Eyeworld

EW INTERNATIONAL 56 January 2015 I n this month's "International outlook," Douglas Jabs, MD, PhD, presents a logical approach to the diagnosis and management of uveitis. The prevailing teaching is that a broad search for underly- ing systemic disease is necessary. Absent any evidence of other organ involvement this search is rarely useful. In this article, EyeWorld highlights the most current thinking on the diagnostic testing related to uveitis. John A. Vukich, MD, international editor by Matt Young and Gloria D. Gamat EyeWorld Contributing Writers and are not helpful in assessing the wider retinal/choroidal picture. Fluorescein and indocyanine green angiography (ICG) still remain important tools in the assessment of uveitis cases. New OCT systems will allow a wider view of the retina, which will bring an extra dimension to the use of this imaging modality. "We have demonstrated the use- fulness of enhanced depth imaging in some forms of panuveitis, iden- tifying abnormalities in the acute phase of the disease," Dr. Pavesio said. "But also if you look later on, when the disease becomes inactive, you can identify generalized choroi- dal thinning." Other techniques, such as laser flare photometry (LFP), have been used in the monitoring of uveitic diseases. "LFP is not yet widely used, but in some centers we are beginning to develop a keen interest in the use of LFP in monitoring disease activity," Dr. Pavesio said. "Uveitis clinics are comparing the usefulness of this method in a busy clinic and how it will affect the decision of clinicians." EW Editors' note: Drs. Cheung, Jabs, and Pavesio have no financial interests related to their comments. Contact information Cheung: gemmy.cheung@snec.com.sg Jabs: douglas.jabs@mssm.edu Pavesio: carlos.pavesio@moorfields.nhs.uk ditions related to the retina or the optic nerve area, have been found to be useful in the diagnosis of selective cases of uveitis. "Electrodiagnostics is not used routinely in every case of uveitis," said Chui Ming Gemmy Cheung, MD, FRCOphth, consultant, ocular inflammation and immunology service, Singapore National Eye Centre. "However, it may be quite useful and give us clues to the di- agnosis when there is doubt. It can be a useful adjunct in the diagnosis and monitoring of selective cases, and particularly useful if we use it in conjunction with the understand- ing of the pathology and disease behavior." Optical coherence tomography (OCT) has been found to be useful in uveitis as well. OCT is useful for monitoring the structural compli- cations in the eyes of patients with uveitis, such as macular edema, or choroidal neovascularization. It can also show damage to the retina and choroidal/retinal pigment epithelial lesions in the posterior uveitides. As such, it is an important tool for managing intermediate, posterior, and panuveitides. "We can look at this application of OCT technology for phenotyping and try to use them as anatomic biomarkers in terms of damage," said Carlos Pavesio, MD, consultant ophthalmic surgeon, Moorfields Eye Hospital, London. However, current OCT images offer a partial view of the retina proach to laboratory testing, which searches for the underlying disease even when there is no evidence of other organ involvement. While most uveitic diseases were presumed to be related to an underlying sys- temic disease or inflammatory con- dition, the fact is that most uveitides are eye-limited. "Only a minority have a system- ic disease associated with them, so spending a lot of time looking for the systemic disease is often fruit- less," Dr. Jabs said. "With the excep- tion of infectious uveitides, we are rarely diagnosing the etiology; we are typically diagnosing the specific uveitic disease." So how should uveitis diagnosis be approached? The more modern approach is to recognize that the clinician's goal is the diagnosis of a specific uveitic disease. "This means characterization of the uveitis along several dimen- sions," Dr. Jabs said. "We should determine the morphology and associated features, the degree of severity, and arrive at a limited differential diagnosis. Proper characterization often leads to a very specific diagnosis." Where investigations come in The likely diagnosis can be derived from the history, the examination, imaging modalities, and limited lab- oratory testing. Laboratory tests can then be used to identify infectious diseases, and when applied carefully, a systemic disease, which cannot be identified from the morphologic picture. As far as imaging in uveitis is concerned, the key is to perform targeted imaging of the affected part of the eye. Two of the most useful imaging techniques for diagnosing posterior and panuveitic entities are fluorescein angiography and fundus autofluorescence. Fluorescein angiography can help distinguish among many of the posterior uveiti- des, such as serpiginous choroiditis, acute posterior multifocal placoid pigment epitheliopathy, and rapidly progressive choroiditis, among others. Fundus autofluorescence is useful in this regard as well. Imaging techniques such as electrodiagnostics including electroretinography (ERG) and electrooculography (EOG), which are used in a wide variety of con- From New York to Singapore, the quest continues to define how we approach uveitic disease S everal misconceptions about uveitis have been common in literature in the past. These include the concept that uveitis is a single disease and the notion that uveitis is the tip of the iceberg for a systemic disease. That is according to Douglas A. Jabs, MD, MBA, professor of ophthalmology and medicine at the Icahn School of Medicine, Mount Sinai, New York. Expanding on the way we think about the disease can lead to a better understanding and approach to its diagnosis, said Dr. Jabs, who spoke at the National Healthcare Group Eye Institute 7th International Ophthalmology Congress in Singapore. "There are more than 30 com- mon forms of uveitic diseases that we deal with," Dr. Jabs said. "We should stop thinking of trying to diagnose the "cause" of uveitis, but instead we should think about diag- nosing the specific uveitic disease. Each disease has its own features, its own course, and its own treatment." Diagnosis of specific uveitic disease The older approach of the etiologic diagnosis of uveitis has problems and has led to a uveitis survey ap- Diagnostic approach to uveitis gets smarter globally Serpiginous choroiditis associated with tuberculosis Source: Carlos Pavesio, MD International outlook

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