Abdelsattar Farrag: Effective approach
for adult anterior uveitis.
I'd like to start by an important introduction
and consideration in anterior uveitis.
First thing is,
why it is important to have an approach for
adult anterior uveitis?
Anterior uveitis is the most frequent
anatomical subtype of uveitis.
It represents around 60% of uveitis cases
in tertiary care, uveitis level.
Moreover, it represents up to 90% of uveitis cases
found in community-based practice.
I would like to highlight a few vital considerations
about pupil dilation when we deal with anterior uveitis.
Firstly, dilated fundus examination is a must.
We can not say it is anterior
without dilated fundus examination.
Secondly in severe cases, try your best to dilate the pupil
with different types of mydriatics.
Finally, if the posterior synechia are new,
then you'll probably only have one chance to break them.
So that would be another important factor
as well as ensuring adequate pupil dilation
to assist the fundus.
The next few minutes,
I'll illustrate a brief step-wise approach
for effective dealing with adult anterior uveitis.
First step is,
follow a standard approach for history taking,
this includes present history of the attack,
past ocular history of previous episodes
and the investigations, surgery or trauma.
Past medical history of arthropathies,
chronic infections, systemic inflammation,
systemic immunosuppression.
Review of all systems,
and here we do a fast review in the first stage.
Family history of family members with uveitis
or related diseases like HLA-B27.
Social history including travel abroad,
TB exposure and sexual history.
Medications including any systemic immunosuppression,
allergies or relevant drug contraindications.
One of the very useful strategies
in uveitis history is u-turn strategy.
This means,
that we can return to take a specific detailed history
relevant to differential diagnoses
after examination of the patient.
In the second step is start your meticulous examination.
Meticulous systematic examination can help
in diagnosis of the aesthesiology.
We need to follow the standard examination protocol
for every structure in the anterior
and posterior segment.
Here, I'll give some examples
of clues that we can get from our examination.
Meticulous examination of the iris also
includes looking for iris heterochromia, iris nodules.
Sectoral iris atrophy can give us a clue also
about viral uveitis.
Increased intraocular pressure also,
could occur in any type of interior uveitis.
However it can reach up to 50 millimeter mercury
in herpetic anterior uveitis.
Gonioscopy baseline in case of
increased intraocular pressure,
and don't forget the documentation
of presence of scleritis or keratitis.
In case of severe anterior uveitis,
look for hypopyon and comment if it is present or not.
Step three, follow an effective approach for investigation.
To achieve this first,
we need to know goals for uveitis investigations.
Identifying aetiology in order
to direct specific treatment.
Identify associated systemic diseases.
Baseline assessment before initiating immunosuppressive,
and imaging for diagnostic or monitoring value.
Generally we don't investigate
for first episodes unilateral uveitis,
or if there is known associated systemic diseases
for uveitis from history,
or typical clinical uveitis syndrome,
like fux, heterochromia, or typical herpetic uveitis.