Imaging in uveitisAnthony Hall

Causes of Vision Loss in Uveitis

1. Cystoid macular oedema 26%

2. Cataract 19%

3. Glaucoma 11%

4. Permanent macular damage 5%

Rothova et al BJO 1996; 80: 332-336

Macular OCT in uveitis

• CMO• 2/3 of uveitis patients

• The leading cause of visual loss

• Drives treatment decisions

• Others• Permanent outer retinal damage

• ERM

• CNVM

Patterns of OCT thickening in uveitis

• A. Cystic

• B. Diffuse

• C. SRF

OCT markers of visual prognosis

• Loss of outer retinal structures• EZ

• Outer limiting membrane

Non CMO causes of visual loss

• ERM

• CNVM

• Retinitis

CNVM

ERM

• ERM

• PTMH

• FTMH

Syphilitic placoid

Ms GH

• 26 yr old 6 days of pain redness and photophobia.

• OH unremarkable

• GH good

• OE Left AAU with normal fundus

• Treatment • Investigation

• Treatment• Intensive topical steroids

• Investigation• U&E

• LFT

• ACE

• VDRL

• HLA B27

• Review at three weeks

• Pain and redness resolved but VA 6/12

Mr DF

• 21 yr old man

• JIA and ongoing uveitis

• Prednisolone, Humira and methotrexate

• Sec cataract and glaucoma

O/E:

OD OS

6/9 VA 6/36

18 IOP 15

++ cells AC ++ cells

++ cells Vitreous ++ cells

No MO DFE

R>L

Apparent MO

OCT

• Managed with left intravitreal TA 4 mg/0.1 ml

RNFL thickness uveitis pts without glaucoma

RNFL thickness uveitis pts with glaucoma

Syphilitic placoid

Pre and post treatment OCT ASPPE

Mr EW

• 65M admitted under ID for non-tuberculous mycobacterial (Mycobacterium chimera) sternal wound + aortic graft infection on b/g of sternotomy for Type A aortic dissection in March 2016• Treated with imipenem, clarythromycin, moxifloxacin

• ID suggest antimicrobial plan: Clarithromycin 500mg BD, moxifloxacin 400mg nocte, rifabutin 300mg mane, Ethambutol 1.2g mane

• Referred to Ophthalmology OPC with mild floaters in R) eye• Nil pain/ LOV

O/E:

OD OS

6/5 VA 6/4

9 IOP 12

17/17 Ishihara 17/17

D+Q AC D+Q

1+ cells Vitreous Nil cells

multifocal deep white lesions in choroid on posterior pole, not affecting

macula/disc

DFE

R>L

multifocal deep white lesions in choroid on posterior pole, not affecting

macula/disc

• 45 yo man with three days of central visual loss

• GH URTI 3 weeks prior

• 6/6 6/60

• RE all clear

• LE vit cells +/-

• Yellow mac lesion with haemorrhage

FA

1 week

6 weeks

Mrs FI

• 59 yr old woman

• 2 yrs progressive visual loss with floaters

• OH unremarkable

• GH good

O/E:

OD OS

6/18 VA 6/18

9 IOP 12

17/17 Ishihara 17/17

1 + cells AC 1 + cells

++ cells Vitreous ++ cells

Multiple pale outer retinal choroidal lesions with pigmentation

DFE Multiple pale outer retinal choroidal lesions with pigmentation

CT

Mr NK

• 59 yr old man

• 10 yrs progressive uveitis and MFC

• OH unremarkable

• GH good

Ms FW

• 28 yr old woman

• URTI followed by painless paracentral scotoma

O/E:

OD OS

6/7.5 VA 6/7.5

9 IOP 12

17/17 Ishihara 17/17

+ cells AC D+Q

1+ cells Vitreous + cells

Confluent pale outer retinal lesions with early pigmentation

DFEConfluent pale outer retinal lesions with

early pigmentation

OCT

Mr TN

• 38 yr old Vietnamese man

• 2 weeks of headache

• 1 Week bilateral central visual loss

O/E:

OD OS

6/36 VA 6/60

7 IOP 5

17/17 Ishihara 17/17

++ cells AC ++ cells

++ cells Vitreous ++ cells

Disc swellingMultifocal cloudy serous detachment

DFE Disc swellingMultifocal serous detachment

OCT

VKH

• Acute phase• Prodrome with HA, meningism,

hearing changes then

• Acute bilat uveitis• Serous detachment

• Disc swelling

• Acutely steroid responsive

• Convalescent phase• Vitiligo and poliosis

• Retinal depigmentation

• Relapsing remitting or chronic uveitis

Mrs VH

• 85 yr old woman presents with 1 week of right sided orbital ache and mild visual loss

• OH bilat cat ext

• GH severe RA, treated with MTX and ritux

• Recent RA related pneumonitis treated with short course of steroids

O/E:

OD OS

6/7.5 VA 6/7.5

9 IOP 12

17/17 Ishihara 17/17

D+Q AC D+Q

1+ cells Vitreous Nil cells

Large single raised mass inferiorly DFE NAD

CT

Causes of Scleritis(n = 188, Foster et al, 1994)

43%

19%

9%

8%

6%

3%

12%

idiopathic

RA

infections

GPA

Rel Pol

PAN/Hep B

Others

Scleritis DDx

Mild Episcleritis, atopy (esp limbal), inflamed pingueculum or pterygium

Moderate HZO, iritis, sinus disease

Severe ACG, HZO, uveitis

Necrotizing SCC, radionecrosis (+/- infection)

Posterior CSR, VKH, uveal effusion syndrome, choroidal primary or secondary,IOI, TED, optic neuritis

Mrs CA

• 31 yr old woman presented with unilateral central distortion

O/E:

OD OS

6/5 VA 6/18

19 IOP 19

D+Q AC D+Q

quiet Vitreous Occ cell only

NAD DFE Multiple quiet flat white lesions around posterior pole

Single raised lesion with surrounding pigment

PIC

• Essex et al

• 136 patients with PIC

• 93% female

• Ave -4 dioptres

• 46% unilateral

• 12% recurrent PIC lesions

• 22% new CNVM

• Median final VA 6/24

Mrs RW

• 45 yr old woman

• Referred with long standing R>L intermediate uveitis

• No longer responding to rptorbital steroids

• GH good

Thank you