doi: 10.1136/inpract.21.7.

370
1999 21: 370-376 In Practice

Andrew Matthews

Equine recurrent uveitis - an update

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E q u i n e r e c u r r e n t u v e i t i s
-
an i m p o r t an t d i f f e r e n t i al
d i ag n o s i s i n c as e s o f ac u t e
o c u l ar
p ai n
E q u i n e r e c u r r e n t u v e i t i s -
an u p d at e
An d r e w Mat t he ws
q u al i f i e d f r o m
t he U n i v e r s i t y o f
E d i n b u r g h i n 1 9 7 6
an d g ai n e d a P hD at
E d i n b u r g h i n 1 9 8 1 .
H e has s i n c e b e e n
i n p r ac t i c e , f o r t he
p as t 1 5 y e ar s i n
K i l m ar n o c k , Ay r s hi r e ,
whe r e he i s a p ar t n e r
wi t h r e s p o n s i b i l i t y f o r
t he e q u i n e s i d e o f t he
p r ac t i c e . H e g ai n e d
an F R C V S f o r
s t u d i e s i n e q u i n e
o p ht hal m o l o g y i n
1 9 9 4 . H i s c l i n i c al
i n t e r e s t s l i e i n al l
as p e c t s o f e q u i n e
o p ht hal m o l o g y , i n
p ar t i c u l ar c o r n e al
d i s e as e an d ap p l i e d
o c u l ar i m m u n o l o g y .
H e i s c o au t ho r o f
' C o l o u r At l as an d
T e x t o f E q u i n e
O p ht hal m o l o g y '
p u b l i s he d b y Mo s b y -
W o l f e .
AND R E W MAT T H E W S
U V E I T I S m ay ar i s e f r o m a n u m b e r o f c au s e s , i n c l u d i n g b l u n t o r p e r f o r at i n g i n j u r y t o t he g l o b e an d , r ar e l y ,
hae m at o g e n o u s s p r e ad o f b ac t e r i al p at ho g e n s s u c h as S t r e p t o c o c c u s e q u i v ar e q u i o r R ho d o c o c c u s e q u i .
O c c as i o n al l y , u v e i t i s m ay b e s e e n i n c as e s o f n e o n at al s e p t i c ae m i a. H o we v e r , ho r s e s m ay b e p r e s e n t e d
wi t h an ap p ar e n t l y e n d o g e n o u s f o r m o f t he d i s e as e , u s u al l y r e f e r r e d t o as e q u i n e r e c u r r e n t u v e i t i s ( E R U ) .
T hi s t e r m i s s y n o n y m o u s wi t h t he o b s o l e t e n o m e n c l at u r e o f ' m o o n b l i n d n e s s ' o r ' p e r i o d i c o p ht hal m i a' .
E R U i s t y p i c al l y a n o n -g r an u l o m at o u s an t e r i o r u v e i t i s o r p an u v e i t i s af f e c t i n g an y ag e , t y p e o r s e x o f
ho r s e , an d i s a p o t e n t i al c au s e o f b l i n d n e s s . B o t h e y e s m ay b e af f e c t e d , al t ho u g h n o t n e c e s s ar i l y
s i m u l t an e o u s l y , an d t he d i s e as e i s p o t e n t i al l y , b u t n o t i n e v i t ab l y , r e c u r r e n t . E R U i s r e l at i v e l y u n c o m m o n
i n t he U K , b u t i s an i m p o r t an t d i f f e r e n t i al d i ag n o s i s i n c as e s o f ac u t e o c u l ar p ai n .
S T R U C T U R E AND F U NC T I O N O F T H E U V E A c ho r o i d an d c ho r i o c ap i l l ar i s . O n e o f i t s m aj o r f u n c t i o n al
r o l e s i s r e g u l at i o n o f t he t r an s f e r o f b l o o d -d e r i v e d
T he u v e a i s m ad e u p o f v as c u l ar , m u s c u l ar , p i g m e n t ar y n u t r i e n t s an d f l u i d s i n t o t he r e t i n a an d i n t r ao c u l ar c o m -
an d c o n n e c t i v e t i s s u e e l e m e n t s an d i s c o n v e n t i o n al l y p ar t m e n t s ac r o s s t he b l o o d -o c u l ar b ar r i e r . A p r i m ar y
d i v i d e d i n t o t he an t e r i o r u v e a, c o m p r i s i n g t he i r i s an d p at ho p hy s i o l o g i c al e v e n t i n u v e i t i s i s c y t o k i n e -d r i v e n
c i l i ar y b o d y , an d t he p o s t e r i o r u v e a, c o m p r i s i n g t he b r e ak d o wn o f t he b l o o d -o c u l ar b ar r i e r , r e s u l t i n g i n
-77 7 r 1 -7 7 7 7 S 7 7 7 7 7 7 7 7 7 -
S i n c e r e l at i v e l y m i n o r i n t r ao c u l ar i n f l am m at i o n has
p o t e n t i al l y d e v as t at i n g c o n s e q u e n c e s f o r o c u l ar f u n c -
t i o n , t he m am m al i an e y e has e v o l v e d t he m e an s b y
whi c h t he i n t r ao c u l ar i m m u n e e f f e c t o r m e c han i s m s
a t l m i t t he i n t e n s i t y an d e x t e n t o f t he
l
r e s p o n e
t o
an t i g e n c hal l e n g e .
T hi s s i t u at i o n o f
n t o ac i s f u n d am e n t al t o t he
Me c han i s m s d e t e r m i n i n g i n t r ao c u l ar
i m m u n e p r i v i l e g e i n t he m am m al i an e y e
*
I n t e g r i t y o f t he b l o o d -o c u l ar b ar r i e r
*
Ab s e n c e o f l y m p hat i c d r ai n ag e i n t he e y e
* R e l at i v e s p ar s i t y o f i n t r ao c u l ar MH C I I + an t i g e n
p r e s e n t i n g c e l l s
* I n hi b i t o r y c y t o k i n e s i n t he o c u l ar f l u i d s
* P o t e n t i al f o r i n d u c t i o n o f T c e l l ap o p t o s i s
* An t e r i o r c ham b e r as s o c i at e d i m m u n e d e v i at i o n
i n t e g r i t y o f t he he al t hy e y e an d i s g e n e r al l y r e f e r r e d
t o as i m m u n e p r i v i l e g e ( S t r e i l e i n an d W e g m an n 1 9 8 7 ) .
