The diseases gathered under the uveitis umbrella are relatively uncommon but particularly troubling, given their potential to leave patients with poor visual outcomes. “There are multiple uveitis syndromes with immediate, vision-threatening implications if not recognized and treated,” Steven Yeh, MD, said at the Uveitis Subspecialty Day on Saturday. “Other uveitides have systemic morbidity.” Don’t-miss diagnoses include the following.
Acute retinal necrosis. Clinical features include granulomatous panuveitis, posterior synechiae, hypertensive iritis, and transillumination defects, said Dr. Yeh. Combination systemic and intravitreal antiviral treatment may be offered, and there is evidence that individuals with less than 50% of retina involvement may derive the most benefit from treatment.
Syphilis. The rate of syphilis in the United States has increased since 2000, and the rate of ocular syphilis is also on the rise.1 There is a distinct gender imbalance in the case load, with men comprising 2/3 of cases. Given the high rate of syphilis and HIV coinfection, any patient diagnosed with ocular syphilis should also have an HIV test. Clinical signs include areas of retinal whitening with “curious preretinal puffballs,” Dr. Yeh said.
Dr. Yeh cited the CDC’s recommendation for a reverse screening algorithm, which guides the clinician along a testing pathway that offers greater sensitivity and specificity than traditional screening. (You can view an archived webinar online.) Standard treatment is intravenous (IV) penicillin.2
Toxoplasmosis. Clinical signs of toxoplasmosis include retinal whitening that may or may not include pigmented scarring. Multiple drug regimens are used for treatment, but the clinician should proceed with extreme caution with regard to local steroid use in any patient with toxoplasmosis (or any other suspected infectious etiology), Dr. Yeh said. Unfortunately, he noted, “toxoplasmosis often has a poor visual outcome despite successful treatment.”
CMV retinitis. Previously, the typical patient with cytomegalovirus (CMV) retinitis also had HIV. Thanks to antiretroviral therapy, this is no longer the case, and affected patients now tend to have systemic immunosuppression (e.g., organ and bone marrow transplant recipients, cancer patients currently receiving chemotherapy). Clinical signs include smoldering—and sometimes subtle—retinitis and inflammation; treatment may include IV or intravitreal ganciclovir or foscarnet or oral valganciclovir. However, Dr. Yeh cautioned, chronic valganciclovir prophylaxis may lead to drug resistance.
Post-Ebola syndrome. Uveitic disease in survivors of the Ebola epidemic ranges from hypertensive anterior uveitis to intermediate uveitis and panuveitis. The clinician’s index of suspicion should be high when examining recent travelers to West Africa and any health care providers who provided care on the front lines of the epidemic, Dr. Yeh said. He noted that treatment guidelines are evolving and urged ophthalmologists to exercise “extreme caution” with regard to any invasive surgery in an Ebola survivor.
Top take-home messages. Dr. Yeh’s 2 take-home messages: 1) Be aware of the short- and long-term outcomes associated with the uveitic diseases. 2) Be sure to evaluate infectious etiologies before initiating steroids.—Jean Shaw
1 Woolston S et al. Morb Mortal Wkly Rep. 2015;64(40):1150-1151.
2 The CDC also provides updates on any shortages of Procaine Penicillin G.
Financial disclosure. Dr. Yeh: Clearside: C; Santen, Inc.: C.
Disclosure key. C = Consultant/Advisor; E = Employee; L = Speakers bureau; O = Equity owner; P = Patents/Royalty; S = Grant support.