Upload
others
View
3
Download
0
Embed Size (px)
Citation preview
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
49
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
51
P’acnes after treatment
Biofilm adherence…
Clinical pointers to P’ acnes…
52
Poor response to topical steroids…
53
HPE
P’acnes
Lens capsule
Yello tan colonies: Blood agar plate
Beaded Fibrin
strands
P acnes
Sarcoids
Toxo
plasma
Fungal
54
Shifting hypopyon in Behcet’s
55
56
Non shifting hypopyon in infective causes
57
EE :Why bother the colour of hypopyon ?
58
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!
75