P r i v i l e g e i s d e t e r m i n e d b y a n u m b e r o f m e c han i s m s
( s e e b e l o w l e f t ) , i n c l u d i n g an t e r i o r c ham b e r as s o c i at -
-e d i m m u n e d e v i at i o n ( AC AD ) . AC AI D r e p r e s e n t s a
s e r i e s o f p r e c i s e i m m u n o l o g i c al r e s p o n s e s t o i n t r a-
o c u l ar an t i g e n c hal l e n g e , r e s u l t i n g i n b o t h l o c al l y
i m p ai r e d e x p r e s s i o n o f d e l ay e d t y p e hy p e r s e n s i t i v i t y
an d s u p p r e s s i o n o f . C 3 f i x i n g an t i b o d y p r o d u c t i o n ,
b u t
wi t ho u t af f e c t i n g an t i g e n s p e c i f i c c y t o t o x i c
T c e l l
ac t i v i t y . I n t hi s way , b y s t an d e r i n t r ao c u l ar t i s s u e s ar e
s p ar e d t he c o l l at e r al e f f e c t s o f u n c o n t r o l l e d T c e l l
d r i v e n i n f l am m at i o n .
I m p ai r m e n t o f AC AI D an d t he o t he r p r o t e c t i v e
m e c han i s m s e x p o s e s t he u v e a t o t he p o s s i b i l i t y
o f
i m m u n e -m e d i at e d i n s u l t . T he m e an s b y whi c h
i m m u n e t o l e r an c e i s b r o k e n d o wn an d i m m u n e -
g e n e r at e d i n f l am m at o r y d i s e as e ar i s e s ar e u n r e s o l v e d .
H o we v e r , t he we l l d o c u m e n t e d as s o c i at i o n o f t he
I n P r ac t i c e * J U L Y / AU G U S T 1 9 9 9
3 7 0
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ac c u m u l at i o n s o f p r o t e i n ac e o u s an d c e l l u l ar d e t r i t u s i n
t he an t e r i o r c ham b e r o r i n t he v i t r e al c ham b e r an d
i n t r ar e t i n al s p ac e , whi c h ar e t he c ar d i n al p r e s e n t i n g
s i g n s o f t he d i s e as e .
T he ae t i o l o g y o f E R U r e m ai n s l ar g e l y a m at t e r o f
c o n j e c t u r e . H o we v e r , i t p r o b ab l y i n v o l v e s a s e r i e s o f
c o m p l e x i m m u n o p at ho l o g i c al e v e n t s ( s e e b o x b e l o w)
c u l m i n at i n g i n t he d i s r u p t i o n o f t he n o r m al i m m u n o -
l o g i c al l y t o l e r an t s t at e o f t he u v e a, l e av i n g t he e y e
v u l n e r ab l e t o i n j u r y r e s u l t i n g f r o m t y p e I I I o r I V hy p e r s e n -
s i t i v i t i e s t o a p r e s u m p t i v e au t o an t i g e n o r he t e r o an t i g e n .
P AT H O L O G Y O F E R U
I n m o s t i n s t an c e s , t he i n i t i al p at ho l o g y i s r e s t r i c t e d t o t he
an t e r i o r u v e a. T he r e i s a m ar k e d l y m p ho c y t i c i n f i l t r at i o n
o f t he c i l i ar y b o d y , wi t h e p i t he l i al hy p e r p l as i a an d i n t r a-
e p i t he l i al ac c u m u l at i o n o f l y m p ho c y t e s . C har ac t e r i s t i c
l y m p ho i d f o l l i c l e s ar e f o u n d wi t hi n t he c i l i ar y b o d y an d
i r i s r o o t . T he r e m ay b e an t e r i o r c ap s u l ar , s u b c ap s u l ar o r
c o r t i c al c at ar ac t s , an d p r e i r i d i al f i b r o v as c u l ar m e m b r an e s
an d i r i d i al n e o v as c u l ar i s at i o n ar e o c c as i o n al l y s e e n .
W i t h r e c u r r e n t at t ac k s , o r i n s e v e r e p r i m ar y e p i s o d e s
o f t he d i s e as e , t he p o s t e r i o r s e g m e n t b e c o m e s af f e c t e d .
T y p i c al l y , t he r e i s c y c l i t i c m e m b r an e f o r m at i o n i n t he
an t e r i o r v i t r e o u s an d p e r i p ap i l l ar y r e t i n al d e t ac hm e n t . I n
s o m e c as e s , l y m p ho c y t i c i n f i l t r at i o n o f t he o p t i c n e r v e
he ad , p e r i p ap i l l ar y r e t i n a an d t e r t i ar y v i t r e o u s i s e v i d e n t
( D u b i e l z i q an d o t he r s 1 9 9 7 ; D . R . B ar r y an d A. G .
Mat t he ws , u n p u b l i s he d o b s e r v at i o n s ) .
C L I NI C AL S I G NS
B e c au s e o f t he m u t i f ac e t e d i m m u n o p at ho g e n e s i s o f
E R U , an d t he l i k e l y i n f l u e n c e o f i n d i v i d u al hap l o t y p e o n
t he e x p r e s s i o n o f t he d i s e as e , a r an g e o f c l i n i c al p r e s e n -
t at i o n s m i g ht b e e x p e c t e d . I n d e e d , s i g n i f i c an t v ar i at i o n
d o e s o c c u r i n t he c l i n i c al s e v e r i t y an d p e r i o d i c i t y o f
r e c u r r e n c e o f at t ac k s am o n g af f e c t e d an i m al s , s u g g e s t i n g
o n s e t o f E R U wi t h i n i t i al e x p o s u r e t o c e r t ai n
L e p t o s p i r a s e r o v ar i an t s , n o t ab l y L i n t e r r o g an s v ar
p o m o n a, i m p l i c at e s t he s e o r g an i s m s i n at l e as t s o m e
i n s t an c e s o f t he d i s e as e ( K al s aw an d D wy e r 1 9 9 7 ) . T he
as s o c i at i o n o f E R U wi t h l e p t o s p i r e s an d , p o s s i b l y ,
o t he r m i c r o b i al p at ho g e n s m ay b e b as e d u p o n an t i -
g e n i c ho m o l o g y b e t we e n m i c r o b i al p e p t i d e s , p o t e n -
t i al l y u v e i t o g e n i c i n t r ao c u l ar au t o an t i g e n s an d c e r t ai n
m aj o r hi s t o c o m p at ab i l i t y c o m p l e x ( MH C I + ) p e p t i d e s .
