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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
differential for panuveitis
SO, VKH, endophthalmitis, sarcoid, toxocara, toxoplasmosis, syphilis, cysticercosis
26
mutton fat KP
granulomatous uveitis (like sarcoid)
27
Koeppe, Busacca, and Berlin nodules
sarcoid iris nodules (pupillary, mid-iris, and peripheral, respectively)
28
SUN scale for grading AC cell
``` 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
order of frequency of different types of uveitis
anterior > pan > posterior > intermediate
30
name 2 scenarios where topical NSAIDs are appropriate
postoperative pseudophakic CME, mild diffuse episcleritis
31
anterior uveitis where sterioids are NOT helpful
Fuchs heterochromic iridocyclitis
32
which generally has higher rise in IOP: durezol QID or PF 8x/day
durezol QID (although approximately therapeutically equivalent at these levels)
33
name 2 scenarios where subtenons or intravitreal steroids should NOT be given
necrotizing scleritis (risk of perforation) and toxoplasmosis
34
relative risks and benefits of intraocular sustained release steroid implants compared to serial injections
lower recurrence, but higher rate of cataract and IOP rise, and also risk of post-operative complications
35
relative contraindications to Ozurdex
aphakia, vitrectomy, decentered IOL (risk of implant migration into AC)
36
maximum amount of daily prednisone that can be given for chronic uveitis ( > 3 months)
10 mg. If inflammation not controlled, must add IMT
37
what should be coadministered with long term steroid treatment
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
what screening test should be ordered for every patient on corticosteroid therapy for greater than 3 months
bone mineral density
39
causes of uveitis that should always be treated with IMT?
VKH, SO, necrotizing scleritis associated with systemic vasculitis, ocular cicatricial pemphigoid, serpiginous choroiditis, Behcet's
40
what preventive medication should be considered to be given to all patients receiving alkylating agents?
trimethoprim-sulfamethoxazole for Pneumocystis jirovecii prophylaxis
41
what class of IMT has been linked to a twofold increase in overall mortality and 3.8-fold increase in cancer mortality?
TNF-alpha inhibitors
42
MOA of azathioprine and methotrexate
azathioprine: purine analog, interferes with DNA replication methotrexate: folic acid analog and inhibitor of dihydrofolate reductase
43
side effects of azathioprine including most common
- most common: GI upset. - myelosuppression rare but worse if also taking allopurinol - reversible hepatotoxicity
44
screening test to consider for all candidates for azathioprine?
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
first line choice for IMT in children
methotrexate
46
IMT drugs that inhibit T-cell signalling
tacrolimus and cyclosporine (calcineurin inhibitors that downregulate IL-2) and sirolimus
47
most common side effects of tacrolimus and cyclosporine
nephrotoxicity in both. also hypertension in cyclosporine
48
first line therapy for necrotizing scleritis associated with systemic vasculitis (i.e. Wegener's)
alkylating agents: cyclophosphamide and chlorambucil
49
specific malignancy risks associated with alkylating agents
cyclophosphamide: bladder cancer chlorambucil: leukemia in patients with polycythema rubra vera
50
most common side effects of cyclophosphamide
hemorrhagic cystitis and myelosuppression most common. sterility is also common
51
TNF-alpha inhibitor that is useless in controlling ocular inflammation
Etanercept
52
mandatory screening test prior to starting adalimumab or infliximab
PPD or quantiferon (these meds can reactivate latent TB)
53
most common symptom in intermediate uveitis
floaters

Intraocular Inflammation and Uveitis (7 decks)

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