Uveitis complications

Infections of the external eye (the eyelids and conjunctiva or cornea) conjunctivitis, keratitis, corneal ulcer are distinguished from intra-ocular infections. The latter include infection of the vitreous (endoph-talmitis), uveitis and retinitis. Orbital and periorbital infections are often due to complications of sinusitis. 

Kuo HK, Lai IC, Fang PC, Teng MC. Ocular complications after a sub-tenon injection of triamcinolone acetonide for uveitis. Chang GungMedJ. 2005 28 85-89. 

Several randomized double-blind trials provided evidence that oral acyclovir 800 mg, five times daily, is the most effective dosage for treating HZO. Studies also stressed the importance of initiating treatment within the first 72 hours to prevent severe complications of HZO (i.e., keratitis, uveitis, secondary glaucoma, scleritis, optic neuritis, and acute retinal necrosis [ARN]).When there is ophthalmic involvement, it is recommended to treat even if the rash has been present for more than 72 hours. In addition, there is evidence that 7 days of treatment may be adequate. Studies have been shown that oral acyclovir may lessen the incidence and duration of postherpetic neuralgia associated with HZO, as shown in Table 11-10. 

The main side effect associated with oral acyclovir, valacyclovir, and femciclovir is intestinal disturbance such as nausea and vomiting. Acyclovir is available in an 800-mg tablet that does not contain lactose therefore it is less likely to cause lactose-related diarrhea. Lower dosages are recommended for treatment of elderly patients with impaired creatinine clearance. Perhaps the most significant factor in fevor of antivirals is that they minimize the common complications of the disease, including dendriform keratopathy, stromal keratitis, and anterior uveitis. 

Additional findings in EKC can include pseudomembrane formation (Figure 26-46) and corneal epithelial sloughing. Symblepharon, scleritis, and anterior uveitis rarely develop. Nasolacrimal system obstruction due to inflammation or adhesion of opposing surfaces, as occurs in symblepharon formation, also is a rare complication. 

Systemic antiviral therapy promotes resolution of HZO skin lesions and reduces the incidence and severity of dendriform keratopathy, anterior uveitis, and stromal keratitis by decreasing the rate of virus replication. All patients with acute HZO should receive antiviral therapy with the goal of minimizing ocular complications. Acyclovir, valacyclovir, and femciclovir are FDA approved for management of herpes zoster. Acyclovir usually is administered orally in dosages of 800 mg five times per day far 7 days. Valacyclovir has better bioavailability when taken orally and can be used with a recommended dosage of 1 g three times a day for 7 days. Famciclovir, which has bioavailability similar to valacyclovir, has an increased half-life and also has the advantage of less frequent administration than acyclovir 500 mg three times a day for 7 days. 

Biomicroscopy is critical in the uveitis assessment. It allows for accurate diagnosis as well as identification of potentially sight-threatening complications. The following structures and areas should be given special attention ... 

Visual acuity is often compromised on presentation in intermediate uveitis. A study in 2001 found a mean entering visual acuity of 6/12 (20/40) in patients with pars planitis on average, children with this disease were foimd to have worse visual acuity than adults at the time of initial presentation. CME is the most common cause of reduced acuity in intermediate uveitis. Other complications, including chronic vitreitis, cataract, and band keratopathy, may ensue in cases of untreated or undertreated intermediate uveitis, resulting in potentially significant visual compromise. 

It is important to perform gonioscopy only in recalcitrant cases of intermediate uveitis to rule out complications such as peripheral anterior synechia and neovascularization. Otherwise, this test is superfluous. 

Complications associated with anterior uveitis may include cataracts, glaucoma, band keratopathy, and CME. Posterior subcapsular cataracts are the most commonly encountered lenticular change associated with chronic uveitis. Additionally, it is well known that long-term topical steroid use can induce or accelerate posterior subcapsular cataract development. 

Band keratopathy is a relatively infrequent complication associated with long-standing uveitis. CME may result from the sustained release of prostaglandins however, this complication is fer more likely in cases of intermediate or posterior uveitis. 

