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Uveitis Diagnosis
Goals of Uveitis Management
When dealing with uveitis, the main
goal of the clinical ophthalmologist is
to manage his patients properly.
Uveitis Diagnosis
Goals of Uveitis Management
To achieve this ultimate goal for each patient,
he
must first make three important
determination:
1. Diagnosis: Accurate diagnosis based on the
identification of the lesion and of its cause.
2. Prognosis: Determine the problem
prognosis.
3. Therapy: Design the best possible
therapeutic regimen to be undertaken.
Diagnosis
1. Categorize the patient’s uveitis as accurately as possible.
2. I.e. to identify the category of uveitis in which the patient’s disease probably belongs.
3. This is important because the:a. Clinical Course
b. Response to therapy and
c. complications
Of the various categories are for the most part known and predictable.
Diagnosis
Once the diagnosis has been
determined, therefore, decisions
relative to:
1. Prognosis
2. Treatment Can be made almost automatically
Diagnosis
The number of “Common Uveitic Entities” is in
fact surprisingly small.
It comprises only some 20-30 entities.
Of course, a list of all possible entities would
run into the hundreds.
Diagnosis Fortunately we can ignore this huge list with impunity
since our smaller one covers 90% or more of the uveitis
cases seen in the general practice of ophthalmology.
The list of “Likely Uveitis Entities” not only relatively
short, but most of the entities are different enough from
others on the list to make clinical differentiation
relatively easy:
Signs and symptoms
Bilaterality
Response to laboratory tests
Predilection with respect to eye, sex and race etc.
Diagnostic Methods
To place a case of uveitis in its proper
uveitic category, the following three
steps must be taken.
1. Naming
2. Meshing
3. Determining the final diagnosis
Naming
Simple and effective approach
Combine all of the terms descriptive of the
salient historical and clinical facts referable
to the case under study in a detailed
“working” name for the patient’s uveitis.
Examples of detailed “Naming”
Example 1 Ch, BL, NG, iridocyclitis, with band
keratopathy, in a 10 years-old white female with arthritic of the right knee.
Example 2 Ch, UL, NG. Iridocyclitis with secondary
cataract, open angle glaucoma and heterochromia in 30-years old white female.
Examples of detailed “Naming
Example 3 Ch, BL, diffuse granulomatous uveitis with
2ndry retinal vasculitis in a 40-year old black
female.
Example 4 Ch, BL diffuse granulomatous uveitis and serous
macular detachments in a 22-year old oriental
male with tinitis and alopecia areata
Meshing
1. The naming process creates a profile or
template of the clinical case in question .
2. The greater the detail, the finer and more
sharply etched the profile.
Meshing
3. The entities (20-30) on the list of “Likely
Uveitis Entities” also has a profile based on
its clinical characteristics.
4. Match the patients profile as closely as
possible with one or more of the known
disease profiles (meshing).
Meshing
5. When the profile of a patient closely resembles the
profile of the uveitic entity, we put the entity on the
list of diagnostic possibilities.
6. Put the entity with the best fitting (meshing) profile
first and the one with the poorest meshing profile last.
Naming and Meshing
Applying the the naming and
meshing procedures to the four
examples of naming given above,
the diagnostic possibilities in order
of likely would be as follows:
Meshing Example 1
Uveitis associated with Juvenile rheumatoid arthritis.
Sarcoid uveitis (less likely) Example 2
Fuch’s Heterochronic iridocyclitis Acute recurrent NG iridocyclitis that has
become chronic. Posner – Schlossman syndrome Severe post-traumatic iridocyclitis 2, 3, 4 – less likely
Meshing Example 3
Sarcoid uveitis Syphilitis Tuberculosis Vogt – koyanagi-Harada syndrome Behects syndrome
Example 4 Vogt-Koyanagi-Harada syndrome Sarcoid uveitis Tuberculosis
Less likely
Possibilities only
Determining the final diagnosis
Working with the small list of diagnostic
possibilities generated by the naming
and meshing processes, we can order:
1. Standard laboratory tests
2. Special tests
3. Request consultation with
other specialties
In order to rule in or rule out the suspected entities
Determining the final diagnosis
Please note that it is only after the
naming and meshing steps that these
tests and consultation should be sought.
Nothing should be ordered routinely .
Determining the final diagnosis
All tests and consultations should be for
the purpose of answering specific
diagnostic questions
This is in the interest of reducing the
cost of medical care, but even more
importantly to encourage clear thinking
and speed up the diagnostic process
Naming
Hx + PE
Clinical characteristics of
known Uveitis Entities
Differential Diagnostic
List
Ordered Differential Diagnostic
List
Reorder Based on Mesh
Laboratory Special Tests Consultations
Uveitic Diagnosis
PROPER PATIENT MANAGEMENT
Known Course
Known Complications
Known Response to Therapy
Naming-Meshing Diagram
Limitations of the naming and meshing system By using the naming-meshing system
and supplementing it with the: Standard test tests Special tests Consultations
We should be able to make correct presumption diagnosis of a case of uveitis in 75-85% of uveitis patients seen in general clinical practice.
Limitations of the naming and meshing system
This means that 15-25% of cases
will either resist categorization or
will present special problems in
response to treatment or
development of complication.
Limitations of the naming and meshing system
All these problems will place such
cases beyond the scope of the
method of attack presented here.
Limitations of the naming and meshing system
There are after all, hundreds of uveitic
entities and we can dealing with a list
of only 20-30.
When the rare entities occur, they will
always create diagnostic problems.
Limitations of the naming and meshing system
Recognizing the limitations of a
system is as important as
recognizing its virtues.
Limitations of the naming and meshing system When clear diagnostic answers are not
forthcoming. When the disease does not follow its
expected course. When the anticipated response to
therapy does not occur. The rarities and the uveitis masquerade
syndromes should be considered and patients should be referred if possible to a uveitis center.