|Year : 2016 | Volume
| Issue : 2 | Page : 86-87
Infectious uveitis – A challenge to ophthalmologists
Ranju Kharel1, Jyotirmay Biswas2
1 Department of Ophthalmology, Tribhuvan University, Institute of Medicine, Kathmandu, Nepal
2 Ocular Pathology Department, Medical and Vision Research Foundation, Sankara Nethralaya, Chennai, Tamil Nadu, India
|Date of Web Publication||20-Mar-2017|
Ocular Pathology Department, Medical and Vision Research Foundation, Sankara Nethralaya, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kharel R, Biswas J. Infectious uveitis – A challenge to ophthalmologists. Kerala J Ophthalmol 2016;28:86-7
“A diagnosis is burden enough without being burdened by secrecy and shame”
Infectious uveitis accounts for majority of the cases of uveitis in developing countries. Risk of vision robbing complications, higher rate of recurrences, absence of effective local therapies and difficulty in diagnosis are the major challenges in management of infectious uveitis.
The horizon of the infectious uveitic etiology encompasses from bacteria to virus and from fungi to parasite. A thoughtful approach and selection of appropriate investigations is needed. The tailored diagnostic approach for the uveitis include comparision of clinical characteristic with known uveitic entities, short listing the etiological possibilities, ordering the relevant lab investigations and ordering extensive investigations only when needed.
India is a tuberculosis endemic zone. Ocular TB has a plethora of clinical presentations and is caused by either direct invasion of the eye by tubercle bacilli or hypersensitivity response to the tubercular antigen. Diagnosis in common practice includes Mantoux test, QuantiFERON TB gold test, X-ray chest or high-resolution computerized tomography of chest Polymerase chain reaction (PCR) for mycobacterium tuberculosis from aqueous or vitreous tap can be done for real time and nested PCR. A course of ATT for 9 months is preferred for ocular TB to reduce the recurrence rate of uveitis.
Ocular toxoplasmosis typically manifests as localized necrotizing retinitis with vitritis presenting as “headlight in the fog” appearance. These can be a preexisting retinochoriodal scar. Treatment consists of pyrimethamine-sulfadiazine combination, clindamycin, trimethoprim-sulfamethoxazole, spiramycin and azithromycin followed by oral steroid. Intravitreal clindamycin with intravitreal corticosteroid can also be used.
Ocular toxocariasis is caused by Toxocara canis/ cati. The characteristic feature is intraocular granuloma which may complicate into tractional retinal detachment, epiretinal membrane, cystoids macular edema and macular hole formation. The treatment is controlling the inflammation with systemic and topical steroids.
Syphilis is caused by Treponema pallidum. A re-emergence of syphilis as a co-infection with HIV is noted. Syphilis is considered as 'the great imitator' with plethora of clinical manifestations and diagnosis requires high index of suspicion. Serological testing include VDRL, RPR, TPHA and FTA-abs. Parenteral penicillin G is the drug of choice for treatments. Ocular syphilis warrants treatment like neurosyphilis, even if the CSF study is normal.
Herpetic uveitis is caused by three herpes viruses, HSV, VZV and CMV. Herpetic uveitis includes anterior uveitis, scleral inflammation and necrotizing retinopathy. Acute retinal necrosis generally affects healthy, immunocompetent young adults with characteristic triad of vitritis, confluent necrotizing peripheral retinitis and vasculitis at the level of deep retina and retinal pigment epithelium. Diagnosis is based on the clinical appearance and course and PCR. Intravenous acyclovir is the current treatment of choice for acute retinal necrosis (15 mg/kg/day) followed by oral antiviral medication, either acyclovir (800 mg 5 times/day), valacyclovir (1 g 3 times/day) or famciclovir (500 mg 3 times/day) up to six weeks or more. Corticosteroid has been used to reduce the inflammatory component. Topical corticosteroid can be used to treat anterior segment inflammation. Some authors recommended to create a “new artificial ora serrata” with laser photocoagulation of posterior pole.
Cytomegalovirus retinitis is the most common opportunistic ocular infection in immunosuppressed individuals. Three patterns of active lesions are hemorrhagic, brush fire and granular. Drugs approved by FDA for treatment of CMV retinitis are ganciclovir, foscarnet, and cidofovir.
Ocular parasitosis likely protozoa, nematodes, cestodes, trematodes, and ectoparasites are mainly prevalent in geographical areas where environmental factors and poor sanitary conditions favor the parasitism between man and animals. Ocular lesions can be due to damage directly caused by the infectious pathogen, indirect pathology caused by toxic products, immune response incited by infections, or ectopic parasitism of the preadult or adult stages. They can present with anterior uveitis, chorioretinitis, vitritis, retinal vasculitis, panuveitis, diffuse unilateral sub acute neuroretinitis, and salt and pepper fundus.
Hence, South Asian countries are fighting battle against infectious diseases like bacterial, viral and parasitic diseases. The correct identification and accurate diagnosis of all this infective organisms especially in uveitis is a challenging situation. Many of these entities are also a major cause of morbidity and mortality, and appropriate, timely management is therefore required to save not only the eye, but also the life of the patient.