BMJ | 16 OCTOBER 2010 | VOLUME 341 53

For the full versios of these !rti"les see

#$%&"o$
CLINICAL REVIEW
'vesti(!tio !) $!!(e$et of uveitis
C!therie M *ul+,
1
Joh V Forrester
2
1
-#er)ee Ro+!l 'fir$!r+,
-#e r)ee -B2. 2/0, U1
2
'stitute of Me)i"!l 2"ie"es,
Uiversit+ of -#er)ee, -#er)ee
-B2. 2/3
Corres4o)e"e to5 C M *ul+
"!therie&(u l+ 6)o " to rs& o r( &u7
Cite this !s5 BMJ 201083415"49:6
)oi5 10&1136;#$%&"49:6
- full, $u"h lo(er !rti"le,
i"lu)i( sever!l $ore i$!(es
!) <e# refere"es, is o
#$%&"o$&
Uveitis is esti$!te) to !""out for 10= of #li)ess i
4eo> 4le of <or7i( !(e i the ?ester <orl)&
1
-
retros4e"tive revie< of 4!tiets !tte)i( ! uveitis
"lii" i the Uite) 1i()o$ fou) th!t :0= of 4!tiets
h!) visu!l i$4!ir$et @visu!l !"uit+ 6;1A or <orseB !)
h!lf of these 4!tiets h!) #il!ter!l visu!l i$4!ir$et&
2
-"ute !terior uveitis, <hi"h is the $ost "o$$o for$ of
uveitis i the U1, usu!ll+ h!s ! (oo) visu!l out"o$e, #ut
other for$s of uveitis h!ve ! 4oorer visu!l 4ro(osis&
Uveitis is !sso"i!te) <ith $!+ s+ste$i" )ise!ses,
i"lu)> i( s!r"oi)osis, %uveile i)io4!thi" !rthritis,
BehCetDs s+>
2OURCE2 -03 2ELECT'O0 CR'TER'-
?e se!r"he) the Co"hr!e Li#r!r+ usi( the ter$s
Euveitis,F EretiitisF, E"horoi)itisF, !) EiritisF& ?e !lso
se!r"he) Me)lie usi( the s!$e se!r"h ter$s, #ut
li$ite) the se!r"h to !rti"les i E(lish& ?e "osi)ere)
r!)o$ise) "otrolle) tri!ls first, follo<e) #+
4ros4e"tive o>r!)o$ise) tri!ls !) l!r(e
retros4e"tive "!se series&
?e revie<e) EeG4ert o4iioF !rti"les o to4i"s <here
tri!l evi)e"e <!s !#set !) !lso use) our 4erso!l
!r"hives&
Core!
)ro$e, !) ife"tious )ise!ses su"h !s tu#er"ulosis&
For
4!tiets <ith s+ste$i" )ise!se ! $!!(e$et !44ro!"h
th!t ivolves "oll!#or!tio <ith other s4e"i!lties is
i$4ort!t& ' !#out h!lf of "!ses, o s+ste$i" !sso"i!tio
is fou) !) uveitis is 4resu$e) to #e !utoi$$ue&
3
The
itro)u"tio of #iolo(i"!l tre!t$ets for $!+
!utoi$$ue "o)itios, !) itr!vitre!l i%e"tio of
)ru(s for so$e e+e )ise!ses, h!s le) to sever!l of these
tre!t$ets #ei( use) i 4!tiets <ith uveitis, )es4ite
li$ite) evi)e"e fro$ r!)o$ise) tri!ls to su44ort their
use& This revie< )is"usses re"et !)v!"es i the
)i!(osis of uveitis, o"ul!r i$!(i(, !) tre!t$ets& 't
)oes ot "over uveitis i)u"e) #+ o"ul!r sur(er+&
'ris
Cili!r+ #o)+
Choroi)
Reti!
@ier eurosesor+
reti! !) outer
4i($et e4itheliu$B
Les
Vitreous
O4ti" )is"
-terior "h!$#er
2"ler!
Fove!
O4ti" erve
SUMMARY POINTS
What is uveitis and who ets
it!
Uveitis )es"ri#es ! (rou4 of itr!o"ul!r ifl!$$!tor+
)isor> )ers th!t $!+ #e rel!te) to ife"tio or !re o>
ife"tive& The uve! "o$4rises the iris, "ili!r+ #o)+, !)
"horoi)& Uveitis $!+ !ffe"t other tissues i the e+e,
ho<ever, i"lu)i( the reti! @uveoretiitisB, reti!l
#loo) vessels @reti!l v!s"ulitisB, the vitreous @vitritisB,
!) the o4ti" erve @4!4illitisB @fi( 1B&
Uveitis !ffe"ts 4eo4le of !+ !(e, #ut $ost stu)ies
h!ve fou) the hi(hest 4rev!le"e i !)ults of <or7i(
!(e&
<1
Uveitis is )efie) #+ its !!to$i"!l lo"!tio, oset,
)ur!> tio, !) "ourse& BoG 1 outlies ! "l!ssifi"!tio of
uveitis #!se) o "osesus fro$ ! re"et eG4ert
<or7i( (rou4& E-terior uveitisF h!s re4l!"e) the ter$s
iritis @ifl!$$!>
"i # | -!to$+ of the e+e& The iris, "ili!r+ #o)+, !)
"horoi) for$ the uve!l tr!"t
tio of the irisB !) Eiri)o"+"litisF @ifl!$$!tio of the
iris !) "ili!r+ #o)+B&
4
$ow does a %atient with uveitis
%&esent!
-"ute !terior uveitis t+4i"!ll+ 4resets <ith ! 4!i>
ful, 4hoto4ho#i", re) e+e !) #lurre) visio,
<6
!lthou(h 4!tiets $!+ ot h!ve !ll these s+$4to$s !t
the st!rt of ! !tt!"7& The 4re)i"tive v!lue of s+$4to$s
i )i!(os> i( uveitis is u7o< #ut 4hoto4ho#i! is
thou(ht to #e i$4ort!t, !lthou(h it is ot s4e"ifi" for
uveitis !s it is !lso 4ro$iet i "ore!l )ise!se& - sti"7+
or $u"oi) )is"h!r(e is ot fou) i uveitis @#ut is
"o$$o i "o%u"tivitisB&
Co%u"tiv!l i%e"tio @re)essB i !"ute !terior uveitis
Uveitis is ! $!%or "!use of visu!l i$4!ir$et i 4eo4le of <or7i( !(e
H!tiets <ith sus4e"te) uveitis shoul) h!ve ! !ssess$et of visu!l !"uit+ !) !
