Algorithm for management of Uveitis

Algorithm for management of Uveitis:

Any patient with uveitis attend to your clinic , first you examine and decide whether its anterior uveitis, intermediate or posterior uveitis. 

Always first rule out infectious uveitis before further investigation of the paients

Some pearls to know is whether its infectious uveitis.

Some pearls which help to diagnose infectious uveitis:

1. Toxoplasmosis:  Vitritis with yellowish full thickness necrotizing retinitis most commonly adjacent to the old scar. 

This picture is clasical of toxopalsmosis and then u can start them of antitoxoplasma agents

Sometimes, atypical presentation like new retinitis lesion without old scar or multiple retinitis lesion can be seen especially in immunocompromised patients. 

2. ARN:

 most commonly seen in immunocompetant person with classical triad of vitritis, retinitis which are more commonly peripheral and vasculitis.

if not treated aggresively they will progress faster with circumferential spread of the retinitis lesion.

3. CMV retinitis:

Classical presentation will be retinitis in periphery with no or very minimal vitritis with some hemorrages associated with it. they can also present as granular variant which progresses slowly. 

4. Syphilis

These can present in various pattern , but the presence of ground glass like small round opacities in posterior hyaloid and inner retina can help to diagnose syphilis.

Once you ruled out these potential infectious disorders, then investigate patients depending on the type of uveitis.

1. Young patient acute anterior nongranulomatous uveitis , first attack , no systemic complaints - no investigations required

2. Acute anterior uveitis nongranulomatous with fibrinous/ hypopyon reaction:

 Get CBC,ESR, Montoux test, chest X ray, LFT, Serum Urea, HLA B 27 as first line of test

3. Chronic anterior uveitis granulomatous/nongranulomatous:

 Get CBC,ESR, Montoux test, chest X ray, LFT, Serum Urea, Serum ACE

4. Intermediate uveitis:

 Get CBC,ESR, Montoux test, chest X ray, LFT, Serum Urea, Serum ACE

5. Posterior/pan uveitis:

 Get CBC,ESR, Montoux test, chest X ray, LFT, Serum Urea, Serum ACE

Most common cause for intermediate/ posterior uveitis being TB/sarcoidosis in India, certain clues  which help to differentiate these lesion.

a. TB - Vasculitis , presence of subvascular hyperpigmented chorioretinal atrophy , choroidal granulomas

b. Sarcoidois: Choroidal granulomas with inferior small multiple yellowish white nonpigmented chorioretinal atrophy

If first line of these tests were inconclusive then go for further tests: 

1. HRCT/CECT chest- which will help to rule out TB vs Sarcoid

2. AC tap/Vitreous TAP - For PCR