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Ocular Disease > Uveitis > Flashcards

Uveitis Flashcards

1
Q

Which IOP lowering class of drugs would you want to avoid when treating a steroid-responder in the management of uveitis?

A

prostaglandins

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2
Q

What are the 3 mainstays of treatment for most uveitis?

A

Corticosteroids, cycloplegics, and treating the underlying cause

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3
Q

Which steroid drops are good choices for anterior uveitis?

A

Pred acetate susp. (generic), 1% Pred Forte (brand), and Durezol

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4
Q

What are the benefits and considerations for using Durezol?

A

Do not have to shake so is simpler for the patient, QID dosing instead of q1hr, stronger, $200-300, can be more likely to increase IOP

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5
Q

What are the benefits and considerations for using Pred Forte?

A

also expensive, have to shake, not as strong as Durezol, or as likely to increase IOP, dosing q1-2hr

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6
Q

When would you consider using a weaker steroid for uveitis?

A

for mild anterior uveitis, and if the patient is a steroid responder

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7
Q

General guidelines for steroid dosing for uveitis

A

hit it hard! q1-2hr for 1-2wks, may need loading dose, maintain dose until AC is free of cells

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8
Q

How do you taper in uveitis?

A

SLOW taper is very important, but can be very variable. Adjust based on severity/propensity for recurrence/length of tx
ex. QID x1wk, TID x1wk, BID x1wk, QD x1wk, stop

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9
Q

Instructions on the Rx for steroid for uveitis

A

ex. Pred Forte, 1 gtt OD q1hr while awake, taper as directed, 0 refills, NO SUBSTITUTION

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10
Q

What is a pulse dose?

A

circumstances when steroids are used for a short period of time and don’t require a taper, such as for corneal/conjunctival disease such as dry eye or episcleritis. Infrequently used in treating uveitis

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11
Q

What are the ocular side effects for topical steroids?

A

increased IOP, PSC, increased risk of bacterial/viral infection

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12
Q

What are some systemic side effects of steroids?

A

increased serum glucose, hyperlipidemia, hypertension, sodium and water retention edema, centripetal obesity, buffalo hump, impaired wound healing, suppression of hypothalamic-pituitary-adrenal system, secondary infections, osteoporosis, psychiatric, gastritis, etc.

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13
Q

What purpose do cycloplegics play in treating uveitis?

A

Cycloplegics prevent ciliary spasm, reducing symptoms and improving comfort of the patient, while stabiling blood aqueous barrier, and preventing formation of posterior synechiae

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14
Q

Which cycloplegics are the best for uveitis?

A

1 is homatropine 5%, can be hard to find though, then atropine, or cyclopentolate.

Scopolamine and tropicamide are not used for uveitis.

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15
Q

What is a contraindication that should be considered when prescribing a cycloplegic for uveitis?

A

narrow angles! and also the stronger cycloplegics are contraindicated in patients with Down syndrome (try to use the weakest ones if required)

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16
Q

What drop do we use to break posterior iris synechiae?

A

10% phenylephrine, in office only

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17
Q

What are other considerations for a uveitis exam?

A

DFE for every anterior uveitis patient same day is required! Have to look for signs of intermediate and posterior uveitis

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18
Q

When is the first follow up for uveitis patients?

A

RTC 1-3 days, not much improvement yet, and don’t release the patient once you start tapering the steroid as rebound inflammation may occur

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19
Q

What can we do for prophylaxis for uveitis?

A

Pred Forte may be used in a low dose indefinitely for those with frequent recurrence or chronic disease. 1 drop Pred Forte QD or every other day. Or small dose 10-20mg prednisone

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20
Q

When would you try oral/intra-/peri-ocular injected steroids?

A

when pred forte isn’t enough in moderate to severe non-infectious inflammation, posterior seg involvement (CME), or when the anterior uveitis is resistant to topicals

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21
Q

What is the usual choice and dose for oral steroids for uveitis?

A

0.5-1.5 mg/kg/day followed by taper (about 40-120 mg daily)

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22
Q

What are the added side effects for steroids injected periocularly (sub-tenon or sub-conj)?

A

sub-conj heme, conj/Tenon scarring, scleral perforation, abscess/infection

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23
Q

What steroids are used IVT for uveitis?

A

IVT triamcinolone (IVTA), Triescence or Kenalog
effective for 3 months in non-vitrectomized eyes

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24
Q

What are some medium to long-duration implanted steroids?

