Ординатура / Офтальмология / Английские материалы / Practical Manual of Intraocular Inflammation_Dick, Okada, Forrester_2008
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PracticalManualof
intraocular Inflammation
AndrewD.Dick
AnnabelleA.Okada
JohnV.Forrester
Informa Healthcare USA, Inc.
52 Vanderbilt Avenue
New York, NY 10017
# 2008 by Informa Healthcare USA, Inc. Informa Healthcare is an Informa business
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International Standard Book Number-10: 0-8493-9183-0 (Hardcover)
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Library of Congress Cataloging-in-Publication Data
Dick, Andrew.
Practical manual of intraocular inflammation/Andrew D. Dick, Annabelle A. Okada,
John V. Forrester.
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978-0-8493-9183-5 (hardcover : alk. paper)
ISBN-10: 0-8493-9183-0 (hardcover : alk. paper)
1. Eye—Inflammation. 2. Uveitis. I. Forrester, John V. II. Okada, Annabelle.
III. Title.
[DNLM: 1. Uveitis—diagnosis. 2. Uveitis—therapy. 3. Inflammation—therapy.
4.Vision Disorders—prevention & control. WW 240 D547p 2008]
RE96.D55 2008 617.70 5—dc22
2008008244
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Preface
There are many excellent examples of reference textbooks covering the bewildering clinical spectrum and complexity of the diagnosis and management of uveitis disorders. When faced with the uveitis patient in clinic, however, patients rarely present as per textbook diagnosis. So the challenge of uveitis requires a systematic approach to clinical assessment and interpretation of investigations to arrive at a management pathway suitable for that patient. This requires an ability to distinguish between infectious and noninfectious causes and the skill to recognize sight-threatening posterior segment inflammation. Alongside, there is a need to diagnose specific uveitic conditions and their association, or otherwise, with systemic disease for appropriate treatment in the longer term and being able to gauge an overall prognosis.
The purpose of this book is, therefore, by no means to compete with the excellent reference texts currently available, or the update texts that are frequently published and that hone in on specific cutting-edge overviews of specific aspects of uveitis. We rather wished to convey a book to complement such works. We feel there is a need to deliver a handbook that can provide a simplified synopsis of the more sight-threatening uveitis conditions, better termed posterior segment intraocular inflammatory disease. A book to fit in the pocket, keep handy in the briefcase, or sit on the office desk and help in the daily task of treating uveitis patients. As such, the book aims to deliver a background to and context of the clinical problems we face in managing patients with uveitis and systematically cover a practical approach to the management of the patient in clinic, while introducing treatment algorithms. We also show where we believe part of the future lies as a result of our increased understanding of the pathogenic mechanisms of disease alongside the explosion of specific immune therapies being developed for clinical use.
Given the increase in the pharmacopoeias available and the increasingly robust evidence of their clinical efficacy, the delivery of “optimal” care remains
iii
iv |
Preface |
challenging. To address some of the difficulties, we hope the book will assist training courses and modules/fellowships in ocular inflammation/uveitis available worldwide. In addition, dedicated accredited specialist training in medical ophthalmology, such as provided by the Royal College of Physicians in the United Kingdom, includes core training in uveitis and is breeding a new cadre of ophthalmic physicians specially trained in the diagnosis and management of ocular inflammatory diseases. We hope that the book will highlight an optimal approach as encouraged by specific training to generate recognized competence in both the diagnosis and monitoring of disease. This avoids the less definitive practice in which the institution and monitoring of the medical therapy is devolved to the internist or rheumatologist who may be less well placed to recognize improvement or worsening in the ocular condition, and so overall there is an arguable tendency never to achieve adequate control of ocular inflammation.
We dedicate the book to the memory of Professor Tetsuo Hida (1948–2008), Chairman of the Department of Ophthalmology, Kyorin University School of Medicine. Professor Hida was a world-renown vitreoretinal surgeon and pastpresident of the Japanese Ophthalmological Society. He will be remembered by a generation of young Japanese ophthalmologists who were fortunate enough to be graced by his knowledge, wisdom, and generosity.
Andrew D. Dick
Annabelle A. Okada
John V. Forrester
Acknowledgments
We are indebted to the help and support of all our colleagues in our respective uveitis services, for their cumulative thoughts over the years, which when distilled have contributed greatly to the genesis of this book. This ongoing dialogue, we hope, has been represented in this practical management handbook. We would also like to thank our fellows in uveitis for their hard work and support and in particular Drs. Lucia Kuffova and Susan Kelly for preparing many of the figures alongside our respective staff from ophthalmic photography departments for their excellence, particularly Ms. Sumie Minemura, Ms. Nozomi Watanabe, Mr. Steve Nielson, and Mrs. Alison Farrow. Also thanks to Dr. Lindsay Nicholson, who generated some of the figures representing immune responses in chapter 1.
