autoimmune disease and the eye - online - pacific university · pdf fileautoimmune disease and...
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![Page 1: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/1.jpg)
Autoimmune Disease and the Eye!Anthony DeWilde, OD FAAO
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Disclosure!
I have no financial disclosures
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Goals!
Manifestations
Diagnosis/Treatment
Referral
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Autoimmune Disease!
Ankylosing Spondylitis Myasthenia Gravis
Chron’s Disease Psoriasis
Giant Cell Arteritis Rheumatoid Arthritis
Graves’ Disease Sarcoidosis
Lupus Erythematosus Sjögren’s Syndrome
Multiple Sclerosis Ulcerative Colitis
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External!
Ptosis
Exophthalmos
Diplopia
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Ptosis!
Myasthenia Gravis
Any patient with Diplopia or Ptosis
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Myasthenia Gravis!
Greek and Latin meaning
“grave muscle weakness”
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Myasthenia Gravis!
Chronic autoimmune neuromuscular disease
Muscle weakness and fatigue
Eyelid muscles first affected in most cases
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Myasthenia Gravis!
Can involve breathing and swallowing
Myasthenic Crisis
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Myasthenia Gravis!
Antibodies destroy or alter receptors for acetylcholine
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Myasthenia Gravis!
In office testing
Ice-pack test
Upgaze test
Cogan lid twitch
Orbicularis resistance
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Arq. Bras. Oftalmol. vol.73 no.2 São Paulo Mar./Apr. 2010
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Myasthenia Gravis!
Other testing
Tensilon
Acetylcholine receptor antibodies
Anti-MuSK antibody (muscle specific kinase)
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Myasthenia Gravis!
Treatment
Cholinesterase inhibition (pyridostigmine)
Corticosteroid
Immunosuppressants
Plasmapharesis
Intravenous IVIg
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Myasthenia Gravis!
Surgery
15% of MG patients have tumor of Thymus
Often require Thymectomy
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Myasthenia Gravis!
RH - 55 yo WM
Healthy eyes
New CN IV Palsy
+DM, +HTN
NO neuro symptoms
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Myasthenia Gravis!
Resolved 6 weeks later
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Myasthenia Gravis!
4 months later
Ptosis
Ice pack
Pre 2mm
Post 9 mm
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Myasthenia Gravis!
Upgaze fatigue
+ Cogan lid twitch
AchR Antibodies very elevated
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Myasthenia Gravis!
RH has difficulty with meds
Variable diplopia!!
Remains ocular only
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Exophthalmos!
Graves’ Disease
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Graves’ Disease!
Autoimmune Disease
Skin
Thyroid
Orbit
Mental Health
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Patient DS!
20/25 OD and OS
IOP 18/18
No APD
Diplopia in lateral and downgaze
Pain in lateral gaze
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Exam!
Exophthalmos OS
Hertel 19/23
Lagophthalmos
Conjunctival edema and injection
Eyelid edema
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Labs!
TSH = 0.003 (normal = 0.47-5.00)
T4 = 20.3 (normal = 4.5-12)
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Referral!
Endocrine
Oculoplastics
Inform PCP of findings
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5 months later!
IOP 18/24
? APD OS
Start IOP Timolol 0.5%
Start Oral Pred (40 mg)
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6 months later!
IOP as high as 38/28
Oral Pred now 80 mg
+ APD OS
IOP 19/19 on Travatan, Cosopt, Alphagan
Refer for Orbital Decompression
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After Orbital Decompression!
Develops Diplopia
But...IOP 12/14 on meds
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Now S/P:
Orbital Decompression
Strabismus Surgery
Eyelid Retraction
Now has 20/80 cataract
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Last Month!
20/20
Single vision
Normal IOP
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Graves’ Disease!
80% are Hyperthyroid
Sweat, tremor, weight loss
10% are Hypothyroid
Cold, weight gain, hair loss
10% are Euthyroid
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Graves’ Disease!
30-50% of Graves’ patients have orbitopathy
2-5% serious complications
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Graves’ Disease!
Dry eye
Injection
Eyelid retraction
Diplopia
Compressive Optic Neuropathy
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Graves’ Disease!
Increased antithyroid antigens
TSH receptor antibodies
Increased T3, T4
Decreased TSH
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Graves’ Disease!
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Graves’ Disease!
Increase in
Fibroblasts
Hyaluronic Acid
Collagen
Adipose
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Graves’ Disease!
Exophthalmos
Hertel
Asian upper limit = 18
White upper limit = 21
Black upper limit = 24
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Graves’ Disease!
