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ptometrists and opticians need to have a strategy for dealing with uveitis. This article will help you to develop a game plan before you are obliged to deal with the uveitis patient on the other side of the slit lamp in your consulting room. You dont need to be afraid of uveitis and it is important not to panic. If you are systematic and thoughtful, you can be amazingly helpful to the patient, GP and your local ophthalmology department. The first and most important question you must ask yourself when you discover intraocular inflammation should be is this an incidental finding at a routine sight test or a symptomatic presentation?. If you divide all uveitis patients into these two categories it will help you enormously. Differential diagnosis There are many different types of uveitis and the style of presentation will often point to a diagnosis. An asymptomatic adult patient with no particular complaints who attends for routine refraction with cells in the anterior chamber will probably have Fuchs uveitis syndrome (FUS). The absence of photophobia, the absence of posterior synechiae, the lack of redness, lack of pain and the presence of characteristic stellate KPs (star shaped keratic precipitates on the corneal endothelium, Figure 1) all help to confirm the diagnosis of FUS. Heterochromia is really quite rare and iris changes are often subtle or absent, so dont be flummoxed if the iris looks virtually the same in both eyes. Secondary glaucoma is also quite uncommon, so dont expect a high pressure in the affected eye. Unilateral posterior subcapsular cataract is commonly found in the visual axis of the affected eye. Vitritis can also be present and patients may confirm the presence of floaters when prompted. Fuchs is
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almost always a uniocular condition and remains confined to the one eye through the course of the disease. Bilateral FUS can occur occasionally but both eyes are affected from the outset. Sequential involvement of the two eyes separated over time is unheard of in FUS. You can make a routine referral for these patients on a GOS18.
History
History For all other presentations of uveitis you must take a meticulous history and make a thorough examination. In the majority of cases the history will actually tell you whats going on and the examination can be used to confirm or refute your working diagnosis.
Systemic questions at presentation 2
History of first episode Painful, aching, tender Photophobic, watery Period of onset variable Vision blurred Absence of foreign body sensation
Systemic questions at presentation 1 Have you ever heard of: Ankylosing spondylitis? Reiters syndrome? Psoriasis? Ulcerative colitis/Crohns disease? Have you got any joint pains/ arthritis? What general problems have you? What medicines do you take?
Do you get low back pain? Is your back stiff when you awake? Do you get sore joints? Do you have sore feet? Any ulcers in mouth or elsewhere? Tick bites, cat scratches, vet On Rx for atypical mycobacteria? Clarithromycin and rifabutin?
Direct questions to ask exposure?
First or recurrent episode? Episode frequency and severity? Only ever been in one eye? Or both? Both simultaneously or at different Whats the vision like between
episodes? times?
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Figure 2 Photophobia makes it difficult for patients to keep their eyes open
Acute First episode, unilateral First episode, bilateral Recurrent episodes cute presentation of chronic A Sub-acute and overspill Chronic/rare/weird/esoteric/arcane
condition
First or recurrent episode? Episode frequency and severity? Only ever been in one eye? Or both? oth simultaneously or at different B hats the vision like between W
episodes? times?
