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![Steroids
Systemic therapy
Preparations Indications
1- Oral prednisolone • Intractable anterior uveitis
resistant to topical therapy and
* 5 mg is the main preparation. anterior sub-Tenon injections.
* Enteric coated tablets are useful in
patients with acidpeptic disease. • Intermediate uveitis unresponsive
to posterior subTenon injections.
2. Injections of (ACTH]
* Useful in patients intolerant to oral • Certain types of posterior or
steroids. panuveitis, particularly with severe
bilateral involvement.](https://image.slidesharecdn.com/newtrendsinmanagementofuveitis-121218014039-phpapp01/75/New-trends-in-management-of-uveitis-28-2048.jpg)
Uploaded byZakaria Ibrahim
New trends in management of uveitis
The document outlines the management of uveitis, covering general investigations, classifications, and treatment options, including both non-specific and specific therapies. It discusses various types of uveitis, their symptoms, signs, complications, and differential diagnoses, as well as detailed management strategies involving medication, surgical interventions, and targeted treatments based on underlying causes. Additionally, it highlights the importance of proper investigations and the use of immunosuppressive agents in resistant cases.
New trends in management of uveitis
- 1. New Trends InManagement Of Uveitis
- 2. Agenda General Investigations Considerations • Classification •Overview Anatomical •Differential Diagnosis Clinical •Lines Of Investigations Pathological (General & Special : • Etiology/Pathogenesis Skin tests •Symptoms Serology •Signs Enzyme assay •Complications Histopathology Imaging HLA typing
- 3. Management • Non-specific treatment mydriatics Steroids Systemic Immunosuppressive agents Interferons physical measures • Specific treatment of the cause • Treatment of complications : Inflammatory glaucoma Post-inflammatory glaucoma Complicated cataract Retinal detachment of exudative type Phthisis bulbi • Surgical management
- 4. General Considerations Classification Anatomical Anterior Clinical uveitis Acute uveitis Intermediate uveitis Chronic uveitis Posterior uveitis
- 5. General Considerations Classification Pathological Suppurative or purulent uveitis * Non-granulomatous uveitis Non-suppurative uveitis * Granulomatous Uveitis
- 6. General Considerations Etiology Infective Syndromes of Non-Infective unknown etiology Exogenous Endogenous Allergic or Sympathetic Traumatic Autoimmune ophthalmitis
- 7. General Considerations Symptoms Ant. Uveitis Post.Uveitis ( Iridocyclitis ) (Choroiditis ) Acute : Patients are free of pain, • Dull pain in the eye or forehead although they report • Impaired vision blurred vision and floaters • photophobia •E xcessive tearing (epiphora). Choroiditis is painless, as the choroid is devoid of Chronic : sensory nerve fibers. may exhibit minimal symptoms
- 8. General Considerations Signs Acute Iridocyclitis Intense circum-corneal ciliary injection small Pupil Keratic precipitates (KPs) – endothelium dusting by myriads of cells Flare and cells ( often intense ) Fibrinous exudate ( if severe ) Hypopyon ( if very severe ) The iris is usually unremarkable; occasionally shows dilated capillaries
- 10. General Considerations Signs Chronic Iridocyclitis Injection ……… mild or absent Pupil ………. Unremarkable KPs........ mutton-fat in granulomatous disease Flare and cells …….. Variable Fibrinous exudate ……. absent
- 11. General Considerations Signs Post.uveitis (Choroiditis) Vasculitis of retinal vessels is possible Isolated or multiple choroiditis foci. Occasionally the major choroidal vessels will be visible through the atrophic scars No cells will be found in the vitreous body in a primary choroidal process .However, inflammation proceeding from the retina (retinochoroiditis) will exhibit cellular infiltration of the vitreous body
- 13. General Considerations Complications Ant. Uveitis Post.Uveitis Acute : Depends on the underlying disease and * Posterior synechiae (PS) …..> rare at severity of the disease presentation but may form later * Cataract ….> absent The inflammatory foci will heal within 2–6 Glaucoma …..> rare weeks and form chorioretinal scars. The scars will result in localized scotomas Chronic : that will reduce visual acuity if the macula * PS – common at presentation is affected * Cataract – rare at presentation but may develop later * Glaucoma – rare at presentation but may develop later
- 14. Differential Diagnosis It is important to note that uveitis can be caused or mimicked by the following : “Masquerade Syndromes”- neoplasms mimicking uveitis Ocular malignant melanoma Retinoblastoma Reticulum Cell Sarcoma (Primary Intraocular Lymphoma) Leukaemia - Lymphoma - Ocular Metastasis Endophthalmitis Retinal detachment Intraocular foreign body
- 15. Investigations General Investigations ESR / Plasma Viscosity/ C Reactive Protein CXR / FBC / Syphilis Serology: TPHA, VDRL Urine analysis (Diabetes Mellitus)
- 16. Investigations Special Investigations Skin Tests: Tuberclin skin tests pathergy test : for diagnosis of Behcet's syndrome Serology: Syphilis Toxoplasmosis *Dye test (Sabin-Feldeman) * Non treponemal :RPR & VDRL * Immunoflurescent antibody * Treponemal : FTA-ABS & MHA- * Heamagglutination tests TP *ELISA
- 17. Investigations Special Investigations Enzyme assay Imaging Biopsy: Ocular biopsies : * (ACE) * Flurescin angiography *Lysozyme has good * Conjunctiva and * Iodocyanine green lacrimal gland sensitivity but less angiography specificity than ACE * Aqueous sample * Ultrasonography (US) * Vitreous biopsy * Optical coherence * Retinal and tornography (OCT) Choroidal biopsies.
