Panuveitis

Panuveitis is inflammation involving the anterior chamber, vitreous, and retina or choroid simultaneously. It may be severe, carries a high risk of vision loss, and has a broad differential, so identification of the cause drives treatment.

• Infectious: tuberculosis, syphilis, toxoplasmosis (severe or in the immunosuppressed), endogenous endophthalmitis (bacterial and fungal), cytomegalovirus and herpes retinitis, Lyme disease, bartonella, toxocariasis, onchocerciasis, leptospirosis, brucellosis.
• Non-infectious: Vogt-Koyanagi-Harada disease, sympathetic ophthalmia, Behçet disease, sarcoidosis, birdshot chorioretinopathy, multifocal choroiditis, juvenile idiopathic arthritis (rare), systemic lupus erythematosus, and granulomatosis with polyangiitis.
• Masquerade: primary vitreoretinal lymphoma, leukaemia, metastatic tumours, retinoblastoma (in children), and paraneoplastic disease.
• Drug induced: immune checkpoint inhibitors, intraocular rifabutin, bisphosphonates.

• Pain, redness, photophobia and floaters, with reduced vision; anterior chamber cells and flare, hypopyon, vitritis (haze), choroidal and retinal lesions, vasculitis, disc oedema, exudative retinal detachment, macular oedema.
• Clues to cause: genital and oral ulcers with occlusive retinal vasculitis (Behçet), poliosis, vitiligo, tinnitus, meningism (Vogt-Koyanagi-Harada), history of penetrating injury (sympathetic ophthalmia), cough and night sweats (tuberculosis), rash (syphilis), immunosuppression, fever and intravenous lines (endogenous endophthalmitis).
• Complications: macular oedema, cataract, glaucoma, retinal detachment, hypotony, phthisis.

• Slit lamp, dilated fundus, optical coherence tomography, fluorescein and indocyanine green angiography, B-scan ultrasound.
• Systemic workup targeted to the pattern: treponemal and non-treponemal serology, interferon gamma release assay and chest CT, ACE and lysozyme, HIV, full blood count, blood cultures (when septic), antinuclear and antineutrophil cytoplasmic antibodies, Toxoplasma serology, HLA-B51 supportive in Behçet, urine analysis, MRI brain and lumbar puncture in neuro ocular syndromes.
• Aqueous and vitreous taps for culture, polymerase chain reaction panel and cytology (lymphoma); biopsy of accessible lesions (conjunctival, lymph node, skin) in sarcoid.
• Do not start steroid only treatment before excluding infection (tuberculosis, syphilis, toxoplasmosis, endogenous endophthalmitis) in a patient with focal chorioretinal lesions.

• Treat the specific cause (antimicrobials for infection, intravitreal antibiotics and vitrectomy for endogenous endophthalmitis, immunosuppression for autoimmune disease).
• For presumed non-infectious panuveitis after infection exclusion: oral prednisolone 1 mg/kg daily (up to 80 mg) or intravenous methylprednisolone 500 to 1000 mg daily for 3 days, tapered over several months; sub-Tenon triamcinolone 40 mg or intravitreal dexamethasone implant 0.7 mg for unilateral or asymmetric disease; topical prednisolone acetate 1 percent and atropine 1 percent for anterior inflammation.
• Early steroid sparing therapy (within 1 to 3 months): methotrexate, mycophenolate, azathioprine or ciclosporin, and adalimumab 80 mg then 40 mg every 2 weeks, or infliximab 5 mg/kg for Behçet and refractory disease.
• Tuberculous or syphilitic disease: specific antimicrobial therapy with adjunctive steroid once covered.
• Surgery: vitrectomy for diagnosis, non-clearing opacities, and tractional or rhegmatogenous detachment; cataract and glaucoma surgery when quiet.
• Monitor drug toxicity and disease activity at 2 to 4 week intervals at first.