I n f e c t i o n , i n j u r y o r s t r e s s m ay r e s u l t i n a c y t o k i n e -
d r i v e n i n c r e as e d t u r n o v e r o f MH C m o l e c u l e s , p o s s i b l y
s t i m u l at i n g t he e l ab o r at i o n o f n o r m al l y s u p p r e s s e d
T c e l l c l o n e s
r e c o g n i s i n g t he s e c r o s s -r e ac t i v e p e p t i d e s
an d p r e c i p i t at i n g an au t o i m m u n e i n f l am m at o r y c r i s i s
( D e s c he n e s an d o t he r s 1 9 9 7 ) . F o l l o wi n g an i n i t i al
e p i s o d e o f u v e i t i s , i n f l am m at o r y u p r e g u l at i o n o f
i n t r ao c u l ar an t i g e n p r e s e n t i n g c e l l s an d f u r t he r l o s s
o f s u p p r e s s o r i n f l u e n c e s m ay s u b s u m e t he r e s i d u al
m e c han i s m s c o n v e y i n g i m m u n e t o l e r an c e , r e s u l t i n g i n
O c u l ar e x am i n at i o n
E x am i n at i o n o f t he e y e s ho u l d p r e f e r ab l y b e c ar r i e d
o u t i n a d ar k e n e d b o x o r e x am i n at i o n r o o m . I n
ac u t e c as e s , t he s e v e r i t y o f o c u l ar p ai n e x p e r i e n c e d
b y t he an i m al m ay n e c e s s i t at e t he u s e o f c he m i c al
r e s t r ai n t t o f ac i l i t at e e x am i n at i o n . T hi s i s b e s t
ac hi e v e d u s i n g a c o m b i n at i o n o f r o m i f i d i n e
( S e d i v e t ; B o e hr i n g e r I n g e l he i m ) an d b u t o r p he n o l
( T o r b u g e s i c ; F o r t D o d g e An i m al H e al t h) . I n
ad d i t i o n , u s e o f an au r i c u l o p al p e b r al o r p al p e b r al
n e r v e b l o c k t e c hn i q u e t o p r o v i d e e y e l i d ak i n e s i a
( B ar n e t t an d o t he r s 1 9 9 5 ) m ay b e he l p f u l i n s o m e
i n s t an c e s .
S i n c e o c u l ar hy p o t o n y i s u s u al l y p r e s e n t i n c as e s
o f E R U , t he i n t r ao c u l ar p r e s s u r e i n t he af f e c t e d e y e
s ho u l d b e as s e s s e d . I n p r ac t i c e t hi s i s m o s t e as i l y
d o n e b y d i g i t al p al p at i o n o f t he g l o b e t hr o u g h t he
c l o s e d u p p e r l i d s , c o m p ar i n g t he t e n s i o n i n b o t h
e y e s s i m u l t an e o u s l y . E x am i n at i o n o f t he c o r n e a an d
an t e r i o r c ham b e r i s m o s t r e ad i l y c ar r i e d o u t u s i n g a
f o c al whi t e l i g ht s o u r c e , s u c h as a p e n l i g ht . I d e al l y ,
s o m e f o r m o f m ag n i f i c at i o n s ho u l d b e av ai l ab l e .
T hi s m ay b e a s i m p l e d i r e c t o p ht hal m o s c o p e ,
al t ho u g h a s l i t l am p b i o m i c r o s c o p e i s t he b e s t
i n s t r u m e n t f o r d e t ai l e d e x am i n at i o n o f t he an t e r i o r
s t r u c t u r e s o f t he e y e . I n s o m e c as e s o f E R U , s u b t l e
an t e r i o r c ham b e r p at ho l o g y c an o n l y b e d e t e c t e d
u s i n g a s l i t l am p . F o r t u n at e l y , s u c h c as e s ar e r ar e
an d a c l i n i c al d i ag n o s i s c an u s u al l y b e r e ac he d u s i n g
b as i c o p ht hal m i c t e c hn i q u e s .
t hat what i s at p r e s e n t r e c o g n i s e d c l i n i c al l y as a s i n g l e
d i s e as e m i g ht b e a s y n d r o m e m ad e u p o f s e v e r al d i s e as e s
d i s t i n g u i s hab l e o n l y b y d e t ai l e d i n v e s t i g at i o n o f t he i r
i m m u n o p at ho l o g i c al b ac k g r o u n d . T hi s i s o f ac ad e m i c
i n t e r e s t o n l y at p r e s e n t .
I n g e n e r al , t he c l i n i c al s i g n s o f E R U ar e t ho s e o f n o n -
e p i s o d i c o r r e c u r r e n t i n f l am m at i o n d r i v e n b y u n as s o c i -
at e d he t e r o an t i g e n s o r b y u n m as k e d t i s s u e au t o an t i -
g e n s . W hat e v e r t he m e c han i s m s i n v o l v e d , i t i s c l e ar
t hat a c o m p l e x i m m u n o l o g i c al e n v i r o n m e n t m u s t e x i s t
i n E R U -af f e c t e d e y e s an d t hat , i n e ac h c as e , an i n d i -
v i d u al s e r i e s o f i m m u n o l o g i c al e v e n t s l e ad s t o a f i n al
c o m m o n p at hway r e s u l t i n g i n t he t y p i c al c l i n i c al s i g n s
o f E R U .
