HOW TO INVESTIGATE A

CASE OF UVEITIS
 Special investigations
Indications
• Recurrent granulomatous anterior uveitis
• Bilateral disease
• Systemic manifestations with out a specific
diagnosis
• Confirmation of suspective ocular picture such
as HLA-A29 testing in birdshort
chorioretinopathy
 Not necessary
• Single attack of mild unilateral acute anterior
uveitis
• A specific uveitis entity
• When a systemic diagnosis compatible with the
uveitis is already apparent
 Skin tests
1. Tuberculin skin test(montoux & Heaf)
• Intradermal inj of purified protein
• Positive
Induration of 5-14 mm with in 48 hours
Negative
• Excludes TB
• May occure in advanced disease
 Weakly positive
• Previous expoure & active disease
• Most people show hypersensitivity after BCG
Vaccination
Strongly Positive (induration >15mm)
• Usually indicates active disease
 Pathergy test
• Increased dermal sensitivity to needle trauma
• Behcet syndrome
• Rarely positive in absence of systemic activity
• Pustule formation
 Serology
Syphilis
• Because of variable presentation
• Serology test rely on detection of nonsepecific
antibodies (cardiolipin) or sepecific antibodies
1. Non-treponemal tests
RPR or VDRL
• Primary infection
• Monitor disease activity
• Response to therapy
• patient’s serum is mixed with carbon like
cardiolipin antigen
• Negative in upto 30% of patients with syphilitic
uveitis
• Becomes negative 6-18 months after therapy
2. Treponemal antibody tests
• Highly sensitive & specific
• More useful to prove past infection or secondary
or tertiary forms of clinical infection
• FTA-ABS & MHA-TP
• Antibody in patient’s serum binds to bacteria and
is visualized by fluoresent dye
• Either positive or negative
• Serological scar
 Toxoplasmosis
1. Dye test (Sabin-Feldman)
• Utilizes live organisms which are exposed to
patient’s serum
• Cell membrane of organisms are lysed in the
presence of specific anti-Toxoplasma lgG
• As a consequence the organism fail to stain with
methylene blue dye
• Gold-standard for diagnosis of toxoplasmosis
2. Immunofluorescent antibody test
• Utilize dead organisms exposed to the
pateint’s serum & antihuman globulin labeled
with fluorescein
• Fluorescent microscope
3. Haemagglutination test
• Involve coating of lysed organism on to the
RBCs serum which are than exposed to the
patient
• Positive sera causes RBCs to agglutinate
 Enzyme-linked Immunosorbent Assay
(ELISA)
• Binding of patients antibodies to an excess of
solid phase antigen
• This complex is then incubated with an enzyme-
liked second antibody
• Assessment of enzyme activity provides
measurement of specific antibody concentration
• Antibodies in aqueous (more specific)
• Other conditions (cat-scratch fever & toxocariasis)
• Any positive titre is significant in the presence of
fundus lesion compatible with toxoplasmic retinitis
 Antinuclear Antibody (ANA)
• ANA is mainly used to identify children with JIA
who are at high risk of developing ant uveitis
• Rheumatoid factor is relevant only when
investigating aetiology of scleritis
 Enzyme assay
1. Angiotensin converting enzyme (ACE)
• Nonspecific test
• Indicates presence of granulomatous disease like
1. Sarcoidosis (elevated in 80% & in acute)
2. TB
3. Leprosy
• Normally elevated in children
2. Lysozyme
• Good sensitivity but less speceficity than ACE for
sarcoidosis
 HLA tissue typing
HLA type Associated disease
B27 Spondyloarthropathies
A29 Birdshot chorioretinopathy
B51 Behcet syndrome
HLA-B7 & POHS & APMPPE
HLA-DR2
 IMAGING
1. Fluorescein angiography (FA)
• Retinal vasculitis
• CMO
• Demonstrating macular ischaemia
• Differentiate between inflammatory and
ischaemic causes of neovascularization
• CNV
• FA is less appropriate in choroiditis
2. Indocyanine angiography (ICG)
• Better for choroidal disease
• It is able to detect non-perfusion of
choriocapillaries
• Provide information regarding inflammation
affecting the stroma

3. Ultrasonography (US)
• It is useful in opaque media especially in
excluding a RD or intraocular mass
4. Optical coherence tomography(OCT)
• Detecting CMO
• Identify vitreoretinal traction as a mechanism
of CMO
 Biopsy
• Histopathology still remains the gold-standard
• Biopsy of the skin and organs may establish the
diagnosis of systemic disorder associated with
ocular manifestations
• Intraocular structures

1.conjunctiva And Lacrimal gland

Is usefulin diagnosis of sarcoidosis but in the
presence of clinically apparent disease
2. Aqueous samples
• For (polymerase chain reaction) PCR
• Viral retinitis (occasionally)

3. Vitreous biopsy
• Infectious endophthalmitis
• Can also be used for the diagnosis of the
infectious condition by obtaining samples for
culture and PCR
• Intraocular lymphomas
4. Retinal And Choroidal biopsies
• Diagnosis not establehed
• No resposeto therapy
• Further deterioration despite therapy
• To exclude possibility of malignancy or
infectious
 Radiology
1. Chest X-rays
To exclude TB and Sarcoidosis
2. sacro-illiac joint X-Rays
Diagnosis of spondyloarthropathy
3. CT & MRI
Of the brain & thorax for
• Sarcoidosis
• Multiple sclerosis
• Primary intraocular lymphoma
• A thorax CT scan may clarify any doubts
regarding the presence of hilar adenopathy