Free T3 and T4
TSH
Anti-thryoglobulin (TSI)
Thyrotropin-Binding Inhibitory Immunoglobulin (TBII)
Thyroid Peroxidase (TPO)
Refer to Endocrine
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Graves’ Disease!
CT allows measurement of
Orbital fat
Lacrimal gland
Extraocular muscles
MRI for serial imaging
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Graves’ Disease!
Treatment
Quiet inflammation - Steroid
Stabilize Thyroid
Medication
Surgery
Radioiodine
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Graves’ Disease!
Treatment
Ocular Comfort
Prism
Surgery
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Graves’ Disease!
Surgery
Orbital Decompression
Strabismus
Eyelid
Cataract
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Graves’ Disease!
Affects up to 1/3 of Graves' patients
Attention
Mood
Anxiety
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Graves’ Disease!
Smoking makes disease worse
Smoking makes treatment less effective
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Diplopia!
Graves’ Disease (common)
Myasthenia Gravis (common)
Multiple Sclerosis (common)
Giant Cell Arteritis (uncommon)
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Multiple Sclerosis!
Is MS an autoimmune disease?
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Multiple Sclerosis!
Demylenating disease
Can cause diplopia
Transient
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Multiple Sclerosis!
Consider testing if:
Young patient
Other neurologic symptoms
Lhermitte symptom
Uhthoff phenomenon
Optic Neuropathy
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Episcleritis!
Not as likely to be autoimmune
Consider testing if
Recurrent
Nodular
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Scleritis!
Rheumatoid Arthritis*
Lupus
Ulcerative Colitis
Ankylosing Spondylitis
Reactive Arthritis
Psoriatic Arthritis
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Episcleritis vs Scleritis!
Episcleritis Scleritis
Vision Normal May reduce
Hyperemia Focal Focal/Diffuse
Pain Mild/Mod Mod/Severe
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Scleritis!
http://www.aao.org/theeyeshaveit/red-eye/scleritis.cfm
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Rheumatoid Arthritis!
Inflammatory damage to small joints
Mostly hands and feet
Pain, swelling, and possible deformity
Can cause pain in larger joints
Hip, shoulder, knees, ankles, and elbows
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Rheumatoid Arthritis!
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Rheumatoid Arthritis!
Diagnosed with a combination
Blood work
X-ray
Clinical signs/symptoms
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Rheumatoid Arthritis!
Treated with NSAIDs for mild cases
Steroids
DMARDs (i.e. Methotrexate)
Immune modulating drugs (i.e. Enbrel)
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Rheumatoid Arthritis!
Most likely systemic cause of scleritis is RA
Only 50% of patients with scleritis have associated condition
Patients with RA and scleritis have
Widespread and aggressive systemic disease
May need more aggressive therapy
![Page 65: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/65.jpg)
Lupus!
Autoimmune disease that affects
Joints, skin, kidneys, blood cells, brain, heart and lungs
Symptoms include
Fatigue, shortness of breath, chest pain
![Page 66: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/66.jpg)
Lupus!
Classic “butterfly” rash on cheeks and nose
![Page 67: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/67.jpg)
Lupus!
Most commonly seen in women of childbearing age
Difficult to diagnose
![Page 68: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/68.jpg)
Lupus!
NSAID
Corticosteroid
Plaquenil
Immune suppression
![Page 69: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/69.jpg)
Cornea/Dry Eye!
Graves’ Disease
Sjögren’s Syndrome
Lupus
Rheumatoid Arthritis
![Page 70: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/70.jpg)
Sjögren’s Syndrome!
Autoimmune disease that mainly causes: dry eye and dry mouth
Can also have joint pain, fatigue, persistent cough
Typically in women over 40
![Page 71: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/71.jpg)
Sjögren’s Syndrome!
Can have association with RA or Lupus
Diagnosis is made by signs/symptoms, blood test
Lip biopsy?
![Page 72: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/72.jpg)
Sjögren’s Syndrome!
Treat specific symptoms
Dryness
Dry eye
Treat salivation (pilocarpine), may also use Plaquenil
![Page 73: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/73.jpg)
Uveitis!
Possible association with autoimmune disease
Less than 50% have known cause
![Page 74: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/74.jpg)
Uveitis!
Scatter approach
Tailored approach
![Page 75: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/75.jpg)
Uveitis!
Tailored approach
Examine/Classify
Working List
Case History
![Page 76: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/76.jpg)
Uveitis!
Examine/Classify
Anterior/Posterior/Pan
Granulomatous/Non
Acute/Chronic
Unilateral/Bilateral
![Page 77: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/77.jpg)
Uveitis!
Ankylosing Spondylitis
Inflammatory Bowel
Reactive Arthritis
Psoriasis
Sarcoidosis
JIA
![Page 78: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/78.jpg)
Uveitis!
