 Good morning, so welcome to UVitis subspecialty day rounds the title of our Presentation our infectious posterior UVA to these Diagnoses not to miss we are going to present some Common posterior UVA to these that are vision-threatening some Uncommon ones that are definitely ocular emergencies and some more unusual Posture UVA to these and some that are ubiquitous and you should always test for So really the question that you need to ask yourself when you're confronted with a patient that you think is Has inflammation in their eye is is it infectious or is it not this is a very important question? And this is answered really through an accurate and thorough history Complete ophthalmic and physical examination and then of course the key is the formulation of differential diagnosis And then laboratory testing and or intraocular fluid sampling is used to confirm or exclude the diagnosis Of certain infections or non infectious diseases There are certain key considerations. Those are the exposure risks for example sexually transmitted diseases HIV status tuberculosis exposures Systemic illnesses these are things that you would glean on your examination review of systems constitutional symptoms organ other organ system involvement The nutritional status of the patient and their their immune status so whether or not this is acquired or iatrogenic or Through age as as we age our immune status wanes a little bit and then of course local factors including recent surgery and trauma the anatomic location of the UV is is extremely important particularly with respect to Where in the back of the eye what tissue is involved for example? Is it a retinitis as you might see in a patient with a necrotizing herpetic retinitis? Or is it a corridor to say for example where tb would more commonly present is it a Unifocal or posifocal disease as such as you might see in toxicoplasmosis or Multifocal as you might see in certain types of herpetic infections and then are the vessels involved Certain certain types of UV entities will affect the veins more than the arteries And then is the optic nerve involved is this a neuro retinitis because your differential diagnosis for a neuro retinitis Will be different than it is for other infectious Ideologies Lotterality is important in that many infectious UV entities will present unilaterally for example necrotizing herpetic retinitis Frequently will present unilateral it although it may become bilateral toxicoplasmosis toxicoriasis are frequently unilateral Other associated signs on the examination such as elevated intraocular pressure Stigmata herpetic infections such as insectile iris atrophy corneal scarring can give you a clue to the diagnosis But laterality is obviously not always helpful as there are some patients with b-27 associated UV it is it can present with hypopia on UV it is The differential diagnosis like to think of it in just broad categories Is it viral is it commonly viral such as herpes over the most common thing and then less common I Infections such as emerging infections depending upon whether we're in the world the patient might be coming from bacterial infections fungal infections I Particularly endogenous type of fungal infections protozoal infections such as toxicoplasmosis and then helmetic Interocular fluid and tissue sampling is very important particularly in presentations in which it is really difficult to just make the diagnosis based on pattern recognition so in the case of Here this no one would mistake this for diagnosis of toxicoplasmic retinocortitis or in an immunocompromised patient In the correct clinical time to context this is CMB retinitis However, you cannot tell just by looking at this what this might be and in immunocompromised patients. This could be many different Diagnoses as is this multi focal sub retinal infiltrates in an elderly patient could represent infection non-infectious UBI's or malignancy so that in UV it is in which the etiology is unclear or the Response to therapy is atypical or the systemic workup is an inconclusive Interocular fluid analysis either from the anterior chamber of the vitreous or sampling the retinor of the quarry can be helpful in distinguishing between an intraocular infection or malignancy where the differential between this is Extremely important in terms of treating the patient and may impact on the systemic health of the patient therapeutic principles Obviously, you do not want to treat an infection with steroids without appropriate specific Antibiotic cover The basic principle is to think about this in the broad differential diagnosis So if you see a patient with a Indeterminate diagnosis You will obtain laboratory testing And you will maybe sample their vitreous or their anterior chamber, but you want to treat broadly treat the infection that could most likely Destroy the eye frequently treating with multi antimicrobial treatment and then withdrawing therapy as your laboratory Laboratories become available or more information becomes available on the patient Corticosteroids are useful particularly topically to treat inflammation But should never be used as monotherapy in patients with infectious UVA that being said corticosteroids can be very helpful in treating the inflammatory component of infectious diseases after the appropriate installation and commencement of Microbial therapy and generally do not treat Intra vitreal with intra vitreal steroids as this can result in the unbridled viral replication And then it is always important to reevaluate your