)il!te) slit l!$4 eG!$i!tio
Chil)re <ith %uveile i)io4!thi" !rthritis shoul) #e s"reee) <ith re(ul!r slit
l!$4 eG!$i!tios to e!#le e!rl+ )ete"tio !) tre!t$et of uveitis
O4ti"!l "ohere"e to$o(r!4h+ is useful for )ete"ti(
!) $oitori( "+stoi) $!"ul!r oe)e$!
'tr!vitre!l tre!t$ets !) #iolo(i"!l !(ets sho< 4ro$ise
i tre!ti( si(ht thre!tei( o>ife"tious uveitis, #ut
tri!l #!se) evi)e"e is li$ite)
CLINICAL REVIEW
5' BMJ | 16 OCTOBER 2010 | VOLUME 341
st!rts, !) is $ost itese, !rou) the e)(e of the "ore! @"ir"u$"ore!lB& ' !
e+e <ith uveitis the 4u4il $!+ #e s$!ller th! o the u!ffe"te) si)e !s
ifl!$$!tio $!+ tri((er $us"le s4!s$ of the iris s4hi"ter& -lter!tivel+, the
4u4il $!+ #e )istorte) #+ 4osterior s+e"hi!e, <hi"h is <here the iris !)heres to
the les& The t!#le lists other "!uses of re) e+e, !lo( <ith their 4reseti(
fe!tures&
Other for$s of uveitis "! 4reset i ! si$il!r <!+ to !"ute !terior uveitis&
Hosterior uveitis, 4!rti"ul!rl+, $!+
BoG 1 | 2t!)!r)ise) o$e"l!ture for uveitisI
-!to$i"!l
J -teriorK4ri$!r+ site of ifl!$$!tio is the !terior "h!$#er
J 'ter$e)i!teK4ri$!r+ site of ifl!$$!tio is the vitreous
J HosteriorK4ri$!r+ site of ifl!$$!tio is the reti! or "horoi)
J H!uveitisKifl!$$!tio i !terior "h!$#er !) vitreous !) reti! or "horoi)
Oset
J 2u))e or isi)ious
3ur!tio
J Li$ite) @L3 $othsB or 4ersistet @M3 $othsB
Course
J -"uteKsu))e oset !) li$ite) )ur!tio
J Re"urretKre4e!te) e4iso)es se4!r!te) #+ 4erio)s of i!"tivit+ <ithout tre!t$et of
N3 $othsD )ur!tio
J Chroi"K4ersistet uveitis <ith rel!4se i O3 $oths !fter )is"otiui( tre!t$et
IFro$ the 2t!)!r)iP!tio of Uveitis 0o$e"l!ture @2U0B ?or7i( *rou4
4
#e #il!ter!l, !) i su"h "!ses 4!tiets $!+ 4reset
<ith <hite e+es !) 4!iless loss of visio& Flo!ters
$!+ #e 4reset if there is ifl!$$!tio i the vitreous&
2o$e t+4es of uveitis, su"h !s uveitis !sso"i!te) <ith
%uveile i)io4!thi" !rthritis, !re $ore isi)ious, !)
su"h 4!tiets !re ofte !s+$4to$!ti"&
What (auses uveitis!
The "!use of uveitis $!+ #e !utoi$$ue, ife"tio
rel!te), )ru( i)u"e), tr!u$!ti", or !sso"i!te) <ith
$!li(!"+ @<he it is 7o< !s the $!sQuer!)e
s+)ro$eB& -#out h!lf of "!ses !re i)io4!thi" !) !re
4resu$e) to #e !utoi$> $ue&
3
BoG 2 sho<s so$e of
the ife"tious "!uses !) s+ste$i" )ise!se
!sso"i!tios&
<: <A
2o$e for$s of "hroi" uveitis h!ve
"h!r!"teristi" fe!tures !) !re (rou4e) to(ether !s uveitis
etitiesKfor eG!$4le, #ir)shot "horioretio4!th+& The
"!uses of uveitis v!r+ !rou) the <orl), <hi"h "! #e
eG4l!ie) 4!rtl+ #+ (eeti" !) eviro$et!l f!"tors& '
! 4ros4e"tive stu)+ of A6. 4!tiets i the 0etherl!)s
uveitis !sso"i!te) <ith RL- B2: #ut <ithout s+ste$i"
)ise!se <!s the $ost "o$$o for$ of uveitis8 s!r"oi)osis
!) seroe(!> tive s4o)+lo!rthro4!thies <ere the $ost
"o$$o s+ste$i" !sso"i!tios8 !) toGo4l!s$osis <!s
the $ost "o$$o ife"tious "!use&
3
R!tes of ife"tious
uveitis, 4!rti"ul!rl+ uveitis !sso"i!te) <ith tu#er"ulosis,
!re hi(her i )evelo4>
i( th! )evelo4e)
"outries&
<14
$ow do %atients with uveitis )ose
vision!
C!uses of visio loss i uveitis i"lu)e "+stoi) $!"ul!r
oe)e$!, "!t!r!"t, se"o)!r+ (l!u"o$!, vitreous
o4!"ities
BoG 2 | 'fe"tios !) s+ste$i" )ise!ses !sso"i!te) <ith
u v e itis
-terior uveitis 0o>
ife"tious 2eroe(!tive
!rthro4!th+ -7+losi(
s4o)+litis ReiterDs
s+)ro$e
'fl!$$!tor+ #o<el )ise!se
Juveile i)io4!thi" !rthritis
2!r"oi)osis
BehCetDs s+)ro$e
'fe"tio rel!te)
Rer4es si$4leG
virus V!ri"ell! Poster
virus Tu#er"ulosis
2+4hilis
'ter$e)i!te uveitis
0o>ife"tious
2!r"oi)osis
Multi4le s"lerosis
L+$4ho$!
Hosterior uveitis !) 4!uveitis
0o>ife"tious
2!r"oi)osis
BehCetDs s+)ro$e
Vo(t>1o+!!(i>R!r!)!
)ise!seI L+$4ho$!
'fe"tio rel!te)
ToGo4l!s$osis
Tu#er"ulosis
C+to$e(!lovirus
2+4hilis
ToGo"!ri!sis
Rer4es si$4leG virus
V!ri"ell! Poster virus
E)o(eous e)o4hth!l$itis
I- $ultis+ste$ ifl!$$!tor+ "o)itio of u7o< "!use
!ffe"ti( the e+es, !u)itor+ s+ste$, $ei(es, !) s7i
@ifl!$$!tor+ "ell )e#ris or vitreous h!e$orrh!(eB,
reti!l v!s"ul!r o""lusios, "horioreti!l s"!rri(,
ifl!$$!tor+ o4ti" euro4!th+, !) reti!l
)et!"h$et&
2
C+stoi) $!"ul!r oe)e$! !) se"o)!r+ "!t!r!"t !re
the le!)i( "!uses of visu!l loss fro$ uveitis i the U1
!) Euro4e&
2 .