Al t ho u g h n o s t u d i e s hav e b e e n d o n e o n t he ho r s e ,
i t i s l i k e l y t hat i n he r i t an c e o f s p e c i f i c MH C ( E L A) al l e -
l e s m ay i n f l u e n c e , b u t n o t d i r e c t l y c au s e , i n t r ao c u l ar
i n f l am m at o r y d i s e as e . S i m i l ar l y , n o n -E L A g e n e s m ay
b e i n v o l v e d i n c r e at i n g t he p e r m i s s i v e g e n e t i c b ac k -
g r o u n d n e c e s s ar y f o r d e v e l o p i n g t he d i s e as e , p o s s i b l y
v i a m e c han i s m s whi c h, f i r s t l y , r e g u l at e ho r m o n e an d
c y t o k i n e p r o d u c t i o n an d , s e c o n d l y , d e t e r m i n e t he
an i m al ' s T c e l l r e p e r t o i r e . I t i s o f i n t e r e s t t hat , i n t he
U S A, a b r e e d p r e d i l e c t i o n f o r t he d i s e as e i s r e c o g n i s e d
i n Ap p al o o s a ho r s e s .
I n P r ac t i c e * J U L Y / AU G L U S T 1 9 9 9
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S
Qu i e s c e n t
5 1 , . .
o f c u t e E R U
C o m m o n
O c u l ar p ai n an d b l e p har o s p as m
L ac r i m at i o n
Mi o s i s
D e c r e as e d i n t r ao c u l ar p r e s s u r e
Aq u e o u s f l ar e / hy p o p y o n
C o n j u n c t i v al hy p e r ae m i a
T u r g i d ' m u d d y ' i r i s
D e e p p e r i l i m b al c o r n e al v as c u l ar i s at i o n
C o r n e al o e d e m a
R ar e
K e r at i c p r e c i p i t at e s *
E p i s c l e r al v as c u l ar i n j e c t i o n
H y p hae m a
I n c r e as e d i n t r ao c u l ar p r e s s u r e
S u p e r f i c i al c o r n e al v as c u l ar i s at i o n
C o m m o n
P o s t e r i o r s y n e c hi ae
An t e r i o r c ap s u l ar / s u b c ap s u l ar c at ar ac t
I r i s hy p o c hr o m i a/ he t e r o c hr o m i a
At r o p hy o f t he g l o b e / p ht hi s i s b u l b i
I n t r av i t r e al d e t r i t u s
R ar e
L e n s l u x at i o n
I r i s n e o v as c u l ar i s at i o n
P o l y c o r i a
B o u n d -d o wn p u p i l
R e t i n al / o p t i c at r o p hy
C ho r i o r e t i n i t i s
G l au c o m a
C o r t i c al c at ar ac t
P e r i p ap i l l ar y r e t i n al d e t ac hm e n t
*T he s e m ay b e m o r e o b v i o u s i n g r an u l o m at o u s d i s e as e
s p e c i f i c u v e al i n f l am m at i o n ( s e e t ab l e ab o v e ) . H o r s e s
m ay b e p r e s e n t e d i n t he ac u t e s t ag e s o f t he d i s e as e ,
whe r e t he r e i s u s u al l y c o n s i d e r ab l e o c u l ar p ai n an d
as s o c i at e d b l e p har o s p as m an d l ac r i m at i o n . I n t he s e
c as e s , t he c l i n i c i an c an u s u al l y o n l y ap p r e c i at e c han g e s
i n t he an t e r i o r s e g m e n t o f t he e y e , s i n c e o p ac i t y i n t he
an t e r i o r c ham b e r p r e v e n t s o p ht hal m o s c o p i c e x am i n at i o n
o f t he m o r e p o s t e r i o r s t r u c t u r e s . I n s u c h i n s t an c e s ,
u l t r as o n o g r ap hy m ay b e u s e f u l t o i d e n t i f y g r o s s
ab n o r m al i t i e s o f t he p o s t e r i o r s e g m e n t , s u c h as r e t i n al
d e t ac hm e n t . H o we v e r , as s e s s m e n t o f m o r e s u b t l e c l i n i -
c al c han g e s i n t he p o s t e r i o r s t r u c t u r e s i s u s u al l y n o t
p o s s i b l e u n t i l t he an t e r i o r c ham b e r has c l e ar e d . I n
p r ac t i c e , v e t e r i n ar y s u r g e o n s m o r e f r e q u e n t l y e n c o u n t e r
t he d i s e as e i n t he q u i e s c e n t s t ag e s , p ar t i c u l ar l y d u r i n g
t he c o u r s e o f r o u t i n e p r e p u r c has e e x am i n at i o n s . H e r e ,
ac c u r at e d i ag n o s i s i s e s s e n t i al b e c au s e o f t he p o s s i b i l i t y
o f s e r i o u s v i s u al d y s f u n c t i o n ar i s i n g f r o m s u b s e q u e n t
ac u t e at t ac k s .
T y p i c al l y , c han g e s o c c u r r i n g i n t he an t e r i o r c ham b e r
d u r i n g t he ac u t e s t ag e s r e f l e c t a n o n -s p e c i f i c c y t o k i n e -
m e d i at e d b r e ak d o wn o f t he b l o o d -aq u e o u s b ar r i e r . T he
an t e r i o r c ham b e r c o n t ai n s an e x u d at i v e ad m i x t u r e o f
p r o t e i n ac e o u s m at e r i al , p r i n c i p al l y f i b r i n , an d m i x e d
i n f l am m at o r y c e l l s ; t he r e l at i v e am o u n t o f p r o t e i n an d
c e l l s ap p e ar s t o v ar y b e t we e n i n d i v i d u al c as e s . O n c e
t he ac u t e i n f l am m at o r y r e s p o n s e s u b s i d e s , p ar t i c u l ar l y
whe r e i m m e d i at e an d e f f e c t i v e t r e at m e n t has b e e n
i n s t i t u t e d , e x u d at i v e d e t r i t u s i s r ap i d l y r e m o v e d f r o m
t he an t e r i o r c ham b e r . E f f e c t i v e e ar l y t r e at m e n t i n
m an y c as e s c an r e s t o r e t he e y e t o m o r p ho l o g i c al an d
f u n c t i o n al n o r m al i t y . I f t r e at m e n t i s i n e f f e c t i v e o r i s
d e l ay e d t he n t he i n e v i t ab l e s e q u e l ae o f p o s t e r i o r
s y n e c hi ae ( ad he s i o n s o f t he i r i s t o t he an t e r i o r l e n s ) an d
c at ar ac t s r e m ai n as a p e r m an e n t l e g ac y o f t he e ar l i e r
ac u t e e p i s o d e .
