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When dealing with uveitis, the main goal of the clinical opthalmologist is to manage his patients properly. To achieve this ultimate goal for each patients, he must firsst make three important determination. (1) Diagnosis : the opthalmologist must take an accurate diagnosis based on the identification of the lesion and its cause. (2) Prognosis : he must determine the probable prognosis. (3) therapy : he must design the best possible therapeutic regimen to be undertaken. Once these determinations have been make, the ophtalmologist will find his overall goal has been reached: he will have a well-managed patient. To this end we offer in this chapter a plan of attack that we offer in this chapter the plan of attack that we hope will help the clinician to analyze and deal with the particular problems presented by his patient and to make the three indispensable determinations named above.
Diagnosis Clearly the most important first step in this process is to categorize the patient’s uveitis as accurately as possible, i.e,. to identify the category od uveitis in which the patient’s disease probably belongs. This is important because the clinical course, the response to therapy, and the potential complication of the various categories are for the most part known and predictable. Once the diagnosis has been determined, therefore, decisions relative to prognosis and treatment can be made. Almost automatically. The number of common uveitic entities is in fact suprisingly small. A list of them is presented in capter 6 and comproses only some 20 or 30 entities. Of course, a list of all possible entities would run into the hundreds. 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 ophtalmologist. We refer to it as the list of “likely uveitic entiites”. Not only is it relatively short, but most of the entities are different enough from the others on the list (in sign, symptoms, bilaterality, response to laboratory test, and predilection with respect to age, sex, race, ect ) to make clinical differentiation relatively easy.
Diagnostic methods To place a case of uveitis in its proper uveitic category, the following three steps must be taken. (1) Naming. As discussed in chapter 2. All of the terms descriptive of the silent historical and clinical facts referable to the case under study should be combined in a detailed “working” name for the patient’s uveitis. This may seem cumbersome at first, but in the long run it is actually the simplest and most effective approach. The following are a few examples of such detailed “naming”
the diagnostic possibilities in order of likehood would be as follows: Examples 1 : (1) uveitis associated with juvenile rheumatoid arthritis. This call “mashing” When the profile of a patient closely resembles the profile of a uveitic entity. but in the near future it should be possible to adapt it very well to computer technology. A preliminary arranging of this short list in the order of likelihood can be made simply by putting the entity with the best fitting (meshing) profile first and the one with the poorest meshing profile last. All tests and consultations should be for the purpose of answering specific diagnostic questions. we leave it off the list. and heterochromia in a 30 years old white female. Examples 2 : chronic unilateral nongranulomatous iridocyclitis with secondary cataract. less likely (2) syphilis (3) tuberculosis (4) vogt-koyanagi-harada syndrome and (5) bechet syndrome Examples 4 : (1) vogt-koyanagi-harada syndrome. the greater the details. 8 and 9. (2) meshing . open angle glaucoma. in order to rule in or out the suspected entities. Working with the small list of diagnostic possibilities generated by the naming and meshing processes. determining the final diagnosis. Since each of the 21 entities on the list of “likely uveitic entities” also has a profile based on its clinical characteristics.Examples 1 : chronic bilateral nongranulomatous iridocyclitis with band keratophaty in a 10 years old white female with arthritis of the right knee. Fortunately the profiles of the likely entities differ considerably from one another so that is rare for the number on the list to exceed three or four. Exmaples 3 : (1) sarcoid uveitis. Less likely (2) sarcoid uveitis Examples 2 : fuchs’ heterochromic iridocyclitis. The nature of the standart laboratory and special tests to be made and of the consultations to be requested are described in chapter 7. Please note that it is only after the naming and meshing steps that these tests and consultations should be sought. the trick now is to match the patient’s profile as closely as possible with one or more of the known disease profiles. Examples 3 : chronic bilateral diffuse granulomatous eveitis with secondary retinal vasculitis in a 40 year old black female Examples 4 : chronic bilateral diffuse granulomatous eveitis and serous macular detachments in a 22 year old oriental male with tinitus and alopecia areata. The details presented in the “naming” of the four examples reduce the diagnostic puzzle to child’s play. (3) the posner-schlossman syndrome (glaucomatocyclitic crisis) and (4) severe post traumatic iridocyclitis. Nothing should be ordered routinely. the finer and more sharply etched the profile. the naming process creates a profile or tamplate of the clinical case in question. we put the entity on a list of diagnostic possibilities. Possibilities only (2) sarcoid uveitis (3) tuberculosis At present the meshing step is largely intuitive. Figure 5. 3. yet the history and physical findings in the cases so described might seem very confusing until simplified and clarified by this naming process. If we apply these naming and meshing procedures to the four examples of naming given above. and when the match is poor. . Less likely (2) acute recurrent nongranulomatous iridocyclitis that has become chronic. but even more importanly to encourage clear thinking and speed up the diagnostic process. we can order standart laboratory and special test and request consultation with other specialist.1 depicts the essentials of the “naming – meshing” system. this is in the interest of reducing the cost of medical care.
