Uveitis: The other red eye (Proceedings)

Definition

Inflammation of the uveal tract (iris or choroid) of the eye, specifically disruption of the blood-aqueous barrier (tight junctions in the ciliary body epithelium and endothelium of iris blood vessels).

Ophthalmic Examination

1. Conjunctival hyperemia

2. Corneal edema

3. Corneal neovascularization

4. Anterior chamber flare or cells

5. miosis

6. Photophobia/blepharospasm

7. iritis

8. Vitritis

9. Chorioretinitis

10. Low IOP

11. Thorough physical examination

12. Temperature

Systemic Disease

Uveitis is most often a consequence of a systemic disease causing specific or nonspecific immunostimulation resulting in a break down of the blood ocular barrier and leakage of protein and cells into the intraocular chambers.

Causes

1.Infection

2.Auto-immune

3.Neoplastic

4.Idiopathic

5.Traumatic

6.Corneal ulcer

7.Glaucoma

Management

Workup

1.CBC, Chem profile, and Urinalysis

2.Appropriate regional titers

3.Chest radiographs

4. Abdominal radiographs/ultrasound.

5.Aqueocentesis

6.Vitreocentesis

7.Full body physical exam!!

Various Etiologies: (not an exhaustive list)

Infectious

Fungal

1. Pyogranulomatous inflammation

2. dentification of organism is gold standard diagnosis

3. Typically inhalation is primary route of infection

4. All cause uveitis with varying degrees of retinal inflammation

5. Long term therapy to prevent recurrence, up to 10 months

6. Organisms endemic areas

a. Blastomycosis

i. Mississippi River valley

b. Histoplasmosis

i. Mississippi River valley

c. Cryptococcosis

i. Worldwide- pigeon droppings

d. Coccidiomycosis

i.Western to Southwestern US

Tick borne

1. Vasculitis and low platelet symptoms

2. Retinal hemorrhages, retinal detachment, uveitis

3. Titers helpful in diagnosis

4. Ehrlichia canis most common, platys possible

5. Rickettsia rickettsii mild lesions

6. Often why doxycycline is used as broad spectrum antibiotic in uveitis

Neoplastic

Lymphoma most common, but can be any systemic cancer.

Perform a full physical exam on every uveitis patient!!

Immune-mediated

Uveodermatologic syndrome (Vogt-Koyanagi-Harada syndrome)

1. Immune reaction against melanocytes

2. Young, adult Akitas predisposed

3. Recurrence common and thus lifelong therapy is warranted

4. Mild to moderate anterior uveitis, often with depigmented "bullet hole" lesions in the pigmented retina

5. Retinal detachment common

Lens induced Uveitis

1. Any breed with cataracts

2. Leakage of lens proteins resulting in immunogenic stimulation

3. Worse in sudden onset cataracts (young dogs or diabetic patients)

4. Trauma induced cataracts

Pigmentary Uveitis

1. Golden Retriever disease, middle age onset

2. Lifelong therapy required

3. Commonly leads to glaucoma and minimal cataracts

Therapy concepts

Topical therapy

Steroids:

Prednisolone acetate 1% (penetrates better than Neo/Poly/Dex)

Non-steroid:

Flurbiprofen or Diclofenac

Systemic therapy

Steroid:

Prednisone (doses based on cause)

Non-steroid:

Rimadyl or Metacam (if suspicious of infectious cause)

Antibiotic therapy

Appropriate for etiology (Doxycycline good choice)

Local Therapy

Subconjunctival steroid injection

Betamethasone: 2-3 days

Triamcinolone: 4-6 weeks

Supportive Therapy

Anti-glaucoma medications

Trusopt/Azopt: best choice as no miosis is caused

Xalatan: only if needed for severe glaucoma

Mydriatics

Atropine: useful for patients with a painful miosis