A

Ozurdex (dexamethasone)
Retisert, Yutiq, Iluvien (flucinolone acetonide)

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25
Q

What are the added side effects for the medium to long-duration implanted steroid options?

A

higher likelihood of IOP spike, RD, vitreous hemorrhage, endophthalmitis, accelerated cataract formation

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26
Q

Ozurdex

A

FDA approved for posterior uveitis, biodegradable, injected into vitreous, effective for 3-6mo

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27
Q

Retisert

A

fluocinolone acetonide implantable device, FDA approved for posterior uveitis, non-biodegradable, sutured to sclera, effective for 2.5 years, higher sustained daily dose and others

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28
Q

Yutiq

A

fluocinolone acetonide insert, non-biodegradable, injected into vitreous, effective for 3 years, FDA approved for non-infectious posterior uveitis, 2019

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29
Q

Iluvien

A

fluocinolone acetonide insert, non-biodegradable, injected into vitreous, effective for 3 years, FDA approved for DME, but may be used off-label in uveitis

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30
Q

Immunosuppressive agents used in uveitis

A

biologics - infliximab, adalimumab, etanercept
antimetabolites - methotrexate, azathioprine, mycophenolate mofetil
T-cell inhibitors, alkylating agents

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31
Q

Humira (Adalimumab)

A

TNFa inhibitor, SQ injection, the only systemic non-steroid med FDA approved for non-infectious uveitis (intermediate, posterior, and pan) 2016. typically used alongside steroid therapy for chronic inflammation
for RA, JIA and HLA B27 diseases

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32
Q

Treatments for infectious uveitis

A

topical/IVT/po/IV antibiotics, antivirals, antiprotozoans, antifungals, etc.

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33
Q

Surgical managment for uveitis

A

unresponsive to medical tx, or for secondary complications like CME, ERM, RD, hypotony, glaucoma, cataract, vitreous opacification, lens-induced uveitis, endophthalmitis, or for placement of drug delivery system

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34
Q

Anterior uveitis symptoms

A

hyperemia, ocular pain (unique dull pain), photophobia, blurred vision, headache, (rarely asymptomatic)

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35
Q

Intermediate/posterior uveitis symptoms

A

possibly asymptomatic, blurred vision, floaters

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36
Q

Case history questions for uveitis

A

Laterality, timing/nature of onset, associated symptoms (positive and negative), aggravating/relieving factors, previous events

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37
Q

uveitis classification for onset

A

acute: sudden onset <6wks duration
chronic: persistent relapse in <3mo after d/c tx
recurrent: repeated episodes separated by periods of inactivity without tx >3mo in duration

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38
Q

granulomatous uveitis classification

A

presence of granulomatous signs: mutton fat KPs, Bussaca iris nodules, choroidal granulomas
due to granulomatous disease

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39
Q

What are the granulomatous diseases that can cause uveitis? (the ones that are capable of causing both gran and non-gran)

A

Lens-induced, VKH, Sympathetic ophthalmia, Sarcoidosis, Herpes, Intraocular foreign body, TB, Syphilis

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40
Q

What are the conditions that can cause uveitis but only non-granulomatous?

A

Toxoplasmosis, Behcets, Traumatic, MS, Onchocerciasis, Toxocariasis, TINU, JIA, Drug-induced, UGH, HLA-B27 diseases, Bartonella, TASS, Glaucomatocyclitic Crisis, Fuchs heterochromatic iridocyclitis, and Lyme disease

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41
Q

When other structures of the eye are involved with anterior uveitis we can refer to them as

A

Keratouveitis, or sclerouveitis

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42
Q

What is the most common form of uveitis (which area in eye)?

A

Anterior uveitis, includes iritis, iridocyclitis, and trabeculitis

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43
Q

Common signs of anterior uveitis

A

conjunctival injection, AC cells and flare, KPs, iris synechiae, hypopyon, iris nodules

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44
Q

Hypopyon

A

layering/settling of WBCs and protein in inferior AC, grading is based on height (ex. 2mm)

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45
Q

What are the 3 types of iris synechiae?

A

Anterior (iris to cornea), posterior (iris to lens), and peripheral anterior (PAS - iris to TM or peripheral cornea)

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46
Q

What secondary complication happens with PAS?