C+stoi) $!"ul!r oe)e$! refers to the
for$!>
*i++e&entia) dianosis o+ &ed e,e-t,%i(a) %&esentin s,.%to.s
Pain Redu(ed vision Photo%ho/ia $a)oes *is(ha&e Othe&
-"ute !terior uveitis Mil) to $o)er!te Re)u"e) or or$!l Hreset R!rel+ Te!ri( or !#set
-"ute (l!u"o$! 2evere 2everel+ re)u"e) Hreset or !#set Hreset Te!ri( or !#set Vo$iti(
2"leritis 2evere Re)u"e) or or$!l -#set -#set -#set
E4is"leritis Mil) or !#set 0or$!l -#set -#set -#set *ritt+
Core!l ul"er #!"teri!l Mo)er!te Re)u"e) or or$!l Hreset -#set Hurulet
Rer4es si$4leG 7er!titis Mo)er!te Re)u"e) or or$!l Hreset -#set ?!ter+
Core!l erosio Mo)er!te Re)u"e) or or$!l Hreset -#set Te!ri(
B!"teri!l "o%u"tivitis -#set 0or$!l -#set -#set Hurulet *ritt+
Vir!l "o%u"tivitis -#set 0or$!l -#set -#set ?!ter+ *ritt+
-ller(i" "o%u"tivitis -#set 0or$!l -#set -#set Mu"oi) or !#set 't"h
CLINICAL REVIEW
'f ife"tio rel!te) uveitis or $!li(!"+ is sus4e"te),
l!#or!tor+ eG!$i!tio of ! !Queous or vitreous
s!$4le usi( $ole"ul!r te"hiQues "! #e useful i
$!7i( ! )i!(osis !) (ui)i( tre!t$et&
<1: <1A
"i 0 | Hosterior s+e"hi!e& The iris !)heres to the les
ifero!s!ll+ @!rro<B, "!usi( )istortio of the
@4h!r$!"olo(i"!ll+ )il!te)B 4u4il& Hosterior s+e"hi!e $!+
ot #e !44!ret util the 4u4il is )il!te)& Hu4il )il!tio <ill
o f te # r e ! 7 t h e s + e " h i!e
tio of oe or $ore flui) fille) "+stoi) s4!"es i the
fove!l or 4erifove!l re(ios of the reti! !) $!+
"o$4li"!te !ll for$s of uveitis, i"lu)i( !terior
uveitis&
*l!u"o$! $!+ #e se"o)!r+ to steroi) tre!t$et or
the result of o"ul!r ifl!$$!tio& Chorioreti!l
s"!rri( !t the $!"ul! "! o""ur <he ! !#or$!l
4rolifer!tio of "horoi)!l #loo) vessels for$s !
"horoi)!l eov!s"ul!r $e$#r!e& These "h!(es !re
si$il!r to those o#serve) i the E<etF for$ of !(e rel!te)
$!"ul!r )e(eer!tio&
' ! retros4e"tive stu)+ of ! "ohort of 4!tiets !t !
)istri"t (eer!l hos4it!l, !"ute !terior uveitis h!) the
lo<est ris7 of visu!l loss, <ith 91= of 4!tiets ret!ii(
or$!l visu!l !"uit+ @6;9 or #etterB&
6
H!uveitis "!rries
the (re!test ris7 of visu!l i$4!ir$et&
2
$ow is uveitis dianosed!
The )i!(osis of uveitis is "ofir$e) <ith ! slit l!$4
eG!$i> !tio& - (eer!list "! !ssess the 4!tietDs
visu!l !"uit+, loo7 for "ir"u$"ore!l i%e"tio, !)
eG!$ie the eGter> !l e+e <ith ! )ire"t
o4hth!l$os"o4e @! S10 les (ives ! $!(ifie) vie<B&
Ur(et referr!l to ! s4e"i!list is ee)e) for further
!ssess$et, <hi"h i"lu)es $e!sure$et of
itr!o"ul!r 4ressure !) ! slit l!$4 eG!$i!tio to
)il!te the 4u4il @fi( 2B&
$ow is the (ause o+ uveitis
identi+ied!
- )et!ile) s+ste$i" histor+ !) ! full 4h+si"!l eG!$i!>
tio is ee)e) to est!#lish <hether uveitis is isol!te) or
4!rt of ! $ultis+ste$ )isor)er& '$$ue st!tus shoul)
#e "osi)ere) !s i$$uosu44resse) 4!tiets !re
4!rti"u> l!rl+ !t ris7 of ife"tio rel!te) uveitis&
2+ste$i" ivesti(!tios shoul) #e )ire"te) !t the
li7el+ "!use of uveitis !) !re (ui)e) #+ the histor+, the
4!tter of o"ul!r ifl!$$!tio @#oG 2B, s+ste$i" si(s,
!) the lo"!l 4!tiet 4o4ul!tio& For eG!$4le, for !
!)ult 4!tiet 4reseti( <ith ! uil!ter!l !terior
uveitis, it <oul) #e i$4ort!t to !s7 !#out s+$4to$s
su"h !s #!"7 4!i, %oit 4!is, stiffess, )i!rrhoe!, !)
$outh ul"ers th!t $i(ht li7 uveitis <ith ! )ise!se
!sso"i!te) <ith RL- B2:& - !)ult 4!tiet <ith ! si(le
!tt!"7 of !"ute !terior
uveitis !) o si(s or
s+$4to$s of s+ste$i"
)ise!se $!+ ot ee) !+
further ivesti(!tios, !)
the v!lue of routie RL-
B2: testi( i this setti(
is ot "le!r&
<16
CLINICAL REVIEW
$ow does o(u)a& i.ain he)%!
O"ul!r i$!(i( is use) to !ssess the site !) severit+ of ifl!$$!tio i the
4osterior se($et of the e+e !) to $oitor the res4ose to tre!t$et& Fu)us
fluores"ei !(io(r!4h+ is 4erfor$e) #+ (ivi( ! itr!veous i%e"> tio of )+e !)
t!7i( seri!l reti!l i$!(es to sho< reti!l v!s"ulitis !) reti!l !) "horoi)!l )ise!se
@fi( 3B& O4ti"!l "ohere"e to$o(r!4h+ is ! o>iv!sive te"holo(+ th!t uses lo<
"ohere"e iterfero$etr+ to 4ro)u"e hi(h resolu> tio, "ross se"tio!l i$!(es of the
reti!& 't $!+ #e use) to i)etif+ "+stoi) $!"ul!r oe)e$! !) "! 4rovi)e !
o#%e"tive $e!sure of reti!l thi"7ess @fi( 4B&
<20
What a&e the ene&a) %&in(i%)es o+ t&eatin uveitis!
