Uveitis Case #1

Authors: Kevin Ly (1), Dr. Alex Kaplan (2)

Affiliations: (1) University of Alberta (2) University of Toronto

ID: 37F, blurred vision and floaters x 2 months.  

Past Ocular History:

  • Granulomatous Acute Anterior Uveitis (Treated 2 years ago)

  • No ocular surgery, no ocular trauma.

Ocular gtts: Prednisolone Acetate QID x4 weeks

Relevant Medical History: immunocompetent - investigations for infectious, inflammatory, and neoplastic causes of uveitis returned negative.

  • IVFA at 19 seconds

    Early Arteriovenous Phase (early laminar flow). 

    Key features include:

    • Capillary drop-out/non-perfusion (1).

    • At the edges of the remaining perfused retina, neovascular bundles temporally and superonasally (2).

    • Vascular architecture and perfusion of macula remains intact. 

  • IVFA at 49 seconds

    Mid-Late Arteriovenous Phase

    Key features include:

    • More apparent peripheral retinal capillary drop-out/non-perfusion nearly 360 degrees (1).

    • Increased intensity of hyperfluoresence of superonasal sea-fan like neovascularization, temporal retinal neovascularization and smaller neovascular bulbs (2).

    • Inferonasal sea-fan like neovascularization underneath the lashes (3).

    • Hypofluoresence from sub-retinal fluid blocking underlying choroidal fluorescence (4).

  • IVFA a 3 minutes 42 seconds

    Late Phase

    Key features include:

    • Increasing hyperfluorescence (intensity and size) of previously mentioned areas of neovascularization, secondary to leakage (1).

    • Hyperfluorescent optic nerve (2).

    • Maintained areas of capillary drop-out and non-perfusion throughout the angiogram secondary to occlusive disease (3).

  • The constellation of reduced vision, intra-ocular inflammation, areas of non-perfusion with secondary neovascularization on IVFA supports the diagnosis of occlusive retinal vasculitis.

    • Systemic inflammatory disease (e.g. SLE, Behçet’s, sarcoidosis)

    • Infectious retinitis

      • CMV, HSV, VZV

      • Tuberculosis

      • Toxoplasmosis

      • Syphilis

    • Retinal vein occlusion

    • Retinal artery occlusion

    • Diabetic retinopathy

    • Ocular ischemic syndrome

    • Susac’s syndrome

    • Idiopathic retinal vasculitis, aneurysms, and neuroretinitis (IRVAN)

  • The IVFA characterizes the extent of the occlusive vasulitis. It confirms peripheral non-perfusion, demonstrates areas of secondary neovascularization that are often challenging to see on fundus exam. It also shows involvement of the optic nerve which is not obvious by fundus examination (1-4).

    1. Rosenbaum JT, Sibley CH, Lin P. Retinal vasculitis. Curr Opin Rheumatol. 2016 May;28(3):228–35. doi:10.1097/BOR.0000000000000271.

    2. Agarwal A, Rübsam A, zur Bonsen L, Pichi F, Neri P, Pleyer U. A Comprehensive Update on Retinal Vasculitis: Etiologies, Manifestations and Treatments. Journal of Clinical Medicine. 2022 Apr 30;11(9):2525. doi:10.3390/jcm11092525.

    3. 1.Arora A, Agarwal M, Chieh Loh N, Amin H, Menia NK, Agrawal R, et al. Diagnostic Workup of Retinal Vasculitis: An Algorithmic Approach. Ophthalmologica. 2024 Sep 5;247(5-6):280–92. doi:10.1159/000541149.

    4. Abu AM, Herbort CP, Tabbara KF. A clinical approach to the diagnosis of retinal vasculitis. International Ophthalmology. 2009 Feb 4;30(2):149–73. doi:10.1007/s10792-009-9301-3.

Next

Uveitis Case #2