A

angle closure glaucoma

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47
Q

What secondary complications can happen with posterior synechiae?

A

pupillary block glaucoma and iris bombe

48
Q

What is the difference between Busacca and Koeppe nodules?

A

Koeppe nodules are on the iris margin and are non-granulomatous, while Busacca iris nodules can be found anywhere on iris surface and are pathognomonic for granulomatous disease

49
Q

What are the signs of intermediate uveitis?

A

vitritis, pars planitis: vitreous cells, haze, snowbanking
(sometimes cells are spillover from AC)

50
Q

What are the possible signs of posterior uveitis

A

Retinitis/choroiditis: infiltrates, RPE atrophy, window defects, RPE hyperplasia, subretinal fibrosis, optic disc edema, CME, SRD, TRD, retinal vasculitis, angiitis, arteritis, periphlebitis, exudates

51
Q

Panuveitis

A

inflammation in several ocular structures (AC and vitreous/retina/choroid)
must rule out infectious endophthalmitis!

52
Q

Approximately how much of NGAU cases (non-traumatic) are idiopathic (no associated systemic or ocular condition)?

A

half

53
Q

Uveitis is more likely to be systemic disease-mediated if

A

bilateral, recurrent, intermediate/posterior seg involved, granulomatous, pediatric, or does not respond to standard therapy

54
Q

Sensitivity definition

A

the proportion of positives that are correctly labeled as such

55
Q

Specificity definition

A

the proportion of negatives that are correctly labeled as such

56
Q

Sensitivity formula (not PPV)

A

Sensitivity = TP/P = TP/(TP+FN)

57
Q

Positive Predictive Value

A

PPV = TP/(TP+FP)

58
Q

Specificity formula (not NPV)

A

Specificity = TN/N = TN/(TN+FP)

59
Q

Negative Predictive Value

A

NPV = TN/(TN+FN)

60
Q

CBC w/diff

A

combines several tests of the hematologic system, inexpensive, fast, common screening of RBCs, WBCs and platelets

61
Q

Neutrophils/PMNs can show:

A

acute bacterial infection and trauma

62
Q

Basophils and Eosinophils can show:

A

allergic or parasitic infection

63
Q

Lymphocytes on bloodwork can show:

A

chronic bacterial or acute viral infections

64
Q

ESR

A

sensitive but not specific, test for acute inflammation, injury and infection
norms for men is age/2 and for women is (age+10)/2
values >30 are typically abnormal

65
Q

CRP

A

non-specific inflammation marker, typically should be <1.0 mg/dL

66
Q

CMP

A

14 tests: glucose, calcium, albumin, total protein, sodium, potassium, CO2, chloride, BUN, creatinine, ALP, ALT, AST liver enzymes, bilirubin

67
Q

ELISA

A

enzyme-linked immunosorbent assay used to detect organisms that aren’t easily cultured
HIV, toxo, TB, cocci, VZV, HSV, Lyme, WNV, HBV

68
Q

IgM on ELISA indicates?

A

recent/active infection

69
Q

IgG in ELISA indicates?

A

previous infection

70
Q

What are the seronegative spondyloarthropathies associated with causing anterior uveitis?

A

Psoriatic arthritis, Ankylosing spondylitis, IBD (Crohn’s and Ulcerative Cholitis), Reactive arthritis, Non-specific HLA-B27 disease

71
Q

HLA-B27+ percentages:

A

Highest prevalence in Whites and northern Europeans (~8%)
Between 32-50% of all cases of anterior uveitis are HLA-B27+
6% of the US population is HLA-B27+
88-90% of those w/ankylosing spondylitis are HLA-B27+
8% of caucasian have the gene, of these 2% will eventually get spondylitis

72
Q

Systemic features of seronegative spondyloarthropathies

A

ocular inflammation (anterior uveitis), sacroiliitis with or without spondylitis on x-ray, inflammatroy asymmetric peripheral arthritis primarily in lower limbs, RF negative, ANA negative, strong association with HLA-B27, mucocutaneous lesions, rare cardiac disease

73
Q

Ankylosing spondylitis

A

most common cause of uveitis among HLA-B27 diseases, young 15-40yo M>F, lower back pain, chronic arthritis of spine and sacroiliac joints, “bamboo spine” deformity

74
Q

What type of uveitis often presents due to ankylosing spondylitis?

