Ординатура / Офтальмология / Английские материалы / Oxford American Handbook of Ophthalmology_Tsai, Denniston, Murray_2011

316 CHAPTER 11 Uveitis

Classification of uveitis (1)

The classification of uveitis may be anatomical, clinical, pathological, or etiological, and all of these may be useful in defining a uveitis entity. Anatomical classification has been formalized by the International Uveitis Study Group (ISUG) and amended by the Standardization of Uveitis Nomenclature (SUN) group (2005) (Table 11.1).

Anterior uveitis accounts for the majority of uveitis cases in Western populations. A much smaller proportion is made up of posterior, intermediate, and panuveitis.

Anatomical classification

Table 11.1 Anatomical classification of uveitis (SUN 2005)

Reprinted with permission from Jabs DA, Nussenblatt RB, Rosenbaum JT (2005). Standardization of Uveitis Nomenclature (SUN) Working Group. Am J Ophthalmol 140:509–516.

Clinical classification

The most recent clinical classification of uveitis is outlined in Table 11.2. Clinical behavior may be further described in terms of onset, duration, and course of uveitis (Table 11.3).

Pathological classification

Pathological classification separates granulomatous and nongranulomatous uveitis. The term granulomatous is sometimes used in the clinical context to describe uveitis with large, greasy, mutton-fat keratic precipitates (macrophages) and iris nodules (which may include Koeppe and Busacca nodules).

318 CHAPTER 11 Uveitis

Classification of uveitis (2)

Differential diagnosis of uveitis by anatomical type

Table 11.4 Differential diagnosis of uveitis by anatomical location

CMV, cytomegalovirus; FHI, Fuchs heterochromic iridocyclitis; HSV, herpes simplex virus; IBD, inflammatory bowel disease; JIA, juvenile idiopathic arthritis; MEWDS, multiple evanescent white dot syndrome; MS, multiple sclerosis; POHS, presumed ocular histoplasmosis syndrome; TB, tuberculosis; VKH, Vogt–Koyanagi–Harada syndrome; VZV, varicella zoster virus.

UVEITIS: ASSESSMENT 319

Uveitis: assessment

All patients require a detailed history (ophthalmic and general) and a thorough ophthalmic examination, including dilated funduscopy of both eyes. In some cases a systemic examination may also be necessary (see Table 11.5).

For example, an apparently classic acute anterior uveitis may have posterior segment involvement (notably CME), may be secondary to more posterior disease (e.g., toxoplasmosis retinochoroiditis), or may be part of a panuveitis (e.g., sarcoid) and have systemic involvement.

Table 11.5 An approach to assessing uveitis

SYMPTOMS OF SYSTEMIC DISEASE IN UVEITIS 321

Symptoms of systemic disease in uveitis

Table 11.8 Systemic review that may provide clues to underlying disease

HIV, human immunodeficiency virus; HSV, herpes simplex virus; IBD, inflammatory bowel disease; JIA, juvenile idiopathic arthritis; MS, multiple sclerosis; RA, rheumatoid arthritis; SLE, systemic lupus erythematosus; TB, tuberculosis; TINU, tubulointerstitial nephritis with uveitis; VKH, Vogt–Koyanagi–Harada syndrome; VZV, varicella zoster virus.

INVESTIGATIONS IN UVEITIS 323

Investigations in uveitis

When to investigate

Ideally, one would perform the minimum number of investigations to obtain the maximum amount of information. The usefulness of each test will depend on the pretest probability of the diagnosis and the specificity and sensitivity of the test. Consider also the potential morbidity of certain tests (e.g., FA or vitreous biopsy). In general, investigations may be performed for the following:

•Diagnosis: by identifying causative or associated systemic disease; by identifying a definite etiology (e.g., an organism).

•Management: monitoring disease activity or complications (e.g., OCT for macular edema); monitoring potential side effects of treatment (e.g., blood tests for some immunosuppressants).

Role in diagnosis

The etiology of most cases of uveitis is not known, although an autoimmune or autoinflammatory cause is often theorized. In most cases, a careful history and examination provides most if not all of the information need for diagnosis (see Table 11.9).

Some uveitis syndromes like FHI, Behçet’s, and toxoplasmosis are diagnosed purely on clinical grounds. Investigations are helpful in identifying uveitis of infective origin (e.g., TB, HSV) or systemic disease (e.g., lymphoma, sarcoidosis, demyelination). The role of some investigations is controversial (e.g., when to test HLA-B27 status).

Role in management

Monitoring disease

This is done almost entirely by clinical examination; however, in certain situations investigations may be helpful. For example:

•Optical coherence tomography (OCT) is extremely useful in establishing macular causes of worsening vision, particularly where clinical diagnosis is difficult because of poor visualization or preexisting macular disease (e.g., epiretinal membrane, CME, macular hole); this has largely replaced FA for this purpose.

•Fluorescein angiography (FA) is particularly helpful in assessing retinal vascular involvement and neovascularization.

•Electroretinogram (ERG) is required for monitoring birdshot retinochoroidopathy.

•Visual fields: for monitoring optic nerve damage due to either disease or associated iIOP or AZOOR complex disorders.

Monitoring therapies

Regular BP, weight, BM, and urinalysis are recommended for patients on systemic corticosteroids. Blood tests (e.g., CBC, urinalysis, LFT) are necessary for some of the other immunosuppresive agents (p. 709).