Unit 6 - Uveitis Flashcards
What is the incidence of uveitis?
1 in 1000
What is the commonest cause of uveitis?
idiopathic
How can uveitis be classified?
Anatomy based: anterior, int, posterior or panuvietis
Pathology based: infection, masquerade or non-infectious
Sign based: granulomatous
Course based: Chronic (less than 3months between episodes), acute, persistent (>3mths) , recurrent (more than 3 months between episodes).
When taking the history of a uveitis patient what should you be asking (6) ?
- TB exposure
- Walking in forests with ticks
- Musculoskeletal pain, childhood arthritis or HLA B27 related morning back stifness
- Weakness/numbness episodes, MS
- Chronic cough or shortness of breath, sarcoid
- Sexual history, HIV/Syphilis
How do you grade A/C activity?
- Measure cells in 1mm X 1mm slit beam:
- 0 = <1cell
- 0.5 = 1-5
- 1 = 6-15
- 2 = 16-25
- 3 = 26-50
- 4 = >50
What are the clinical signs to look for in uveitis (7)?
- Posterior syncehiae
- KPs
- Iris granulomas
- CMO
- Retinal/choroidal lesions
- Vitreous haze
- Red eye, circumcorneal or entire eye.
What are the two objetives when treating acute and chronic uveitis?
Chronic: prevent and treat complications
Acute: suppress inflammation and alleviate symptoms
What topical treatments can be used in the treatment of uveitis?
- Steroids (hourly, then down to 6/day in two days then taper)
- NSAID (can be used in addition esp with CMO)
- Glaucoma drops (to prevent steoid induced glaucoma)
What local treatments can be used in Uveitis?
- Triamcinolone either orbital floor injection or sub-tenon injection or intravitreal
- Dexamethasone intra-vitreal e.g. ozurdex
What systemic treatment can be used in uveitis?
In order of use:
- Steroids
- Steroid sparing immunosuppressants e.g. mycopheolate, motefil
- Biologics, anti-TNF antibodies e.g Humira, effective but expensive
What are the indications to consider systemic meds in uveitis?
- Moderate to severe disease
- Bilateral
- Underlying systemic disease
- Risk of sight loss
What is HLA-B27 and how is associated with HLA-B27 disease?
- HLA-B27 is a genetic variant of an immune system protein
- 10% of white europeans have it
- HLA-B27 is an association not a cause
What are the clinical features of HLA-B27 related uveitis?
- Non-granulomatous
- Acute, recurrent attacks
- Hypopyon and fibrin
- Maybe associated with:
- Ankylosing spondylitis
- Psoriatic arthritis
- Crohn’s disease
What are the ocular and systemic signs and symptoms of Behcets disease?
- Anterior uveitis
- Retinal vasculitis
- Erythema nodosum
- Mouth and genical ulcers
- Vasculitic multisystem disease
What pattern will be shown on FFA in Behcets disease?
Ferning
What are the risk factors of developing Behcet’s disease?
- HLA- B51 in 50% of cases
- Found in groups along the silk route, less likely if those people are no longer living in their native homes.
What population is most affected by sarcoidosis?
Young afro-caribean women or older caucasian women.
What is sarcoidosis?
Multisystem inflammatory disorder
What sort of ocular disease does sarcoid produce?
Anterior, granulomatous uveitis
+ conjunctival granulomas
What are the systemic clinical features of sarcoid?
Sarcoid granuloma can appear anywerhe in the body but the lungs affected in 90%.
Skin lesions:
- lupus pernio, raised purple patches on face that look like rosacea++
- erythema nodosum, raised lumps on lower legs
What does APMPPE stand for?
Acute posterior multifocal placoid pigment epitheliopathy.
What are the ocular signs and symptoms of APMPPE?
- Painless central vision loss
- Bilateral but asymmetric
- Well defined scotomas
- Very mild or no anterior uveitis
- Creamy, yellow pale retinal lesions which are dark on ICG
What systemic symptoms are there in APMPPE?
Flue-like viral illness a few days before presentation.
What population is most affected by APMPPE?
- M=F
- Young adults
What is the prognosis in APMPPE?
spontaneously resolves over weeks to months without treatment
What are the risk factors in the development of birdshot chorioretinopathy?
- >99% HLA-A29
- slightly more women than men 60:40
- Typically 40-50 white women
What are the signs and symptoms of birdshot chorioretinopathy?
- Blurred vision
- Floaters
- Photopsia
- Night blindness
- Colour blindness
- Low grade vitritis
- Retinal vascular leakage = CMO
- Multiple deep cream-coloured lesions which show well on ICG
What signs reassure you that a choroidal naevus is benign?
- Flat or less than 2mm in height
- de-pigmented halo
- drusen (indicates chronicity = good)
- asymptommatic
- regular margins
- variably pigmented
(Feeling V HARD)
When should you refer a choroidal naevus?
- Greater than 2mm in thickness
- SRF
- Symptoms
- <3mm from optic nerve
- Halo absence
- Drusen absence
- Orange lipofuscin pigment
- Ultrasonic hollowness
(3+ signs = 50% risk of malignancy)
If none of these signs risk of conversion to melanoma is very low 3% in 5 years.
What investigations should be conducted on a choroidal naevus?
- OCT
- B-scan
- ?FFA if you suspect CNVM or malignant melanoma
What does CHRPE stand for?
Congenital hypertrophy of the RPE.
What does CHRPE look like?
- Well-demarcated
- Flat or evenly elevated
- Darkly pigmented with a depigmented central dip
- Usually peripheral or mid-periphera
- Median largest basal diameter is 4.5mm
What significant variants of CHRPE are there?
- Bear track, multiple smaller lesions in groups.
- Familial adenomatous polyposis (FAP) irregular shaped, associated with bowel cancer
What does torpedo maculopathy look like?
Torpedo shaped loss of RPE
Temporal to foveal pointing to fovea
What two types of choroidal haemangiomas are there?
Circumcribed - no systemic associations
Diffuse - may be associated with other haemagiomas