A

unilateral, alternating, recurrent acute anterior uveitis

75
Q

DX and TX for ankylosing spondylitis

A

DX: SI x-ray, ESR and CRP may also be elevated
TX: oral steroid and mydriatic, referral to rheumatology, good repsonse to NSAIDs, also immunosuppressive therapy, physical therapy

76
Q

Psoriatic arthritis

A

causes NGAU, conjunctivitis, is in 1-2% of the caucasian population
DX: clinical suspicion, rheumatology consult
TX: corticosteroid, mydriatics, NSAIDs, other immunosuppressive therapy, physical therapy

77
Q

Reactive arthritis

A

young 15-40yo M>F, systemic triad: urethritis, arthritis, mucocutaneous (mouth and genital) lesions. Ocular: conjunctivitis and NGAU

78
Q

IBD

A

GI symptoms and arthritis that waxes and wanes, anterior uveitis, episcleritis
DX: GI consult, colonoscopy w/biopsy

79
Q

IBD tx

A

Ocular tx - steroid and mydriatic
Systemic tx - immunosuppressive therapy (be careful with NSAIDs as can exacerbate GI symptoms), surgical excision of inflamed bowel, physical therapy

80
Q

Sarcoidosis

A

multisystem granulomatous disease, non-caseating (skin, eye, lung, lymph node involvement), african descent, F>M, adults, mortality of 3-10%
Symptoms: SOB, fever, fatigue, pulmonary granulomas, skin lesions
Ocular: dry eye, eyelid/orbital granulomas, uveitis (often anterior granulomatous, and often bilateral)

81
Q

Sarcoidosis testing/dx

A

elevated serum ACE, elevated serum/urine calcium, abnormal CXR: bilateral hilar lymphadenopathy, abnormal gallium scan (panda and lambda sign), definitive dx w/biopsy showing non-caseating granulomas

82
Q

Sarcoidosis tx

A

ocular tx: steroid, mydriatic, ATs for dry eye, oculoplastics consult if granulomas affecting lids
systemic tx: steroids and other immunosuppressive therapy
pulmonology, dermatology, etc.

83
Q

VKH

A

primarily in darker complexions, 20-40yo, slight F>M, an autoimmune disorder involving multiple systems (ocular, auditory, nervous, and integumentary), often HLA-B22+

84
Q

VKH symptoms and ocular presentation

A

Ocular: diffuse granulomatous uveitis w/SRD, reccurence common, starts as choroiditis and gets worse, to bilateral panuveitis and SRD, “sunset glow” fundus
Prodromal phase: fever, HA, neck stiffness, vertigo
Systemic: tinnitus, vitiligo, poliosis, alopecia

85
Q

Behcet disease

A

relapsing vasculitis/inflammatory disorder, triad: ocular inflammation, oral/genital aphthous ulcers (painful), skin lesions
Asian M>F, often HLA-B51+
Tx: systemic steroids limited so need to use other immunomodulatory therapy

86
Q

Behcet disease ocular manifestations

A

Anterior uveitis with hypopyon, often recurrent but not chronic
also possible: retinal vasculitis, retinal hemorrhages, and vein occlusions, mac edema, optic disc edema

87
Q

OIS

A

characterized by lack of blood flow to the eye, thrombotic in carotid arteries, >50yo with new-onset anterior uveitis, M>F, mild AC reaction (20% of the time), dot and blot hemes, amaurosis fugax, ischemia eventually, TIAs and CVAs

88
Q

OIS tx

A

OIS uveitis is non-responsive to steroids
can do a carotid endarterectomy when benefit outweighs risks

89
Q

Intermediate uveitis DDx

A

Idiopathic, sarcoidosis, syphilis, Lyme, cat scratch disease, MS, intraocular lymphoma

90
Q

MS associated intermediate uveitis

A

Often with pars plana snowbanking, demyelinating disease of CNS
Dx with MRI
1% of pts with MS will have uveitis
1% of uveitis pts will have MS

91
Q

What percent of all uveitis cases are pediatric?

