Evaluation of the Uveitis Patient
Uveitis
§ Group of inflammatory disease§ Affects multiple eye locations§ Potentially blinding
Evaluation Approach
§ Different uveitis causes, classifications§ Provide accurate description§ Generate differential diagnosis§ Directed ancillary, laboratory testing
Uveitis classification
§ Location§ Severity and course§ Pathology§ Demographics§ Laterality§ Etiology
Example 1
§ 25 yo caucasianman
§ Acute recurrent bilateral NG IC
§ One eye at a time§ Low back stiffness
Example 2
§ 40 yo asian woman§ Chronic bilateral G
panuveitis§ Serous retinal
detachment§ Systemic symptoms
Example 3
§ 50 yo caucasianwoman
§ Chronic G panuveitis
§ Vitritis, deep yellowish lesions
Uveitis Classification
§ Iritis§ Iridocyclitis§ Intermediate uveitis
Uveitis ClassificationPosterior
§ Retinitis§ Retinochoroiditis§ Chorioretinitis§ Choroiditis§ Panuveitis
Uveitis Classification
§ Multifocal (Diffuse )
Let’s Do a Hx and Exam…
Uveitis HistoryDemographics
§ Age § Sex§ Race
Uveitis HistoryHPI
§ Antecedent Events§ Course§ Treatment§ Previous workup
Uveitis History
§ Geography§ Family History§ Personal history:pets, diet, sex, drugs
Uveitis Symptoms
§ Acute IC§ Chronic IC§ Chronic intermediate§ Retinitis/retinochoroiditis§ Chorioretinitis/Choroiditis
Uveitis SignsIOP
§ Acute§ Chronic
Uveitis SignsExternal
§ Conjunctiva/sclera§ Pupil§ Lids
Uveitis SignsExternal
§ Conjunctiva/sclera§ Pupil§ Lids
Uveitis SignsExternal
§ Conjunctiva/sclera§ Pupil§ Lids
Uveitis SignsExternal
§ Conjunctiva/sclera§ Pupil§ Lids
Uveitis SignsSLE:KP
§ Size § Location
TechniquesSlit beam: “optical knife”
Uveitis SignsA/C Cell Grading
§ 0= none§ Occasional=1-4§ 1+=5-9§ 2+=10-19§ 3+=20-50§ 4+=>50
A/C Signs
§ Hypopyon
Uveitis SignsFlare Grading
§ 0=none§ 1+=faint§ 2+=moderate (clear details)§ 3+=marked (hazy details)§ 4+=severe (plastic, fibrin)
Iris
§ Color§ Nodules (koeppe, bussaca)§ Topography§ Vessels§ Synechiae
Iris
§ Color§ Nodules (koeppe,
bussaca)§ Topography§ Vessels§ Synechiae
Iris
§ Color§ Nodules (koeppe, bussaca)§ Topography§ Vessels§ Synechiae
Iris
§ Color§ Nodules (koeppe,
bussaca)§ Topography§ Vessels§ Synechiae
Iris
§ Color§ Nodules (koeppe,
bussaca)§ Topography§ Vessels§ Synechiae
Iris
§ Color§ Nodules (koeppe,
bussaca)§ Topography§ Vessels§ Synechiae
Iris
§ Color§ Nodules (koeppe,
bussaca)§ Topography§ Vessels§ Synechiae
Uveitis SignsSLE:Lens
§ Pigment§ Cataract
Uveitis SignsOphthalmoscopy
§ SLE§ Indirect
Uveitis SignsVitreous Opacity Grading
§ Ophthalmoscopy§ Clarity§ Grading
Vitreous Signs
§ Vitreous cells§ Snowballs§ Snowbanks
Retinal Vessels
§ Arterioles§ Venules§ Neovascularization
Optic Nerve
§ Swelling§ Inflammatory§ Granulomatous
§ Neovascularization
Optic Nerve
§ Swelling§ Inflammatory§ Granulomatous