Here are some key questions you should ask. Have you ever had anything like this before? This question can save you a lot of time and effort. Find out if the patient has ever had anything similar before, and if so, did they attend the Hospital Eye Service? Has someone already made a diagnosis? You need to decide whether this is a first presentation or a recurrent problem. Ask what happened, when it happened, what was the sequence of events and ask if both eyes are affected or just one. Did the problems come on rapidly over one or two days? Or is it difficult to be precise about the onset of symptoms, which have developed over a few weeks or months? Is the eye painful what sort of pain? Does the pain increase on accommodation or in direct light? If the patient is photophobic, (Figure 2) ask if the photophobia is mild or severe. Is there a family history of arthritis or joint problems? Does the patient have any other diseases which may be associated with uveitis? Any joint problems, skin problems, bowel problems or frequent mouth ulcers (Figure 3)? Do they take any prescription medicines especially eye drops prescribed at the eye clinic or
by the GP? Ask specifically if the patient has ever heard of: Ankylosing spondylitis Psoriasis or psoriatic arthritis Reactive arthritis Reiters syndrome Sarcoid or sarcoidosis Behets disease Do they know anyone with a chronic cough or a diagnosis of TB? By now you should have arrived at a differential diagnosis. If somebody has a prior history of recurrent acute anterior uveitis, and they present with a painful
photophobic red eye, then ask if this episode feels just the same as the previous time(s). Foreign-body sensation implies corneal or conjunctival irritation and is most unusual in iritis or uveitis, so use this question to help differentiate between keratoconjunctivitis and intraocular inflammation. Categorise the patients presentation as one of the following: Incidental finding in a patient with few or no symptoms Recurrent episode of an acute presentation with pain and photophobia First ever presentation of a painful photophobic red eye Slow onset, subacute or chronic presentation with a known diagnosis Hitherto undiagnosed chronic uveitis without symptoms Hitherto undiagnosed chronic uveitis with vision affected. Signs Use your examination to corroborate, confirm or refute the working hypothesis you have developed with your history and direct questions. Are the eyes red? Is only the affected eye red? Is there the typical ciliary blush or circumciliary injection of acute anterior uveitis? (Figure 4). Specific signs to look for are keratic
Figure 6 Hypopyon
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Examination
Photophobia Red painful eye (s) Circumciliary injection/ciliary blush Keratic precipitates Cells/hypopyon Flare Aqueous appearance Miosed pupil
Possible immediate complications of acute anterior uveitis
Figure 7 Choroidal and retinal changes secondary to TB
Posterior synechiae Iris bomb Secondary glaucoma Angle closure Uveitic Steroid induced
Possible late complications of recurrent acute anterior uveitis
Band keratopathy Seclusio pupillae Secondary glaucoma damage dvanced glaucoma after repeated A ataract (Initially posterior subcapC Hypotony Phthisis
sular, eventually, white mature LO) episodes
Figure 8 Always examine the fundus in uveitis patients. This image shows pathognomonic candlewax dripping appearance of retinal phlebitis in sarcoidosis
down pupil, as established synechiae are unlikely to shift (Figure 10). Intermediate uveitis Intermediate uveitis (IU) is almost always a bilateral condition. The hallmark is the presence of cells in the anterior vitreous of both eyes. To see these cells you have to focus on the posterior lens then push forward very slightly with the slit-lamp joystick. You will see cells if they are there. There are often a few cells in the AC, but the diagnosis can be clinched by examining the inferior peripheral vitreous. Pale clumps of inflammatory cells hanging relatively immobile anchored in the vitreous close to the retinal surface are called snowballs and they are pathognomonic of IU. Occasionally there may be pale infiltrates in the inferior pars plana too, which is why IU is sometime called pars planitis. Decide whether the vitreous is clear or murky. Are the retinal details easily seen or are they unclear because of vitreous haze. Dont get hung up on a classification of the vitritis, but rather decide if it is mild or severe. Its best not to get too deeply involved in discussions about IU. Roughly 30 per cent of cases are idiopathic, 30 per cent are associated with sarcoid and 30 per cent associated with multiple sclerosis. The other 10 per
Figure 9 Slit-lamp appearance of iris bomb as a result of seclusio pupillae. (360-degree posterior synechiae). Discuss with on-call ophthalmologist immediately
down through 360, a situation called seclusio pupillae then you may see iris bomb (Figure 9). The iris looks like a ring doughnut seen from above. Although the intraocular pressure can be very high in acute iris bomb, normal or low pressure is often seen if the situation has been present for a while. Dont be surprised if dilating drops do not work effectively on a stuck
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1 2 3
Which of the following is NOT associated with acute anterior uveitis? A Ciliary flush B Aqueous cells and flare c Mydriatic pupil D Photophobia Which of the following are characteristic of Fuchs uveitis syndrome? A Photophobia B Posterior synechiae c Redness D Stellate keratic precipitates Which of the following systemic diseases is not associated with uveitis? A Behcets disease B Sickle cell anaemia c Crohns disease D Reiters syndrome