A

6%

92
Q

Most pediatric uveitis is:

A

anterior, non-infectious, due to JIA (95% of non infectious pediatric cases are JIA or other spondyloarthropathies)

93
Q

JIA

A

Chronic bilateral NGAU (recurrent, often asymptomatic!)
oligoarticular JIA at highest risk, RF negative, make up 95% of childhood anterior uveitis, F>M, age 4-16
can present with band keratopathy, and irregular pupil due to posterior synechiae

94
Q

pediatric uveitis prognosis with the presence of synechiae

A

(+) PS: 58% ended up 20/200 or worse
(-) PS: 3% ended up 20/200 or worse

ANA+, younger age, and uveitis preceding arthritis is also associated with poorer outcomes

95
Q

Managing JIA uveitis

A

ANY CHILD with uveitis warrants rheumatology consult
pts with chronic anterior uveitis should be seen at least q3mo

96
Q

TINU: Tubulointerstitial Nephritis and Uveitis Syndrome

A

Bilateral NGAU
possible cell-mediated hypersensitivity, F>M, children and young adults, rare
systemic: high ESR, proteinuria, increased urinary beta 2 microglobulin, and serum creatinine

97
Q

TINU dx and tx

A

DX: renal biopsy, nephrology, pediatrics, urinary beta 2 microglobulin
TX: topical steroid/cycloplegic, systemic steroids/immunomodulators
recurrence in >50% of cases with uveitis

98
Q

Glaucomatocyclitic Crisis

A

20-50yo, M=F, recurrent, unilateral trabeculitis, mild NGAU, extremely high IOP, mild discomfort, diagnosis of exclusion, tx with IOP lowering drops, corticosteroids QID

99
Q

Fuchs heterochromic iridocyclitis

A

young adults, M=F, idiopathic, chronic mild unilateral NGAU, stellate KP, smooth iris, heterochromia in later stages, unilateral PSC

100
Q

Lens-induced uveitis

A

auto-immune type reaction to excessive leakage of lens material, accompanied by ocular hypertension, r/o endophthalmitis! and sympathetic ophthalmia

101
Q

UGH - Uveitis Glaucoma Hyphema Syndrome

A

triad of anterior uveitis, hyphema, and increased IOP, can be caused by AC-IOL friction against iris or from iris implants

102
Q

What do you assume hyphema is from if no trauma/surgical history?

A

assume NVI

103
Q

considerations when a patient has hyphema

A

wait until cleared before doing gonio to look for angle recession, limit physical activity, sleep w/head elevated, manage any ocular HTN, sx management if non-clearing, uncontrolled IOP, or corneal staining

104
Q

Traumatic uveitis

A

20% of all iritis, young M>F, NGAU
Vossius ring, dx: h/o of recent injury
tx: cycloplegic, pred acetate 1% QID usually sufficient

105
Q

Vossius ring

A

pigment on anterior capsule of lens due to severe blunt trauma
mimics pigment due to posterior synechiae

106
Q

Endophthalmitis symptoms

A

redness, sensitivity to light, vision loss, pain (RSVP)
INFECTIOUS!

107
Q

managing endophthalmitis

A

treat empirically, don’t wait for confirmation, IVT antibiotics
presenting VA is most important prognostic indicator
review importance of lid hygiene with patients before surgery!

108
Q

TASS

A

rare sterile inflammation in the immediate post-op period (12-24hr) after cataract sx
tx: topical steroid once endophthalmitis is ruled out, otherwise treat as infectious

109
Q

Sympathetic ophthalmia

A

rare inflammatory condition in which one eye with penetrating injury or surgery incites an inflammatory response in the other eye. presents as a granulomatous non-necrotizing inflammation in uveal tract of both eyes (bilateral panuveitis)

110
Q

Drug-induced uveitis

A

bisphosphonates (Bonia and Fosamax), oral fluoroquinolones (moxi), rifabutin, systemic sulfonamides, cidofovir, intradermal vaccines (influenza, hepatitis B, BCG)

111
Q

Immune recovery uveitis

A

immune response after HIV+ individuals start HAART therapy and CD4+ T-lymphocytes rise. Low-grade vitritis with or without papillitis, CME, ERM

112
Q

Uveitis in pregnancy/breastfeeding

A

pred forte is not tested in human trials but is expected to be low risk for the fetus due to limited systemic absorption
when in doubt call the OB

113
Q

Acute Uveitis (causes summary)

A

Traumatic, ankylosis spondylitis
(not complete)

114
Q

Chronic uveitis (causes summary)

A

Fuchs heterochromic iridocyclitis, JIA
(not complete)

115
Q

Bilateral uveitis (causes summary)

A

TINU, JIA, sarcoidosis
(not complete)

Ocular Disease (14 decks)

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