Uveitis: Diagnosis and Treatment

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Anterior Uveitis Acute Non-Granulomatous

• Idiopathic
• Can be treated with corticosteroids such as Prednisolone 1% gID
• Cycloplegics can be used
• Severe inflammations can be treated with oral NSAIDS or immunosuppressors
• Spondyloarthropathies
• Ankylosing spondylitis
• Reiter's syndrome, also called reactive arthritis or postinfectious arthritis
• Inflammatory bowel disease
• Ulcerative colitis
• Crohn's disease or regional enteritis
• Psoriatic arthritis

Idiopathic Uveitis

• Most common type
• Occurs only in the anterior
• Non-granulomatous (small KP)
• No systemic risk factors (i.e., AIDS, immunosuppression, pre-existing ocular disease or surgery)
• Can present as a single episode, should screen for syphilis
• Treat topically with steroids and cycloplegics

Spondyloarthropathies - Ankylosing Spondylitis

• "Ankylosis" is the stiffening or joint fixation
• "Spondylitis" is the inflammation of one or more vertebrae
• HLA B27 is positive in most cases
• Onset in males in third or fourth decade
• A chronic inflammatory disease
• Causes arthritis of the spine and hips
• Presents with an insidious onset of pain and stiffness in the lower back or buttocks

More on Ankylosing Spondylitis

• Exact cause is unknown, and there is no cure.
• 90% of patients are HLA-B27 positive.
• HLA-B27 positive patients have a 1 in 4 chance of developing ankylosing spondylitis or eye disease.
• 25% of patients present ocular manifestations
• Anterior uveitis
• Either eye is affected at different times; bilateral is rare.
• May be associated with Crohn's disease or ulcerative colitis.

Ankylosing Spondylitis Diagnostic Criteria

• Low back pain over 3 months' duration, unrelieved by rest
• Pain and stiffness in the thoracic cage
• Limited chest expansion
• Limited motion in the lumbar spine
• Past or present evidence of iridocyclitis
• Bilateral radiographic sacroiliitis
• Radiographic syndesmophytosis
  • Bony growth inside the ligament
• Diagnosis requires four of the five clinical criteria or bilateral radiographic sacroiliitis and one other criterion

Ankylosing Spondylitis Treatments

• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Naproxen 500mg BID or indomethacin 50 mg q 8-12h
• Sulfasalazine (DMARDs)
• Anti-inflammatory properties inhibit leukotriene synthesis
• Tumor necrosis factor-α (TNF-α) antagonists
• Enterecept
• Infliximab
• Corticosteroids (oral and topical)
• Topical mydriatics
• Cardiologist evaluation for heart block or aortic insufficiency risks
• Rheumatologist consult

Reiter's Syndrome

• Reactive arthritis (ReA)
• Autoimmune condition that develops in response to infection
• Associated with gastrointestinal (GI) infections
• Shigella
• Salmonella
• Campylobacter
• Genitourinary (GU) infections
• Especially with Chlamydia trachomatis is the #1 cause

More on Reiter's Syndrome

• Classic Triad
• Iritis (conjunctivitis, keratitis, scleritis, episcleritis)
• Arthritis
• Urethritis (non-infectious)
• 50% of patients have eye involvement.
• Males are affected more than females Young adults (20-40 y/o) may have it
• 75% are HLA-B27 positive
• Symptoms include fever, malaise, myalgias, arthralgias, dysuria, urinary urgency/discharge, and after 1-4 weeks an infection.
• Signs: arthritis (asymmetric), knees, sacroiliac joints, ankles, keratoderma blenorrhagica on feet and hands, circinate balanitis, painless mouth ulcers.

Details of Reiter's Syndrome

• The syndrome includes conjunctivitis
• Oral ulceration
• Urethritis
• Circinate balanitis
• Achilles tendonosis / plantar fasciitis (enthesitis)
• Keratoderma blennorrhagica on sole
• Non-painful ulcers

Reiter's Syndrome Treatment

• Oral NSAIDs
• If allergic to NSAIDs corticosteroids are used
• Topical initial steroids
• Intra-articular steroids
• Systemic steroids
• Antibiotics are prescribed if 1st line is Chlamydia
• Use tetracycline 250-500 mg QID or Doxycycline 100 mg PO q12hr on day 1, then 100 mg PO qDay x 7 days for Shigella, Salmonella
• Use Erythromycin 250-500 mg QID for pregnant women and children
• DMARDs (disease modifying antirheumatic drugs) given if NSAIDs are contrainidcated or ineffective
• Sulfasalazine Methotrexate
• Anti-TNF (Entanercept and Infliximab)
• Rheumathologist evaluation needed to diagnose the pathology

Inflammatory Bowel Disease (IBD)

• Ulcerative colitis (UC) major type of IBD with Crohn disease
• Idiopathic chronic relapsing inflammatory disease
• Crohn disease affects any part of the Gl tract.
• UC typically involves only the large bowel.
• Pseudopolyps can occur
• Crypt abscesses
• The 2nd and 3th decades are the most common onset Signs and symptoms:
• Rectal bleeding
• Frequent stools
• Mucous discharge from the rectum
• Tenesmus occasionally
• Left Lower abdominal quadrant pain
• Pyoderma gangrenosum can occur
• Arthritis can be present

