mutton fat KP

A

granulomatous uveitis (like sarcoid)

27
Q

Koeppe, Busacca, and Berlin nodules

A

sarcoid iris nodules (pupillary, mid-iris, and peripheral, respectively)

28
Q

SUN scale for grading AC cell

A 
Cells per high power field (1mm x 1mm beam @ 45-60 degrees)
0: < 1
0.5+: 1-5
1+: 6-15
2+: 16-25
3+: 25-50
4+: > 50
29
Q

order of frequency of different types of uveitis

A

anterior > pan > posterior > intermediate

30
Q

name 2 scenarios where topical NSAIDs are appropriate

A

postoperative pseudophakic CME, mild diffuse episcleritis

31
Q

anterior uveitis where sterioids are NOT helpful

A

Fuchs heterochromic iridocyclitis

32
Q

which generally has higher rise in IOP: durezol QID or PF 8x/day

A

durezol QID (although approximately therapeutically equivalent at these levels)

33
Q

name 2 scenarios where subtenons or intravitreal steroids should NOT be given

A

necrotizing scleritis (risk of perforation) and toxoplasmosis

34
Q

relative risks and benefits of intraocular sustained release steroid implants compared to serial injections

A

lower recurrence, but higher rate of cataract and IOP rise, and also risk of post-operative complications

35
Q

relative contraindications to Ozurdex

A

aphakia, vitrectomy, decentered IOL (risk of implant migration into AC)

36
Q

maximum amount of daily prednisone that can be given for chronic uveitis ( > 3 months)

A

10 mg. If inflammation not controlled, must add IMT

37
Q

what should be coadministered with long term steroid treatment

A

Always calcium and vitamin D. PPI or H-2 blocker if h/o GERD or if must also be on NSAIDs (although recommend not taking both steroids and NSAIDs if avoidable)

38
Q

what screening test should be ordered for every patient on corticosteroid therapy for greater than 3 months

A

bone mineral density

39
Q

causes of uveitis that should always be treated with IMT?

A

VKH, SO, necrotizing scleritis associated with systemic vasculitis, ocular cicatricial pemphigoid, serpiginous choroiditis, Behcet’s

40
Q

what preventive medication should be considered to be given to all patients receiving alkylating agents?

A

trimethoprim-sulfamethoxazole for Pneumocystis jirovecii prophylaxis

41
Q

what class of IMT has been linked to a twofold increase in overall mortality and 3.8-fold increase in cancer mortality?

A

TNF-alpha inhibitors

42
Q

MOA of azathioprine and methotrexate

A

azathioprine: purine analog, interferes with DNA replication
methotrexate: folic acid analog and inhibitor of dihydrofolate reductase

43
Q

side effects of azathioprine including most common

A
  • most common: GI upset.
  • myelosuppression rare but worse if also taking allopurinol
  • reversible hepatotoxicity
44
Q

screening test to consider for all candidates for azathioprine?

A

TMPT (important in drug metabolism) activity. helps determine risk of myelosuppression. if low, don’t give, if intermediate, give reduced dose. if high, can give higher dose

45
Q

first line choice for IMT in children

A

methotrexate

46
Q

IMT drugs that inhibit T-cell signalling

A

tacrolimus and cyclosporine (calcineurin inhibitors that downregulate IL-2) and sirolimus

47
Q

most common side effects of tacrolimus and cyclosporine

A

nephrotoxicity in both. also hypertension in cyclosporine

48
Q

first line therapy for necrotizing scleritis associated with systemic vasculitis (i.e. Wegener’s)

A

alkylating agents: cyclophosphamide and chlorambucil

49
Q

specific malignancy risks associated with alkylating agents

A

cyclophosphamide: bladder cancer
chlorambucil: leukemia in patients with polycythema rubra vera

50
Q

most common side effects of cyclophosphamide

A

hemorrhagic cystitis and myelosuppression most common. sterility is also common

51
Q

TNF-alpha inhibitor that is useless in controlling ocular inflammation

A

Etanercept

52
Q

mandatory screening test prior to starting adalimumab or infliximab

A

PPD or quantiferon (these meds can reactivate latent TB)

53
Q

most common symptom in intermediate uveitis

A

floaters

Intraocular Inflammation and Uveitis (7 decks)

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