www.ophthalclass.blogspot.com has the complete class on uveitis for undergraduate medical students. This presentation is the fourth in the series and deals with the management of uveitis.
Radiation Dosimetry Parameters and Isodose Curves.pptx
Management of uveitis
1. Management of uveitis
DR. ANUPAMA KARANTH
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2. Anti-inflammatory agents
‘-itis’ = inflammation
Treatment : stop inflammation
Use anti-inflammatory drugs
Most potent of such agents : Corticosteroids
Corticosteroids are the mainstay of therapy in uveitis
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3. Complicating the issue
What if the cause is infectious?
Specific anti-infective agent is indicated
Corticosteroids may even worsen the infection when given
alone
When the cause is immune related?
Corticosteroids will be effective
Associated side effects maybe significant
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4. Management of uveitis
Finding the etiology
Narrow down list of differentials by history and examination
Appropriate investigations (ocular and systemic)
Referrals for systemic associations
Treating the inflammation
Specific therapy
Non-specific therapy
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5. Few ocular investigations
Fundus fluorescein angiogram
• Cystoid macular edema (complication)
• Serpiginous choroidopathy (pattern of lesion)
Ultrasonography
• Especially in cases of media opacities
Ocular tissue analysis
• Aqueous tap
• Vitreous tap
• Chorioretinal biopsy
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11. Cycloplegic mydriatics
To relieve ciliary spasm and pain
To prevent posterior synechiae and break the ones already
formed
Partly broken posterior synechiae
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12. Cycloplegic mydriatics
Shorter acting
Tropicamide eye drops (effective up to 3 hrs)
Cyclopentolate drops (up to 24 hrs)
Longer acting
Homatropine eye drops (up to 4 days)
Atropine eye drops (up to 7-14 days)
Cycloplegia relieves pain and a mobile pupil prevents posterior synechiae www.ophthalclass.blogspot.com
13. 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
‘Use enough soon enough’
To always start with a higher dose and taper before stopping
To investigate before starting
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15. Complications of corticosteroids
Topical Periocular Systemic
As for topical
As for topical
Cataract Weight gain
Peptic ulcer
Ptosis
Osteoporosis
Glaucoma Diabetes
Scleral perforation
Hypertension
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16. Immunosuppressives
In corticosteroid resistant or intolerant cases
In vision threatening inflammations - as first line
Specific cases
Beh et’s syndrome
Sympathetic ophthalmitis
VKH syndrome
Necrotizing sclerouveitis
Adverse reactions can be severe and life threatening
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17. Immunosuppressives
Alkylating
Antimetabolites T-cell inhibitors
agents
Methotrexate Cyclophosphamide Cyclosporine
Azathioprine Chlorambucil Tacrolimus
Watch out for nephrotoxicity, hepatotoxicity and marrow toxicity www.ophthalclass.blogspot.com
18. Surgery in uveitis
Diagnostic
AC tap
Vitreous biopsy
Chorioretinal biopsy
Therapeutic
Cataract
Glaucoma
Retinal detachment
Vitrectomy
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20. Management of complications
Cataract surgery
If no active inflammation for at least 3 months
Perioperative steroids
Heparin surface modified IOLs
Glaucoma
Anti-glaucoma topical medication
Peripheral iridotomy / iridectomy in iris bombé
Trabeculectomy with mitomycin C or 5 fluorouracil
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21. Management of complications
Cystoid macular edema
Control of inflammation - corticosteroids
NSAIDs
Pars plana vitrectomy if persistent vitritis
Hypotony
Intensive corticosteroids and cycloplegia
Pars plana membranectomy for cyclitic membrane
Vitreous opacification
Pars plana vitrectomy
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23. Anterior uveitis
35 yr old male
Ciliary congestion, fine KPs, AC flare, posterior synechiae and
hypopyon in RE
Similar history of redness a year ago
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29. Intermediate uveitis…
Management
Lymph node biopsy
Caseating granulomatous lesions
Physician diagnosis - tuberculosis
Systemic management
ATT – fever responded within 4 days
Ocular management
On 1 week follow up, vision drop of 2 lines
Systemic corticosteroids under cover of ATT for short period (1mg/kg
body wt of prednisone, tapered and stopped within 4 weeks)
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30. Posterior uveitis
35 year old, HIV positive female
Sudden painless loss of vision RE
Ocular examination
Spill over fine KPs
CMV retinitis in the fundus
CD4 count – 50
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