INVESTIGATIONS RELATED

TO UVEITIS
DR. M. USMAN SADIQ
Indications
Granulomatous inflammation
Recurrent uveitis
Bilateral disease
Systemic manifestations without a specific diagnosis
Confirmation of a suspected ocular picture which
depends on the test result as part of the criteria for
diagnosis such as HLA-A29 testing for birdshot
chorioretinopathy.
Not Indicated
Single attack of mild unilateral AAU without
suggestion of a possible underlying disease.

A specific uveitis entity such as sympathetic
ophthalmitis and Fuchs cyclitis.

When a systemic diagnosis compatible with the
uveitis is already apparent such as Behet disease
or sarcoidosis.

Tuberculin Skin Tests
Pathergy Test
Lepromin Test

SKIN TESTS
Tuberculin skin tests (Mantoux and
Heaf)
involve the intradermal injection of purified protein
derivative of M. tuberculosis.

Positive result is characterized by the development
of an induration of 514 mm with 48 hours.

Negative result usually excludes TB, but may also
occur in patients with advanced consumptive
disease.
Weakly positive result does not necessarily
distinguish between previous exposure and active
disease. This is because most individuals have
already received BCG (Bacille CalmetteGurin)
vaccination and will therefore exhibit a
hypersensitivity response.

Strongly positive result (induration > 15 mm) is
usually indicative of active disease since this level of
response is not expected after long exposure to the
vaccine.
Pathergy Test
Pathergy test (increased dermal sensitivity to
needle trauma) is a criteria for the diagnosis of
Behet syndrome, but the results vary and it is only
rarely positive in the absence of systemic activity.

A positive response is the formation of a pustule
following pricking of the skin with a needle
Lepromin test
Lepromin test involves intradermal injection of an
extract of leprosy bacilli.

It differs from the tuberculin test because it becomes
positive after several weeks.

It is strongly positive in tuberculoid leprosy and
negative in lepromatous leprosy.
Skin tests in the investigation of uveitis. (A) Positive tuberculin skin reaction; (B)
strongly positive tuberculin skin reaction; (C) positive pathergy test in Behet
syndrome
Non-treponemal tests
Treponemal antibody tests
Dark-ground microscopy
SEROLOGY FOR SYPHILIS
Because of the variable presentation serology
should be performed in all patients with uveitis who
require investigation.

Serological tests rely on detection of nonspecific
antibodies (cardiolipin) or specific treponemal
antibodies.

Non-treponemal tests
such as rapid plasma reagin (RPR) or Venereal
Disease Research Laboratory (VDRL) are best used
to diagnose primary infection, monitor disease
activity or response to therapy based on titre.

The patient's serum is mixed with commercially
prepared carbon-like cardiolipin antigen.
The results may be negative in up to 30% of
patients with documented syphilitic uveitis. They also
tend to become negative 618 months after
therapy.

Treponemal antibody tests
Treponemal antibody tests are highly sensitive and
specific and more useful to prove past infection, as
well as active secondary or tertiary forms of clinical
infection.

The fluorescent treponemal antibody absorption test
(FTA-ABS) and the more specific micro-
haemagglutination Treponema pallidum test (MHA-
TP) are most commonly used.

The antibody in the patient's serum binds to
bacteria and is visualized by a fluorescent dye.

The result cannot be titrated and is either positive
(reactive) or negative (non-reactive).

A positive result always remains positive (serological
scar).
Dark-ground microscopy
Dark-ground microscopy of exudate from a
mucocutaneous lesion is reliable if positive.


Serological tests for syphilis. (A) Rapid plasma regain (RPR) for syphilis
showing clumping of the antigenic particles (left) after 4 minutes; (B) positive
fluorescent treponema antibody test (FTA-ABS) for syphilis
Dye test (Sabin-Feldman)
Immunofluorescent antibody
Haemagglutination tests
ELISA
SEROLOGY FOR TOXOPLASMOSIS
Dye test
Dye test (Sabin-Feldman) utilizes live organisms
which are exposed to the patient's serum
complement.

The cell membranes of the organisms are lysed in
the presence of the specific anti-toxoplasma IgG,
and as consequence the organisms fail to stain with
methylene blue dye.

This test remains the gold standard for the diagnosis
of toxoplasmosis.
Immunofluorescent antibody
Immunofluorescent antibody tests utilize dead
organisms exposed to the patient's serum and
antihuman globulin labelled with fluorescein.