Aq u e o u s f l ar an d a s u b t l e n y p e p y e n
I n P r ac t i c e * J U L Y / Au G u s T 1 9 9 9
Qu i e s c e n t Ac u t e
3 7 2
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An t e r i o r
c ap s u l ar c at ar ac t s c o m m o n l y f o l l o w an t e r i o r
u v e i t i s . T he s e hav e a g r an u l ar ap p e ar an c e r e s u l t i n g f r o m
f o c al n e c r o s i s an d p r o l i f e r at i v e r e p ai r o f t he l e n s
e p i t he -
l i u m , an d m ay hav e t ag s o f p i g m e n t e d i r i d i al t i s s u e
at t ac he d . P o s t -u v e i t i c s u b c ap s u l ar v ac u o l at i o n an d
c o r t i c al c at ar ac t p r o b ab l y r e s u l t f r o m m e t ab o l i c i n j u r y t o
l e n s c e l l s b y i n f l am m at o r y m e t ab o l i t e s , i n c l u d i n g f r e e
r ad i c al s an d l y m p ho k i n e s , d e r i v e d f r o m t he an t e r i o r
c ham b e r .
G l au c o m a i s i n c r e as i n g l y r e c o g n i s e d as a s e q u e l a o f
E R U ( Mi l l e r an d o t he r s 1 9 9 5 ) , an d m ay b e m o r e c o m -
m o n t han p r e v i o u s l y s u p p o s e d . T he e l e v at i o n i n i n t r a-
o c u l ar p r e s s u r e p r o b ab l y r e s u l t s f r o m a c o m b i n at i o n o f
p o s t -i n f l am m at o r y o b s t r u c t i o n o f t he u v e o s c l e r al ( u n c o n -
v e n t i o n al ) aq u e o u s o u t f l o w an d b l o c k ag e o r c o l l ap s e o f
t he d r ai n ag e an g l e ( c o n v e n t i o n al o u t f l o w) .
S o m e au t ho r s r e g ar d p e r i p ap i l l ar y c ho r i o r e t i n i t i s -
t he ' b u t t e r f l y l e s i o n ' - as p ar t o f t he E R U c o m p l e x . I t
c an ar i s e i n c o n j u n c t i o n wi t h an t e r i o r s e g m e n t d i s e as e i n
s o m e c as e s o f E R U , b u t i n t he ab s e n c e o f an t e r i o r s e g -
m e n t d i s e as e i t c an n o t b e r e g ar d e d as d i ag n o s t i c o f E R U
i n t hat e y e .
D I AG NO S I S
D i ag n o s i s o f E R U i s b as e d s o l e l y u p o n c l i n i c al s i g n s .
An c i l l ar y t e s t s s u c h as b l o o d b i o c he m i s t r y o r s e r o l o g y
hav e l i t t l e d i ag n o s t i c o r p r o g n o s t i c v al u e . I n p r ac t i c e ,
an y at t e m p t s t o i d e n t i f y a s p e c i f i c ae t i o l o g y ar e g e n e r al -
l y u n r e war d i n g an d , i n an y e v e n t , d o n o t i n f l u e n c e t he
t he r ap e u t i c p r o t o c o l . H o we v e r , whe r e t he c l i n i c i an e l e c t s
t o i n v e s t i g at e t he p o s s i b l e i n v o l v e m e n t o f an i n f e c t i o u s
ag e n t , c o m p ar i s o n o f p l as m a an d aq u e o u s hu m o u r an t i -
b o d y t i t r e s wi l l p r o v i d e t he m o s t i n f o r m at i o n . I t s ho u l d
b e n o t e d t hat an t e r i o r c ham b e r p ar ac e n t e s i s i n E R U
c as e s i s n o t wi t ho u t an i n he r e n t r i s k o f f u r t he r c o m p r o -
m i s i n g t he i n f l am e d e y e .
T he d i f f e r e n t i al d i ag n o s e s o f E R U ar e t ho s e
c o n d i t i o n s as s o c i at e d wi t h ac u t e o c u l ar p ai n an d an t e r i o r
s e g m e n t o p ac i t y ( s e e b o x b e l o w) .
i MAf m s u e -. - R U
O c l a
t r am
i t ; t U l c e r ai v k e r at i t i s : y ; 0
n o w " -u l c e r ( i m m u n o g e i
k e at i s
UO *u l o n c ho c e r c i as i s ( r ar e i n t he U I K )
* I n 0 0 t r ao c u ar n e o p as i a ( r ar e ) V
P r m ar y g l au c o m a ( r ar e )
T R E AT ME NT
An t i -i n f l am m at o r y ag e n t s
I n t r e at i n g E R U , t he p r i m ar y ai m i s t o ac hi e v e an d
m ai n t ai n t he r ap e u t i c l e v e l s o f an t i -i n f l am m at o r y ag e n t s ,
p r i n c i p al l y c o r t i c o s t e r o i d s , wi t hi n t he e y e ( W hi t l e y an d
o t he r s 1 9 9 3 ) . T o r e ac h e f f e c t i v e i n t r ao c u l ar c o n c e n t r a-
t i o n s , c o r t i c o s t e r o i d s m ay b e ad m i n i s t e r e d b y t hr e e
r o u t e s ( s e e b o x o v e r l e af ) . I n p r ac t i c e a c o m b i n at i o n o f
t he s e r o u t e s i s c o m m o n l y u s e d .
3 7 3
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* T o p i c al ad m i n i s t r at i o n b y d i r e c t i n s t i l l at i o n o r an
i n d we l l i n g l av ag e s y s t e m *
*
S u b c o n j u n c t i v al o r s u b -T e n o n ' s i n j e c t i o n
* P ar e n t e r al ad m i n i s t r at i o n
*I n g e n e r al , whe n t r e at i n g E R U , t he s i m u l t an e o u s
t o p i c al ad m i n i s t r at i o n o f d i f f e r e n t d r u g s m u s t b e
av o i d e d as d i l u t i o n an d was h o u t f r o m t he e y e wi l l
s e r i o u s l y c o m p r o m i s e t r e at m e n t . T he r e s ho u l d b e
an i n t e r v al o f at l e as t 1 5 m i n u t e s b e t we e n ad m i n i s -
t r at i o n o f d i f f e r e n t d r u g s
T o c r o s s t he i n t ac t c o m e al b ar r i e r , t o p i c al l y ad m i n i s -
t e r e d c o r t i c o s t e r o i d s m u s t b e b i p has i c al l y p o l ar an d , i n
t hi s r e s p e c t , t he e s t e r i c o r al c o ho l f o r m u l at i o n s ar e b e t t e r
B o u n d -d o wn p u o l r i s 0 c t
u
I o
an d i r s
t han t he ac i d i c s . P r e d n i s o l o n e i s t he o r e t i c al l y s u p e r i o r i n
i t s i n t r ao c u l ar an t i -i n f l am m at o r y ac t i v i t y t han d e x a-
m e t has o n e , an d t he d r u g o f c ho i c e f o r u s e i n E R U i s
1 p e r c e n t p r e d n i s o l o n e ac e t at e ( P r e d F o r t e ; Al l e r g an ) .
