Uveitis: A Clinical Manual for Ocular Inflammation

280 Pages·1995·11.588 MB·English

by  E. Mitchel Opremcak M.D. (auth.)

Uveitis
E. Mitchel Opremcak
Uveitis
A Clinical Manual for
Ocular Inflammation
With Line Illustrations by Kendra Kachelein
With 140 Illustrations, 78 in Full Color
Springer-Verlag
New York Berlin Heidelberg London Paris
Tokyo Hong Kong Barcelona Budapest
E. Mitchel Opremcak, M.D.
Associate Professor of Ophthalmology
The Ohio State University
465 West Tenth Street
Columbus, OH 43210
USA
Cover illustration by Kendra Kachelein. Background: Posterior synechiae in an eye with
uveitis. Foreground: Normal eye.
Library of Congress Cataloging-in-Publication Data
Opremcak, E. Mitchel.
Uveitis: a clinical manual for ocular inflammation / E. Mitchel
Opremcak.
p. cm.
Includes bibliographical references and index.
ISBN-13: 978-1-4612-8685-1
1. Uveitis. I. Title.
[DNLM: 1. Uveitis. WW 240 062u 1994)
RE351.067 1994
617.7'2-dc20
DNLMIDLC
for Library of Congress 94-13826
CIP
Printed on acid-free paper.
© 1995 Springer-Verlag New York Inc.
Softcover reprint of the hardcover I st Edition 1995
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While the advice and information in this book are believed to be true and accurate at
the date of going to press, neither the authors nor the editors nor the publisher can
accept any legal responsibility for any errors or omissions that may be made. The
publisher makes no warranty, express or implied, with respect to the material con
tained herein.
Production managed by Terry Kornak; manufacturing supervised by Jacqui Ashri.
Typeset by Asco Trade Typesetting, Hong Kong.
9 8 765 4 321
ISBN-B: 978-1-4612-8685-1 e-ISBN: 978-1-4612-4174-4
DOl: 10.\007/978-1-4612-4174-4
This book is dedicated to Shelley Ann and Jessica Lee,
and to Colleen Marie, their mother, whom I have loved
with all my heart
Preface
As a garden is to a gardener, so a book is to its author. Nurtured out
of love, both are a source of pride and hope. Microbiology, immunol
ogy, infectious diseases, rheumatology, and ophthalmology are the
seeds of this textbook on uveitis. Over the years, these branches of
medicine have been cultivated and garnered to care for patients
with inflammatory diseases of the eye, a most hardy species in the
family of ocular maladies.
The aim of this clinical manual is to give both a serviceable frame
work and practical information on ocular inflammatory disease. The
first section is devoted to general principles and commonly held sup
positions in the field of uveitis. A system of diagnosis, based on the
differential, is also offered. Traumatic uveitis is addressed in the sec
ond section. The third part examines infectious diseases that have
been identified with uveitis. These are frequently curable forms of
ocular inflammation caused by replicating foreign antigens. The
fourth section of this textbook considers inflammatory diseases of
the eye with a presumed autoimmune mechanism. A disobedient,
autoreactive immune response is postulated to playa role in these
forms of uveitis. Masquerade and idiopathic conditions are dis
cussed in the final chapters. Etiology, epidemiology, pathogenesis,
clinical presentation, diagnosis, differential diagnosis, treatment, and
prognosis are provided for each disease syndrome.
As with most gardens, there are many styles and delightful
entrances to the field of uveitis. The writings and fruition of other
authors including Alan C. Woods, Theodore F. Schlaegel, G. Ri
chard O'Conner, Ronald E. Smith, Robert A. Nozik, Robert B. Nus
senblatt, Alan G. Palestine, Ellen Kraus-Mackiw, Jack K. Kanski,
and William J. Dinning should be accessed and are well worth the
journey.
Time transforms all vistas. Closely held ideas and concepts in the
field of uveitis will without a doubt change as we gain more under
standing of these challenging diseases. Forthwith, I offer one such
path, a single season, an evanescent view of the realm; flowers amid
weeds, mosses upon stone.
Asagao no Above the fence,
matamata taranu a morning glory stretches
kakine kana. still unsatisfied.
Shukyo, Haiku Poet, 1826 A.D.
E. Mitchel Opremcak
vii
Acknowledgments
It would require a separate text to encompass the profound influence
and teaching of my many mentors. I must acknowledge, however, the
instruction, kindness, and support of the following individuals:
Drs. Robbins and Angell, Drs. De Gowin and De Gowin, Dr. Earl N.
Metz, Dr. Ronald L. Whisler, Dr. William H. Havener, Dr. Torrence A.
Makley Jr., Dr. Elson L. Craig, Dr. Paul A. Weber, Dr. Frederick H.
Davidorf, Dr. Charles D. Regan, Dr. Evangelos S. Gragoudas, Dr.
Donald J. D~mico, Dr. Carmen A. Pulliafito, Dr. Johanna M. Seddon,
and Dr. Lloyd M. Aiello.
Medical students, residents, and fellows with whom I have worked
including Dr. Michael B. Raizman, Dr. Ramzi Hemady, Drs. Neil M.
and Susan B. Bressler, Dr. David K. Scales, and Dr. Ivo Kocur.
Nancy A. Kelso, Beth A. Ferguson, Holly N. Dotin, and Diane M.
Combs for their boundless energy, enthusiasm, and valued friend
ship.
Kendra E. Kachelein and Esther T. Silverman for their skillful medi
cal illustration and thoughtful editing.
All of my patients and their referring ophthalmologists for their
trust and for allowing me to participate in their care.
Most of all, to Dr. C. Stephen Foster-without whose philosophy,
expertise, discipline, and instruction the cogent and viable aspects of
this endeavor would be but ephemeral. I bid both my gratitude and
heartfelt admiration.
viii
Contents
Preface ............................................................. vii
Acknowledgments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii
General Principles
1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
General Information.............................................. 3
Definitions .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Epidemiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Pathology /Pathophysiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Classification. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Etiology and Diagnostic Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . 9
2 Symptoms and Signs of Uveitis............................. 14
Symptoms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Signs............................................................. 14
3 Clinical Approach to the Patient with Ocular
Inflammation................................................... 31
Methods of Diagnosis in Uveitis.................................. 31
Differential-Based Diagnostic System............................. 31
4 Laboratory Testing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Routine and Frequently Ordered Tests. . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Tests Individualized for the Differential Diagnosis............... 49