The $!!(e$et of uveitis is )eter$ie) #+ <hether uveitis is rel!te) to ife"tio
or is o>ife"tive !) #+ the li7elihoo) of ! thre!t to si(ht&
:
Most 4!tiets <ith !"tive
uveitis !) !ll those <ith !"ute !terior uveitis ee) tre!t> $et& Tre!t$et is ot
ee)e) for so$e for$s of "hroi"
"i 3 | Choroi)!l eov!s"ul!r $e$#r!e i ! uveitis etit+ 7o< !s ser4i(ious
"horoi)o4!th+& The "horoi)!l eov!s"ul!r $e$#r!e "! #e see !s ! (re+ lesio @!rro<sB
<ith ! !)%!"et h!e$orrh!(e o the reti!l 4hoto(r!4h @-B #ut is e!sier to see o the
fluores"ei !(io(r!$ @BB, <here
it is ! <hite "olour #e"!use it fills <ith fluores"ei )+e& The o#liQue sh!)o< is ! $!r7er th!t
4oits to the fove!, !)
the "lose 4roGi$it+ of the "horoi)!l eov!s"ul!r $e$#r!e to the fove! $!7es this ! si(ht
thre!tei( lesio& -tro4h+ of the reti! !) "horoi) !rou) the o4ti" )is" @"!use) #+
4revious ifl!$$!tioB !44e!rs +ello< !) 4i($ete) o the 4hoto(r!4h #ut )!r7 o the
fluores"ei !(io(r!$ #e"!use it is ot 4erfuse) <ith )+e
e!se !) <ith ! "o$#i!tio of s+ste$i" !) itr!vitre!l
tre!t$et i e)o(eous e)o4hth!l$itis& Ro<ever,
the i$$ue res4ose to the ife"tio is thou(ht to #e
4!rtl+ res4osi#le for the ifl!$$!tio !) for the
result!t o"ul!r )!$!(e !) visu!l loss& 't is for this
re!so th!t to4i"!l !) s+ste$i" steroi)s !re ofte use)
to su44ress ifl!$$!tio i 4!tiets <ith ife"tio
rel!te) uveitis
:
!) <h+ i so$e ist!"es uveitis
4ersists !fter the ife"> tio h!s #ee tre!te)& To4i"!l
steroi)s shoul) #e use) <ith "!re i e+es <ith her4es
si$4leG uveitis #e"!use of the ris7 of eG!"er#!tio of
"ore!l e4itheli!l )ise!se&
Uveitis !sso"i!te) <ith toGo4l!s$osis
- Co"hr!e revie< of !ti#ioti" tre!t$et for o"ul!r
toGo> 4l!s$osis re4orte) ! l!"7 of evi)e"e for routie
!ti> #ioti" tre!t$et for !"ute toGo4l!s$!
retio"horoi)itis
A
#ut there <ere o tri!ls ev!lu!ti(
$o)er !ti#ioti" re(i$es&
"i ' | O4ti"!l "ohere"e to$o(r!4h+ of the $!"ul!, "etre) o the fove! sho<i( @-B "+stoi)
$!"ul!r oe)e$! !) @BB resolutio !fter s+ste$i" tre!t$et& The horiPot!l lie o the left h!)
4i"ture sho<s <here the "ross se"tio!l i$!(e h!s #ee t!7e& The fove! @!rro<B is or$!ll+
thier th! the rest of the reti!, #ut <ith "+stoi) $!"ul!r oe)e$! the or$!l !r"hite"ture is
lost !) flui) fille) "+sts @!rro< he!) ti4B )istort the reti!
uveitis if the ifl!$$!tio is ot "osi)ere) to #e si(ht
thre!tei(& The !i$ of tre!t$et is r!4i) resolutio of
o"ul!r ifl!$$!tio <ith restor!tio of visio& 't is
i$4or> t!t to "hoose the )ru( !) route of )eliver+ to
esure 4eetr!tio to the site of the o"ul!r
ifl!$$!tio&
Whi(h t&eat.ents a&e used +o& non1in+e(tive a(ute
ante&io& uveitis!
To4i"!l steroi)s
- t!4eri( "ourse of to4i"!l steroi)s h!s #ee the st!)>
!r) tre!t$et of !"ute !terior uveitis si"e the 19.0s,
!lthou(h ! s+ste$!ti" revie< fou) little evi)e"e to
su44ort su"h )ru(s for !terior uveitis&
9
- r!)o$ise)
"otrolle) tri!l @RCTB fou) th!t the use of 4re)isoloe
!"et!te 1= e+e )ro4s is !sso"i!te) <ith resolutio of
s+$4to$s !) si(s of !"ute !terior uveitis i A0>90=
of 4!tiets !t four <ee7s&
10
Herio"ul!r steroi) i%e"tios or
s+ste$i" "orti"osteroi)s !re use) i severe "!ses of !"ute
!terior uveitis !) to tre!t "+stoi) $!"ul!r oe)e$!&
3il!tio of the 4u4il
0o evi)e"e eGists to su44ort $+)ri!ti" use i uveitis,
#ut st!)!r) 4r!"ti"e is to )il!te the 4u4il i the !"ute
4h!se <ith ! $+)ri!ti" !(et su"h !s "+"lo4etol!te or
!tro4ie e+e )ro4s to tr+ !) #re!7 !+ 4osterior
s+e"hi!e th!t h!ve for$e), re)u"e the for$!tio of
e< 4osterior s+> e"hi!e, !) !llevi!te )is"o$fort&
- H-T'E0TD2 HER2HECT'VE
$ow is in+e(tion &e)ated uveitis
t&eated!
' ife"tio rel!te) uveitis the 4riorit+ is to tre!t the
u)erl+i( ife"tio, <ith s+ste$i" tre!t$et i the
"!se of ife"tios su"h !s tu#er"ulosis, s+4hilis, !)
L+$e )is>
Whi(h t&eat.ents a&e used +o& (h&oni( non1
in+e(tive uveitis!
