ADENOVIRAL KERATOCONJUNCTIVITIS

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RED EYE- UVEITIS

• Brig Mazhar Ishaq
• Advisor in Ophthalmology,
• Comdt Armed Forces Institute Of Ophthalmology,
• Rwp

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ANATOMICAL CLASSIFICATION

• ANTERIOR UVEITIS
• IRITIS
• IRIDOCYCLITIS
• INTERMEDIATE UVEITIS
• POSTERIOR UVEITIS
• PANUVEITIS

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POSTERIOR UVEITIS

• Involves the fundus posterior to the vitreous
  base
• - Retinitis - Choroiditis -
  Vasculitis

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SARCOIDOSIS

• Presentation
• - Acute
• - Insidious
• Ocular features
• - AAU - CAU
• - Intermediate
• - Candlewax drippings
• - Multifocal choroiditis
• - Retinal granulomas

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TUBERCULOSIS

• Anterior segment involvement
• Tuberculous uveitis
• - Anterior uveitis, - Choroiditis
• - Periphlebitis

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TOXOPLASMOSIS

• Presentation
• - Unilateral sudden onset of floaters
• Signs
• - Spill-over anterior uveitis -
  Satellite lesion - Multiple foci are uncommon
  - Severe vitritis (headlight in the fog)

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TOXOPLASMOSIS
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BEHCET SYNDROME

• Recurrent oro-genital ulceration
• Ocular features
• AAU - cold abscess
• Retinitis
• Retinal vasculitis
• Vitritis,

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BEHCET SYNDROME
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FUNGAL UVIETIS
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INVESTIGATIONS

• Indications
• Recurrent granulomatous anterior uveitis
• Bilateral disease
• Systemic manifestations with out a specific
  diagnosis
• Confirmation of suspective ocular picture such as
  HLA-A29 testing in birdshort chorioretinopathy

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NOT NECESSARY

• Single attack of mild unilateral acute anterior
  uveitis
• A specific uveitis entity
• When a systemic diagnosis compatible with the
  uveitis is already apparent

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INVESTIGATIONS

• Obtain a history, attempting to define the
  etiology.
• Complete ocular examination, including an IOP
  check and a dilated fundus examination.

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SKIN TESTS

• Tuberculin skin test (montoux Heaf)
• Intradermal inj of purified protein
• Positive
• Induration of 5-14 mm with in 48 hours
• Negative
• Excludes TB
• May occure in advanced disease

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PATHERGY TEST

• Increased dermal sensitivity to needle trauma
• Behcet syndrome
• Rarely positive in absence of systemic activity
• Pustule formation

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SEROLOGY

• SYPHILIS
• Non-treponemal tests
• RPR or VDRL
• Primary infection
• Monitor disease activity
• Response to therapy

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• Immunofluorescent antibody test
• Haemagglutination test

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Enzyme-linked Immunosorbent Assay (ELISA)

• Antibodies in aqueous (more specific)
• Other conditions (cat-scratch fever
  toxocariasis
• Antinuclear Antibody (ANA)
• In children with JIA who are at high risk of
  developing ant uveitis

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ENZYME ASSAY

• Angiotensin converting enzyme (ACE)
• Nonspecific test
• Granulomatous disease like
• - Sarcoidosis (elevated in 80 in acute)
• - TB
• - Leprosy
• Lysozyme
• Good sensitivity but less speceficity for
  sarcoidosis

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HLA TISSUE TYPING

• HLA type Associated disease
• B27 Spondyloarthropathies
• A29 Birdshot chorioretinopathy
• B51 Behcet syndrome
• HLA-B7 POHS APMPPE
• HLA-DR2

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IMAGING

• Fluorescein angiography (FA)
• Retinal vasculitis
• CMO
• Indocyanine angiography (ICG)
• Better for choroidal disease

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• Ultrasonography (US)
• It is useful in opaque media especially in
  excluding a RD or intraocular mass
• Optical coherence tomography(OCT)
• Detecting CMO
• Identify vitreoretinal traction as a mechanism of
  CMO

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BIOPSY

• Histopathology still remains the gold-standard
• conjunctiva And Lacrimal gland
• - Sarcoidosis
• Aqueous samples
• - For (polymerase chain reaction) PCR
• - Viral retinitis (occasionally)
• Vitreous biopsy
• - Infectious endophthalmitis

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RADIOLOGY

• Chest X-rays
• - To exclude TB and Sarcoidosis
• Sacro-illiac joint X-Rays
• - Diagnosis of spondyloarthropathy
• CT MRI
• - Sarcoidosis
• - Multiple sclerosis
• - Primary intraocular lymphoma

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TREATMENT

• AIM
• Prevent vision threatening complications
• Relieve patients discomfort
• Treat the underlying cause
• FOUR GROUP OF DRUGS
• Mydriatics
• Steroids
• Cyclosporine
• Cytotoxic agents

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TREATMENT

• Mydriatics
• To give comfort
• To prevent formation of posterior synechia
• To break down synechia
• Drugs (atropine, homatropine, scopolamine,
  tropicamide)

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TREATMENT

• Steroids (mainstay of treatment)
• Topical administration
• Complications (glaucoma, posterior sub capsular
  cataract, corneal complications, systemic side
  effects)
• Periocular injections
• Severe acute anterior uveitis
• Adjuvant to topical/systemic
• Poor compliance
• Pre op

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TREATMENT

• Systemic therapy
• Preparations
• Prednisolone 5mg
• Indications
• Rules
• Start with large dose then reduce
• Initial dose 1-1.5 mg/kg BW
• Before breakfast
• Taper off
• Less than 2 weeks abrupt stop

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TREATMENT

• Side effects
• Short term
• Long term

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TREATMENT

• Cyclosporin
• Steroid sparing agent
• Complications are hypertension and nephrotoxicity
• Cytotoxic drugs
• Potentially blinding bilateral reversible uveitis
• Intolerable side effects from systemic steroids
  therapy.

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THANK YOU