your patient On a regular basis and reconsider your diagnosis if they are not responding in the way that you think so our first presenter is going to be Dr. Shakur we have the Honor of our entire UBI's division presenting here, so I hope you Enjoy this Where's the computer? All right now after Laura the mic Al's it has a little bit of a height advantage here, but I'm going to present a couple of patients, but the first one is is Residents, I'm sorry a fellowship nightmare. We've all had a few of those in this one We really were at a loss of As to how we could have proceeded differently A 61 year old gentleman African-american with a history of systemic sarcoidosis presented to us in California in 2010 in August And for two months he had a history of blurry vision and photophobia in The left eye and he been diagnosed a few weeks earlier by a local ophthalmologist with anterior uveitis He's diabetic Hypertensive has gout chronic renal disease and in late 2005 he complained of progressive fatigue ataxia falling and confusion He's diagnosed with neuro sarcoidosis based on a thoriscopic biopsy of his hyalur lymph nodes Which showed non-KZ 18 granulomas He came in with hydrocephalus Meninger encephalitis and a lymphocytic predominant pleocytosis He was initially treated with steroids and methotrexate at a fairly low dose and In 2007 began to have worsening pulmonary sarcoid with restrictive lung disease In 2009 he was started on treatment with cell sept to a final dose of three grams a day And he began to develop cardiac conduction abnormal Anomalies that were presumed secondary to sarcoidosis Don't forget to check people's hearts when they have sarcoid his past ocular history was really only significant for cataract extraction in the past and a history of Zoster to the First division of the trigeminal nerve on the left side His examination was significant for a Little bit of a affron pupillary defect, which I thought may just be my imagination and For the residents which appendage is this? Anybody Ashley yes, and what do you see on the nose? Yeah, so it's a nodular kind of Dermal or post dermal rash And what do you call this in sarcoidosis anybody? Very good. Yeah, so this is very good. So it's so this is lupus pernia Which is a have a hallmark of cutaneous sarcoidosis He had that His anterior chambers should one plus cell three plus flare he had one plus seven these anterior vitreous and a lot of haze so And you can see a little bit of posterior vitreous cell in the OCT on both sides He's diagnosed with anterior and intermediate uveitis Likely secondary to sarcoidosis with a small small affron pupillary defect His infectious labs were negative so a few days later we injected him with a subtenon skin log in the left side He was seen in follow-up. He removed at reported improvement in his photophobia, but no improvement in vision and now Although his vision was the same at 2,200 He now has a 1.2 log affron pupillary defect and I cannot stress how important it is to actually measure an affron pupillary defect Judith Warner, and I would agree on one thing here But Measure them because they do change and when they change it's important to image His cell has improved his uveitis has improved his OCT shows a little bit of swelling But we recommended an MRI to look at his optic nerve this gentleman does have neurosarcoidosis Lee What do you see on this MRI? It's part of his brain missing or is this something else Well, it looks like that, but it's actually it's a flow artifact from his ventricular shunt So when things flow rapidly In T1 you end up with a void a flow void Anyway, that's just cool. And then his optic nerve over here this pre-chiasmal optic nerve You can see a little bit of contrast enhancement So he was diagnosed with an optic neuropathy in consultation with our neuropathy Ophthalmology colleagues in San Francisco and with neurology. We presumed that this was sarcoid optic neuropathy You're treated with IV-soluble medrawl for five days started on ramicade a week later continued on cell sept and transitioned to oral prednisone at 60 milligrams His vision continued to decline until two days later. He was no light perception in the left eye bad and Then he disappeared for a month and When he comes back a month later, he complains of decreased vision in his right eye as well as unsteadyness of gait He is now no light perception in 2040 in the right eye. It's got a complete aphrodiputile defect and What do we see here? Conradie so whitening of the retina but what do you see in Somebody with uviatus would you expect such a clear view? No, right, so that's something to keep a note of and you can see in the periphery has got areas of retinal whitening here as well and Is OCT? Chris if you can tell me where the location of the whitening is So the inner retina so you can see like there's a complete loss of retinal architecture over here So could this be sarcoid pan uviatus that's unlikely on so much immunosuppression and you certainly don't expect to see red little whitening Could it be viral retinitis? So we performed a vitreous tap. We admitted him to neurology for IV acyclovir Lumbar puncture was also performed and This PCR of his vitreous and CSF was positive for varicella zoster virus We recommended stopping the solid medrawl and switching from IV acyclovir to Gans acyclovir and Foscarnet and We started intervitural injections of Gans acyclovir and Foscarnet alternating at high dose unfortunately over the next three days he continued to progress progress