Lo"!l tre!t$ets
Corti"osteroi)s $!+ #e )elivere) to4i"!ll+ !s e+e )ro4s,
lo"!ll+ !s 4erio"ul!r or itr!vitre!l i%e"tios, or !s !
itr!vitre!l i$4l!t& Corti"osteroi)s ee) to #e use) <ith
E' !$ ! .0 +e!r ol) <o$!& M+ uveitis st!rte) 22 +e!rs !(o, <he ' <o7e u4 <ith ! 4!iful
re) e+e& The )o"tor s!i) it <!s ! ife"tio #ut the e+e (ot <orse !) evetu!ll+ ' <!s
referre) to the hos4it!l, <here the+ tol) $e ' h!) uveitis& The+ (!ve $e i%e"tios of
steroi) ito the e+e, <hi"h "!l$e) thi(s )o<, #ut it fl!re) u4 !(!i & & & ' <!s (ive $ore
i%e"tios of steroi) #ut the ' )evelo4e) ! "!t!r!"t& -fter the "!t!r!"t sur(er+ ' <et #li)
i th!t e+e&
E- fe< +e!rs l!ter ' (ot uveitis i the other e+e& ' <!s referre) to -#er)ee !) st!rte) o
"i"los4ori, <hi"h <or7e) for $!+ +e!rs #ut the st!rte) to iterfere <ith $+ 7i)e+s,
!) ' h!) to #e "h!(e) to $+"o4heol!te& -t the $illeiu$ ' )evelo4e) o4ti" euritis
!) $ulti4le s"lerosis !) <!s h!vi( )iffi"ult+ <ith $+ <or7 !s ! 4ri$!r+ s"hool
te!"her& ' <!s (ive ! s"ri#e !) s$!ller "l!ssesKth!7 (oo)ess for the 3is!#ilit+
3is"ri$i!tio -"t&
EM+ visio h!s #ee (etti( <orse re"etl+, #ut ' h!) #ee 4utti( off "!t!r!"t sur(er+ !s '
<!s terrifie) of losi( the visio i $+ ol+ e+e& ' h!) the
o4er!tio +ester)!+ !) to)!+ ' "! see so$e letters o the
T2elleU "h!rt !(!i& 'f $+ visio st!+s li7e this ' "!
$!!(e&F
0ote5 The 4!tietDs visu!l !"uit+ h!) i$4rove) fro$ E"out
fi(ersF @<orse th! 6;60B to 6;1A
"!re #e"!use of the !sso"i!te) "o$4li"!tios, rel!te) to
the )ose !) )ur!tio of tre!t$et, <hi"h i"lu)e r!ise) itr!o"ul!r 4ressure !)
for$!tio of "!t!r!"t&
0o>r!)o$ise) itervetio!l stu)ies
<40 <41
!)
retros4e"tive "!se series
<42
fou) th!t itr!vitre!l "orti"osteroi) i%e"tios
<ere !sso"i!te) <ith ! si(ifi> "!t short ter$ i$4rove$et i visu!l !"uit+, #ut
the te$4or!r+ tre!t$et effe"t li$its their usefuless for tre!ti( "hroi"
uveitis&
11
- r!)o$ise) 4ros4e"tive stu)+ fou) th!t ! fluo> "ioloe !"etoi)e
"orti"osteroi) i$4l!t sur(i"!ll+ i$4l!te) ito the vitreous "!vit+ !"hieve)
#etter "o> trol of o"ul!r ifl!$$!tio th! s+ste$i" steroi)s !) o>#iolo(i"!l
i$$uosu44ressive !(ets, #ut of the
TOH'C2 FOR FURTRER RE2E-RCR
J Clii"!l effi"!"+, s!fet+, !) "ost effe"tiveess of itr!vitre!l tre!t$ets !)
#iolo(i"!l !(ets for uveitis
J The t!r(ete) !44ro!"hKi)etif+i( !) 4re"isel+ t!r(eti( the i$$ue
$e)i!tors res4osi#le for )ifferet for$s of uveitis
J Me!sures of effi"!"+ for "lii"!l tri!lsKsi(le or "o$4osite e) 4oitsV
J Use of o>iv!sive o"ul!r i$!(i( to 4rovi)e o#%e"tive !) re4ro)u"i#le $e!sures
of )ise!se !"tivit+
J '$4rove) )i!(osti" $etho)s for )ete"ti( ife"tious uveitis
-33'T'O0- L E3UC - T'O0- L R E 2 O U R C E 2
For he!lth 4rofessio!ls
J J!#s 3-, Rose#!u$ JT, Foster C2, Roll!) *0, J!ffe *J, Louie J2, et !l& *ui)elies
for the use of i$$uosu44ressive )ru(s i 4!tiets <ith o"ul!r ifl!$$!tor+
)isor)ers5 re"o$$e)!tios of ! eG4ert 4!el& Am J Ophthalmol 200081305492>
.13&
J '$rie FR, 3i"7 -& Biolo(i"s i the tre!t$et of uveitis& Curr Opin Ophthalmol
200:81A54A1>6&
J 1h! --, 1ell+ RJ, C!rri$ /'& -"ute !terior uveitis& BMJ 200983395#29A6&
For 4!tiets
J Uveitis 'for$!tio *rou4 @<< < &u v e itis & e tBKH!tiet le) or(!is!tio th!t h!s li7s
<ith o4hth!l$olo(ists& The (rou4 rus ! ifor$!tive <e#site !) 4ro)u"es ! $!(!Pie
@UveitisB for 4!tiets !) "lii"i!s
J Bir)shot Uveitis 2o"iet+ @<< < &# ir) s h o t&o r( &u 7 BK-ffili!te) to the Uveitis 'for$!tio
*rou4, this is ! su44ort (rou4 for 4!tiets <ith #ir)shot "horioretio4!th+
J BehCetDs 2+)ro$e 2o"iet+ @<< < &# e h " e ts &o r( &u 7 BKHrovi)es su44ort !) ifor$!tio
o !ll !s4e"ts of BehCetDs s+)ro$e, i"lu)i( uveitis
J Ro+!l 0!tio!l 'stitute of Bli) Heo4le @<< < &r i# &o r( &u 7 BK?or7s to e!#le 4eo4le
<ith si(ht loss to live their lives i)e4e)etl+
e+es <ith ! i$4l!t th!t st!rte) the tri!l <ith ! !tur!l
les, $ost @AA=B <et o to h!ve "!t!r!"t sur(er+ !)
21= reQuire) (l!u"o$!
