clinical case presentation

1. CLINICAL CASE PRESENTATION
Dr. Samten Dorji
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2. • 38 year old male complained of right eye pain
and redness for 5 days duration.
CHIEF COMPLAINT
Personal information
He is from Zhemgang, married with two children and is gardener by profession

3. • He developed slow onset of pain in his right eye
and increase progression of pain. He had
associated redness, photophobia, excessive
tearing and reduced vision.
HISTORY OF CHIEF COMPLAINT

4. • No joint pain
• No history of asthma or symptoms suggestive of
chest infection
• No gastro intestinal symptoms
• No history of haematuria or urethral discharge
• No skin conditions
SYSTEMIC REVIEW

5. • Past ocular history/ocular medications/systemic
medications/comorbidities/allergies/family
history/social history
• No pets in house
HISTORY CONT.

6. Examination
Right eye Left eye
Visual acuity 6/60 6/6
With pinhole 6/12 6/6
Color vision Normal Normal
Extraocular movements Normal Normal
Lids and adnexa Normal Normal
Conjunctiva and sclera Circumcorneal congestion Normal
Cornea Clear Clear
Anterior chamber Cells grade +4 and flare
grade +3
Normal
Iris and lens Posterior synechia Normal
Pupil Round regular and miotic Round regular and reactive
IOP by Icare 13 mmhg 11 mmhg
Dilated Funduscopy NAD NAD

7. • 38 year old male presented to eye OPD with
right eye pain with redness for 5 days duration
with associated photophobia, excessive tearing
and reduced vision. On examination there was
no significant findings in his left eye. On his right
eye his visual acuity was 6/12 with pin hole. He
had circumcorneal congestion and had grade +4
cells and grade +3 flare in anterior chamber with
posterior synechia and miosis. He doesn’t have
any clinical features suggestive of systemic
disorder.
CASE SUMMARY

8. DIAGNOSIS
Acute anterior uveitis
Supporting points
• Unilateral eye pain with
photophobia and redness with
excessive tearing for duration of 5
days.
• Circumcorneal congestion with
anterior chamber cells and flare
with posterior synechia and miosis.
• Fundus appeared normal
Non-Supporting points
• Slow onset
Aetiology
• Idiopathic
• HLA-B27 associated uveitis
• Behcet disease
• Lyme disease

9. Differential diagnosis
• Posterior uveitis with spill over into the anterior chamber
• Traumatic iritis
• Infectious keratouveitis

11. Chest X ray PA= NAD

12. • Cycloplegic drops
• Antibiotic drops
• Prednisolone drops
• Oral prednisolone
MANAGEMENT

13. SUBJECT REVIEW
Acute anterior uveitis

14. • Introduction
• Clinical features
• Investigation
• Treatment
OUTLINE

15. • Uveitis is the inflammation of the uveal tract
INTRODUCTION

16. Clinical course
Acute Chronic Recurrent
Aetiology
Infectious Noninfectious

17. Histology
Granulomatous Nongranulomatous
Anatomy
Anterior uveitis Intermediate
uveitis
Posterior
uveitis
Panuveitis

21. • In a large community-based study, the vast
majority of uveitis cases were anterior (71%),
followed by posterior uveitis (5%) and
intermediate and panuveitis (1% each).
• The most common causes of anterior uveitis are
idiopathic (38−56%), the seronegative
spondyloarthropathies (21−23%), juvenile
idiopathic arthritis (JIA; 9−11%), and herpetic
keratouveitis (6−10%).

22. • Presentation: sudden onset of unilateral pain,
photophobia and redness, which maybe
associated with lacrimation.
• Visual acuity is usually good at presentation
except in eyes with severe hypopyon
CLINICAL FEATURES

23. External examination Miosis
Endothelial dusting Aqueous flare and cells

24. Cells in field Grade (anterior chamber cells)
<1 0
1-5 +-
6-15 +1
16-25 +2
26-50 +3
>50 +4
Description Grade (aqueous flare)
Nil 0
Just detectable +1
Moderate (iris and lens details clear) +2
Marked (iris and lens detail hazy) +3
Intense(fibrinous exudate) +4

25. Fibrinous exudate Hypopyon
Posterior synechiae
Low IOP

26. Investigation
INDICATIONS NOT INDICATED
Granulomatous inflammation Single attack of mild unilateral
AAU
Recurrent uveitis Sympathetic ophthalmitis and
Fuchs cyclitis
Bilateral disease When systemic disease is
already apparent
Systemic manifestation
Confirmation