Intermediate uveitis may not warrant any therapeutic intervention in mild cases where the visual acuity is 20/40 or better. However, medical therapy is required for most patients. Macular edema is a frequent complication and requires prompt management to prevent permanent vision loss. In general, topical steroids are minimally effective in intermediate uveitis, except in those patients who are aphakic. Periocular and systemic steroids are substantially more efficacious. Periocular steroid injections are preferable in unilateral presentations and in children, whereas oral or other systemic routes are required for bilateral cases. For steroid-resistant intermediate uveitis, immunosuppressive therapy or surgery (cryotherapy and vitrectomy) may be necessary. Complications associated with intermediate uveitis include persistent CME,... 

Ocular complications are rare with systemic use of this class of drugs. Lid edema, conjunctivitis, chemosis, anterior uveitis, and scleral reactions have been reported with high-dose administration of sulfenilamide. The observed reactions appear to be analogous to systemic hypersensitivity reactions, such as urticaria and edema, seen in some patients who are allergic to sulfonamides. Several cases of Stevens-Johnson syndrome have been reported in patients of Japanese or Korean descent who were given oral metha-zolamide, a sulfonamide used to decrease lOP. Stevens-Johnson syndrome tends to show acute ocular involvement in 69% of affected individuals.This is stratified into mild ocular involvement in 40%, moderate in 25%, and severe in 4%. Late complications can occin and are usually in the form of severe ocular surfece disease and trichiasis. 

Ocular complications are of particular importance iritis can be induced by dying microfilariae and may call for topical or systemic glucocorticoid treatment. Associated complications include chorioretinitis, anterior uveitis, and punctate keratitis. Changes can also occur in the posterior... 

A heavier-than-water fluorinated silicone oil was used in the treatment of 30 selected cases of complicated retinal detachment due to proliferative vitreoretinopathy (n = 19), proliferative diabetic retinopathy with traction detachment (n = 2), giant retinal tears (n = 5), ruptured globe with retinal detachment (n = 2), massive choroidal effusion with retinal detachment (n = 1), and acute retinal necrosis with retinal detachment (n = 1) (13). Initial retinal reattachment was achieved in all cases. Complications included redetachment (n = l), cataract (n = 6), raised intraocular pressure (n = 4), hypotony (n = 4), keratopathy (n = 3), uveitis sjme-chia formation (n = 3), phthisis (n = 2), choroidal hemorrhage (n — 1), and vitreous hemorrhage n = 1). 

Common complications of IBD include rectal fissures, fistulas (Crohn s disease), perirectal abscess (ulcerative colitis), and colon cancer, in addition to hepatobiliary complications, arthritis, uveitis, skin lesions (including erythema nodosum and pyoderma gangrenosum), and aphthous ulcerations of the mouth. 

Ocular complications including iritis, uveitis, episcleritis, and conjunctivitis occur in up to 10% of patients with IBD. The most commonly reported symptoms with iritis and uveitis include blurred vision, eye pain, and photophobia. Episcleritis is associated with scleral injection, burning, and increased secretions. These complications may parallel the severity of intestinal disease, and recurrence after colectomy with ulcerative colitis is uncommon. 

Intraocular injections are associated with significant complications and often must be repeated at regular intervals in patients with a chronic disease such as uveitis. Similar difficulties are associated with periocular injections although the complication rate is lower and those that do occur are usually less severe. The main... 

A subsequent Phase II, multicenter, randomized, double-masked, placebo-controlled clinical trial was performed in patients undergoing phacoemulsification and intraocular lens implantation (18). Only one eye per patient was eligible for treatment and exclusion criteria included previous uveitis, concurrent anterior segment disease or intraoperative surgical complications. Patients were randomized in a 2 1 ratio into an active treatment group or a control group. Patients in the two... 

Corticosteroids have been used to treat a variety of ocular diseases. Traditionally, delivery of corticosteroids for posterior-segment eye diseases has been achieved through oral systemic therapy and periocular injections. Oral corticosteroids have not been widely used to treat DME, but when used for posterior inflammatory uveitis, they require high concentrations to reach therapeutic levels in the posterior segment. These high doses often result in systemic side effects (24). Periocular corticosteroid administration often must be repeated and may be associated with complications such as ptosis and inadvertent needle penetration of the globe. 

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