H o we v e r , t he b i o c he m i c al an d m i c r o v as c u l ar e n v i r o n -
m e n t o f t he i n f l am e d e y e wi l l m ar k e d l y i n f l u e n c e t he
b i o av ai l ab i l i t y an d p har m ac o k i n e t i c s o f an y d r u g an d
he n c e d r u g s e l e c t i o n m ay b e v al i d l y b as e d u p o n t he
e x p e r i e n c e o f t he c l i n i c i an . C e r t ai n l y , 0 -1 p e r c e n t
d e x am e t has o n e al c o ho l ( Max i t r o l ; Al c o n L ab o r at o r i e s )
p r o d u c e s g o o d c l i n i c al r e s u l t s . T he f r e q u e n c y o f i n s t i l l a-
t i o n o f t o p i c al c o r t i c o s t e r o i d s v ar i e s ac c o r d i n g t o t he
f o r m u l at i o n - s o l u t i o n s s ho u l d b e i n s t i l l e d ho u r l y an d
s u s p e n s i o n s e v e r y t hr e e t o f o u r ho u r s . T he i n t e r v al s
b e t we e n i n s t i l l at i o n m ay b e i n c r e as e d whe n c o n c u r r e n t
s u b c o n j u n c t i v al ad m i n i s t r at i o n i s u s e d .
Al t ho u g h t o p i c al i n s t i l l at i o n o f c o r t i c o s t e r o i d s t he o -
r e t i c al l y ac hi e v e s hi g he r an t e r i o r c ham b e r l e v e l s t han
s u b c o n j u n c t i v al ad m i n i s t r at i o n , a c o m b i n at i o n o f t he t wo
r o u t e s i s p r o b ab l y t he b e s t ap p r o ac h. I m p o r t an t l y , t he
s u b c o n j u n c t i v al o r s u b -T e n o n ' s r o u t e s ho u l d b e u s e d
whe r e p o s t e r i o r
u v e i t i s i s s u s p e c t e d .
F o r s u b c o n j u n c t i v al
B n p u p l an d
i n j e c t i o n , 2 m g d e x am e t has o n e s o d i u m p ho s p hat e ( D e x a-
d r e s o n ; I n t e r v e t ) m ay b e ad m i n i s t e r e d e v e r y 24 ho u r s .
H o we v e r , r e p o s i t r o l p r e p ar at i o n s ( e g , 24 t o 4 0 m g
m e t hy l p r e d n i s o l o n e ac e t at e [ D e p o m e d r o n e ; U p j o hn ]
r e p e at e d at s e v e n - t o 1 4 -d ay i n t e r v al s ) ar e o f t e n u s e d d u e
t o t he i r e x t e n d e d d u r at i o n o f ac t i o n . I t s ho u l d b e n o t e d
t hat r e p o s i t r o l p r e p ar at i o n s m ay r e s u l t i n g r an u l o m a
f o r m at i o n at t he i n j e c t i o n
s i t e .
O r al p r e d n i s o l o n e ( 1 t o 2 m g / k g o n c e d ai l y ) o r i n t r a-
m u s c u l ar d e x am e t has o n e ( 0 . 0 6 m g / k g
o n c e d ai l y
f o r f i v e
t o s e v e n d ay s ) c an b e u s e d as an ad j u n c t
t o t o p i c al
o r
s u b c o n j u n c t i v al ad m i n i s t r at i o n . I f p r o l o n g e d
u s e o f o r al
p r e d n i s o l o n e i s i m p l e m e n t e d , t he wi t hd r awal s ho u l d b e
t ap e r e d . T he c l i n i c i an s ho u l d b e awar e o f t he p o s s i b l e
u n t o war d s i d e e f f e c t s o f p ar e n t e r al c o r t i c o s t e r o i d s ,
i n
p ar t i c u l ar l am i n i t i s . H o we v e r , i n t he au t ho r ' s o p i n i o n
t he
p o t e n t i al l y v i s i o n -s p ar i n g b e n e f i t s o f p ar e n t e r al
c o r t i c o -
s t e r o i d s , i n p ar t i c u l ar d e x am e t has o n e , o u t we i g h
t he r i s k s
_
as s o c i at e d wi t h t he i r u s e . I _ _ _ V
P ar e n t e r al an d o r al n o n -s t e r o i d al an t i -i n f l am m at o r y
d r u g s ( NS AI D s ) ar e f r e q u e n t l y u s e d i n t he m an ag e m e n t o . d e m a d e l i n e ar c o e o t ( s s r a. )
o f E R U . T he s e hav e an an al g e s i c e f f e c t i n ad d i t i o n t o
27 A
I n P r ac t i c e
.
J U L Y / AU G U S T 1 9 9 9
. 1 / , #
group.bmj.com on October 6, 2010 - Published by inpractice.bmj.com Downloaded from
t he i r an t i -i n f l am m at o r y ac t i v i t y . No c o m p ar at i v e e f f l c a-
c y s t u d i e s o f t he s e d r u g s i n E R U hav e b e e n p u b l i s he d .
