Eye Inflammation Lecture 18 PDF

Eye Inflammation  u Episcleritis Eye u Uveitis Inflammation u Case discussions  Cause of inflammation? u Body’s methods of protecting tissues and organs u Efficient, non-specific response caused by injury, infection, autoimmune processes or...

Eye Inflammation  u Episcleritis Eye u Uveitis Inflammation u Case discussions  Cause of inflammation? u Body’s methods of protecting tissues and organs u Efficient, non-specific response caused by injury, infection, autoimmune processes or idiopathic conditions u White blood cells and other immune factors protect against foreign pathogens such as bacteria and viruses u In certain conditions the body becomes symptomatic u Redness u Heat u Swelling u Pain u Acute u Chronic  Cause of inflammation? u Inflammatory response differs in vascular and avascular tissue u Vascular tissues u Inflammation helps defend the body u Vasodilation leads to redness and an increase in size of the blood vessels u Increase in vascular permeability u Allows fluid to get to affected area u White blood cells migrate into the tissue to fulfill their role and attempt to remove the offending agent Cause of inflammation? u Avascular tissues u Inflammation is a problem u Can lead to tissue damage and scarring u Normal cornea is transparent and maintains itself as an immune privileged site u If not adequately treated, chronic inflammation can lead to u Deposition of fibroblasts, tissue hardening and destruction, neovascularization and pannus  Patient work up u Our careful questioning and examination will help to differentiate between the potential causes of red eye. Essentially, we need to know the underlying cause so we can treat it u The main ones associated with red eye are (or the main associations/considerations with red are) u Infection u Inflammation u Trauma u Degeneration Episcleritis  Episcleritis u This is a common condition u Usually it is self-limiting, but it can be recurrent u It is most common in young women u Although it is not normally associated with systemic disease it is thought that up to 1/3 may be associated with u Rheumatoid arthritis u Systemic lupus erythematosus u Inflammatory bowel disease  Episcleritis u Presentation u Sudden onset u Red eye with mild discomfort u Usually unilateral u May have slight epiphora/watering  Episcleritis u Signs u Redness can be sectoral or diffuse u Simple episcleritis which accounts for 80% of cases u Can also be seen as slightly raised with injection u Nodular episcleritis which accounts for 20% of cases u This type will have a greater foreign body sensation u The A/C is usually quiet u There is no effect on the cornea  Episcleritis u Investigation u Careful history to ask about possible systemic involvement u Detailed anterior segment examination to exclude other possible causes u The hyperaemia is superficial and blanches with a topical vasoconstrictor (phenylephrine 10%)  Episcleritis: u Management and advice u Normally just reassurance that this is self-limiting u Cold compresses can help give symptomatic relief u Lubricating drops can also be recommended for discomfort  Episcleritis u Management and advice u Typical treatment plan for IP u IP Optometrists can treat more severe cases with a mild topical steroid e.g. fluorometholone bd - qds for 1-2 weeks u The evidence for using a topical NSAID is inconsistent u More severe cases may need systemic non-steroidal anti-inflammatory treatment, e.g. flurbiprofen 100mg tds or naproxen 500mg bd  Uveitis Type Site of inflammation Includes Iritis Anterior Chamber Anterior uveitis Iridocyclitis Anterior cyclitis Pars planitis Intermediate uveitis Vitreous Posterior cyclitis Retinitis Choroiditis (focal, Retina Posterior uveitis multifocal or diffuse) Choroid Vasculitis Neuroretinitis Entire uveal tract and Panuveitis retina  Symptoms of Uveitis Symptoms of Anterior Uveitis Symptoms of Intermediate Uveitis Symptoms of Posterior Uveitis Redness Floaters Reduced vision Photophobia Flashes Flashes Lacrimation Floaters Reduced vison Pain Visual field loss