v
Contents
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
iii |
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
.. |
v |
1. What Are We Dealing With? . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
1 |
Uveitis---Posterior Segment Intraocular Inflammation (PSII) . . . . . . . . . . . |
. . |
1 |
Standardization of Uveitis Nomenclature . . . . . . . . . . . . . . . . . . . . . |
. . |
2 |
Disease Burden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
4 |
What Are We Dealing With? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. . |
4 |
Regional Differences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. . |
5 |
Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
5 |
Noninfectious Uveitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
5 |
How Should We Classify Our Patients? . . . . . . . . . . . . . . . . . . . . . . . . . |
. . |
6 |
Immunopathology of Noninfectious PSII . . . . . . . . . . . . . . . . . . . . . . . . |
. . |
7 |
What Triggers Uveitis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
7 |
Immunity and the Autoinflammatory Response . . . . . . . . . . . . . . . . . . |
. |
8 |
Evidence for Autoinflammatory Disease . . . . . . . . . . . . . . . . . . . . . . |
. |
10 |
Practical Classification for Management . . . . . . . . . . . . . . . . . . . . . . . . . . |
|
14 |
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
|
14 |
2. Clinical Assessment of Patients with Posterior Segment |
|
|
Intraocular Inflammation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
|
17 |
General Features and Clinical Evaluation of Intraocular Inflammation |
|
|
in the Clinic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
|
17 |
Clinical Evaluation—Symptoms and Signs . . . . . . . . . . . . . . . . . . . . . . . . |
|
18 |
Defining Clinical Onset and Course of Uveitis—Standardized |
|
|
Nomenclature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
18 |
Defining Active Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
18 |
Arterial Vs. Venous Involvement . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
26 |
Evidence of Associated Choroidal Vasculopathy . . . . . . . . . . . . . . . . |
. |
26 |
Clinical Signs of Structural Changes Associated with PSII . . . . . . . . . |
. |
30 |
vii
viii Contents
Determining Infectious vs. Noninfectious PSII . . . . . . . . . . . . . . . . . . . |
. . |
32 |
Determining Sight-Threatening Disease . . . . . . . . . . . . . . . . . . . . . . . . |
. . |
34 |
Assessing Coexisting Systemic Disease in PSII . . . . . . . . . . . . . . . . . . . |
. . |
34 |
General Investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. . |
36 |
Tailored Investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
36 |
Tailored Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
38 |
Utilizing Ocular Imaging in the Management of Noninfectious PSII . . . . |
. . |
39 |
Angiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
39 |
Fluorescein Angiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. . |
40 |
Indocyanine Green Angiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. . |
43 |
Optical Coherence Tomography . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
46 |
Utilizing Visual Function Tests in the Management of Noninfectious PSII . . |
47 |
|
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. . |
49 |
3. Practical Evaluation of the Patient in the Clinic . . . . . . . . . . . |
. |
51 |
Differential Diagnosis Based on Predominant Ocular Feature . . . . . . . . . |
. . |
52 |
Vitritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
53 |
Papillitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
54 |
Retinal Vasculitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
54 |
Retinal Infiltrates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
57 |
Choroiditis (Choroidal White Dots and Other White Lesions) . . . . . . . |
. |
59 |
Serous Retinal Detachment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
60 |
Panuveitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
63 |
Descriptions and Workup for Specific Disease Entities . . . . . . . . . . . . . |
. . |
64 |
Infectious Diseases: Viral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
65 |
Infectious Diseases: Bacterial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
75 |
Infectious Diseases: Fungal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
83 |
Infectious Diseases: Parasitic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
86 |
Presumed Autoinflammatory Diseases, with Systemic Manifestations . . . |
91 |
|
Presumed Autoinflammatory Diseases, Without Systemic Manifestations . . |
104 |
|
Neoplastic Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
115 |
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
|
117 |
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
|
117 |
4. Instituting and Monitoring Therapy for Sight-Threatening |
|
|
Uveitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
|
123 |
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
|
123 |
The Decision to Treat Sight Threatening Ocular Inflammation (STOI) . . . |
124 |
|
Treatment of Posterior Segment STOI . . . . . . . . . . . . . . . . . . . . . . |
. |
124 |
Treatment of Anterior Segment STOI . . . . . . . . . . . . . . . . . . . . . . . |
. |
125 |
Aims of Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
|
126 |
Infectious Posterior Segment STOI . . . . . . . . . . . . . . . . . . . . . . . . |
. |
127 |
Infectious Anterior Segment STOI . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
130 |
Contents ix
Noninfectious Posterior Segment STOI . . . . . . . . . . . . . . . . . . . . . . |
. |
131 |
Noninfectious Anterior Segment STOI . . . . . . . . . . . . . . . . . . . . . . |
. |
136 |
Investigation Prior to Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
137 |
Infectious STOI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
138 |
Noninfectious STOI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
138 |
Monitoring Response to Treatment/Assessing Severity . . . . . . . . . . . . . . |
. |
139 |
Vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
140 |
Clinical Ocular Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
140 |
Ocular Investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
140 |
Monitoring the Emergence of Side Effects . . . . . . . . . . . . . . . . . . . . . . |
. |
143 |
Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
145 |
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
146 |
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
146 |
5. Immunomodulatory Therapy . . . . . . . . . . . . . . . . . . . . . . . . . |
|
149 |
What Is Immunomodulatory Therapy? . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
150 |
Corticosteroids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
152 |
Immunosuppressive Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
153 |
Azathioprine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
155 |
Methotrexate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
156 |
Mycophenolate Mofetil (Cellcept) . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
158 |
Cyclophosphamide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
158 |
Cyclosporin A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
160 |
Tacrolimus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
161 |
Biologic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
162 |
Interferon-a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
162 |
Infliximab . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
163 |
Other Biologic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
165 |
Locally Administered Corticosteroids . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
166 |
Periocular and Intravitreal Injections . . . . . . . . . . . . . . . . . . . . . . |
. |
166 |
Fluocinolone Acetonide Intravitreal Implant . . . . . . . . . . . . . . . . . . |
. |
169 |
Perioperative Medical Management . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
171 |
Preoperative Anti-inflammatory Therapy . . . . . . . . . . . . . . . . . . . . |
. |
171 |
Intraoperative Anti-inflammatory Therapy . . . . . . . . . . . . . . . . . . . |
. |
172 |
Postoperative Anti-inflammatory Therapy . . . . . . . . . . . . . . . . . . . . |
. |
174 |
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
174 |
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
174 |
6. Research Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
|
181 |
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
181 |
The Clinical Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
181 |
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
181 |
Investigative Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
182 |
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
. |
184 |