4 5 6
Which of the following is the most likely cause of mutton fat KPs? A Chronic granulomatous anterior uveitis B Pars planitis c Acute anterior uveitis D Fuchs uveitis syndrome Which of the following is an immediate complication of acute anterior uveitis? A Phthisis B Hypotony c Iris bomb D Lens opacification What is the average number of recurrences expected by a patient with recurrent acute anterior uveitis during their lifetime? A One B Three c Six D 10
Successful participation in this module counts as one credit towards the GOC CET scheme administered by Vantage and one towards the Association of Optometrists Irelands scheme. The deadline for responses is November 19 2009
starting medication. They struggle to get an immediate GP appointment and many GPs are reluctant to prescribe appropriate topical steroids for fear of exacerbating undiagnosed conditions like herpes simplex keratitis. The medical insurance organisations regularly publish reports of GPs being sued for treating patients with topical steroids, but they never publish vignettes of the countless patients who have developed complications of iritis because of the delay in commencing appropriate treatment. The most useful thing the optometrist can do when dealing with an acute presentation of iritis is to aggressively
dilate the pupil. The pain and photophobia are largely due to iris spasm, so dilating the pupil relieves the pain and photophobia, breaks any synechiae which may be forming and permits examination of the fundus which is an important part of the evaluation of every uveitis patient. Teifi James runs a regional uveitis
clinic at Calderdale Royal Hospital in Halifax, West Yorkshire. Declaration of interest: Mr James has a financial interest in The EyeBag Company which sells warm compresses which are used in conjunction with mydriatic drops to dilate the pupil in the presence of posterior synechiae
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shrinkage occurs, then the traction exerted on the retina may be responsible for retinal holes or breaks. Most retinal detachments are caused by one or more small breaks or holes in the retina. Fluid may then pass through the hole and separate the photoreceptors from the retinal pigment epithelium (Figure 1). Light perception is impaired, and patients will perceive a blind spot (scotoma). If the area of detachment extends, the blind spot will also increase in size. Vision will deteriorate as the impaired light perception obscures the whole visual field. Although some shrinkage of the vitreous body occurs naturally with ageing and usually causes no damage to the retina, abnormal growth of the eye (as in myopia), inflammation or injury may also cause the vitreous to shrink. In most cases, a significant change in the structure of the vitreous body occurs before the development of a retinal detachment.
Causes and risk factors of retinal detachment Retinal holes or breaks occur in about 1 per cent of the adult population each year. Retinal detachment will affect about one in 10,000 people a year. Therefore it can be estimated that a patient with a retinal break or hole has a 1 per cent risk of developing a retinal detachment. Retinal detachment may occur at any age, but more frequently in the middle-aged or elderly. It is also more likely to develop in patients with myopia or a family history of retinal detachments. Severe trauma to the eye, such as bruising or a penetrating wound, may be the cause, but in the great majority of cases, retinal detachment is the result of internal changes of the vitreous associated with ageing. Some retinal detachments are caused by other diseases: tumours (exudative detachments), severe inflammations or complications of diabetes (tractional detachments). These so-called secondary detachments do not cause holes or
Figure 1 Patient 1: ocular coherence tomography (OCT Stratus): imaging of the posterior retina: vertical section of the macula in a retinal detachment not involving the macula
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Figure 2 Patient 2: scanning laser ophthalmoscopy (Optomap): asymptomatic temporal superior retinal detachment detected by retinal image screening, macula is still attached
Figure 3 Patient 1: scanning laser ophthalmoscopy (Optomap): superior retinal detachment before surgery, macula still attached
detachment are treated by gas injection alone (pneumatic retinopexy). The retina is reattached by injection of expanding gas into the vitreous cavity (a procedure that can be performed under local anaesthesia) followed by careful positioning of the head. Once the retina is reattached, the retinal break or hole can be sealed by laser photocoagulation or cryotherapy. However, this procedure does not relieve the traction exerted by the vitreous on the retina and in 20 per cent of the cases, the detachment will recur. Successful retinal detachment surgery
should generally attempt to achieve two objectives: Permanently relieve vitreous traction Seal the holes or breaks until the scarring process around the retinal lesion is complete. Two procedures can achieve these two objectives: scleral buckling surgery and vitrectomy. In scleral buckling surgery, the standard procedure is to place a thin silicone band which is sewn on the sclera to create a dimple on the eye wall.