Case History
Ask specific questions
Decide if special testing needed
![Page 79: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/79.jpg)
Uveitis!
Acute Anterior Unilateral Nongranulomatous
Ankylosing Spondylitis
Inflammatory Bowel
Psoriasis
Reactive Arthritis
![Page 80: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/80.jpg)
Uveitis!
Ankylosing Spondylitis
Lower Back Pain
Worse with Rest
Wake up with pain
Better with NSAIDS
![Page 81: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/81.jpg)
Uveitis!
Inflammatory Bowel
GI symptoms
Cramps, diarrhea, bloody stools
Diet modification, Immune modulation, Surgery
Refer to GI
![Page 82: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/82.jpg)
Uveitis!
Psoriasis
Skin plaques - joints, scalp
Arthritis ~ 5%
Steroid creams, Immune modulation
Refer to Dermatology
![Page 83: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/83.jpg)
Psoriasis!
![Page 84: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/84.jpg)
Uveitis!
Reactive Arthritis
Acute Arthritis
Typically knee, ankle, foot
Skin lesions, urethritis, diarrhea
Pain modification
Refer to Rheumatology
![Page 85: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/85.jpg)
Uveitis!
Chronic Anterior Bilateral Granulomatous
Sarcoidosis
![Page 86: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/86.jpg)
Uveitis!
Sarcoidosis
Multisystemic, Granulomatous Disease
90% have lung involvement
Skin involvement common
Order chest x-ray
ACE is non-specific
![Page 87: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/87.jpg)
Uveitis!
Asymptomatic Anterior Unilateral Nongranulomatous
Juvenile Idiopathic Arthritis
![Page 88: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/88.jpg)
Uveitis!
Juvenile Idiopathic Arthritis
Joint pain/stiffness/swelling
Unilateral cataract
Pediatrician/Rheumatology referral
![Page 89: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/89.jpg)
Retina!
Plaquenil
![Page 90: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/90.jpg)
Plaquenil!
Ganglion, Photoreceptor, RPE
Atrophy
Scotoma
Irreversible Damage
![Page 91: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/91.jpg)
Plaquenil!
HCQ
1000 g
400 mg/day
>7 years
![Page 92: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/92.jpg)
Plaquenil!
Quantify risk
1-7 years
1/1000
>7 years
1/100
![Page 93: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/93.jpg)
Plaquenil!
Find HCQ toxicity before visible on fundus evaluation
Prevent irreversible vision loss
![Page 94: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/94.jpg)
Plaquenil!
![Page 95: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/95.jpg)
Plaquenil!
Testing
mfERG
FAF
VF
OCT
![Page 96: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/96.jpg)
Plaquenil!
VF
24-2, 30-2 not sufficient
10-2 white on white (or red)
![Page 97: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/97.jpg)
Plaquenil!
![Page 98: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/98.jpg)
Plaquenil!
False Positives
What is Sensitivity/Specificity?
Consider risk of developing toxicity
![Page 99: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/99.jpg)
Plaquenil!
Risk before 7 years = 1/1000
Risk after 7 years = 1/100
If Specificity = 90%
10-100 times more FALSE positives than TRUE
![Page 100: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/100.jpg)
Plaquenil!
Pro:
Available
Inexpensive
Interpretation
Con:
Subjective
Patients dislike
False Positives
![Page 101: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/101.jpg)
Plaquenil!
![Page 102: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/102.jpg)
Flying Saucer!
![Page 103: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/103.jpg)
Flying Saucer!
![Page 104: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/104.jpg)
OCT!
Pro:
Available
Objective
Interpretation
Con:
Early detection
Cost
![Page 105: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/105.jpg)
Plaquenil!
2002 Recommendations
High risk if > 6.5 mg/kg/day
Color vision
10-2 or Amsler
![Page 106: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/106.jpg)
Plaquenil!
2011 Recommendations
High risk if 1000g cumulative dose
NO Color vision or Amsler Grid
10-2 combined with
OCT, FAF, mfERG
![Page 107: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/107.jpg)
Plaquenil!
(+) HVF, (+) SD-OCT
(+) HVF, (-) SD-OCT
(-) HVF, (+) SD-OCT
(-) HVF, (-) SD-OCT
![Page 108: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/108.jpg)
![Page 109: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/109.jpg)
![Page 110: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/110.jpg)
Plaquenil!
Frustrations
False positives
No gold standard
We are the authority
Benefits of Plaquenil
![Page 111: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/111.jpg)
Case!86 Year Old White Male
Blur at distance
Ocular History: Early AMD
Medical History
Psoriatic Arthritis
HTN
CAD
Hyperlipidemia
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Case!
