www.ophthalclass.blogspot.com has the complete class on uveitis for undergraduate medical students. This presentation is the fourth in the series and deals with the management of uveitis.

1. Management of uveitis
DR. ANUPAMA KARANTH
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2. Anti-inflammatory agents
 ‘-itis’ = inflammation
 Treatment : stop inflammation
 Use anti-inflammatory drugs
 Most potent of such agents : Corticosteroids
 Corticosteroids are the mainstay of therapy in uveitis
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3. Complicating the issue
 What if the cause is infectious?
 Specific anti-infective agent is indicated
 Corticosteroids may even worsen the infection when given
alone
 When the cause is immune related?
 Corticosteroids will be effective
 Associated side effects maybe significant
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4. Management of uveitis
 Finding the etiology
 Narrow down list of differentials by history and examination
 Appropriate investigations (ocular and systemic)
 Referrals for systemic associations
 Treating the inflammation
 Specific therapy
 Non-specific therapy
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5. Few ocular investigations
Fundus fluorescein angiogram
• Cystoid macular edema (complication)
• Serpiginous choroidopathy (pattern of lesion)
Ultrasonography
• Especially in cases of media opacities
Ocular tissue analysis
• Aqueous tap
• Vitreous tap
• Chorioretinal biopsy
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6. Few systemic investigations
Sarcoidosis Tuberculosis Toxoplasmosis Syphilis
Angiotensin
Antitoxoplasma Serology –
converting Chest X-ray
antibody VDRL, FTA-ABS
enzyme
Serum calcium Mantoux test
Chest X-ray
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7. Commonly ordered tests
 Core lab tests
 Compete blood count and ESR
 Chest X-ray
 Serum ACE
 VDRL, FTA-ABS
 Other tests depending on clinical suspicion
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8. Treatment
 Medical
 Specific
 Non specific
 Surgical
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9. Medical therapy
 Specific – etiology dependent
 ATT – Tuberculosis
 Parenteral penicillin – Syphilis
 Sulfa and pyrimethamine – Toxoplasmosis
 Tetracyclines – Lyme disease
 IV Acyclovir –Acute retinal necrosis
 IV Ganciclovir – CMV retinitis
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10. Medical therapy
 Non-specific
 Cycloplegic – mydriatics
 Corticosteroids
 Immunosuppressives
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11. Cycloplegic mydriatics
 To relieve ciliary spasm and pain
 To prevent posterior synechiae and break the ones already
formed
Partly broken posterior synechiae
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12. Cycloplegic mydriatics
 Shorter acting
 Tropicamide eye drops (effective up to 3 hrs)
 Cyclopentolate drops (up to 24 hrs)
 Longer acting
 Homatropine eye drops (up to 4 days)
 Atropine eye drops (up to 7-14 days)
Cycloplegia relieves pain and a mobile pupil prevents posterior synechiae www.ophthalclass.blogspot.com

13. Corticosteroids – the mainstay of therapy
 Depending on the site of inflammation and severity
 Topical
 Periocular
 Systemic
 Topical drops will not be effective for intermediate, posterior and
panuveitis
 ‘Use enough soon enough’
 To always start with a higher dose and taper before stopping
 To investigate before starting
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14. Corticosteroids
Topical Periocular Systemic
Prednisolone Methylprednisolone Prednisone
Dexamethasone Triamcinolone Methylprednisolone
Fluoromethalone Betamethasone
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15. Complications of corticosteroids
Topical Periocular Systemic
As for topical
As for topical
Cataract Weight gain
Peptic ulcer
Ptosis
Osteoporosis
Glaucoma Diabetes
Scleral perforation
Hypertension
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16. Immunosuppressives
 In corticosteroid resistant or intolerant cases
 In vision threatening inflammations - as first line
 Specific cases
 Beh et’s syndrome
 Sympathetic ophthalmitis
 VKH syndrome
 Necrotizing sclerouveitis
 Adverse reactions can be severe and life threatening
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17. Immunosuppressives
Alkylating
Antimetabolites T-cell inhibitors
agents
Methotrexate Cyclophosphamide Cyclosporine
Azathioprine Chlorambucil Tacrolimus
Watch out for nephrotoxicity, hepatotoxicity and marrow toxicity www.ophthalclass.blogspot.com

18. Surgery in uveitis
 Diagnostic
 AC tap
 Vitreous biopsy
 Chorioretinal biopsy
 Therapeutic
 Cataract
 Glaucoma
 Retinal detachment
 Vitrectomy
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19. Complicated cataract
Polychromatic lustre and breadcrumb appearance www.ophthalclass.blogspot.com

20. Management of complications
 Cataract surgery
 If no active inflammation for at least 3 months
 Perioperative steroids
 Heparin surface modified IOLs
 Glaucoma
 Anti-glaucoma topical medication
 Peripheral iridotomy / iridectomy in iris bombé
 Trabeculectomy with mitomycin C or 5 fluorouracil
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21. Management of complications
 Cystoid macular edema
 Control of inflammation - corticosteroids
 NSAIDs
 Pars plana vitrectomy if persistent vitritis
 Hypotony
 Intensive corticosteroids and cycloplegia
 Pars plana membranectomy for cyclitic membrane
 Vitreous opacification
 Pars plana vitrectomy
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22. Management of uveitis …
…a few examples
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23. Anterior uveitis
 35 yr old male
 Ciliary congestion, fine KPs, AC flare, posterior synechiae and
hypopyon in RE
 Similar history of redness a year ago
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24. Anterior uveitis…
Posterior
synechiae, pupil bound
down
Hypopyon
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25. Anterior uveitis…
 Management
 History and examination to narrow the differentials – nothing
significant
 The core lab tests – Mantoux highly significant
 Referral to pulmonologist – confirm diagnosis of tuberculosis
 Co-management
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26. Anterior uveitis…
 Ocular management
 Topical corticosteroids
 Prednisolone eye drops hourly, tapered as per response
 Homatropine eye drops 3 times a day
 Follow up for
 Inflammation
 Intraocular pressure
 Complications
 Systemic management
 Anti-tuberculosis therapy
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27. Intermediate uveitis
 13 year old girl
 Fever of unknown origin, 1 month
 Redness both eyes, 1 week
 Eye examination
 Spill-over anterior uveitis
 Anterior vitreous exudates / snowballs
 Systemic examination
 Lymphadenopathy
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28. Intermediate uveitis…
Cells and exudates in the anterior vitreous www.ophthalclass.blogspot.com

29. Intermediate uveitis…
Management
 Lymph node biopsy
 Caseating granulomatous lesions
 Physician diagnosis - tuberculosis
 Systemic management
 ATT – fever responded within 4 days
 Ocular management
 On 1 week follow up, vision drop of 2 lines
 Systemic corticosteroids under cover of ATT for short period (1mg/kg
body wt of prednisone, tapered and stopped within 4 weeks)
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30. Posterior uveitis
 35 year old, HIV positive female
 Sudden painless loss of vision RE
 Ocular examination
 Spill over fine KPs
 CMV retinitis in the fundus
 CD4 count – 50
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31. Posterior uveitis…
CMV retinitis – granular retinal necrosis, frosted branch angiitis
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32. CMV retinitis
 Management
 Antiretroviral therapy
 IV Ganciclovir 5mg / kg body wt bid – induction course 2
weeks
 Maintenance – 5mg / kg body wt od
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