H o we v e r , t he m o r e r e c e n t l y d e v e l o p e d NS AI D s , i n
p ar t i c u l ar s o m e o f t he p he n y l al k an o i c ac i d s s u c h as
k e t o p r o f e n ( K e t o f e n ; Me r i al ) , ar e b e l i e v e d t o hav e an
i n hi b i t o r y i n f l u e n c e o n b o t h t he l i p o x y g e n as e an d c y c l o -
o x y g e n as e p at hway s . W he t he r t hi s c o m b i n e d i n hi b i t o r y
ac t i v i t y o c c u r s at t he r ap e u t i c d o s e s has n o t b e e n e s t ab -
l i s he d ; n e v e r t he l e s s , t he p o t e n t i al l y b r o ad e r s p e c t r u m o f
an t i -i n f l am m at o r y ac t i v i t y p r o b ab l y m ak e t he s e t he
NS AI D s o f c ho i c e i n E R U . C ar p r o f e n ( Z e n e c ar p ;
V e r i c o r e ) i s a we ak c y c l o -o x g e n as e i n hi b i t o r wi t h n o
l i p o x y g e n as e i n hi b i t o r y ac t i v i t y , b u t ac t s as a f r e e r ad i c al
s c av e n g e r an d c an s t i m u l at e s u p p r e s s o r T c e l l s , m ak i n g
i t p o t e n t i al l y u s e f u l i n m an ag i n g E R U . I n p r ac t i c e ,
f l u n i x i n m e g l u m i n e ( F i n ad y n e ; S c he r i n g P l o u g h) has a
we l l t r i e d an d p o t e n t an al g e s i c an d an t i -i n f l am m at o r y
ac t i v i t y i n c as e s o f e q u i n e u v e i t i s , an d i s a c o m m o n f i r s t
c ho i c e ag e n t . T he s e d r u g s ar e u s u al l y i n i t i al l y ad m i n i s -
t e r e d i n t r av e n o u s l y an d f o l l o we d u p o r al l y at t he d i s c r e -
t i o n o f t he c l i n i c i an . F l u r b i p r o f e n ( O c u f e n ; Al l e r g an )
an d d i c l o f e n ac ( V o l t ar o l O p ht ha; C i b a V i s i o n ) ar e av ai l -
ab l e as s o l u t i o n s f o r t o p i c al o p ht hal m i c u s e . H o we v e r ,
t he c o s t an d n e e d f o r ho u r l y i n s t i l l at i o n m i t i g at e ag ai n s t
t he i r u s e i n E R U . F o l l o wi n g r e s o l u t i o n o f an ac u t e
e p i s o d e o f E R U , l o n g -t e r m o r al ad m i n i s t r at i o n o f as p i r i n
( 3 0 m g / k g o n c e d ai l y ) i s r e c o m m e n d e d b y s o m e au t ho r s
as a m e an s o f at t e m p t i n g t o r e d u c e t he i n c i d e n c e o f
r e c u r r e n c e .
Mo r e n o v e l an t i -i n f l am m at o r y d r u g s m ay c o m e i n t o
u s e i n t he f u t u r e . P r o m i n e n t am o n g t he s e i s c y c l o s p o r i n e
A, a T -c e l l t ar g e t e d i m m u n o m o d u l at i n g d r u g . T hi s d r u g
m ay p r o v e t o b e o f v al u e i n m an ag i n g t he s m al l n u m b e r
o f c as e s o f E R U whi c h f ai l t o r e s p o n d t o c o r t i c o s t e r o i d s .
H o we v e r , t he f o r m u l at i o n s c u r r e n t l y av ai l ab l e f o r t o p i c al
u s e p r o b ab l y d o n o t ac hi e v e t he r ap e u t i c l e v e l s o f t he
d r u g i n t he an t e r i o r c ham b e r , al t ho u g h t hi s m ay c han g e
as n e w v e hi c l e s f o r t he d r u g ar e d e v e l o p e d .
Al t ho u g h an t i b i o t i c s ar e wi d e l y u s e d i n t r e at i n g E R U ,
t he r e i s l i t t l e r at i o n al e f o r t he i r u s e .
My d r i at i c s
I t i s n e c e s s ar y t o ac hi e v e an d m ai n t ai n m y d r i as i s i n
c as e s o f E R U t o p r e v e n t s y n e c hi ae f o r m at i o n an d m i n -
i m i s e t he r i s k o f p u p i l l ar y b l o c k . T o d o t hi s a 1 t o 4 p e r
c e n t at r o p i n e s o l u t i o n s ho u l d b e i n s t i l l e d ho u r l y u n t i l
m y d r i as i s i s ac hi e v e d an d t he r e af t e r as o f t e n as i s n e c e s -
s ar y t o m ai n t ai n m y d r i as i s d u r i n g t he ac u t e e p i s o d e . I n
s t u b b o m c as e s , t o p i c al 1 0 p e r c e n t p he n y l e p hr i n e m ay b e
u s e d i n c o n j u n c t i o n wi t h at r o p i n e .
S u r g e r y
R e c e n t l y , s u r g i c al v i t r e c t o m y has b e e n r e p o r t e d t o
s u c c e s s f u l l y p r e v e n t f u r t he r ac u t e e p i s o d e s i n s o m e c as e s
o f E R U , al t ho u g h t he t e c hn i q u e has had l i t t l e v i s i o n -
s p ar i n g e f f e c t ( F r u hau f an d o t he r s 1 9 9 8 ) .
Nu r s i n g c ar e
S o m e g e n e r al n u r s i n g p r o c e d u r e s s ho u l d b e i m p l e m e n t -
e d i n c as e s o f E R U . T he s e i n c l u d e :
* K e e p i n g t he ho r s e i n a d i m l y l i t s t ab l e ;
* R e g u l ar c l e an s i n g o f o c u l ar d i s c har g e s ;
* Ap p l i c at i o n o f p e t r o l e u m j e l l y t o t he f ac e t o av o i d
s c al d i n g ;
* F e e d i n g hay f r o m t he g r o u n d ;
* P r e v e n t i o n o f s e l f -t r au m a.
I n P r ac t i c e
*
J U L Y / AU G U S T 1 9 9 9 3 7 5
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P R O G NO S I S
Mo s t c as e s o f E R U wi l l r e s p o n d t o ag g r e s s i v e m e d i c al
t he r ap y an d , i f i n i t i at e d e ar l y i n t he c o u r s e o f t he
d i s e as e , e f f e c t i v e t r e at m e n t c an r e s t o r e t he e y e t o g r o s s
n o r m al i t y , p ar t i c u l ar l y whe r e c han g e s ar e r e s t r i c t e d t o
t he an t e r i o r s e g m e n t . H o we v e r , p o s t e r i o r s e g m e n t
p at ho l o g y , s u c h as i n t r av i t r e al i n f l am m at o r y d e t r i t u s , c an
t ak e u p t o s i x t o e i g ht m o n t hs t o r e s o l v e . An y d e l ay i n
t r e at m e n t wi l l i n e v i t ab l y hav e s e r i o u s c o n s e q u e n c e s f o r
o c u l ar f u n c t i o n , i n c l u d i n g u l t i m at e l y b l i n d n e s s .