And it is usually painless Decreased vision And again it is usually painless And possibly floaters  Causes of Uveitis Infectious Inflammatory Malignancy Other Syphilis HLA-B27 Associated Lymphoma Idiopathic Tuberculosis Inflammatory Bowel Disease Retinoblastoma Medication-induced HSV Psoriatic arthritis CMV Sarcoidosis Toxoplasmosis Tubulointerstitial nephritis and Rubella uveitis VZV Post-infectious Iritis  Introduction to Anterior Uveitis u By definition anterior uveitis is inflammation which affects the iris. u Acute anterior uveitis is the most common presentation of uveitis and it can be recurrent u Non granulomatous where there is a sudden onset with fine keratic precipitates (KPs) - more likely to be idiopathic u Granulomatous which tends to be chronic and with mutton fat KPs. It is usually associated with an underlying systemic disease  Incidence u The prevalence varies depending on location, but it affects 12 in 100,00 people each year u Accounts for somewhere in the region of 75 – 90% of all cases of uveitis u Can occur in isolation without any association with illness or inflammation elsewhere in the body u Can be due to infection such as herpes zoster and herpes simplex. u It may be associated with illness affecting multiple parts of the body u Up to 50% of patients with AAU are HLA B27 positive  HLA B27 u Most common systemic illnesses associated with HLA B27 are: u Ankylosing spondylitis u Reactive arthritis u Seronegative rheumatoid diseases u Psoriatic arthritis u Inflammatory bowel disease  Iritis u Presentation u Sudden onset painful eye u Usually unilateral u May be bilateral  Iritis: u Signs u Circumcorneal injection u Anterior chamber cells and flare u Keratic precipitates may be fine or large (mutton fat) u Other variable signs include: u Fibrin u Hypopyon u Iris abnormalities u Raised or low IOP u Some anterior vitreous cells (spill over) u Cystoid macular oedema  Iritis u Symptoms u Pain u Photophobia u Redness u Blurred vision  Iritis u Investigation u Thorough history to ascertain any systemic links u Full anterior segment examination u Dilated examination to exclude posterior involvement  Patient history Questions to ask Possible underlying cause Joint pain Ankylosing Sponylitis Back pain Ankylosing Sponylitis/HLA B27 positive Bowel problems 5% of patients with ulcerative colitis or Crohns will have anterior uveitis Mouth ulcers Beçhet’s Disease Genital ulcers Beçhet’s Disease/Syphilis Risky sexual practices Syphilis Skin rashes Psoriatic arthritis/Sarcoid Insect bites Lyme Disease Foreign travel (or if the patient came to the UK from another country eg if from India then greater risk of TB) Dry cough TB/Sarcoid Night sweats TB/Sarcoid Sudden weight loss TB/Sarcoid Recent tattoos Possible delayed hypersensitivity reaction or sarcoid (not fully understood) General Health Recently been unwell  Iritis u Management and advice u If underlying systemic disease and posterior involvement has been ruled out u IP optometrists may treat this condition u Frequent steroid and mydriatic on a reducing dose over 6 weeks u Review within 48hrs to ensure drops are working u Referral to ophthalmology if no improvement in one week  Iritis: management and advice u Typical IP treatment plan u Topical steroid u Frequency depends on severity (hourly until the eye is white) u Generally u 6 times daily for 1 week u 5 times daily for 1 week u qds for 1 week u tds for 1 week u bd for 1 week u od for 1 week u Cycloplegic tds for up to 7 days  Blood tests for ocular disease u Full Blood Count (FBC) u The full blood measures various factors including: u Red blood cell count u Haemoglobin u White blood cell count u Platelets u Useful in chronic conditions and monitoring treatments u Also conditions such as orbital cellulitis  Blood tests for ocular disease u Investigation of inflammation and infection u Tests carried out include u Erythrocyte sedimentation rate (ESR) u Non specific marker of inflammation u Sign of chronic or longer term inflammation u May be elevated in u Infections u Neoplasms u Vasculitis u Tissue disorder: eg giant cell arteritis  Blood tests for ocular disease u Investigation of inflammation and infection u Tests carried out for this include u C-Reactive Protein (CRP) u Sign of recent or acute phase inflammation or infection u Reduces as the condition subsides u More sensitive than ESR?  