Uveitis AAO Self Assessment Flashcards
A purified protein derivative (PPD) test greater than ____ mm is considered positive in all individuals.
a) 5 mm
b) 10 mm
c) 2 mm
d) 15 mm
D) The PPD is read 48-72 hours after placement, and induration measured. A reading greater than 15 mm is considered positive in all individuals. In individuals at risk, including health care workers or potential contacts with active cases, 10 mm is considered positive. In individuals with AIDS or positive chest X-ray findings, 5 mm is considered positive. A 2 mm PPD would be considered negative.
Which of the following is a recommended treatment for serpiginous choroiditis involving the macula?
a) Alkylating agents
b) Biologics
c) Acyclovir
d) Topical corticosteroids
A) Vision threatening macular serpiginous choroiditis requires prompt institution of strong immunomodulatory therapy. Success has been reported for alkylating agents and for use of transplant-dose therapy with cyclosporine A, azathioprine, and prednisone. Corticosteroids alone are often insufficient to treat this condition. While there has been some discussion suggesting a herpetic and tuberculous etiology for serpiginous choroiditis, definitive evidence has not been demonstrated, and acyclovir should be used adjunctively if at all. Topical corticosteroids have no effect on this condition.
A male patient with uveitis and a history of unprotected sex with prostitutes is suspected of having syphilitic uveitis. His rapid plasma reagin (RPR) testing syphilis serology is negative. What is the next step in his evaluation?
a) Do blood cultures for syphilis. b) Treat with penicillin. c) Obtain a fluorescent treponemal antibody absorption (FTA-ABS) test. d) Do a paracentesis for darkfield microscopy.
C) A false-positive RPR is possible in late syphilis, which uveitis is likely to be. A FTA-ABS is more likely to be positive, with false negatives being very rare. Other treponemal absorption tests, such as the microhemagglutination-Treponema pallidum (MHA-TP), are also useful. One problem with the FTA-ABS is false positives, especially if weakly reactive. Although treating with penicillin may be reasonable, and severe and fatal reactions are rare, the best next step is to try to diagnose. Blood cultures are not feasible for diagnosing syphilis. Availability of darkfield microscopy is very limited, it requires great expertise, it can result in a false negative, and although a positive result would clinch the presence of spirochetes, it would not necessarily confirm syphilis.
For the past year, a patient with bilateral (anterior uveitis) has recurrent episodes characterized by 2-3 + anterior chamber cells every time prednisolone actetate 1% drops are reduced. She has modest pain, redness, and photophobia associated with episodes. Even with prednisolone acetate at 4 times per day, she has 1+ cells. She has 4 clock hours of posterior synechiae and keratic precipitates (KP) in Arlt’s triangle that resolve when the corticosteroids are increased. The KP are white and not spidery or spindly. She has a visually significant cataract and is anxious to pursue cataract surgery right away. The patient does not have posterior uveitis or cystoid macular edema. What is the next step in their management?
a) Methotrexate and intensive topical corticosteroids in the perioperative cataract surgery period b) Intravitreal fluocinolone acetonide implant c) Immunomodulatory systemic agent d) Increase the prednisolone actetate 1% to every hour in the cataract surgery perioperative period
C) The standard is to maintain good control of the inflammation for 3 months before pursuing surgery. It is perilous to do otherwise unless the uveitis is very mild and without sequelae, and certainly would be appropriate for this patient who has chronic disease with recurrences whenever she decreases the topical medications to a reasonable, sustainable level. Recurrences of uveitis or chronic active uveitis can cause great damage, and so it is important to make sure the inflammation is well controlled on a regimen the patient is tolerating before surgery. Inflammation after cataract surgery can result in a devastating and persistent cystoid macular edema. Membranes creating traction on the retina or cilliary body may cause retinal detachment or hypotony. If a lens implant is placed, there can be “cocooning” of the lens implant. If the inflammation is severe, it can lead to persistent precipitates on the lens implant which can be visually significant. This patient needs systemic immune-modulatory therapy such as methotrexate. However, methotrexate may take more than 2 weeks to start acting. Therefore, using methotrexate for only 2 weeks and using are not sufficient. The fluocinolone acetonide implant is not approved for anterior uveitis. Such an approach is feasible if there is chronic cystoid macular edema. The symptoms and presence of posterior synechiae, the nature of the keratic precipitates, and the response to coriticosteroids indicate that this is not Fuchs’ heterochromic iridocyclitis (FHI), which can be bilateral. This is important because FHI does not require such aggressive preoperative therapy.
