Don’t think anterior - apan.net · TB, Herpetic, Hansen’s disease ... Middle Age - Reiter's,...
Transcript of Don’t think anterior - apan.net · TB, Herpetic, Hansen’s disease ... Middle Age - Reiter's,...
Anterior chamber tap done
AC tap showing basophilic cohesive tumour cells suggestive of Retinoblastoma
Hypopyon
55 year old man, developed bilateral hypopyon
Peripheral blood count showed chronic myeloid leukaemia
21 year old girl, immunocompetent
Ant segment
Acute anterior uveitis
K.P.s – small to large
Raised IOP
Vitreous cells
Always dilate and see the fundus including
periphery using depression to rule out ARN,
Pars planitis in anterior uveitis
Clinical Approach to
Anterior Uveitis
Dr Jyotirmay Biswas
Director of Uveitis and Ophthalmic pathology
Sankara Nethralaya
Chennai
ClassificationCLINICAL
Acute / Chronic / Recurrent / Healed
MORPHOLOGICAL
Granulomatous / Nongranulomatous
ANATOMICAL
Anterior / Intermediate/ Posterior/ Panuveitis
ETIOLOGICAL
Etiological Classification
1. Infectious
2. Noninfectious
3. Traumatic
4. Idiopathic
5. Masquerade syndromes
TB, Herpetic, Hansen’s disease
HLA B27 related, JIA related, Sarcoidosis,
Acute tubulointerstitial nephritis and uveitis
Surgical / Non surgical
Fuch’s, Posner-Schlossman
Juvenile xanthogranuloma, leukaemias,
retinoblastoma, IOFB
Age
Children - JIA, Infection, Masquerade - RB
Young Adults - FHU, Idiopathic
Middle Age - Reiter's, Ankylosing spondylitis,
Older Patients – Masquerade syndrome/ Infections
Any Age - Toxoplasmosis,
Sarcoidosis, TB, Syphilis.
Ocular History - Laterality
Unilateral : Fuchs
Traumatic
Herpetic
Lens related
Bilateral : JIA
Unilateral / Bilateral : Sarcoid
TB
History
Systemic History
General S/S – recent illness
Quick Review of systems
DM / HT / IHD / TB/ APD
Specific questions
Joint pains,joint swelling
Low backache
Skin rashes – Sarcoidosis, psoriasis, Hansen’s
disease, HZO
Recent illness – viral fever/ UTI
Recent dental procedures
In children – recent vaccination
Treatment History
Only eyedrops? – Steroids/ NSAIDs
Any oral medication - steroids/ NSAIDs
Duration of treatment
Current treatment / last dose
Any self medication
Any complications?
Glaucoma – treatment history; current medication
Surgery
TABLE 4. The SUN Working Group Grading
Scheme for Anterior Chamber Flare
0 None
1+ Faint
2+ Moderate(iris &lens details clear)
3+ Marked(iris &lens details hazy)
4+ Intense(fibrin or plastic aqueous)
Grade Description
TABLE 3. The SUN Working Group Grading
Scheme for Anterior Chamber cells
0 <1
0.5+ 1-5
1+ 6-15
2+ 16-25
3+ 26-50
4+ >50
GradeCells in Field (1mm
by 1mm slit beam)
NON-GRANULOMATOUS UVEITIS
Onset - well defined
Course - acute
Injection - +++
Pain - +++
KP's - fine
Iris nodules - absent
Posterior segment -
rarely involved
HLA B 27 related uveitis
GRANULOMATOUS UVEITIS
Onset - insidious
Course - chronic
Injection - +
Pain - +
Iris nodules - +
KP's - mutton fat
Posterior segment –
may be involved
Sarcoid uveitis
HypopyonAnkylosing spondylitis
Behcets disease
Infection
Lens induced uveitis
Malignancy
HLA B 27 ant Uveitis
Hyphaema Viral uveitis
Trauma
Malignancies
Fuchs
Chronic uveitis with
rubeosis
Any severe uveitis
Post anterior
chamber taps
1 2 3 4 5 6 MW
160bp
52 year old being treated with steroids for chronic
postoperative uveitis for 2 years
Nested PCR from AC tap detected
P acnes targeting 16SrRNA region
AC
tap
+ control
High IOP
Chronic angle closure
glaucoma
Pupillary block glaucoma
Glaucomatocyclitic crisis
Viral – herpetic
Toxoplasma
Syphilis
Fuchs heterochromic
iridocyclitis
Steroid induced glaucoma
ANTERIOR UVEITIS
TOPICAL STEROIDS+
MYDRIATIC-CYCLOPLEGICS
NON RESPONDING
SYSTEMIC STEROIDS
IMMUNOSUPPRESSIVE AGENTS
NON RESPONDING
Summary
Take a uveitis oriented history
Complete eye and systemic exam
Identify the anatomic location of the primary
inflammation
Tailored lab investigations that can help
establish etiology and guide management of
the disease
TABLE 3. The SUN Working Group Grading
Scheme for Anterior Chamber cells
0 <1
0.5+ 1-5
1+ 6-15
2+ 16-25
3+ 26-50
4+ >50
GradeCells in Field (1mm
by 1mm slit beam)
TABLE 4. The SUN Working Group Grading
Scheme for Anterior Chamber Flare
0 None
1+ Faint
2+ Moderate(iris &lens details clear)
3+ Marked(iris &lens details hazy)
4+ Intense(fibrin or plastic aqueous)
Grade Description