Blood tests for ocular disease u Investigation of inflammation u Uveitis has many potential causes and tests include u FBC u ESR u CRP u Renal function tests (Urea and electrolytes – U&E) u Viral serology u Serum ACE (usually raised in sarcoid) u Syphilis testing u Chest x-ray u HLA gene testing u T Spot  Blood tests for ocular disease u Investigation of inflammation u HLA gene testing for uveitis u HLA-B27 in anterior uveitis u HLA-B51 in Bechet’s syndrome u HLA-A29 in Birdshot chorioretinopathy Patient 1 u 32 year old Female u c/o painful red left eye u Sensitive to light u Vision slightly reduced u Onset 3 days Symptoms u Pain u Photophobia u Redness u Blurred vision u May also have tearing, lid puffiness and some drooping of the eyelid may be seen Signs u Anterior segment inflammation – may be severe u Circumlimbal injection u KPS especially inferior u AC cells & flare u Hypopyon u Posterior synechiae u Anterior vitreous cells Anterior uveitis - signs  Investigation u VA u IOPS u Anterior segment exam u Conjunctiva u Cornea for KPs u Iris for atrophy/nodules u A/C u Dilated exam u Check vitreous for activity. u Sometimes have slight overspill from A/C so always look further back u Retinal changes/vasculitis  Anterior uveitis - examination u OCT u 11.7% of HLA B27 have CMO  Further Investigations When to do this? Blood Tests including u CRP u ESR u HLA B27 And u Chest x-ray  Prognosis u HLA B27 iritis: u Tendency to recur u Affect one eye, then the other  Patient 2 u LS Caucasian female u 10 years old at initial presentation u Examination showed: u R. 6/9 L.6/5 u Anterior chamber u RE cells grade 2 and posterior synechiae u LE cells grade1 u No posterior involvement u No cystoid macular oedema  Patient 2 u Provisional diagnosis anterior uveitis linked to possible juvenile idiopathic arthritis (JIA) u Topical treatment was adjusted to: u RE maxidex 6 x daily for 2 days reducing to 4 x daily ongoing u LE maxidex 4 x daily ongoing u BE cyclopentolate 3 x daily for 5 days  Patient 2 u Blood tests were ordered: u Anti nuclear antibodies (ANA) u Rheumatoid factor u HLA-B27 u Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP u Some extra blood tests were ordered u Full blood count (FBC) u Checks on kidney and liver function - (U&E and LFT) u The next appointment was scheduled for 2 weeks  Patient 2 u At this follow up vision improving and eye was no longer red u VA 6/6 R&L u A/C quiet - No posterior synechiae u Joints still sore u Blood test result positive rheumatoid factor u Decision to commence methotrexate u Also to start to reduce steroid drops over next 6 weeks u Next appointment was scheduled for 8 weeks u At next follow up patient was using maxidex once a day and both A/Cs were quiet, and the joint pain had reduced u The clinical decision was to carry on 1 drop of maxidex once a day with the methotrexate and review on 2 months again  Juvenile Idiopathic Arthritis (JIA) u One of the commonest chronic rheumatic diseases in children u Swelling or limited joint range and pain on movement for at least 6 weeks duration with no identifiable cause and onset younger than 16 years old u Various risk factors and these include female gender, age of arthritis onset younger than 4 years old affecting 2-4 joints in the first 6 months of the disease (oligo-arthritis) and a positive antinuclear antibody (ANA) test (see later). u Most patients who have eye inflammation associated with JIA do not report or show the classic signs and u May be undetected for several months u Present with complications u Posterior synechiae u Macular oedema  Juvenile Idiopathic Arthritis (JIA) u Complications u Band keratopathy u Cataract u Glaucoma u Macular oedema u Laboratory testing includes: u Antinuclear antibodies