When the rare entities occur. the uveitis needs to have been categorized and its natural history known so that the vision-threatening and ocular morbidity signs that call for treatment can be identified. we should be able to make the correct presumtive diagnosis of a case of uveitis as estimated : i.Limitations of the naming-meshing system By using the naming-meshing system and supplementing it with the standard laboratory tests. and if resistance to appropriate therapy continues. No discussion of therapeutic approaches to uveitis should omit acknowledgment and discussion of one of the most powerful assistants available in the therapeutic armamentarium. and we are dealing here with a list of only 20-30. To fulfill these five therapeutic aims.e. after all. if steroid are used. our scheme should be abandoned. Furthermore. Since v=every form of ub=veitic therapy can have damaging side effectsm it is imperative that treatment be undertaken only when the disease may cause serious ocular damage. And these problems will place such cases beyond the scope of the method of attack presented here. But this means that an estimated 15-25% of cases will either resist categorization or will present special problems in response to treatment or the development of complications. Therapy All therapeutic regimens should have the following five aims : (1) to preserve central visual acuity (2) to preserve the visual fields (3) to prevent discomfort and ocular morbidity (4) to prevent or minimize serious vision. special tests. if possible. Decisions as to whether or not to treat and in what form and what follow up care will be necessary imply inadequate knowladge of the natural course of the disease. Prognosis The only rational approach to prognosis is based on knowledge of the natural history of the disease under study. the patient should be referred. when the disease does not follow its expected course. This . based on the natural course of most of the important uveitic entities.threatening or discomfort provoking complications and (5) to minimize iatrogenic threats to central or peripheral vision and any iatrogenically induce ocular discomfort or morbidity. to a uveitis center. prognostic information shoud have warned that the inflammation in that entity is noy benign and that if allowed to continue. for example. living tissues sometimes respond unpredictably or idiosyncratically to the invasion of organisms and antigens on the one hand and to their response to antimicrobial and anti-inflammatory therapy on the other. If dilators are used.. hundreds of uveiric entities. When clear diagnostic answers are not forthcomming. it will have untoward effects. in 75 – 85 % of uveitis patients seen in general clinical pratice. The rarities and uveitis masquerade syndrome should be considered. or when the anticipated response to therapy does not accur. This prognostic information. and consultations summarized in chapter 6. is available in abbreviated form in chapter 6 and in section three. prognostic information should have indicated that posterior synechiae are a danger. Recognizing the limitations of a system is as important as recognizing its virtues. they will always create diagnostic problems. There are.
anterior uveitis. of course. and certainly most underutilized therapeutic weapon is the patient himself. There cannot be a more highly motivated observer or a more dedicated medical assistant then he. It is impossible to achieve one without having knowledge of the other two. and wait for the natural predisposition of the disease to halt it course. prognostic and therapeutic) are very closely related. Prompt therapy at that early time often easily aborts what might otherwise evolve into a severe. . reduce the inflammation. the two can wark together to complement and supplement each other. When so enlisted as an active participant in the monitoring and treatment of his own disease. see his physician as soon as possible to have his observations confirmed and to be sure that a second factor.perhaps most powerful. is to ask no more than his own best self-interest. Subtle exacerbations of chronic eveitic activity are also subject to detection. prodormal event that signals the onset of an acute uveitic attack. at much a session the subtleties of the disease and the advantages of including the patient in yhe management of his own case can be thoroughly explained. recurrent. subtle changes in photophobia. It shoud also be apparent that one rarely cures a patient of his uveitis. it will be well worth scheduling a “talk session” . Summary It should be clear to the discerning reader that the three goals (diagnostic. metamorphosia. If there seems to be a good chance that the patient can be enlisted as an obsever of his own disease and perhaps trained to be a therapeutic assistant. recalcitrant recurrence. and therapy can then be instituted before any damage has accurred. shape and reactivity. The patient should. and pupillary size. the best hope is to minimize the complications. To ask this most concerned person to make daily observations of visual acuty. it is not uncommon for a patient with acute. injection. In the vast majoriity of cases. bring about a remission. So although the patient is no substitute for the physician.