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1、Uveitis and Systemic Disease,Classification When to investigate ? Common Causes Systemic associations,Uveitis and Systemic Disease,Uveitis,Uveitis, a term correctly used to describe inflammation of the uveal tract (iris, ciliary body, choroid) alone, in reality comprises a large group of diverse dis
2、eases affecting not only the uvea but also the retina, optic nerve and vitreous. Uveitis is a major cause of severe visual impairment and has been estimated to account for 10-15% of all cases of total blindness in the USA. In surveys of the causes of blindness uveitis has usually not been included a
3、nd is probably underestimated,Uveitis and Systemic Disease,Complications from chronic uveitis,Complications from chronic uveitis are common and may result in severe visual loss Macular oedema can complicate any type of uveitis and can cause substantial visual loss. Cataract is common in chronic uvei
4、tis and its treatment with corticosteroids. Techniques for cataract surgery and perioperative management have improved greatly, and most patients with uveitis are now suitable for intraocular lens implantation and do well.18 Glaucoma is the most overlooked complication of chronic uveitis and has sev
5、eral causes.19 Medical management with topical agents such as blockers control the elevation of intraocular pressure in most patients. Some patients also require oral carbonic anhydrase inhibitors, while surgical intervention is reserved for those who have progressive visual loss or uncontrollable i
6、ntraocular,Uveitis and Systemic Disease,Uveitis and Systemic Disease,Uveitis and Systemic Disease,Uveitis and Systemic Disease,Uveitis and Systemic Disease,Uveitis and Systemic Disease,Uveitis and Systemic Disease -History and examination,When to investigate,One of the most pressing questions that a
7、rises in the mind of every ophthalmologist who sees a new case of uveitis is “what is the cause of this disease?“ In evaluating patients with uveitis, the ophthalmologist must consider that a lengthy list of infections, autoimmune systemic diseases, distinctive inflammatory conditions and masquerade
8、 syndromes may all cause uveal inflammation. Despite this array of potential diagnoses, the vast majority of patients have disease that defies categorisation.,Uveitis and Systemic Disease-avoid a shotgun approach to investigation ! Do not wade in like John Wayne !,General Investigations,A recent ret
9、rospective review of patients with various types of uveitis showed the following abnormal results: full blood count: 23/113 (20.3%), plasma viscosity / ESR: 37/108 (34.2%), VDRL/TPHA: 3/70 (4.3%), angiotensin converting enzyme (ACE): 9/77 (10.8%) and chest x-ray (CXR): 15/103 (14.6%). Sarcoidosis wa
10、s diagnosed in eight patients who had an abnormal CXR raised ACE. All patients with symptoms of other organ system dysfunction or general malaise should be investigated to rule out under-lying systemic disease.,Uveitis and Systemic Disease,Uveitis and Systemic Disease,Uveitis and Systemic Disease,HL
11、A-B27 disease.,Debate exists as to whether patients with the commonest type of uveitis (acute anterior uveitis - AAU) should be investigated. It is well recognised that approximately 50% of patients with AAU are HLA-B27 positive. A number of these patients will give a history of an associated HLA-B2
12、7 disease. HLA-B27-associated AAU often presents with a number of clinical clues which help in diagnosis: it is usually recurrent, unilateral but alternating, with severe anterior chamber inflammation (posterior synechiae, fibrin and hypopyon).,Useful investigations for chronic uveitis,Chest x ray D
13、iagnosis of tuberculosis, sarcoidosis, lymphoma, lung carcinoma Syphilis serologyDiagnosis of syphilis HLA-A29Diagnosis of birdshot chorioretinopathy Mantoux testAnergic response despite prior BCG vaccination is consistent with sarcoidosis. Strong positive response without prior vaccination suggests
14、 exposure to tuberculosis HIV serologyIf patient of high risk status or clinical picture suggests HIV related uveitis such as cytomegalovirus retinitis Lyme disease serologyIf patient from endemic area or with history of exposure and suggestive symptoms Antinuclear antibodiesIf clinical picture sugg
15、ests juvenile chronic arthritis ANF ANCA Rhem Factor Aqueous and vitreous biopsiesDiagnosis of infective endophthalmitis and intraocular lymphoma,Uveitis and Systemic Disease,Ankylosing Spondylitis30% of AS patients develop iritis, especially if male; iritis may precede arthritis rarely retinal vasc
16、ulitis / vitritis. Acute anterior uveitis lasting 2-6 weeks, good prognosisInvestigations in suspected ankylosing spondylitis X-ray sacroiliac joints HLA B27 (positive in more than 90% ),Uveitis and Systemic Disease,Associations of Reiters SyndromeOccurs if genetically predisposed (HLA B27); 60 - 90
17、% association MF Exposure to certain urethritis / dysentery organisms: e.g. Chlamydia, Yersinia, Shigella, Salmonella, Campylobacter. The order of manifestation is normally: urethritis conjunctivitis arthritis. Ocular 20% anterior uveitis, 60% conjunctivitis, episcleritis, keratitis, post-uveitis. Reiters disease can sometimes result in hypopyon formation,
