|
|
This is only a preview of the paper
Click here to register and get the full text.
Existing members click here to login
|
|
|
Posterior uveitis is often chronic and a range of endogenous and exogenous diseases may be associated with this syndrome including: sarcoidosis, syphilis, Behcet’s syndrome, Vogt Koyanagi Harada disease and of those without apparent systemic associations, sympathetic ophthalmia and birdshot chorioretinopathy. It is essential to carefully consider the possibility of an infectious cause for chronic posterior uveitis. SYSTEMIC DISEASE ASSOCIATIONS Systemic disease may present as chronic uveitis with sarcoidosis being the commonest association in the UK. Sarcoidosis has protean ocular manifestations and may present with a spectrum of ocular signs including: anterior and/or posterior uveitis, retinal vascular sheathing and optic disc abnormalities. In Japan, Behcet’s disease is the commonest systemic disease associated with chronic uveitis and in other parts of the world, it may be tuberculosis. The clinical picture of smoldering chronic uveitis often with acute exacerbations and occlusive retinal vasculitis should prompt enquiries about mouth ulcers, genital tract ulceration, arthritis and thrombophlebitis characteristic of Behcet’s syndrome. Uveitis, choroidal lesions, serous retinal detachments and optic neuropathy in a patient with a prior history of headache, dysacusis or neck stiffness should make the ophthalmologist consider the diagnosis of Vogt Koyanagi Harada disease. There are a number of purely ocular syndromes which should be considered in patients with chronic posterior uveitis. A history of trauma or intraocular surgery should alert the ophthalmologist to the possibility of sympathetic ophthalmia. Multiple punched out pigmented chorioretinal scars in the posterior pole or periequatorial fundus asoociated with a fluctuating panuveitis are the typical signs of the syndrome of multifocal choroiditis with panuveitis. Birdshot chorioretinopathy and serpiginous choroidopathy are rare but important ocular syndromes to recognise to avoid unnecessary investigations for systemic disease. Intraocular lymphoma may present as a chronic uveitis in the older patient and should be considered when there are clinical features which seem inappropriate such as: florid signs of posterior uveitis, particularly vitritis and vitreous veils without macular oedema, a poor response or non-sustained to seemingly appropriate immunosuppressive treatment, progressive retinal or choroidal infiltration despite treatment or hypopyon in a relatively quiet eye. Intraocular tumors particularly retinoblastoma in children, may also occasionally present in this manner. The only investigations performed in virtually all patients are a chest X ray, angiotensin converting enzyme and sometimes syphilis serology as these investigations may significantly alter the long term management of patients. A broad screening battery of investigations has a low diagnostic yield and is inappropriate management for uveitis. Table 2 lists investigations widely recognised to alter the management of chronic uveitis and their indications. In patients with apparent idiopathic disease, an open mind needs to be kept about aetiology. Newly appearing symptoms or signs such as arthralgia or erythema nodosum may prompt further disease directed investigations. MANAGEMENT OF PATIENTS WITH CHRONIC UVEITIS Patients are followed on a regular basis to determine disease activity, ocular complications present and side effects of medication, either topical or systemic. (see Table 3). There are many possible causes for reduced vision in patients with chronic uveitis and not all reduced vision equates with the need for increased anti- inflammatory therapy. The endpoint of therapy in anterior uveitis is the abolition of cells rather than flare, which may become chronic, from the anterior chamber.
Approximate Word count = 2079
Approximate Pages = 8.3
(250 words per page double spaced)
|
|
|
|
|
|