Post on 31-Mar-2018
transcript
Moncef Khairallah, MD
Department of Ophthalmology
Fattouma Bourguiba University Hospital
Faculty of Medicine, University of Monastir
Monastir, Tunisia
A proper classification of
uveitis is important for:
the everyday practice:
- differential diagnosis
- work-up
- management
- and prognosis
clinical studies
INTRODUCTION
Moncef Khairallah, Tunisia
Classification of uveitis
Moncef Khairallah, Tunisia
Classification of uveitis
Bloch-Michel E, Nussenblat RB. International Uveitis Study Group Recommendations for the evaluation of intraocular inflammatory disease. Am J Ophthalmol 1987;103:234-235 Standardization of Uveitis Nomenclature (SUN) for Reporting Clinical Data. Results of the First International Workshop. Am J Ophthalmol 2005;140:509-516
Structural complications: macular edema, optic disc edema, neovascularization
should not be considered in classifying the anatomic location of the uveitis
Type Primary site of Entities inflammation Anterior uveitis Anterior chamber Iritis Anterior cylitis Iridocyclitis
Intermediarte uveitis Vitreous Parsplanite Cyclitis postériure Hyalite Uvéite postérieure Rétine ou choroïde Focale, multifocale, ou choroïdite diffuse Chorio-rétinte Retinochoroïdte Rétinite Neurorétinite Panuveitis Chambre antérieure, vitré, et
Anatomic classification
Cells and flare in AC Keratic precipitates (KPs)
Posterior synechiae
• Clinical features
Moncef Khairallah, Tunisia
Classification of uveitis
Type Primary site of Entities inflammation
Anterior uveitis Anterior chamber Iritis Anterior cyclitis
Iridocyclitis Vitreous Intermediate inflam.vitreous base Old terms: Posterior cyclitis
uveitis Hyalitis, basal RC Pars planitis (due to infl. of the vitreous base)
ou choroïdite diffuse Chorio-rétinte Retinochoroïdite Rétinite
Anatomic classification
Vitritis Snowballs Snowbank Periph.vascular sheathing CME Optic disc swelling Absence of focus of CR
•Clinical features
Moncef Khairallah, Tunisia
Classification of uveitis
Type Primary site of Entities inflammation
Anterior uveitis Anterior chamber Iritis Iridocyclitis Anterior cylitis Pars planitis Intermediate uveitis Vitreous Posterior cyclitis Hyalitis
Posterior uveitis Retina or choroid Focal, multifocal, or diffuse choroiditis Chorioretinitis Retinochoroiditis Retinitis, vasculitis Neuroretinitis
Anatomic classification
Moncef Khairallah, Tunisia
Classification of uveitis
Type Primary site of Entities inflammation
Anterior uveitis Anterior chamber Iritis Iridocyclitis Anterior cyclitis
Intermediate uveitis Vitreous Pars planitis Posterior cyclitis Hyalitis Posterior uveitis Retina or choroid Focal, multifocal, or diffuse choroiditis Chorioretinitis Retinochoroïditis Retinitis, vasculitis Neuroretinitis
Panuveitis Anterior chamber, vitreous, and retina or choroid
Anatomic classification
Moncef Khairallah, Tunisia
Classification of uveitis
This distinction is important and useful in orienting
the work-up and differential diagnosis of uveitis
Non-granulomatous uveitis Granulomatous uveitis
Moncef Khairallah, Tunisia
Classification of uveitis
Fine KPs producing endothelial dusting
Fibrinous clotting or hypopion in severe cases
Posterior synechiae: common if severe inflammation
Non-granulomatous uveitis
Moncef Khairallah, Tunisia
Classification of uveitis
Most common causes of non-granulomatous
uveitis:
- HLA B27 related uveitis
- Behçet’s disease
- Juvenile idiopathic arthritis
- Uveitis associated with scleritis
Non-granulomatous uveitis
Moncef Khairallah, Tunisia
Classification of uveitis
KPs larger than the dusty KPs Iris nodules
Koeppe
Fine to medium size
Medium size
Large size
(mutton-fat KPs)
Busacca
Granulomatous uveitis
Moncef Khairallah, Tunisia
Classification of uveitis
Most common causes of granulomatous uveitis:
- Sarcoidosis
- Tuberculosis
- Syphilis
- Herpetic uveitis
- Fuchs uveitis
- Toxoplasmosis
- Posner-Schlossmann syndrome
Granulomatous uveitis
Moncef Khairallah, Tunisia
Classification of uveitis
Not an absolute classification:
a granulomatous uveitis may initially present as
non-granulomatous
Moncef Khairallah, Tunisia
Classification of uveitis
On characteristics of uveitis
On degree of inflammation and activity
of uveitis
On visual damage
On response to therapy
On complications
Moncef Khairallah, Tunisia
Classification of uveitis
Category Descriptor Comment
Onset Sudden
Insidious
Duration Limited ≤ 3 months duration
Persistent > 3 months duration
Course Acute Episode characterized by sudden onset and
limited duration
Recurrent Repeated episodes separated by periods of
inactivity without treatment ≥ 3 months in
duration
Chronic Persistent uveitis with relapse in < 3 months
after discontinuing treatment Moncef Khairallah, Tunisia
Classification of uveitis
Anterior
chamber cells
Anterior
chamber flare Vitreous cells Vitreous flare (Haze)
Moncef Khairallah, Tunisia
Classification of uveitis
Clinical classification
Term Definition
Inactive Grade 0 cells
Worsening
activity
Two step increase in level of inflammation (e.g
anterior chamber cells, vitreous cells or haze) or
increase from grade 3 + to 4 +
Improved activity Two step decrease in level of inflammation (e.g.
anterior chamber cells, vitreous cells or haze) or
decrease to grade 0
Remission Inactive disease for ≥ 3 months after
discontinuing all treatments for eye disease
Moncef Khairallah, Tunisia
Classification of uveitis
Alterations noted on: visual
acuity (from… to….. ), visual
field, electrophysiology testing
The visual damage can be :
- Severe: if visual loss is ≥ 50% than predisease vision or if there is a ≥ 50% loss of the ERG amplitudes from normal
- Mild: if visual loss is < 50 % from baseline or if ERG amplitudes are decreased by < 50%
Moncef Khairallah, Tunisia
Classification of uveitis
Responsive
Resistant to anti-infectious treatment (infectious uveitis)
Resistant to corticosteroid therapy ( No clinical
improvement or worsening despite 2 weeks of treatment
with maximum dose )
Corticodependent: Yes (how much is needed?), No
Resistant to immunosuppressive therapy: No clinical
improvement despite a trial of at least 3 months
Moncef Khairallah, Tunisia
Classification of uveitis
Simple uveitis
Complicated uveitis :
cataract, ocular
hypertension, cystoid
macular edema, others
Associated systemic
complications: Yes or No
Moncef Khairallah, Tunisia
Classification of uveitis
The etiology of uveitis:
Needs to be recognized
Using a systematic approach, based on epidemiological data, history, a comprehensive ocular and physical examination, and guided tests
A masquerade syndrome should be excluded
An infectious cause should always be considered
and ruled out first
Moncef Khairallah, Tunisia
Classification of uveitis
1. Infectious (11 à 52 %)
2. Systemic non-infectious
3. Specific ocular entities
4. Idiopathic (30 to 50%)
Moncef Khairallah, Tunisia
Classification of uveitis
Clear, standardized classification and proper terminology are
important for clinical practice and research
The IUSG and SUN classifications are important steps in
the standardization process, but further clarifications and
rectifications are needed
Moncef Khairallah, Tunisia
Classification of uveitis
Thank you for your attention