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Figure 4 Patient 1: scanning laser ophthalmoscopy (Optomap): superior retinal detachment seven days after surgery: cryotherapy, scleral buckling, gas bubble
It is crucial to be sure that the examination has been appropriate, that the patient is properly informed of what is going on and that adequate recall procedures are in place
Figure 5 Patient 1: scanning laser ophthalmoscopy (Optomap): superior retinal detachment one month after surgery: cryotherapy, scleral buckling, and small residual gas bubble
This scleral buckle is secured around the eyeball under the conjunctiva, and the wall of the eye is moved closer to the detached retina, sealing the break or hole. The scleral buckle may also move the retina closer to the vitreous and thus relieve vitreous traction. Before placing the silicone band, a freezing device is placed externally and the break or hole is frozen across the eye wall, which provokes a scarring process around the retinal lesion (cryotherapy). In some
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cases (superior breaks), a gas injection can be associated (Figure 4 and 5). Vitrectomy is the removal of the vitreous as completely as possible which relieves vitreous traction. Gas or silicone is introduced into the eye to seal the break or hole and laser is applied to heal the retinal lesion. (Figure 6 and 7). The great majority (75-90 per cent) of all simple cases can be cured with one operation.Inmorecomplexcases,several operations may be necessary. Five per cent of cases will never reattach due to continual shrinkage of the vitreous and the development of fibrous growths on the retina, particularly if the detachment
is long-standing. If the retina is not reattached, the eye will ultimately become blind. If the macula is detached, the recovery is worse. Therefore, it is important that diagnosis and treatment are performed rapidly.
References 1 Ahmadieh H, Moradian S, Faghihi H, et al. Anatomic and visual outcomes of scleral buckling versus primary vitrectomy in pseudophakic and aphakic retinal detachment: six-month follow-up results of a single operationreport no. 1. Ophthalmology, 112:1421 9, 2005
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Which of the following best describes retinal detachment? a A separation of the retina from the choroid B A separation of the vitreous from the retina C A separation of the inner sensory retina from the outer pigmentary retina D A separation of the nerve fibre layer from the ganglion cell layer What is the estimated risk of a patient with a retinal break or hole developing a retinal detachment? a 1 per cent B 10 per cent C 50 per cent D 90 per cent Which of the following is associated with exudative detachments? a Myopia B Trauma C Lattice degeneration D Choroidal tumour
4 5
What percentage of detachments treated by pneumatic retinopexy recur? a 10 per cent B 20 per cent C 40 per cent D 60 per cent What is tobacco dust? a Large floaters often perceived as spiders webs B Debris in the area anterior to the vitreous but behind the lens C Debris in the anterior chamber D Post-surgical debris after vitrectomy What percentage of detachments can never be reattached? a None B 5 per cent C 10 per cent D 20 per cent
2 3
Successful participation in this module counts as one credit towards the GOC CET scheme administered by Vantage and one towards the Association of Optometrists Irelands scheme. The deadline for responses is November 12 2009
Ophthalmol, 94:670 3, 1982. 13 Wilkinson C: Interventions for asymptomatic retinal breaks and lattice degeneration for preventing retinal detachment. Cochrane Database Syst Rev, CD003170, 2005. 14 Wolfensberger TJ: Foveal reattachment after macula-off retinal detachment occurs
faster after vitrectomy than after buckle surgery. Ophthalmology, 111:1340 3, 2004.
Carl Arndt is a consultant ophthalmologist based at Reims University Hospital, France and Dorothea Arndt works for the British Red Cross in London
Figure 6 Patient 3: scanning laser ophthalmoscopy (OPTOMAP): superior retinal detachment with macular involvement before surgery: note the horse shoe break
Figure 7 Patient 3: scanning laser ophthalmoscopy (Optomap): superior retinal detachment with macular involvement six weeks after surgery (vitrectomy, laser, gas): note the scarring around the location of the break which is typical for laser treatment, and the residual vitreous on the temporal side
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