T o p i c al an t i -i n f l am m at o r y t r e at m e n t s ho u l d c o n t i n u e
f o r at l e as t 3 0 d ay s af t e r t he r e s o l u t i o n o f c l i n i c al s i g n s ,
an d t hi s m ay he l p t o r e d u c e t he l i k e l i ho o d o f r e c u r r e n c e .
H o we v e r , i n t he f i n al an al y s i s i t i s n o t p o s s i b l e t o p r e d i c t
whi c h c as e s wi l l b e r e c u r r e n t o r whi c h m ay i n v o l v e t he
o t he r e y e , an d o wn e r s s ho u l d b e war n e d t o r e g ar d an y
s i g n s o f o c u l ar d i s c o m f o r t as an e m e r g e n c y an d s e e k
p r o f e s s i o n al as s i s t an c e .
A s m al l n u m b e r o f c as e s o f E R U f ai l t o r e s p o n d t o
t r e at m e n t d e s p i t e ag g r e s s i v e t he r ap y an d c an c au s e c o n -
s i d e r ab l e an x i e t y t o b o t h t he o wn e r an d t he v e t e r i n ar y
s u r g e o n . Mo s t o f t he s e c as e s wi l l r e s o l v e s p o n t an e o u s l y
0
0
-
AW L
I I
wi t h t i m e , b u t e x t e n s i v e i n t r ao c u l ar d am ag e i s i n e v i t ab l e .
S u c h c as e s , al o n g wi t h b l i n d e y e s s u b j e c t t o r e p e at e d
ac u t e e p i s o d e s , ar e c an d i d at e s f o r e n u c l e at i o n .
R e f e r e n c e s
B AR NE T T , K . C . , C R I S P I N, S . M. , L AV AC H , J . D . & MAT T H E W S , A. G .
( 1 9 9 5 ) E x am i n at i o n o f t he e y e an d ad n e x a. I n C o l o u r At l as an d T e x t
o f E q u i n e O p ht hal m o l o g y . L o n d o n , Mo s b y -W o l f e . p p 1 5 7 -1 7 2
D E S C H E NE S , J . , R O Y , M. & R O C H A, R . ( 1 9 9 7 ) I m m u n o l o g y o f u v e i t i s .
I n F o u n d at i o n s o f C l i n i c al O p ht hal m o l o g y , V o l 2. E d s W . T as m aan
an d E . A. J ae g e r . P hi l ad e l p hi a, L i p p i n c o t t -R av e n . p p 1 -1 3
D U B I E L Z I Q, R . R . , R E ND E R , J . A. & MO R R E AL E , R . J . ( 1 9 9 7 ) D i s t i n c t i v e
m o r p ho l o g i c f e at u r e s i n t he c i l i ar y b o d y i n e q u i n e r e c u r r e n t u v e i t i s .
V e t e r i n ar y an d C o m p ar at i v e O p ht hal m o l o g y 7 , 1 6 3 -1 6 7
F R U H AU F , B . , O H NE S O R G E , B . , D E E G E N, E . & B O E V E , M. ( 1 9 9 8 )
S u r g i c al m an ag e m e n t o f e q u i n e r e c u r r e n t u v e i t i s wi t h s i n g l e p o r t
p ar s p l an a v i t r e c t o m y . V e t e r i n ar y O p ht hal m o l o g y 1 , 1 3 7 -1 5 1
K AL S AW , C . M. & D W Y E R , A. E . ( 1 9 9 7 ) R o l e o f l e p t o s p i r al i n f e c t i o n
i n e q u i n e r e c u r r e n t u v e i t i s . ht t p : / / www. u s aha. o r g / s p e e c he s /
l e p e r u 9 7 . ht m l ( D at e c o n s u l t e d : 1 0 . 2. 9 9 )
MI L L E R , T . R . , B R O O K S , D . E . , G E L AT T , K . N. , K I NG , T . C . , S MI T H , P . J . ,
S AP I E NZ A, J . S . & P E L L I C ANE , C . P . ( 1 9 9 5 ) E q u i n e g l au c o m a: c l i n i c al
f i n d i n g s an d r e s p o n s e t o t r e at m e n t i n 1 4 ho r s e s . V e t e r i n ar y an d
C o m p ar at i v e O p ht hal m o l o g y 5 , 1 7 0 -1 8 2
S T R E I L E I N, J . W . & W E G MANN, T . G . ( 1 9 8 7 ) I m m u n o l o g i c p r i v i l e g e i n
t he e y e an d t he f e t u s . I m m u n o l o g y T o d ay 8 , 3 6 2-3 6 6
W H I T L E Y , R . D . , MI L L E R , T . R . & W I L S O N, J . H . ( 1 9 9 3 ) T he r ap e u t i c
c o n s i d e r at i o n s f o r e q u i n e r e c u r r e n t u v e i t i s . E q u i n e P r ac t i c e 1 5 ,
1 6 -22
I n P r ac t i c e * J U L Y / AU G U S T 1 9 9 9
I n P r ac t i c e
B i n d e r s
B i n d e r s f o r I n P r ac t i c e ar e av ai l ab l e f r o m :
T G S S u b s c r i b e r S e r v i c e s
6 B o u r n e E n t e r p r i s e C e n t r e
W r o t ham R o ad
B o r o u g h G r e e n , K e n t T N1 5 8 D G
T e l e p ho n e 0 1 7 3 2 8 8 4 0 23
F ax 0 1 7 3 2 8 8 4 0 3 4
P r i c e 6 . 8 5 ( i n c p o s t ag e )
T he r e d -c o l o u r e d b i n d e r s e ac h ho l d
a y e ar ' s s u p p l y o f i s s u e s
P ay m e n t wi t h o r d e r p l e as e
3 7 6
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