Special Blood Tests.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Radiologic Testing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Fluorescein Angiography. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Ultrasonography. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Tissue Biopsy .................................................... 53
5 Medical Therapy for Uveitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
General Principles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Nonspecific Therapy-General Considerations. . . . . . . . . . . . . . . . . . . 59
Specific Therapy-General Considerations. . . . . . . . . . . . . . . . . . . . . . . 60
ix
x Contents
Topical Medical Therapy for Uveitis.............................. 61
Regional Medical Therapy for Uveitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Systemic Medical Therapy for Uveitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
6 Surgical Treatments in Uveitis............................... 78
General Information. ............................................. 78
Surgical Challenges in the Patient with Uveitis. . . . . . . . . . . . . . . . . . . 78
Surgical Procedures and Considerations in Uveitis............... 80
Ocular Inflammation Associated with Trauma
7 Traumatic Uveitis... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Nonsurgical Trauma .................... . . . . . . . . . . . . . . . . . . . . . . . . . 89
Surgical Trauma and Postoperative Inflammation. . . . . . . . . . . . . . . . 91
Ocular Inflammation Associated with Infectious
Diseases
8 Viral Diseases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Viral Diseases Associated with Keratouveitis. . . . . . . . . . . . . . . . . . . . . 97
Viral Diseases Associated with Retinitis and Uveitis.............. 100
Acute Retinal Necrosis Syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Ocular Manifestations of Infection with IllY and AIDS........... 117
Cytomegalovirus Retinitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
9 Bacterial Diseases ............................................. 134
Treponema pallidum-Syphilis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
Borrelia burgdorferi-Lyme Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Leptospira species-Leptospirosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
Mycobacterium tuberculi-Tuberculosis ........................... 139
Mycobacterium leprae-Leprosy................................... 141
Brucella species-Brucellosis...................................... 142
Whipple's Disease................................................ 143
10 Fungal Diseases............................................... 149
Histoplasmosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Candidiasis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Coccidiomycosis ................................................. 153
Sporotrichosis.................................................... 154
Cryptococcosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
11 Protozoal Diseases ............................................ 159
Toxoplasmosis ................................................... 159
Amoebiasis....................................................... 162
Trypanosomiasis................................................. 163
Giardiasis .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Pneumocystosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Contents xi
12 Helminthic Diseases.......................................... 170
Toxocariasis...................................................... 170
Ascariasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
Onchocerciasis ................................................... 172
Loiasis ........................................................... 174
Cysticercosis ............... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
Diffuse Unilateral Subacute Neuroretinitis....... .. ....... .... .. . . 176
13 Insect Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
Ophthalmomyiasis............................................... 180
14 Animal Disease................................................ 182
Ophthalmia Nodosa.............................................. 182
Ocular Inflammation Associated with Immunologic
Diseases
15 Type I Hypersensitivity.... ... .. .. ... ....... ........... ....... 187
Hay Fever. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
Atopic Keratoconjunctivitis....................................... 188
Vernal Keratoconjunctivitis....................................... 189
16 Type II Hypersensitivity...................................... 191
Cicatricial Pemphigoid........................................... 191
Lens-Induced Uveitis............................................. 193
17 Type III Hypersensitivity..... ..... .. . ....... .... .. .. ......... 197
Ankylosing Spondylitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
Behc;:et's Disease.................................................. 200
Churg-Strauss Syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
Cogan's Syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
Dermatomyositis and Polymyositis............................... 202
Erythema Multiforme (Stevens-Johnson Syndrome) .............. 203
Inflammatory Bowel Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
Juvenile Rheumatoid Arthritis.................................... 205
Psoriatic Arthritis ................................................ 207
Reiter's Syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
Relapsing Polychondritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Rheumatoid Arthritis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
Polyarteritis Nodosa.... ... ....... ..... .. ........ .. .... .. ..... ... . 213
Systemic Sclerosis With or Without Scleroderma................. 214
Sjogren's Syndrome.............................................. 215
Systemic Lupus Erythematosus................................... 216
Temporal Arteritis or Giant Cell Arteritis......................... 218
Wegener's Granulomatosis....................................... 219
18 Type IV Hypersensitivity..................................... 228
Skin Disorders ................................................... 228
Sclera/Conjunctiva/Cornea...................................... 229
xii Contents
Iris and Ciliary Body. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
Vitreous Disorders............................................... 233
Retina............................................................ 236
Choroid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
Sarcoidosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
Ocular Inflammations Associated with Masquerade
Syndromes
19 Neoplastic and Infectious Diseases Masquerading as
Uveitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
Intraocular Lymphoma (Reticulum Cell Sarcoma) . . . . . . . . . . . . . . . . 265
Infectious Endophthalmitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
Chronic Anaerobic Endophthalmitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
Index ................................................................ 273