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.