A patient with deep ocular pain and subretinal fluid is suspected of having posterior scleritis with an exudative retinal detachment. What finding would confirm a diagnosis of posterior scleritis?
a) Cystoid macular edema b) Vitritis c) Vitreous hemorrhage d) A "T" sign on B-scan ultrasound
D) Posterior scleritis may be difficult to diagnose because of its occult location. Although posterior scleritis can be associated with intraocular inflammation, vitritis, and cystoid macular edema, such findings are non-specific. Fluid exudation between the sclera and posterior Tenon’s capsule near the optic nerve, detectable by echography or MRI, may show the highly characteristic “T-sign”.
What is the most common cause of decreased visual acuity from the inflammation in idiopathic intermediate uveitis?
a) Retinal detachment b) Cystoid macular edema c) Glaucoma d) Vitreous hemorrhage
B) Multiple studies confirm cystoid macular edema is the most common cause of decreased vision in patients with intermediate uveitis. Glaucoma is often due to corticosteroid treatment, though a small number of patients can have sufficient anterior chamber inflammation to form enough synechiae to result in a uveitic glaucoma by that mechanism. Vitreous hemorrhage and retinal detachment can occur, presumably secondary to vitreous traction from the virtitis or from organized vitreous secondary to previous inflammation.
What infectious agent has been associated with Fuchs heterochromic iridocyclitis?
a) Syphilis b) Herpes zoster c) Herpes simplex d) Rubella
D) Both epidemiologic and polymerase chain reaction studies suggest rubella is associated with Fuchs heterochromic iridocyclitis. This is problematic, because we do not have good agents to treat rubella virus infections.
Which form of juvenile idiopathic arthritis is most likely to be associated with anterior uveitis?
a) Polyarticular b) ANA-; RF+ c) Pauciarticular d) Still's disease
C) Between 25% and 40% of ANA+, pauciarticular onset patients with juvenile arthritis will develop uveitis. The uveitis associated with this disorder tends to be asymptomatic, but very persistent, and is associated with very high rates of complication.
A patient with Vogt-Koyanagi-Harada disease was treated with high-dose oral prednisone and had resolution of her serous retinal detachments. The dose has been gradually decreased, and 4 months into therapy, she is on prednisone 20 mg daily. She is on topical prednislolone acetate 1% QID and her visual acuity is 20/30 both eyes. There are 2+ cells in the anterior chamber of both eyes with no vitritis, cystoid macular edema, or subretinal fluid. What is the most appropriate next step?
a) Start a corticosteroid-sparing immunomodulatory agent b) Posterior subtenon injections of triamcinolone acetonide c) Increase the oral prednisone to 40 mg/day d) Place a flucinolone implant
A) The goal generally is to have a patient on 10 mg prednisone per day or less by 6 months; if not, a corticosteroid-sparing immunomodulatory agent is needed to allow further weaning of the prednisone. This is considered the standard of care. Periocular injections do not tend to be as effective in the chronic anterior uveitis associated with VKH disease, but could be considered. The flucinolone implant is not approved for anterior chamber inflammation.
When is it diagnostically useful to obtain an antinuclear antibody (ANA) test in a patient with isolated anterior uveitis and NO skin, joint, or other systemic problems?
a) Always b) When the bilateral anterior uveitis is acute c) Never d) When the unilateral anterior uveitis is chronic
C) An ANA is usually obtained to evaluate the possibility of systemic lupus erythematosis (SLE). SLE is rarely if ever associated with isolated anterior uveitis. In addition, many patients have positive ANA testing without systemic disease, and the diagnosis of SLE is made on multiple criteria, not only ANA testing. If SLE is suspected, a systemic examination with antibody testing including ANA is indicated. SLE is most commonly associated with scleritis or retinal vasculopathy if there are intraocular complications of disease. Even then it is uncommon for SLE to present initially with ocular inflammation. Retinal or choroidal vasculopathy raises concern of central nervous system involvement and requires urgent consultation with internal medicine or rheumatology.
Which micro-organism has been associated with Fuch’s hetereochromic iridocyclitis by PCR studies?
a) A fungus b) A parasite c) A bacteria d) A virus
D) Recent epidemiologic studies and studies using polymerase chain techniques have suggested viruses, particularly rubella and cytomegalovirus to be associated with Fuch’s heterochromic iridocyclitis (FHI). Previous speculation of an association with toxoplasmosis was based primarily on the concurrence of inactive chorioretinal scars and serologic positivity in some patients.