Ulcerative Colitis (UC) Treatments

• Hospitalization may be required
• Intravenous high-dose corticosteroids can be methylprednisolone 10-80mg IM or IV
• Oral Corticosteroid outpatients or maintenance needed if there are Gastrointestinal illnesses
• Alternative medications for treatment are:
  • TNF inhibitors (Infliximab or Adalimumab) Immunosuppressant agents (Cyclosporine or Tacrolimus) Gastrointestinal consult needed for reactivating an anterior uveitis

Crohn's Disease

• Is an idiopathic chronic disease
• Relapsing condition characterized by multifocal full-thickness granulomatous inflammation
• Affects any segment of the Gl tract from the mouth to the anus including "skip lesions"
• Patients are more prone to the development of malignancy at 2nd – 3th decades

Irritable Bowel Syndrome (IBS)

• Associated arthritis and iridocyclitis
• Peripheral arthritis
  • 12% of who have ulcerative colitis as well
  • 20% with regional enteritis
• Clinical spondylitis is linked with bowel inflammation in 4% to 7%
• HLA-B27 is present in 53% to 75% of patients with spondylitis and inflammatory bowel disease

Treatment

• Topical corticosteroids and mydriatic drops
• Activity follows the same course as inflammatory activity of bowels
• Systemic treatment can help ocular inflammation
• Surgically inflamed bowels sometimes reported for other medical reasons can coincide with lesser ocular inflammation problems

Behcet's Disease

• Idiopathic multisystem syndrome
• Rare vasculitic disorder
• Has a triad of aphtous ulcers, genital ulcers, uveitis (often in div, painful spots)
• Clinical syndrome characterized by acute-onset iridocyclitis with hypopyon and could present posterior intraocular inflammation
• High incidence in Japan and Mediterranean countries
• Positive HLA-B5 test
• Mortality 5% 5-10 years
• Etiology includes Autoimmune response (infectious agent or environmental antigen trigger)
• interplay between infectious-agent exposure and genetic factors Herpes simplex virus (HSV), Streptococcus, Staphylococcus Species and Escherichia coli

Behcet's Disease Diagnostic criteria for common clinical manifestations

1. Recurrent aphthous stomatitis
2. Genital aphthous ulcers
3. Uveitis
4. Synovitis(inflamm of Mucosa of Mouth)
5. Cutaneous vasculitis
6. Meningoencephalitis (fever, headache, neck stiffness, CSF pleocytosis) Ulcers are the first signs in 70% of patients

More information on Behcet's Disease

• Is a painful condition in the mouth 98-100%
• Ocular inflammation in 70% and more severe in men.
• Bilateral AAU, hypopyon
• Onset - relapsing/remitting acute and panuveitis and retinal vasculitis
• Hypopyon, iris sector ischemia, posterior synechiae and cataract formation in severe iridocyclitis
• Vasculitis and oral ulcers

More on Behcet's Disease

• Aphthous ulcers
• Erythem Nodosum
• Uveitis Hypofyn
• Meningitis
• Sinus Thrombosis
• Midbrain lesion

Clinical Presentation

• Multiple choriorretinal presentations
• Ocular or recurrent inflammation
• Chest X-ray

Behcet's disease Treatments

• Oral ulcer treatment: sucralfate or topical corticosteroids
• Ocular disease treatment: topical corticosteroids, mydriatic agents, oral azathioprine, prednisolone Interferon-alfa
• GI lesions treatment: oral corticosteroids and immunosuppressants
• Arthritits treatmetns : oral or local corticosteroid, NSAIDs, colchicine (take azathioprine, TNF alfa antagonists )

Fuch’s Heterochromic Iridocyclitis

• Uveitis Syndrome
• Chronic non-granulomatous condition at age 40
• No gender effect
• Cause not known (maybe associated a rubella virus, toxoplasmosis, HSV, CMV)
• 2-3% uveitis patients and asymtomatic
• Unilateral 90-5
• Affects both eyes but usually unilateral, non granulomatous, rare posterior cynichiae
• Has gray on stellate KP
• Iris Nodule 30% can be koeppe or Busacca
• Glaucoma 60%.
• Posterior subscapular frequent

Fuch’s treatments

• Topical timolol to lower iop
• Control glaucoma or related issues
• Perform cataract surgery to lower risk of complications like poor Miasis, inflammation and glaucoma

Juvenile Idopathic Arthritis

• Most systemic with childhood anterior uveitis
• Prevalence of 1/1000 to 12/100 people
• Unknown origin with beginnings at age of 16
• Persists for 6weeks and up with 50% having an active disease
• 4 or less joints involved which Knee is the most common
• Girls are 5x more suseptible than boys around age 2
• ANA test positive 75% for 10-16 years old