Medications
Plaquenil
Fluocinonide
Coreg
ASA 325 mg
![Page 113: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/113.jpg)
Case!
Patient at VA since 1999
Every exam: RPE changes OS>OD
Called AMD
20/20- OD and OS
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Case!
September 2010
Ring shaped atrophy OS
Fundus Photos/OCT
![Page 115: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/115.jpg)
Fundus OS!
![Page 116: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/116.jpg)
Fundus OS!
![Page 117: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/117.jpg)
SD-OCT - OS!
![Page 118: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/118.jpg)
SD-OCT - OS!
![Page 119: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/119.jpg)
SD-OCT - OD!
![Page 120: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/120.jpg)
Management!
Discontinue Plaquenil
See Rheumatologist -- Patient refused initially
![Page 121: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/121.jpg)
Management!
Patient eventually discontinued meds
Asymptomatic
Good outcome?
![Page 122: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/122.jpg)
Vascular!
Arterial Disease
Vasculitis
![Page 123: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/123.jpg)
Arterial Disease!
CRAO
Giant Cell Arteritis
Up to 10%
![Page 124: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/124.jpg)
Vasculitis!
Wegener’s
Polyarteritis Nodosa
Giant Cell Arteritis
![Page 125: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/125.jpg)
Optic Nerve!
Optic Nerve Edema
Optic Atrophy
![Page 126: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/126.jpg)
Optic Nerve!
Giant Cell Arteritis
Graves’ Disease
Lupus
Multiple Sclerosis
Sarcoidosis
![Page 127: Autoimmune Disease and the Eye - online - Pacific University · PDF fileAutoimmune Disease and the Eye! Anthony DeWilde, OD FAAO. ... Uveitis! Possible association ... Case by Case](https://reader034.vdocuments.site/reader034/viewer/2022051721/5a86d2ac7f8b9a87368de3da/html5/thumbnails/127.jpg)
Giant Cell Arteritis!
Profound Vision Loss
Bilateral in 14 days in 1/3 if Untreated
Systemic Complications
Treatable
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Systemic Symptoms!
Jaw Claudication (Odds Ratio 9.0)
Neck Pain (Odds Ratio 3.4)
Anorexia (Odds Ratio 2)
Hayreh SS, et al. Giant Cell Arteritis: Validity and Reliability of Various Diagnostic Criteria. Am J Ophthalmol 1997;123:285-96
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Less Predictable!
Headache
Fever
Scalp Tenderness
MalaiseHayreh SS, et al. Giant Cell Arteritis: Validity and Reliability of Various Diagnostic Criteria. Am J
Ophthalmol 1997;123:285-96
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Headache!
A-AION - 46% had Headache
NA-AION – 54% had Headache
Could Mislead
Hayreh SS, et al. Giant Cell Arteritis: Validity and Reliability of Various Diagnostic Criteria. Am J Ophthalmol 1997;123:285-96
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Average Number of Symptoms = 3
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Testing!
Labs – ESR, CRP, CBC, Platelets
Fluorescein Angiography
Ultrasound, PET, MRI – Limited Benefit
Temporal Artery Biopsy
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Labs!
ESR
> 33 mm/h
Sensitivity 92%
Specificity 92%
CRP
> 2.45 mg/dl
Sensitivity 100%
Specificity 82%
CBC
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ESR + CRP!
Sensitivity 99%
Specificity 97%
Hayreh SS, et al. Giant Cell Arteritis: Validity and Reliability of Various Diagnostic Criteria. Am J Ophthalmol 1997;123:285-96
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Platelets!
Odds Ratio:
ESR > 47 mm/hr = 1.5
CRP > 2.45 mg/dL = 5.3
Platelets > 400,000/"L = 4.2
All 3 elevated = 8
Walvick MD, Walvick MP. Giant Cell Arteritis: Laboratory Predictors of a Positive Temporal Artery Biopsy. Ophthalmology 2011;118:1201-1204
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Additional Testing!
Temporal Artery Biopsy
Gold Standard
Case by Case
Side Effects
Necrosis, Infection, Nerve Damage
Bilateral?
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MR. A!
63 y/o White Male
New onset headache, temporal pain, neck pain
NO vision complaints
EOM full
NO APD
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MR. A!
Labs
ESR = 56
CRP = 1.37
Pending Temporal Artery Biopsy
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MR. A!
Started on 40 mg Pred
When he tapers, headaches return
What about vision?
20/70 and VF reduction
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MR. A!
When Pred resumed, vision returned to 20/25
Visual Field improved
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Goals!
Manifestations
Diagnosis/Treatment
Referral