and The retinal whitening is now splitting his fovea so This is a gentleman with systemic sarcoidosis presenting initially as neuro sarcoidosis He has anterior and intermediate uviatus. He has retrovulver optic neuropathy It's presumptively treated with high-dose steroid and immunomodulatory therapy as you would in somebody with neuro sarcoid and optic neuropathy And he ends up with a necrotizing herpetic retinitis in the right eye and worsening optic neuritis in the left so optic neuropathy and an immunocompromised person with neuropathosis and this is progressive outer retinal necrosis in a patient with severe autoimmune disease with An iatrogenic component so progressive outer retinal necrosis Is a rapidly progressive necrotizing retinal Retinitis usually caused by various ill-asostovirus in about 70% and 30% caused by herpes simplex one or two It's typically seen in patients with a CD4 count of less than 50 Visual outcomes are poor. This is this has an abysmal prognosis even with antiviral therapy It's been reported in other immunocompromised states as well including after bone marrow transplant after lymphoma after high dose steroid and Classically seen in patients with HIV and AIDS It's been reported as well just a few years before I saw my patient When optic neuropathy which was presumed to be Inflammatory in nature ended up being infectious and treated with systemic corticosteroids This is a patient treated by dr. Davis at Baskin-Pammer So was the optic neuropathy secondary to sarcoidosis a very slow disaster I think we very well proved to ourselves that it was infectious unfortunately How do we treat this patient without exacerbating his systemic disease? Neurology did not want to stop Steroids did not want to stop remiccate and did not want to stop cell sept Cardiology didn't want to either this patient was quite ill With that level of immunosuppression treatment of this patient's eyes is doomed to fail What's his prognosis well, I can tell you now five years later. He's still 2040, but his visual field is less than five degrees So necrotizing viral retinitis is include acute retinal necrosis Progressive outer retinal necrosis and CMV retinitis. I'll leave out the last three in the interest of the last one in the interest of time This is a 54 year old gentleman referred to us Some years back for iritis When you look in the back you can see that there's a little bit more going on Eric you're going to be my fellow next year somebody will pick on you. What do you see here? So kind of this retinal whitening in the periphery multiple foci started to become confluent With some hemorrhage, but not a lot. So this is Acute retinal necrosis It's an necrotizing retinitis caused by herpes simplex or varicella zoster patients with RNA usually immunocompromised But it may also be seen in immunocompromise But it may be seen in the immunocompromise Patients come in with hot eyes moderate to significant retritis optic discidema and an optic neuropathy if not treated promptly Bilaterality will happen in 70% after after a month It's a clinical diagnosis, but it can be fortified by using PCR for verse for the herpes viruses and for toxoplasma because there is a atypical toxoplasma with retinitis that can mimic armed Conventionally you treat this with IV acyclovir Without treatment there will be involvement in 20s to 70% in the other eye Systemic acyclovir reduces that risk to six that to 13% other treatment protocols the one that I favor Oral valacyclovir to a dose of two grams three times a day gives you IV equivalent levels Intravitrile gas acyclovir or Intravitrile foscarnate may be used oral prednisone may be added aspirin may be associated with better visual outcomes late findings do include Pigmentary changes retinal detachment does happen in about 70% Barricade late barricade laser. However is controversial And retinal detachment is complicated lots of PVR. You need a buckle. You need oil Here's a arn Retina that seems to be clearing a little bit. You can see that there's very vascular clearing of the retinitis and Ultimately, this progresses into kind of this Swiss cheese appearance with pigmentary changes resolving retinitis That's why they get retinal detachment Here's a 34 year old patient with HIV and the CD4 count at 10 You can see a lot of retinal whitening a little bit of blood but not very much But what stands out here is how clear the view is the absence of vitritis Make makes you think about immunocompromised states This is progressive outer retinal necrosis a better example a more typical example than the patient I presented in the beginning This is a herpetic retinitis in immunocompromised patients with rapidly progressive multifocal lesions lower level of vitritis and vasculitis and whereas aren't spreads rapidly this spreads like Well, like nobody's business this this can wipe out the entire retina in a couple of days The treatment for this is either a cyclone or foscarnate organ cycle for IV treatment is recommended high-dose Intervitual Gans cycle or foscarnate or their combination and these progress despite treatment So in conclusion remember viral retinitis is not always something you see That you did not cause Viral retinitis can be iatrogenic we do immunosuppress more and more patients in this era and Do look for infectious uvea to these in the immunocompromised and then most importantly just as a Kind of a wide Statement always dilate the pupil in an eye with uveitis and to uveitis is often not anterior Thank you to the photographers you