sur(er+&
12
Bev!"iPu$!# !) r!i#iPu$!# !re v!s"ul!r
e)otheli!l (ro<th f!"tor ihi#itors th!t h!ve #ee use)
!s itr!vit> re!l i%e"tios for uveitis !fter their su""ess
i tre!ti( "horoi)!l eov!s"ul!r $e$#r!es
!sso"i!te) <ith !(e rel!te) $!"ul!r )e(eer!tio&
0either )ru( is li"ese) for use i uveitis, !) ol+
r!i#iPu$!# is li"ese) for tre!ti( !(e rel!te)
$!"ul!r )e(eer!tio& - "lii"!ll+ si(ifi"!t
i$4rove$et i visu!l !"uit+ <!s re4orte) i ! l!r(e
retros4e"tive series of 4!tiets <ith ifl!$> $!tor+
"horoi)!l eov!s"ul!r $e$#r!es tre!te) <ith
#ev!"iPu$!#,
13
The tre!t$et effe"ts of itr!vitre!l
)ru(s !re tr!siet, e"essit!ti( re4e!te) i%e"tios&
E!"h i%e"tio "!rries ! s$!ll #ut !))itive ris7 of
visu!l loss fro$ "o$4li"!tios su"h !s
e)o4hth!l$itis, "!t!r!"t, !) reti!l )et!"h$et&
2+ste$i" steroi)s !) i$$uosu44ressio
'ter!tio!l (ui)elies for the use of i$$uosu44res>
sive )ru(s i 4!tiets <ith o"ul!r ifl!$$!tor+
)isor)ers <ere 4u#lishe) i 2000&
14
Curretl+, o
li"ese) i$$uo> su44ressive tre!t$ets !re !v!il!#le
for uveitis&
The (ui)elies re"o$$e) "orti"osteroi)s !s the first
lie s+ste$i" tre!t$et for 4!tiets <ith si(ht thre!te>
i( uveitis& 2+ste$i" "orti"osteroi)s !re usu!ll+ st!rte)
!t ! hi(h )ose !) the t!4ere)& 2+ste$i" i$$uosu4>
4ressio $!+ #e st!rte) for
4!tiets <ho h!ve 4oorl+
"o> trolle) o"ul!r
ifl!$$!tio <ith
s+ste$i" steroi)s or for
4!tiets i <ho$ o"ul!r
ifl!$$!tio h!s
re"urre) o re)u"i( the
steroi) )ose&
'$$uosu44ressive
tre!t$et
is #e(u e!rl+ i the tre!t$et of "ert!i )ise!sesKfor eG!$4le, 4osterior )ise!se or
4!uveitis !sso"i!te) <ith BehCetDs s+)ro$e, i <hi"h visu!l out"o$es h!ve #ee
sho< to #e 4oor <ith "orti"osteroi)s !loe&
14
2$!ll RCTs of !P!thio4rie, "i"los4ori, !) t!"roli$us !) l!r(e retros4e"tive series
of 4!tiets t!7i( $+"o4he> ol!te $ofetil !) $ethotreG!te h!ve re4orte) #eefit
fro$ these )ru(s i the "otrol of o"ul!r ifl!$$!tio !) the 4reserv!tio or
restor!tio of si(ht i uveitis&
1.>19 <4.
Biolo(i"!l !(ets
Biolo(i"!l !(ets h!ve re"etl+ #ee itro)u"e) for 4!tiets <ho h!ve ot
res4o)e) to tre!t$et <ith s+ste$i" steroi)s !) oe or $ore of the
"ovetio!l i$$uosu44ressive !(ets& Ro<ever, the fi)i(s of ! retros4e"tive
stu)+
20
su44ort ! (ro<i( o4iio !$o( eG4erts
21
th!t e!rl+ use of #iolo(i"s i
4!tiets <ith severe, si(ht thre!tei( o"ul!r ifl!$$!tio $!+ 4re> vet si(ht loss
$ore effe"tivel+ th! <he these !(ets !re use) !s ! l!st resort&
'fliGi$!# !) !)!li$u$!# !re tu$our e"rosis f!"tor W ihi#itors th!t h!ve #ee
sho< i s$!ll, 4ros4e"tive, o>r!)o$ise) stu)ies to "otrol o"ul!r ifl!$$!tio
i !)ults !) "hil)re <ith uveitis th!t is refr!"tor+ to other i$$uosu44ressive
!(ets&
22 23
'terfero W h!s #ee use) <ith ot!#le su""ess i BehCetDs s+)ro$e,
<ith "otrol of o"ul!r ifl!$$!tio !"hieve) i 92= of 4!tiets i oe o>
r!)o$ise) tri!l,
24
!) h!s #ee sho< to #e effe"tive i uveiti" "+stoi) $!"ul!r
oe)e$! i t<o o>r!)o$ise) tri!ls&
2. 26
What a&e the &is2s o+ i..unosu%%&essive t&eat.ent +o& uveitis!
3!t! o the ris7 of ife"tio <ith lo( ter$ i$$uosu4> 4ressio for uveitis !re
li$ite), #ut re4orte) tri!ls !) "!se series see$ to sho< th!t the ris7 of serious
ife"tios is lo<&
1.>19 22> 26 <4. <..><.:
Most "o$$ol+ use) i$$uo> su44ressive )ru(s
)i) ot i"re!se over!ll $ort!lit+ or "!"er rel!te) $ort!lit+ i ! l!r(e
retros4e"tive "ohort stu)+ of 4!tiets <ith o"ul!r ifl!$$!tor+ )ise!se&
2:
?hether tu$our e"rosis f!"tor ihi#itors i"re!se $or> t!lit+ or "!rr+ ! ris7 of
eo4l!si! i 4!tiets <ith o"ul!r ifl!$$!tio is ot "le!r&
2:
Can su&e&, (an he)%!
O"ul!r sur(er+ $!+ #e i)i"!te) (a) to o#t!i o"ul!r s!$> 4les for )i!(osti" 4ur4oses,
(b) to !llo< visu!l reh!#ili> t!tio throu(h "!t!r!"t or vitre"to$+ sur(er+, !) (c) for
4reserv!tio of visio i uveiti" (l!u"o$!&
Whi(h %atients shou)d /e s(&eened +o& uveitis!
Chil)re <ith %uveile i)io4!thi" !rthritis shoul) #e s"reee) for uveitis <ith
re(ul!r slit l!$4 eG!$i!tios& Best 4r!"ti"e (ui)elies for s"reei( <ere issue)
%oitl+ #+ the Ro+!l Colle(e of O4hth!l$olo(ists !) the British 2o"i> et+ for H!e)i!tri"
!) -)oles"et Rheu$!tolo(+ i 2006&
2A
?e th!7 the 4!tiets <ho "otri#ute) to this !rti"le8 the o4hth!l$i" 4hoto(r!4hers Vi"tor Be!ttie !)
To+ Johsto !t -#er)ee Ro+!l 'fir$!r+8 !) Chee Che(, <ho !ssiste) <ith the o"ul!r i$!(es&
Cotri#utors5 Both !uthors 4l!e) the revie<& CM* )i) the liter!ture se!r"hes !) <rote the first )r!ft& Both
!uthors revie<e) the liter!ture !) "otri#ute) to the fi!l )r!ft& CM* is the (u!r!tor&
/.34(o. a&(hive
Hrevious !rti"les i this
series
5 Chroi" 4elvi" 4!i i
<o$e
@BMJ 20108 3415"4A34B
5 Re!) !) e"7
"!"erKH!rt 2
@BMJ 201083415"4690B
5 Re!) !) e"7
"!"erKH!rt 1
@BMJ 201083415"46A4B
5 3i!(osis !)