- 18. Investigations Special Investigations Radiology: 1. Chest radiographs are to exclude tuberculosis and sarcoidosis. 2. Sacroiliac joint x ray is helpful in the presence of a spondyloarthropathy in the presence of symptoms of low back pain and uveitis. 3- CT and MRI of the brain and thorax are useful in sarcoidosis , multiple sclerosis and primary intraocular lymphoma HLA typing: HLA type Associated disease B27 Ankylosing A29 spondylitis B51 Bircishot HLA - B7& DR2 chorioretinopathy
- 19. Management Non-specific treatment mydriatics Steroids Systemic Immunosuppressive agents Antimetabolites Interferons physical measures Specific treatment of the cause Treatment of complications : Inflammatory glaucoma Post-inflammatory glaucoma Complicated cataract Retinal detachment of exudative type Phthisis bulbi Surgical management
- 20. I.Non-specific treatment Mydriatics Steroids Systemic Immunosuppressive Agents Interferons Physical measures
- 21. Mydriatics Short-acting Long –acting Tropicamide (0. 5% and 1 %)..> 6h Atropine 1% Cyclopentolate (0. 5% and 1 %)..>24 h is the most powerful cycloplegic and mydriatic Phenylephrine (2.5% and l0%) ..> 3h with a duration of action ‘’ but no cycloplegic effects ‘’ lasting up to 2 weeks
- 22. Mydriatics Indications To relieving spasm of the ciliary muscle and pupillary sphincter ( usually with atropine ) To reduce exudation by decreasing hyperaemia and vascular permeability To increases the blood supply to anterior uvea To prevent formation of posterior synechiae by using a short-acting mydriatic which keeps the pupil mobile. To break down recently formed synechiae with intensive topical mydriatics (atropine. phenylephrine) or subconjunctival injections of Mydricaine
- 23. Steroids periocular injection Intravitreal injection Topical eyedrops Systemic or ointment Route of administration
- 24. Steroids Topical Steroids Indications Treatment of acute anterior uveitis Frequently then gradually tapered . Often discontinued by 5-6 weeks Treatment of chronic anterior uveitis is more difficult because the inflammation may last for months and even Complications Corneal systemic side Glaucoma Cataract complications effects
- 25. Steroids Periocular injections Advantages over topical steroids Therapeutic concentrations behind the lens may be achieved. water-soluble drugs incapable of penetrating the cornea when given topically, can enter the eye trans-sclerally. when given by periocular injection along-lasting effect can be achieved with depot preparations such as (methylprednisolone acetate " Depomedrone" ).
- 26. Steroids Periocular injections Indications Severe acute anterior uveitis Intermediate uveitis As an adjunct to topical or systemic therapy in resistant chronic anterior uveitis Poor patient compliance with topical or systemic medication At the time of surgery in eyes with uveitis
- 27. Steroids Intravitreal injection * Intravitreal steroid injection of is currently under evaluation. * It has been used successfully in resistant uveitic chronic cystoid macular oedema.
- 28. Steroids Systemic therapy Preparations Indications 1- Oral prednisolone • Intractable anterior uveitis resistant to topical therapy and * 5 mg is the main preparation. anterior sub-Tenon injections. * Enteric coated tablets are useful in patients with acidpeptic disease. • Intermediate uveitis unresponsive to posterior subTenon injections. 2. Injections of (ACTH] * Useful in patients intolerant to oral • Certain types of posterior or steroids. panuveitis, particularly with severe bilateral involvement.