u Rheumatoid factor  JIA management u Can be complex u Uveitis: topical steroids and cycloplegia u Severe inflammation: systemic steroids may be used u If the clinician unable to stop topical therapy then systemic immunosuppression indicated u In children this usually methotrexate u Methotrexate blocks action of folic acid u Patients also need to take folic acid supplement u If treatment with methotrexate fails then biologic treatments such as adalimumab (humira or amgevita) considered  Patient 3 u 64 year old female u Painful right eye u Onset 2 weeks u C/O light sensitivity u Blurred vision u Floaters u Red eye  Patient 3 u Detailed history reveals: u No history of joint or lower back pain u No reported bowel problems u No mouth or genital ulcers u No night sweats u No skin rashes u Patient reports having a dry cough for the last 3 months u She has not travelled abroad recently and hasn’t been in contact with anyone who has TB  Patient 3 u Clinical findings: u VA R. 6/18 L. 6/6 u IOP R: 23mmHg L: 18mmHg u Large mutton fat KPs on the endothelium of right eye u A/C cells ++ u No posterior synechiae u Dilated exam shows vitreous cells+ and several large floaters inferiorly u Inferior fundus shows several discrete white lesions  Patient 3 u Differential diagnosis u These include: u Sarcoid uveitis u Syphilis u Tuberculosis u Behçet's disease  Patient 3 - Sarcoid u Multisystem disorder u Eye affected in 25% of patients u Acute anterior uveitis occurs in 60% and posterior segment disease in 25% u It accounts for 3-10% of all cases of uveitis u It affects females more than males u There are peaks in 3rd and 6th decade u It is common in Afro-Caribbeans, Irish and Scandinavians  Patient 3 - Sarcoid u Multisystem disorder u Cause is unknown u Granulomas developing in affected organs u Commonly u Lungs u Lymph nodes u Skin u Eyes  Patient 3 - Sarcoid u Patients with sarcoid uveitis will have some or all of the following symptoms: u Blurred vision u Photophobia u Floaters u Pain u Redness  Patient 3 - Sarcoid u Anterior Signs u Circumcorneal injection u Conjunctival granuloma u Mutton fat KPs u A/C cells and flare u Posterior Synechiae u Vitreous cells u Iris granulomas and nodules  Patient 3 - Sarcoid u Other signs to look out for on examination are u Intermediate signs: u Vitreous cells u Snowballs – usually seen in the inferior vitreous u Snowbanking u Posterior signs: u CMO (which is the commonest cause of decreased VA) u Vasculitis Sarcoid uveitis u Posterior signs u Vasculitis Sarcoid uveitis Posterior signs vasculitis Vein = Artery = inflammation infection Sarcoid Eg viral TB Beçhets Syphilis MS Vasculitis Artery  Vein = inflammation Vasculitis u Sarcoid Vein u TB u Beçhets u Syphilis u MS Sarcoid uveitis Posterior signs Pale chorio-retinal lesions  Sarcoid uveitis treatment u Anterior: u Aggressive treatment with topical steroid and cycloplegic to prevent Posterior synechiae u Intermediate: u Monitor if VA better than 6/12 and no CMO u Treatment u If there is CMO then the following treatment protocol is considered, starting with: u Topical: Maxidex and Acular QDS for 1/12 u Periocular: orbital floor injection of triamcinolone u Intravitreal: Ozurdex Iluvien u Systemic: Steroids u Immunosuppression such as methotrexate, mycophenolate, azathioprine and ciclosporin  Investigations u Blood tests u ESR u CRP u Serum ACE u Chest x-ray u High resolution volumetric CT scan of the chest  Sarcoid uveitis treatment u Posterior/vasculitis: u This will always be systemic u Steroid tablets u Immunosuppression such as azathioprine and cyclophosphamide u Newer generation biologics including infliximab and humira have recently been approved for non-infectious posterior uveitis u Prognosis: u Variable u 2/3 experience a benign self-limiting course with spontaneous remission  Patient 4 u Case background and symptoms and history: u 45 year old female u c/o flashing lights and floaters u Affecting both eyes u Reduced vision u Poor vision at night u Onset 6 months  Patient 4 u Detailed history reveals: u No history