28. Skin test
Tuberculin test Pathergy test
Lepromin test

29. 1. Non-treponemal test= rapid
plasma reagin
2. Treponemal antibody test=
fluorescent treponemal
antibody absorption test and
microhaemagglutination
treponema pallidum test
3. Dark ground microscopy
Serology
Syphilis Toxoplasmosis
1. Dye test(Sabin-Feldman)= gold standard
2. Immunofluorescent antibody test
3. Haemagglutination tests
4. Enzyme linked immunosorbent assay (ELISA)

30. Enzyme assay
Sarcoidosis
Tuberculosis
Leprosy
Serum angiotensin
converting enzyme
Lysozyme assay
HLA tissue typing
HLA type Associated disease
B27 spondyloarthropathies
A29 Birdshot chorioretinopathy
B51 Behcet syndrome

31. Optical coherence tomography

32. Radiology
Chest X ray Sacro iliac joint X ray
CT and MR

33. 1. Conjunctival and lacrimal gland biopsy
BIOPSY

34. Treatment
Mydriatics
Short acting Long acting
Tropicamide (6 hours) Homatropine (2 days)
Cyclopentolate(24 hours) Atropine(2 weeks)
Phenylephrine(3 hours)
Promote comfort
Break down
recently formed
posterior
synechiae
Prevent formation
of posterior
synechiae

35. Topical steroids
AAU CAU
• Frequent instillation of
drops at first
• The frequency is tapered
off once the inflammation
gets controlled
• Exacerbations treated as
AAU
• The intensity of flare can
also indicate an active
process
• Follow up of patient
regularly

36. Complication
Elevation of IOP

37. Periocular steroid injection
Advantages
• Therapeutic concentrations behind the lens
may be achieved
• Trans-sclerally entrance
• Prolonged effect
Indications
• First line therapy in unilateral
intermediate or posterior uveitis
• Supplement systemic therapy or when
systemic steroids are contraindicated
• Poor compliance
• At time of surgery

38. Complication
Globe penetration
Increased IOP
Ptosis
Sub dermal fat atrophy
Extraocular muscle paresis
Optic nerve injury
Retinal and choroidal vascular occlusion
Cutaneous hypopigmentation

39. Systemic steroids
• Oral prednisolone and intravenous infusion of methylprednisolone
Indications
• Intermediate uveitis unresponsive to
posterior sub tenon injection
• Posterior or panuveitis, particularly
with bilateral involvement
• Prior to intraocular surgery
• Anterior uveitis resistant to topical.
Contraindications
• Poorly controlled diabetes
• Peptic ulceration
• Osteoporosis
• Active systemic infection
• Psychosis on previous exposure to
steroids
Short term side effects Long term side effects
• Dyspepsia
• Mental changes
• Electrolyte imbalance
• Aseptic necrosis of the head of the
femur
• Cushingoid state
• Osteoporosis
• Limitation of growth
• TB reactivation
• Cataract
• Diabetes and myopathy

40. Antimetabolites
Azathioprine Methotrexate Mycophenolate mofetil
Indications Behcet syndrome
Vogt-Koyanagi-Harada
syndrome
Uveitis associated with
sarcoidosis and
Juvenile idiopathic
arthritis
Alternative to
azathioprine
Dose and
route
Starting dose=1-3mg/kg
After 1-2 weeks dose is
doubled
Stopped only after disease
has been inactive for over
1 year and the daily steroid
dose is under 7.5mg
Adult:10-25mg weekly
Children:30mg
Folic acid 2.5-5mg/ day
1-2 g daily orally
Side effects Bone marrow suppression,
hepatotoxicity and nausea
+ acute pneumonitis Gastrointestinal
disturbance and bone
marrow supression
Monitoring CBC and LFT CBC and LFT CBC

41. Calcineurin inhibitors
Ciclosporin Tacrolimus
Indications Behcet syndrome, intermediate
uveitis, birdshot choroidopathy,
Vogt-Koyanagi-Harada syndrome,
sympathetic ophthalmitis and
idiopathic retinal vasculitis
Alternative to Ciclosporin
Dose and route 2.5-7.5mg/kg daily orally 1-0.25mg/kg daily orally
Side effects Nephrotoxicity, hyperlipidaemia,
hepatotoxicity, hypertension,
hirsutism and gingival hyperplasia
Hyperglycaemia, neurotoxicity and
nephrotoxicity
monitoring Blood pressure, RFT and LFT + blood glucose

42. Biological blockers
Interleukin receptor antagonists Tumour necrosis factor alpha antagonist
Daclizumab and anakinra Infliximab and adalimumab

43. • Introduction
• Clinical features
• Investigation
• Treatment
SUMMARY

44. THANK YOU