More on Juvenile Idopathic Arthritis

-anterior is asymptomatic with dangerous loose vision, can be detected by screening -(-4 cell and rarely complain) • Bilateral 70% • Hypopion absent • Common posterior synechiae • Band keratopathy and cataract, common in severe cases

Juvenile Idopathic Arthritis treatment

• Peditrician rheumatoligist
• Topical cortisteriod effective in 80% of patietns
• Mydriatric agens can prevent exacerbatins
• Some sever case require
  • Periocular steroidds
  • Infiximab adalinmub cicloposin Aggregations of Ca+ in corneal cells that are inflamed
  • Oral Corticosteroid
  • Methotrexate

Lyme Disease

• Most common vector born illness in the US
• Caused by infection with the spirochete Borrelia burgdorferi
• Spreads to humans by bites from infected ticks of the genus Ixodes
• Deer ticks cause it
• Can have intermediate uveitis

Lyme Disease Findings

• starts with Neurologic implications and complications starting starts early disease are Flu-like symptoms, Hearing Loss and Paralysis of Fact

Lyme Early stage finding

-EM is called by “Bulls eye" Rash -Fever and Malagias/Athragia

• Tendre local athropathy not defuse

Lyme Disease diagnoses

• Perform enzyme immunoassy
• Also do western blot testing to confirm

Lyme Disease Treatments

• Adults will need Doxycylcine
• Amoxicuon or cefuroxime
• Kids will need Amoxicillin and azithromycin
• Neuro cases that require IV peniciilin
• Ceftriaxone with Ocular Treatments

Glaucomatocyclitic (GC) Crisis Posner-Schlossman Syndrome

GC = Self recurring episodes of elevated Iop with open angle caused by cycilictis from 20-50 years

• Unilaterallity on eyes that afected
• Larger pupal
• Iop Elevation out of proportion to level of inflammation (40- 60mmHg) Decrease vision
• Affected ey will indicate a larger pupil 20-50 year patients Will see "coloured-halos" of light and Elevated

GC Patophysiology and treetments

• Patophys believed to cause inflammation and cause travecular
• Perform Topical Timolal .25%

Chronic Uveitis Granulomatous

• Can caused by Sarcoisis, Herpers, Zoster or TB

Sarcoidosis

• Systemic granulomatosis condition that comes from African Americans with 10:1
• Lung / Interthroatic nodes
• Cause be intermediate and poster uveitis that is in cooler climats

Symptoms of Sarcoidosis

• Aseomatic but on lungs it can cause fever shorteness of breathe and hermpotysis. The Lofgren syndrome(fever, bilateral hilar lymphadenopathy, and polyarthralgias) is also common in Scandinavian

More on Sarcoidosis

• Ocular inflammation occurs in 25-70%
• Has choronic anterior uveitis, Mutton fat KP at brown,Bussace or Koeppe
• 5% of pulmonary patients die, and 10% die in CNS, if untreated can cause blindness

Sarcoidosis Diagnosis

• • +w80's in lungs • has hiliar adenopathy and • ACE 60-90%
• Serum lysozyme

Sarcoidosis Treatments

Topical Steroids for Cytoplegic such as "Atropiin" & Predisone

Tuberculosis treatments

• Ocular Tb is not asociadted with pluamonry but pupuamory is common 13-15% Unilateral and Keratits 35-40 Choridial for 15+ days is associated with agressivle

More one TB

can affect eyelid. / and cornea has granulomoa

TB diagnosis

• if acute: Igm@, PCRmost important with "cavitation

TB treatments

Antibes and steroid with agents to combat

Herpes Sumplex

Severe SPK"s that affect Cornea and Uvea that cause "Bulb" end and had severe SPK issues

• Affect cornea urea. Sectoral iris atrophy White Inflates Treatments : acyclovir and steriod

Herpes Zoster

• V1 dermatological It's like chicken pop where 50% has hzv igm Will have glaucoma

Treatments for herpes zoster

Steroids to treat inflamm

• Topical steroids and acyclovir

• Syphilis*:

• It has anterior uveitis and can be life sacing Neuro and cardio affect FTA and VDRL Give mass desoses

Ocular Siphilis

• Chanre can occur (Primary in 2-6 weeks) -Secondary has 6 week and may or may not occur (macerated with lesions) -Teritiary May have Argyll Roberson or pupil may have Oler adthopy

Tramautic Irtitis

• The eye recites 2nd degree tramua It has a hyphema bleeding that covers vessels

Vossius Bing

• Trauma with white wbc

Traums will casue glaucoma Requires examination 1-2 days Requires steriods

Maligancy

• Lyphomas and Granulas Treated with Chemo

Maloanocuytes Can't be amelanotic , may occur with glaucoma (50-60 age range)

This quiz addresses the diagnosis and treatment of uveitis, covering topics such as monitoring during acute episodes, syphilis as 'The Great Masquerader,' differential diagnoses for chronic anterior uveitis, and considerations for tertiary syphilis. It also explores ocular tuberculosis and ankylosing spondylitis.