- 29. Steroids Systemic therapy General rules of administration • Start with a large dose and then reduce . • A reasonable starting dose of prednisolone is 1mg/kg per day given in a single morning dose. • Once the inflammation is brought under control , reduce the dose gradually over several weeks. • If steroids aregiven for less than 2weeks , there is no need for gradual reduction.
- 30. Steroids Systemic therapy Side effects • Dyspepsia • Mental changes short term • Electrolye imbalance • Aseptic necrosis of the head of the therapy femur , and very rarely • Hyperosmolar , Hyperglycemic non- ketotic coma • A Cushngoid state Long term • • Osteoporosis Reactivation of infections such as TB therapy • Cataract • Limitation of growth in children
- 31. Systemic Immunosuppressive agents Antimetabolites T-cell inhibitors Indications of Immunsuppressives: 1. Sight-threatening uveitis. Which is usually bilateral , non- infectious , reversible and has failed to respond to adequate steroid therapy. 2. Steroid-sparing therapy in patients with intolerable side effects from systemic steroids.
- 32. Azathioprine Methotrexate Mycophenolate Systemic Immunosuppressive mofetil agents Antimetabolites Indications mainly Behçet disease include variety of alternative to other chronic non-infectious anti- metabolites uveitis Dose 1-3 mg/kg per day (50 mg is 7.5-25mg in a single 1 g per day tabletet) orally once daily or dose once weekly in divided doses. Side effects • bone marrow suppression •bone marrow •gastrointestinal • gastrointestinal suppression disturbance disturbances and •hepatotoxicity and • bone marrow hepatotoxicity. •Pneumonitis suppression. are serious but rarely occur with low-dose administration. The most common side effects are gastrointestinal. Monitoring complete blood count every full blood counts and full blood counts and 4-6 weeks and liver function liver function tests liver function tests tests every 12 weeks every 1-2 months. every 1-2 months
- 33. Interferons Indications Routes of administration & Dose recombinant human IFN-α has • Interferon-α is given by subcutaneous been used with success to treat injection a variety of posterior uveitides, including those associated with • started as a high dose of daily injections then tapered to lower-dose intermittent injections •Behçet • Vogt-Koyanagi-Harada • With this regimen, corticosteroids are disease tapered to as low doses as possible, and other immunosuppressants are •sympathetic ophthalmia and discontinued prior to initiation of IFN-α idiopathic causes. therapy
- 34. Interferons Side effects •The most common side effect of IFN-α therapy is flu-like symptom Significant adverse effects •leukopenia, • alopecia, •elevated hepatic enzymes, •depression, and other central nervous system (CNS) effects • Drug-induced lupus
- 35. Physical measures 1-Hot fomentation Itis very soothing diminishes pain and increases circulation, and thus reduces the venous stasis. As a result more antibodies are brought and toxins are rained. Hot fomentation can be done by dry heat or wet heat. 2- Dark goggles These give a feeling of comfort, by reducing photophobia, lacrimation and blepharospasm.
- 36. II. Specific treatmentof the cause • Unfortunately, in spite of the advanced diagnostic tests, still it is not possible to ascertain the cause in a large number of cases. • So a full course of antitubercular drugs for underlying Koch’s disease, adequate treatment for syphilis, toxoplasmosis etc…, when detected should be carried out. • When no cause is ascertained, a full course of broad spectrum antibiotics may be helpful by eradicating some masked focus of infection in patients with non- granulomatous uveitis.
- 37. III. Treatment ofcomplications Inflammatory glaucoma Post-inflammatory Complicated cataract (hypertensive uveitis) glaucoma
- 38. III. Treatment ofcomplications Retinal detachment of Phthisis bulbi exudative type
- 39. IV. surgical managementof patient with uveitis Surgical indications in the management of uveitis include visual rehabilitation diagnostic biopsy when findings may change the treatment plan removal of media opacities to monitor the posterior segment Despite advances in anti-inflammatory and immunomodulatory therapy, permanent structural changes can occur in the eye that are best managed with surgery (e.g. cataract formation, secondary glaucoma, retinal detachment) In preparing the eye for surgery, medical treatment should be intensified for a minimum of 3 months to achieve complete quiescence of inflammation (i.e. complete eradication of anterior chamber cells, active vitreous cells).