$!!(e$et of B!rrettDs
oeso4h!(us
@BMJ 201083415"4..1B
5 M!!(i( !!e$i! i
"riti"!ll+ ill !)ults
@BMJ 201083415"440AB
Co$4eti( iterests5 -ll !uthors h!ve "o$4lete) the Uifie) Co$4eti(
'terest for$ !t h tt 4 5;;<< < &i" $ %e &o r( ;" o iX ) is " lo s u re &4) f @!v!il!#le o
reQuest fro$ the "orres4o)i( !uthorB !) )e"l!re th!t @1B the !uthors
h!ve o fi!"i!l su44ort for the su#$itte) <or78 @2B JVF )oes
"osult!"+ for -##ott !) is )ue to 4!rti"i4!te i ! rese!r"h tri!l
ivolvi( !)!li$u$!#8 @3B their s4ouses, 4!rters, or "hil)re h!ve o
fi!"i!l rel!tioshi4s th!t $!+ #e relev!t to the su#$itte) <or78 !)
@4B the !uthors h!ve o o>fi!"i!l iterests th!t $!+ #e relev!t to
the su#$itte) <or7&
Hrove!"e !) 4eer revie<5 0ot "o$$issioe)8 eGter!ll+ 4eer
revie<e)&
H!tiet "oset o#t!ie)&
1 2uttor4>2"hulte M2, Rothov! -& The 4ossi#le i$4!"t of
uveitis i #li)ess5 ! liter!ture surve+& Br J Ophthalmol
19968A05A44>A&
2 3urr!i OM, Tehr!i 00, M!rr JE, Mor!)i H, 2t!vrou H, Murr!+ H'&
3e(ree, )ur!tio !) "!uses of visu!l loss i uveitis& Br J Ophthalmol
20048AA511.9>62&
3 Rothov! -, Buitehuis RJ, Mee7e C, Bri7$! CJ, Lisse -,
-l#erts C, et !l& Uveitis !) s+ste$i" )ise!se& Br J Ophthalmol
19928:6513:>41&
4 2t!)!r)iP!tio of Uveitis 0o$e"l!ture @2U0B ?or7i( *rou4&
2t!)!r)iP!tio of uveitis o$e"l!ture for re4orti( "lii"!l
)!t!& Results of the first iter!tio!l <or7sho4& Am J
Ophthalmol
200.81405.09>16&
. Rothov! -, 2uttor4>v! 2"hulte M2, Frits Treffers ?, 1i%lstr! -&
C!uses !) freQue"+ of #li)ess i 4!tiets <ith o"ul!r
ifl!$$!tor+ )ise!se& Br J Ophthalmol 19968A05332>6&
6 M!ii R, OD2ulliv! J, Re))+ -, ?!tso 2, E)elsto C& The ris7 of
"o$4li"!tios of uveitis i ! )istri"t hos4it!l "ohort& Br J
Ophthalmol
20048AA5.12>:&
: 3i"7 -3, O7!)! --, Forrester JV& Practical manual of
intraocular inflammation& 'for$! Re!lth"!re, 200A&
A *il#ert RE, R!r)e M, 2t!for) M& -ti#ioti"s versus "otrol
for toGo4l!s$! retio"horoi)itis& Cochrane Database Syst
ev
2002815C300221A&
9 'sl!$ 0, H!vesio C& Uveitis @!"ute !teriorB& BMJ Clin !vi" 200:8125:0.&
10 Lote4re)ol Et!#o!te U2 Uveitis 2tu)+ *rou4& Cotrolle)
ev!lu!tio of lote4re)ol et!#o!te !) 4re)isoloe !"et!te i
the tre!t$et of !"ute !terior uveitis& Am J Ophthalmol
1999812:5.3:>44&
11 V! 1ooi% B, Rothov! -& The 4ros !) "os of itr!vitre!l
tri!$"ioloe i%e"tios for uveitis !) ifl!$$!tor+ "+stoi)
$!"ul!r oe)e$!& Ocul #mmunol #nflamm 20068145:3>A.&
12 H!vesio C, /ierhut M, B!iri 1, Co$sto"7 TL, User 3?& Ev!lu!tio of !
fluo"ioloe !"etoi)e steroi) i$4l!t versus st!)!r) s+ste$i"
ther!4+ i oife"tious 4osterior uveitis& Ophthalmolo$y
2010811:5.6:>:.&
13 M!sour -M, -rel!vo JF, /ie$sse F, Mehio>2i#!i -, M!"7ese F,
-)!
-& Lo( ter$ visu!l out"o$es of itr!vitre!l #ev!"iPu$!# i
ifl!$$!tor+ o"ul!r eov!s"ul!ris!tio& Am J Ophthalmol
2009814A5310>6&
14 J!#s 3-, Rose#!u$ JT, Foster C2, Roll!) *0, J!ffe *J, Louie J2, et
!l&
*ui)elies for the use of i$$uosu44ressive )ru(s i 4!tiets <ith
o"ul!r ifl!$$!tor+ )isor)ers5 re"o$$e)!tios of ! eG4ert 4!el&
Am J Ophthalmol 200081305492>.13&
1. Y!Pi"i R, H!P!rli R, B!res C*, TZPZ Y, OP+!P(! Y, 2il$! -, et !l& -
"otrolle) tri!l of !P!thio4rie i BehCetDs s+)ro$e& % !n$l J Me"
1990832252A1>.&
16 0usse#l!tt RB, H!lestie -*, Ch! CC, 2te4hes * Jr, Mello< 23,
*ree 2B& R!)o$iPe), )ou#le>$!s7e) stu)+ of "+"los4orie
"o$4!re) to 4re)isoloe i the tre!t$et of e)o(eous uveitis&
Am J Ophthalmol
19918112513A>46&
1: Mur4h+ CC, *reier 1, Hls7ov! J, 3u"! L, Frost 0-, Forrester JV, et !l&
C+"los4orie vs t!"roli$us ther!4+ for 4osterior !) iter$e)i!te uveitis&
Arch Ophthalmol 200.81238634>41&
1A 3!iel E, Thore JE, 0e<"o$# C?, Hu%!ri 22, 1!C$!P RO, Lev+>
Cl!r7e *-, et !l& M+"o4heol!te $ofetil for o"ul!r ifl!$$!tio& Am
J Ophthalmol
201081495423>32&
19 *!(!4utr! 2, 0e<"o$# C?, Liese(!( TL, 1!C$!P RO, J!#s 3-,
Lev+> Cl!r7e *-& MethotreG!te for o"ul!r ifl!$$!tor+ )ise!ses&
Ophthalmolo$y
20098116521AA>9A&
20 Y!$!)! Y, 2u(it! 2, T!!7! R, 1!$oi 1, 1!<!(u"hi T, Mo"hiPu7i M&
Co$4!riso of ifliGi$!# versus "i"los4ori )uri( the iiti!l 6>
$oth tre!t$et 4erio) i BehCet )ise!se& Br J Ophthalmol
201089452A4>A&
21 Lee R?J, 3i"7 -33& Tre!t e!rl+ !) e$#r!"e the evi)e"e i f!vour
of !ti> T0F>W ther!4+ for Beh"etDs uveitis& Br J Ophthalmol
20108945269>2:0&
22 3i!P>Llo4is M, *!r"[!>3el4e"h 2, 2!lo$ 3, U)!o)o H, Rer\)eP>
*!rfell! M, Bos"h>Morell F, et !l& -)!li$u$!# ther!4+ for refr!"tor+
uveitis5 ! 4ilot stu)+& J Ocul Pharmacol &her 200A82453.1>61&
23 2uhler EB, 2$ith JR, *iles TR, L!uer -1, ?erthei$ M2, 1urP 3E, et !l&
'fliGi$!# ther!4+ for refr!"tor+ uveitis5 2>+e!r results of ! 4ros4e"tive
tri!l&
Arch Ophthalmol 2009812:5A19>22&
24 1]tter ', /ierhut M, E"7stei -1, Vothei R, 0ess T, *Z!+)i ', et !l&
Ru$! re"o$#i!t iterfero !l4h!>2! for the tre!t$et of BehCetDs
)ise!se <ith si(ht thre!tei( 4osterior or 4!uveitis& Br J Ophthalmol
20038A:5423>31&
2. Hls7ov! J, *reier 1, Forrester JV& 'terfero>W !s ! effe"tive
tre!t$et for o>ife"tious 4osterior uveitis !) 4!uveitis& Am J
Ophthalmol
200:81445..>61&
26 3euter CME, 1oett! ', *ue!+)i ', 2tue#i(er 0, /ierhut M& 'terfero
!l4h!