§ Neovascularization
Optic Nerve
§ Swelling§ Inflammatory§ Granulomatous
§ Neovascularization
Retinitis
§ CMV§ Syphilis§ Toxoplasmosis§ Fungal§ Herpetic
Chorioretinal Scars
§ Sarcoid§ Syphilis§ MCP§ Histo§ AMPPE/Serpiginous§ VKH§ Toxo§ SO
Chorioretinal Scars
§ Sarcoid§ Syphilis§ MCP§ Histo§ AMPPE/Serpiginous§ VKH§ Toxo§ SO
Chorioretinal Scars
§ Sarcoid§ Syphilis§ MCP§ Histo§ AMPPE/Serpiginous§ VKH§ Toxo§ SO
Chorioretinal Scars
§ Sarcoid§ Syphilis§ MCP§ Histo§ AMPPE/Serpiginous§ VKH§ Toxo§ SO
Chorioretinal Scars
§ Sarcoid§ Syphilis§ MCP§ Histo§ AMPPE/Serpiginous§ VKH§ Toxo§ SO
Chorioretinal Scars
§ Sarcoid§ Syphilis§ MCP§ Histo§ AMPPE/Serpiginous§ VKH§ Toxo§ SO
Chorioretinal Scars
§ Sarcoid§ Syphilis§ MCP§ Histo§ AMPPE/Serpiginous§ VKH§ Toxo§ SO
Chorioretinal Scars
§ Sarcoid§ Syphilis§ MCP§ Histo§ AMPPE/Serpiginous§ VKH§ Toxo§ SO
Chorioretinal Scars
§ Sarcoid§ Syphilis§ MCP§ Histo§ AMPPE/Serpiginous§ VKH§ Toxo§ SO
Chorioretinal Scars
§ Sarcoid§ Syphilis§ MCP§ Histo§ AMPPE/Serpiginous§ VKH§ Toxo§ SO
Chorioretinal Scars
§ Sarcoid§ Syphilis§ MCP§ Histo§ AMPPE/Serpiginous§ VKH§ Toxo§ SO
Diagnostic Evaluation of Uveitis
Diagnostic Testing
§ Directed Approach§ Based on differential diagnosis
(Hx,Exam)§ Shotgun testing
Types of Diagnostic Tests
§ Ancillary tests§ Laboratory tests
Ancillary TestsExamples
§ Ultrasound§ OCT§ FA§ FAF§ ICG§ ERG§ VF
Ancillary tests-FA
§ CME§ “White dot syndromes”§ VKH/Scleritis/SO§ Placoid syphilitic uveitis§ AMPPE/serpiginous§ Retinitis
CME Angiographic Characteristics
§ Early coarse perifovealhyperfluorescence
§ Late petalloidleakage
CME Angiographic Characteristics
§ Early coarse perifovealhyperfluorescence
§ Late petalloidleakage
ICG
§ Supports clinical dx§ MEWDS§ Birdshot§ MCP
ICG-hypofluorescent spots
OCT
§ Diagnose, monitor CME
Ultrasonography
§ Macular thickening§ Choroidal
thickening§ Vitreous
hemorrhage§ Retinal detachment§ Pre-surgical
planning
Laboratory TestsExamples
§ Serum chemistry§ Serology§ HLA-typing§ Skin Tests§ Radiological imaging
Radiological Imaging
§ CXR:sarcoid,TB§ CT/MRI
§ MS§ Foreign body§ Lymphoma§ Posterior Scleritis§ Sarcoid
Radiological Imaging
§ CXR:sarcoid,TB§ CT/MRI
§ MS§ Foreign body§ Lymphoma§ Posterior Scleritis§ Sarcoid
Serology
§ Toxocara§ Toxoplasmosis (IgG, IgM)§ Lyme§ Syphilis§ Cat Scratch (Bartonella)
HLA Testing
§ HLA A29: Birdshot§ HLA-B27:AS,PA,IBD, Reiter’s
Diagnostic TestsSkin Tests
§ PPD§ Histo§ Cocci
Diagnostic Vitrectomy
Diagnostic Vitrectomy Indications
§ Negative lab work-up§ Diagnostic uncertainty: CA, infection§ Atypical therapeutic response
IOFB
Paint from car
Uveitis Evaluation Summary
§ Accurate description§ Detailed history§ Orderly examination§ Generate differential diagnosis§ Order directed laboratory tests§ Begin appropriate treatment