Investigations in anterior uveitis · 2018-08-11 · Sarcoidosis River water Granuloma Mantoux/HRCT...

Current approach of Investigations in anterior uveitis

Dr.S.Bala Murugan

Consultant

Aravind Eye Hospital

Pondicherry

26% of anterior uveitis > systemic disease;

Hence a complete and

thorough evaluation is warranted.

Why investigate anterior uveitis?

Discern type of anterior uveitis

Non granulomatousGranulomatous

Adult Children

HLA B27HLA B 27

ANA

PPD/ CXR

ACE

VDRL / FTAbs

PPD/ CXR

ACE

Urine: B2 microglobulin

If you don’t know

what you are looking for,

you may not find an answer

or

worse you may find the

wrong one

WHY INVESTIGATE

UVEITIS

Provides a 'definitive' etiology

Identify underlying systemic disease

Confirm/ reject a

diagnosis

Helps in the RX

1. When etiology is clear

2.Traumatic anterior uveitis

3.??Fuch’s anterior uveitis

4. First attack of low grade anterior nongranulomatous uveitis

When is investigations of anterior uveitis

NOT required?

What happens if you do not order the correct diagnostic tests as required?

Topical steroids

H/o native t/t for injury

with vegetable

matter

Fungal uveitis

42 year lady C/O Pain, redness,

BCVA 6/36

Do we need to read articles to investigate

anterior uveitis?

26 /M with poor personal hygiene presented with….

Before we investigate….Basics in uveitis

10 yr old girl

Nil systemic

Recurrent attacks left eye

Transient response to topical

steroids

Tuberculosis

Leprosy

Sarcoidosis

River water Granuloma

Mantoux/HRCT chest-Normal

S,ACE-Normal

No skin changes

History of bathing in pond

PCR from AC granuloma

Subtle findings matters! VARIATION IN ANTERIOR CHAMBER DEPTH

Peripherally shallow

Centrally deep

UBM > CYCLITIC MEMBRANE

CONFIGURATION OF Keratic precipitates

Rule out Pseudo FUCH’S:Syphilis, sarcoid

Immune rings in chronic CMV infections

Perform AC tap for viruses

Posner schlossman syndrome

HLA B27 anterior uveitis

Proven AS / HLA B 27 population

80 to 90% of patients with AS >

positive for HLA-B27

10-15% of people with HLA-B27 gene

End up developing AS /

spondyloarthritis.

10-20% of patients > will test

negative for HLA B27

Iris nodules gives a wonderful clue

Koeppes = Both granulomatous and non granulomatous

Bussaca’s indicates granulomatous uveitis

Angle KPs= Berlin’s sign

Order Gonio=

Tent shaped PAS

Lisch’s nodules> order investigations for NF

BRUSCH FELD FLECKS> DOWN’S SYNDROME

To sum up…

Drug induced anterior uveitisOral Moxifloxacin induced

anterior uveitis!

BADI vs BAIT

PS smeared on ALC with broad

base

Drug history is crucial!

45/ M, acute fibrinous

anterior uveitis

Uveitis work up: not

contributory

???

???21/ F NG ANT uveitis+ scleritis

Anterior endophthalmitis/? TASS

Masquerades as anterior uveitis

Focus on the atypicality!

Lens induced anterior uveitis

Courtesy:

Prof.J.Biswas

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Following treatment

Lens induced uveitis

Light microscope:

Macrophages laden with lens

matterLucid vitreous in B-Scan

Investigations guided by findings in anterior exam> Pseudophakia induced uveitis OCT-

CME

AS-OCT > Haptic eroding iris

Gonio: No angle erosion

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P’acnes after treatment

Biofilm adherence…

Clinical pointers to P’ acnes…

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Poor response to topical steroids…

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HPE

P’acnes

Lens capsule

Yello tan colonies: Blood agar plate

Beaded Fibrin

strands

P acnes

Sarcoids

Toxo

plasma

Fungal

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Shifting hypopyon in Behcet’s

55

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Non shifting hypopyon in infective causes

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EE :Why bother the colour of hypopyon ?

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Which presentation in uvea is complete without TB AND SYPHILIS ?

PPD/ IGRA/PCR/ DIRECT EXAMINATION/Biopsy/Chest

imaging

JIA associated anterior uveitis

ANA RA FACTORIncreased

ESRPauciarticular

type

45/F. Defective Vn, Obese,Diffuse Gr STELLATE KPS

Gonio: Tent shaped

PAS

Biopsy

mandatory?

LFT not useful outside Japan

Babu et al. [30] showed hilar lymphadenopathy and fissural nodules were significantly more common inocular sarcoidosis patients compared with ocular tuberculosis on high-resolution chest computerizedtomography.

HRCT : Tell me a sign that suggests

Sarcoid > TB

Hilar lymphadenopathy / fissural nodules

TINU : Urinary alpha1- and beta2-macroglobulin!

Krebs von den Lunge-6 (KL-6) is a human glycoprotein ELEVATED

IN TINU/ SARCOID

HPE-renal biopsy of TINU

H & E stain:

widespread interstitial inflammation with a predominant mononuclear cell infiltrate

What is the recent advance?Identify the cell type in AC!

BASELINE WORK UP

Total leukocute

count

Differential count

Erythrocyte sedimentation

rate

PPD/IGRA VDRL/TPHAChest X ray /

Imaging adjuncts

S.ACE / S.Lyzozyme

Thank you!

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