Which of the following statements does not accurately describe sympathetic ophthalmia?
a) Sympathetic ophthalmia may be differentiated from Vogt-Koyanagi-Harada syndrome by the absence of vitiligo and alopecia in the former. b) Phacoanaphylaxis has been noted in up to 25% of patients with sympathetic ophthalmia. c) Sympathetic ophthalmia rarely occurs within 2 weeks of injury. d) High-dose systemic corticosteroids are the initial treatment of choice in sympathetic ophthalmia.
A) Sympathetic ophthalmia is a rare, bilateral, granulomatous uveitis that may occur following ocular trauma or surgery. The onset of inflammation rarely occurs within 2 weeks of injury and may not occur until decades after trauma. The majority (90%) of cases, however, begin within 1 year. Symptoms in sympathetic ophthalmia typically include pain, photophobia, blurred vision, and decreased accommodation. Examination may reveal keratitic precipitates on the cornea, anterior uveitis, vitritis, retinal edema, papillitis, and the yellow-white subretinal pigment epithelium (RPE) Dalen-Fuchs nodules. Fluorescein angiography typically shows multiple pinpoint areas of hyperfluorescence. Pathologic examination of eyes with sympathetic ophthalmia has shown a frequent association of phacoanaphylaxis (up to 25%). Sympathetic ophthalmia may be difficult to distinguish clinically from Vogt-Koyanagi-Harada (VKH) syndrome, because they share not only similar ocular findings, but also systemic findings such as vitiligo and alopecia. Vitiligo and alopecia, which are typical in VKH, may also be seen in sympathetic ophthalmia, although less commonly. Debate still exists as to the benefit of enucleating the exciting eye once sympathetic ophthalmia has begun. However, high-dose systemic corticosteroids (100-200 mg) have been shown to be effective in the initial treatment of sympathetic ophthalmia. In patients unable to tolerate systemic corticosteroids, immunosuppressive agents such as methotrexate, azathioprine, or cyclosporin may be used.
A 28-year-old Hispanic woman presents with three days of headache and loss of vision in both eyes. She was admitted for suspicion of meningitis, although she has no fever. There was a mild lymphocytic response noted in her cerebrospinal fluid; stains for microbes were negative, and cultures are negative to date. On examination she has a moderate bilateral anterior uveitis and vitritis with serous retinal detachments. There is no retinal necrosis. What is the most appropriate therapy?
a) Intravitreal acyclovir b) Systemic corticosteroids c) Await viral cultures of the cerebrospinal fluid before starting treatment d) Cyclophospahmide
B) This is a typical presentation of Vogt-Koyanagi-Harada disease, for which the treatment is high-dose systemic corticosteroids.
What disorder is best characterized by a unilateral, mild, anterior uveitis with a sentinel keratic precipitate (KP) and high intraocular pressure (IOP).
a) Fuch's heterochromic iridocyclitis b) Sarcoidosis c) Glaucomacyclitic crisis (Posner-Schlossman syndrome) d) Juvenile idiopathic arthritis-associated anterior uveitis
C) Increased intraocular pressure in anterior uveitis can be secondary to chronic inflammatory damage to angle structures, iris bombe, or corticosteroids, however, in the setting of mild uveitis and increased pressure at the beginning of an episode, viral anterior uveitis must be considered. Glaucomacyclitic crisis is a self-limited, mild, unilateral anterior uveitis with increased intraocular pressure, not secondary to corticosteroids. Viruses have been implicated, although due to the self-limited nature of the process and the facts that CMV may be the virus involved, at least in some cases, and that oral ganciclovir is not as well tolerated as acyclovir, antiviral therapy is not often used. Fuchs heterchromic idirdocycloitis is a chronic anterior (and sometimes intermediate) uveitis. There are diffuse stellate keratic precipitates. The uveitis with juvenile idiopathic arthritis is chronic and bilateral. Sarcoidosis is rarely if ever associated with a mild recurrent anterior self limited uveitis with increased intra-ocular pressure without corticosteroid use.
What is the most common non-ocular finding in Adamantiades-Behcet disease?
a) Central nervous system vasculitis b) Arthritis c) Oral or genital ulcers d) HLA-B51 positivity
C) There are many systemic findings in Adamantiades-Behcet disease, but the most common are oral and genital ulcers. Systemic vascular involvement may be fatal and is certainly of concern, but is less common. HLA-B51 is associated with Adamantiades-Behcet disease, but not so strong that it has a high positive and negative predictive value. Additional ocular manifestations of Adamantiades-Behcet disease, including acute anterior uveitis may include hypopyon formation and an occlusive retinal vasculitis that may be blinding.