2>-5 ! e< tre!t$et o4tio for lo( l!sti( refr!"tor+ "+stoi)
$!"ul!r e)e$! i uveitis& - 4ilot stu)+& etina 20068265:A6>91&
2: 1e$4e JR, 3!iel E, 3u JH, Foster C2, *!(!4utr! 2, R!ish -, et !l&
Over!ll !) "!"er rel!te) $ort!lit+ i 4!tiets <ith o"ul!r
ifl!$$!tio tre!te) <ith i$$uosu44ressive )ru(s5 retros4e"tive
"ohort stu)+& BMJ
200983395#24A0&
2A Ro+!l Colle(e of O4hth!l$olo(ists, British 2o"iet+ for H!e)i!tri"
!) -)oles"et Rheu$!tolo(+& *ui)elies for s"reei( for uveitis i
%uveile i)io4!thi" !rthritis @J'-B& 2006&
<< < &r" o 4h th& ! " &u 7 ; ) o " s ; 4 u # li" ! tio s ; Juveile-rthritis&4)f&
-""e4te)5 : 2e4te$#er 2010
ANS WE R S TO E N *6A M ES 7 % 8394 For lo( !s<ers (o to the E)u" !tio "h!el o
#$%&"o$
C - 2E REHORT -#)o$i!l 4!i !) )i!rrhoe! i ! tee!(er
1 3iffereti!l )i!(oses to #e "osi)ere) !re ifl!$$!tor+ #o<el )ise!se, "oeli!" )ise!se, Me"7elDs
)iverti"ulu$, ife"tio, solit!r+ re"t!l ul"er, !ller(i" "olitis, itussus"e4tio, !) "osti4!tio <ith
overflo< !) "o"urret !!l fissure& The $ost li7el+ )i!(osis is ifl!$$!tor+ #o<el )ise!se !), i this
"!se, CrohDs )ise!se&
2 *ro<th f!ilure, leth!r(+, 4u#ert!l )el!+, !rthro4!th+, 4s+"hi!tri" )istur#!"es, !) !use! <ith or <ithout
vo$iti( !re !ll fou) i ifl!$$!tor+ #o<el )ise!se& EGtr!itesti!l $!ifest!tios su"h !s er+the$!
o)osu$ !) 4+o)er$! (!(reosu$ !re fou) i #oth ul"er!tive "olitis !) CrohDs )ise!se& Li4
s<elli(, $outh ul"ers, !) orof!"i!l (r!ulo$!tosis, !lo( <ith 4eri!!l )ise!se @s7i t!(s, fissures,
fistul!s, !) !#s"essesB, !re !lso fou) i CrohDs )ise!se&
3 Chil)re 4reseti( <ith these s+$4to$s shoul) h!ve ! full #loo) "out8 tests for er+thro"+te
se)i$et!tio r!te, seru$ ure!, seru$ "re!tiie, !) seru$ !l#u$i8 !) ! "oeli!" s"ree& -ll "hil)re
sus4e"te) of h!vi( ifl!$$!tor+ #o<el )ise!se shoul) u)er(o u44er !) lo<er (!stroitesti!l
e)os"o4+ <ith #io4sies t!7e !t !ll levels irres4e"tive of the 4rese"e or !#se"e of s+$4to$s i the
u44er (!stroitesti!l tr!"t& '$!(i( of the s$!ll #o<el shoul) !lso #e "osi)ere) i !ll "hil)re <ith
CrohDs )ise!se !) i
those i <ho$ ! )i!(osis
of ul"er!tive "olitis is
u"ert!i& R!)io(r!4h+
<ith s$!ll #o<el follo<
throu(h is the $ost
"o$$ol+ use) i$!(i(
te"hiQue8 ho<ever, <hite
"ell s"!i( or (!)oliiu$
eh!"e) $!(eti"
reso!"e i$!(i( !re other
suit!#le $etho)s&
4 EG"lusive eter!l utritio or
steroi)s shoul) #e "osi)ere) to
i)u"e re$issio& Both h!ve
eQu!l effi"!"+,
#ut eter!l utritio is
o< the st!)!r) 4r!"ti"e
i 4!e)i!tri"s #e"!use it
offers utritio!l su44ort !s <ell !s i)u"i( re$issio& Usi( eG"lusive eter!l utritio !lso !voi)s the
si)e effe"ts th!t !re !sso"i!te) <ith the use of hi(h )ose steroi)s&
. O"e the 4!tietDs "lii"!l "o)itio h!s i$4rove), i$$uosu44ress!t ther!4+ <ith ! !(et
su"h !s !P!thio4rie or $er"!4to4urie shoul) #e )is"usse) <ith the "hil) !) their f!$il+&
2T-T'2T'C-L ^UE2T'O0
0u$#er ee)e) to tre!t
-s<ers b !) c !re true,
<here!s a !) " !re f!lse&
O0 E_-M'0-T'O0 ^U'/
TouriQuets
-s<ers B !) C !re "orre"t&
-0-TOMY ^U'/
Coro!l
"o$4ute)
to$o(r!4h+ of
the siuses
- Ri(ht $!Gill!r+ ifu)i#ulu$
B Ri(ht $i))le tur#i!te
C Ri(ht $!Gill!r+ !tru$
3 Crist! (!lli
E Left iferior tur#i!te