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Panuveitis - 8/7/2012

posted Aug 7, 2012, 11:13 AM by Rohit Das   [ updated Dec 27, 2012, 7:17 AM by Purnema Madahar ]

Today, in Resident Report with Dr. Berger, Stephanie Behringer was gracious enough to share a case of uveitis with us. Her patient was a 34 year old African-American female presenting with 2 days of severe right eye pain, followed by one day of blurry vision. On exam, she was noted to have a red right eye, decreased visual acuity, and on ophthalmic exam, was noted to have retinal hemorrhages, specifically Roth Spots… interesting! Overall, she had questionable anterior, but definitive posterior segment uveitis; i.e., potentially PANuveitis. At this stage of her workup and natural history, the diagnosis is not completely clear.

  • Uveitis, by definition, is inflammation of the middle portion of the eye (basically everything except the capsule and cornea).
  • The anterior portion is essentially everything anterior to the lens (including the iris and cilliary body), and the posterior portion is everything behind the lens.
  • Anterior disease generally presents with pain, with variable vision-related issues, while posterior involvement is generally painless, but is more likely to present with visual changes (and much more serious for that reason).
  • Treatment is tailored around the infectious agent (if applicable), and topical and/or systemic steroids.

Anterior uveitis is more common than posterior involvement (about 4 times). The differential for uveitis is actually fairly limited, and consideration towards systemic inflammatory and infectious illnesses is most important. In one series of 881 patients (though I think this study was guilty of referral bias), approximately 50% of cases were (definitely or presumed) related to a systemic illness. Of systemic illnesses, sarcoidosis and HLA-B27 seronegative spondlyoarthropathies were most common. Sarcoidosis is something we see frequently in our population, so please try to familiarize yourself with it (a review on ocular sarcoidosis is attached).

A quick note on Roth Spots:

  • They were first described in 1872 by our dear friend Moritz. His initial description was that Roth Spots were retinal hemorrhages with a white center, representing disseminated foci of bacterial abscesses on heart valves.
  • Subsequently, this white center has actually been shown to be nothing more than coagulated combination of platelets and fibrin.
  • Why is this important? Roth Spots are NOT limited to endocarditis. In fact, many diseases that compromise retinal vasculature can lead to the visualization of Roth Spots, and this is a relatively long list.

My Three Questions for the Day – some food for thought...

  • What percentage of patients with sarcoidosis present with solely ocular symptoms?
  • What are 5 inflammatory illnesses that cause uveitis? Five infectious illnesses?
  • In a patient with uveitis, what diagnostic tests should one proceed with?

Thanks for all your feedback! In reference to yesterday's daily, Marcus Bachhuber wrote (reference attached):

attached is an article from Clinical Infectious Disease this month looking at antiretroviral prescribing errors. The study examined admissions at Johns Hopkins in 2009 and found ARV errors within the first 24 hours in approximately 30% of admissions of people with HIV. Most of the errors were fixed the next day, however. Errors in protease inhibitors (dose and dosing schedule) were the most common. The only variable that seemed to increase the odds of an incorrect order for ARVs was admission to a surgical service--but errors were still common on the Medicine floors and even on the HIV/AIDS service. Bottom line: be careful!

 Until next time...

 


Uveitis and Systemic Disease
Rothova et. al., British Journal of Opthalmology 1992, 76: 137-141

Rothova, British Journal of Opthalmology 2000, 84: 110-116

Ling et. al., Postgradual Medical Journal BMJ 1998, 74: 581-582

Courtesy of Marcus Bachhuber:
Yehia et. al., Clinical Infectious Diseases, Advanced Pub 2012, May 31st
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