of joint or lower back pain u No reported bowel problems u No mouth or genital ulcers u No night sweats u No skin rashes u No history of a dry cough u No recent foreign travel u No history of TB contact Patient 4 u Clinical findings: u VA R. 6/9 L. 6/9 No pinhole improvement. u IOP R: 18mmHg L: 18mmHg u No circumcorneal redness either eye u Cornea clear in both eyes u A/C very mild activity cells + in both eyes u No posterior synechiae u Dilated exam shows vitreous cells+ in both eyes u Fundus shows several pale cream lesions in the mid periphery of both eyes  Patient 4 u Differential diagnosis: u Tuberculosis u Sarcoid u Syphilis u Birdshot chorioretinopathy  Birdshot chorioretinopathy discussion u Uncommon chronic bilateral posterior uveitis u Unknown aetiology u Typically characterised by hypopigmented choroidal lesions ¼ to ½ optic disc diameter u HLA A29 is a strong genetic risk factor 95% of Pxs u Usually occurs in middle aged (40 – 60 years old) affecting Caucasian adults with slight female preponderance u Accounts for 1-2% of all types of uveitis  Birdshot chorioretinopathy examination u Anterior segment signs generally absent - mild anterior uveitis is sometimes observed u Posteriorly oval cream coloured lesions radiate from the optic disc to the equator u Nearly always involve the inferior and nasal peripapillary area u Over time lesions can become atrophic - not normally pigmented u May be a moderate vitritis present u Vasculitis also seen which affects retinal veins u CMO is common - leading cause of visual loss Birdshot chorioretinopathy progression u Disease may progress in the following way: u Early stage signs are retinal vascular leakage u Middle stage signs include the birdshot lesions u Late stage signs u CMO u Vascular attenuation u Retinal pigment epithelium changes u Optic nerve atrophy u Subretinal neovascularisation  Birdshot chorioretinopathy investigation u HLA testing to look for HLA A29 u If this is negative consider sarcoid u Visual field testing can show various defects u Multiple foci u Arcuate u Enlarged blind spot u Central defect u OCT to check for CMO u Fluorescein angiography (FFA) to look for retinal vessel leakage, and hyperfluoresence of the optic disc (hot disc) u Indocyanine green (ICG) may reveal fundus lesions early u Electrodiagnostic tests: ERG/EOG can often show attenuation  Differential diagnosis u Could include: u Infections: u White dot syndromes (usually affect one u TB eye only) u Syphilis u APMPPE (Acute posterior multifocal placoid pigment epitheliopathy) u Ocular histoplasmosis u MEWDS (Multiple evanescent white dot u Non Infectious: syndrome) u Vogt Koyanagi Harada Syndrome u PIC (Punctate inner choroidopathy) u Sympathetic ophthalmia u AZOOR (Acute zonal occult outer u Masquerade syndromes – eg Lymphoma retinopathy) u Posterior Scleritis u Sarcoidosis Birdshot chorioretinopathy treatment u 20% may achieve remission and have a self-limiting disease u Most patients have recurrent exacerbations u Treat the CMO u Systemic steroids and immunosuppressants such as tacrolimus and mycophenolate can be used u More recently the biologic Humira has been shown to be effective and, as already mentioned, it is licensed for non-infectious uveitis u Prognosis: u Without treatment up to 22% of patients will lose VA < 6/60 u With treatment VAs remain stable or improved in up to 89% of patients  Summary u As optometrists uveitis may be a condition we see rarely u IP optometrists can now manage the first presentation of anterior uveitis u Complex disease u Ask yourself the following when dealing with patients who have uveitis: u Is there underlying systemic disease? u If not, consider the first aid advice in the College of Optometrists CMGs, and referral to an ophthalmologist as per your local protocols u If not, and you are an (IP) optometrist then treat the inflammation and arrange suitable follow up appointments u If there is the possibility of systemic disease then this will need referral to a suitable specialist to investigate and manage this appropriately