One of the most common reasons for referral to the Rheumatologist from the Ophthalmologist is the young subject with recurrent or troublesome episodes of uveitis, often in association with a positive ANA or other features suggestive of an autoimmune aetiology such as a raised ACE. The query is whether such subjects have an underlying systemic disease contributing to their uveitis. Certain features can help narrow down the D/D.
1. HLA B27 associated spondarthritis presents with acute unilateral anterior uveitis that improves within 3 months but often recurs in the other eye. Therefore simultaneous or closely spaced occurrence of uveitis in both eyes is not characteristic of this condition, even if arthralgias are present. Prognosis is excellent.
2. The uveitis associated with IBD is often more chronic, posterior to the lens, and bilateral and more common in women. In subjects with IBD, the uveitis often presents prior to bowel symptoms (10/17 in one series).
3. Anterior uveitis is associated with the presence of deposits on the back of the cornea, called keratic precipitates (KP). In the case of sarcoidosis, these KPs are often large and greasy, therefore fine keratic precipitates make sarcoid unlikely.
4. The uveitis of sarcoid is often chronic, bilateral, posterior as well as anterior and unaccompanied by systemic features.
5. Syphilitic uveitis may not be accompanied by systemic features, In Asians, always rule out tuberculosis.
6. In subjects above the age of 45 with chronic posterior uveitis, rule out lymphoma, particularly DLBCL type of NHL. Higher risk in HIV positive cases. Thus, lymphoma is an uveitis mimic.
7. In children with JIA, uveitis is more common in those with oligoarticular arthritis and positive ANA. Polyarticular involvement and absence of ANA are less commonly associated with arthritis.
8. Behcet's disease often causes a panuveitis, is often associated with retinal vasculitis, is silent, and thus can lead to blindness. It's important to be aware that while anterior uveitis presents with pain, redness, photophobia, headache or brow pain and constricted pupils, posterior uveitis presents with a white eye, is silent, and can only be picked up initially by the presence of vitreous cells on slit lamp examination. Being silent, it can lead to blindness, and therefore needs a high index of suspicion. This is also true for children with JIA.
9. Multiple sclerosis can be associated with pars planitis (intermediate uveitis).
10. TINU or Tubulointerstitial Nephritis with Uveitis is a rare condition that combines uveitis with interstitial nephritis. It can be sen in subjects with Sjogren's syndrome or sarcoid.
11. Other autoimmune conditions that present less commonly with uveitis are SLE and GPA (Wegener's).
.....after this read,thr is no need to look for plausible causes of Uveitis...tnx....it also suggest how a clinician have to be alert abt other associated findings which can corroborate to the condition...say for example TINU...the two system afflictions r poles apart but share a common cause...!!
ReplyDelete....is it proper to take apples @2-3 pcs per day persistently for more thn a yr,if U had a h/o of Gout & Hyperuricemia on & off....ur comments...Tnx...!
ReplyDelete....pl inform whn time permits....nothing urgent....abt 2 molecules : Acarbose : its long term use,safety, nd Ur experience with it...also Sitagliptin tabs 50 & 100mg....Tnx...!!
ReplyDeleteSorry for the delay.
ReplyDeleteI wouldn't consider acarbose (alpha-glucosidase inhibitor) at all because of the flatulence and diarrhoea it engenders. There are better. more acceptable and cheaper alternatives.
As for sitagliptin, probably only use as monotherapy is in subjects who cannot have metformin, sulfonylureas or pioglitazone because of renal failure or because they'd tolerate hypoglycaemia poorly, i.e the elderly. However. it is more expensive and a less potent agent in achieving euglycemia, as compared with glinides (e.g. repaglinide), which is also considered safe in renal impairment.
As an add on therapy, sitagliptin can be considered when there is inadequate glycaemic control with metformin, sulfonylureas or pioglitazone. Again, expense and limited efficacy probably means that there are better alternatives.
In a patient with type 2 diabetes without renal or hepatic dysfunction, I'd start with metformin. If there is inadequate control, I'd add a short acting sulfonylurea such as glipizide. However, for very poor control, such as HbA1c>8.5%, I'd skip sulfonylureas and add insulin. If the patient is unable to afford insulin, I'd consider adding pioglitazone.
If the patient has renal failure, I'd avoid metformin and start with repaglinide or sitagliptin, with a preference for repaglinide as it is more effective.
......Gud to receive ur opinion....which I must say settles the issue....ur considerations r crystal clear nd unambiguous...Tnx...!!!
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