The results are read using a fluorescent microscope.
Positive immunofluorescent antibody test
Haemagglutination tests
Haemagglutination tests involve the coating of
lysed organisms on to red blood cells which are
then exposed to the patient's serum; positive sera
cause the red cells to agglutinate.

Haemagglutination test
ELISA
Enzyme-linked immunosorbent assay (ELISA)
involves binding of the patient's antibodies to an
excess of solid phase antigen.

This complex is then incubated with an enzyme-
linked second antibody.

Assessment of enzyme activity provides
measurement of specific antibody concentration.

The test can also be used to detect antibodies in the
aqueous which are more specific than those in the
serum, and is useful in other conditions such as cat-
scratch fever and toxocariasis.

Any positive titre, even in undiluted serum, is
significant in the presence of a fundus lesion
compatible with toxoplasmic retinitis.

Reactivation of ocular disease alone will have no
impact on the titre.
ELISA test showing positive (yellow-brown) and negative wells
Serum ACE
Lysozyme assay
ENZYME ASSAY
Serum ACE
Serum angiotensin-converting enzyme (ACE) is a
non-specific test which indicates the presence of a
granulomatous disease such as sarcoidosis,
tuberculosis and leprosy.

Elevation of ACE occurs in up to 80% of patients
with acute sarcoidosis but may be normal during
remissions.

The normal serum level in adults is 32.1 8.5 IU.

In children the levels tend to be higher and
diagnostically less useful.

In patients with suspected neurosarcoid ACE can be
measured in the cerebrospinal fluid.

ACE may also be elevated in other conditions such
as tuberculosis, lymphoma and asbestosis.

Lysozyme assay
Lysozyme assay has good sensitivity but less
specificity than ACE in the diagnosis of sarcoidosis
but performing both tests seems to increase
sensitivity and specificity.


HLA TISSUE TYPING
HLA tissue typing
FA
ICGA
OCT
IMAGING
Flourescein angiography (FA)
Evaluation of retinal vasculitis.

Diagnosis of macular disease, particularly cystoid
macular oedema (CMO) and choroidal
neovascularization (CNV).

Demonstrating macular ischaemia as the cause of
visual loss rather than CMO.

Differentiation between inflammatory and
ischaemic causes of retinal neovascularization.

Diagnosis of specific uveitis entities that have
characteristic features on FA (e.g. acute posterior
multifocal placoid pigment epitheliopathy and
Harada disease).
Indocyanine green angiography
Indocyanine green angiography (ICGA) is better
suited for evaluating choroidal disease because the
dye does not readily leak out of choroidal vessels
which are better visualized through the RPE.

ICGA is able to detect non-perfusion of the
choriocapillaris and provide information regarding
inflammation affecting the choroidal stroma.

OCT
Optical coherence tomography (OCT) is useful in
detecting complications such as macular oedema,
epiretinal membranes and subretinal fluid.

It is also useful in delineating the anatomical layer
of the inflammatory focus.

RADIOLOGY
Chest X-ray is frequently requested to exclude
tuberculosis and sarcoidosis.

Sacroiliac joint X-ray is helpful in the diagnosis of
a spondyloarthropathy in the presence of symptoms
of low back pain and uveitis.

CT and MR of the brain and thorax may be
appropriate in the investigation of sarcoidosis,
multiple sclerosis and primary intraocular
lymphoma.

A thorax MR scan may clarify any doubts regarding
the presence of hilar lymphadenopathy.
BIOPSY
Histopathology still remains the gold standard for
definitive diagnosis of many conditions.

Biopsies of the skin or other organs may establish
the diagnosis of a systemic disorder associated with
the ocular manifestations, such as sarcoidosis.

However, intraocular structures are relatively
inaccessible to this procedure without running the
risk of significant morbidity.
Conjunctival and lacrimal gland biopsy may useful
for the diagnosis of sarcoidosis but only in the
presence of clinically apparent disease.

Aqueous samples for polymerase chain reaction
(PCR) may occasionally be useful in the diagnosis of
viral retinitis.

Vitreous biopsy, apart from its well-established
role in infectious endophthalmitis, can also be used
for the diagnosis of other infectious conditions by
obtaining samples for culture and PCR.

It is also used for the diagnosis of intraocular
lymphoma.
Retinal and choroidal biopsies may be useful in
the following situations.

Diagnosis not established.
No response to therapy.
Further deterioration despite therapy.
Exclusion of malignancy or infection.

THANKS