UVEITIS-MANAGEMENT

BY JOE P JOHN 2OO9 BATCH

WORKUP & EVALUATION

Lab workup is not necessary in all cases {e.g. mild, unilateral non-granulomatous uveitis or a known predisposing systemic disease} Indications for requesting lab studies: Unremarkable history and physical examination Bilateral uveitis Granulomatous uveitis Recurrent uveitis

LAB STUDIES

CBC,ESR {NON-SPECIFIC} ANA{autoimmune disorders} SERUM ACE,lysosyme{Sarcoidosis}

CBC,ESR {non-specific}

ANA {autoimmune disorders}

Serum ACE,lysosyme {Sarcoidosis} HLA-B27 {Seronegative spondyloarthropathies} HLA-B5 {Behcets diaease} VDRL,RPR,FTA-ABS {Syphilis} PPD {Tuberculosis , Sarcoidosis} HIV antibody {AIDS}

IMAGING STUDIES

Chest X-ray is indicated if tuberculosis or sarcoidosis is considered

..

Sacroiliac X-ray is indicated if HLA- B27 related diseases are suspected

Brain MRI may be needed if multiple sclerosis is a

possibility.{ intermediate uveitis}

Fluorescein angiography or ocular sonography may

be needed in certain types of posterior uveitis

TREATMENT
1.

Aims of therapy : To prevent vision threatening complications

2.
3. a) b)

To relieve patients discomfort

To treat underlying cause It includes Physical measures Non specific treatment

c)
d)

Specific treatment
Treatment of complications


i.

Physical measures Hot application : diminishes pain, increases circulation

ii.
a)

Dark goggles : to reduce photophobia

Non specific treatment Cycloplegic mydriatics: to relieve ciliary spasm, To prevent posterior synechiae and break the ones already formed Atrophine1% eye ointment OR drops instilled 2-3 times per day

A.

B.

In atropine allergy 2% homatrophine OR 1% cyclopentolate instilled 3-4 times per day

For more powerful cycloplegic effect 0.25 ml sub conjunctival injection of mydriacin

C.

.
D.

Mydriacin(a mixture of atropine,adrenaline and procaine)

E. b) i.

Cycloplegics is continued for 2-3 weeks

Corticosteroids-the mainstay of therapy

Depending on the site of inflammation and severity Topical Periocular Systemic

Topical drops will not be effective for intermediate ,

posterior and panuveitis

TOPICAL CORTICOSTEROIDS

Commonly used: dexamethasone, prednisolone In iridocyclitis Actions: Anti inflammatory action, Anti allergic, Fibrinolytic,

Decrease vascularity

Dose: 1. 0.5-2% drops &ointment/3h 2. 10 mg/cc subconjunctival inj.twice per week

Side effects : Cataract, glaucoma

PERIOCULAR

INJECTIONS

Triamcinolone acetonide 40

mg/ml

Methylprednisolone 80mg/ml Able to reach therapeutic

concentration behind lens

In cystoid macular oedema, severe anterior

uveitis,intermediate uveitis

Complications:scleral perforation, ptosis

SYSTEMIC CORTICOSTEROIDS

Methylprednisolone 60-100mg/day for 2 weeks

In suppurative iridocyclitis, staph. Foci

Complications : weight gain, peptic ulcer, osteoporosis,diabetes,hypertension Both topical and systemic are gradually tapered at weekly interval and continued for 6-8weeks Analgesics and NSAIDS : if corticosteroids is contraindicated

Immunosuppressives
In corticosteroid resistant or intolerant cases
In vision threatening inflammations as first line Specific cases Behcets syndrome,sympathetic ophtalmitis,vkh syndrome,necrotising sclerouveitis Antimetabolites:methotrexate,azathioprine Alkylating agents:cyclophoshamide,chlorambucil

T-cell indicators:cyclosporine,tacrolimus

SPECIFIC TREATMENT

Etiology dependent ATT - Tuberculosis Parenteral penicillin - Syphilis

Sulfa and pyrimethamine - Toxoplasmosis

IV Ganciclovir - CMV retinitis

Treatment of complications
Inflammatory glaucoma : 0.5% timolol maleate eyedrops twice a day and tab acetazolamide 250mg thrice a day + usual treatment of iridocyclitis Post inflammatory glaucoma : laser iridotomy or surgical iridectomy Complicated cataract : lens extraction Phthisis bulbi : Enucleation operation

Thank you