RSS-Feed abonnieren
DOI: 10.1055/a-0828-7395
Diagnostische Strategie und therapeutisches Dilemma bei akuter posteriorer und Panuveitis
Diagnostic Strategy and Therapeutic Dilemma in Acute Posterior and PanuveitisPublikationsverlauf
eingereicht 11. Oktober 2018
akzeptiert 25. Dezember 2018
Publikationsdatum:
14. Februar 2019 (online)
![](https://www.thieme-connect.de/media/klimo/201904/lookinside/thumbnails/10-1055-a-0828-7395_kl0100-1.jpg)
Zusammenfassung
Die breite Differenzialdiagnose der akuten posterioren und Panuveitis, die meist jüngere Individuen und in mehr als der Hälfte beide Augen betrifft, macht die rasche diagnostische Einordnung und die therapeutische Entscheidung wegen ihrer erheblichen Konsequenzen für den weiteren Verlauf zu kritischen Schritten. Das Risiko eines bleibenden Visusverlustes infolge eines verzögerten Therapiebeginns ist dabei ebenso bedeutsam wie das Einleiten einer nicht genügend wirksamen Therapie. Klinische Präsentation (anatomische Lokalisation und Entzündungstyp), Verlauf und sekundär das Ansprechen auf die Akuttherapie lassen eine erste diagnostische Eingrenzung zu, wobei eine infektiöse Ätiologie in bis zu einem Drittel der Fälle vorliegt. Die häufigste akute posteriore Uveitis bei immunkompetenten Patienten ist eine akute virale Netzhautnekrose. Diese lässt sich oft klinisch nicht sicher von einer Behçet-Uveitis unterscheiden, solange keine systemischen Manifestationen vorliegen. Bis zur definitiven diagnostischen Einordnung muss deshalb bei makulabedrohender Erkrankung spätestens 24 Stunden nach Beginn einer antiviralen und antiparasitären Akuttherapie eine hochdosierte Steroidtherapie begonnen werden. Den therapeutischen Konsequenzen der Fehleinschätzung der Erkrankung stehen prognostische Überlegungen gegenüber, die ein aggressives Vorgehen gerade bei akuten posterioren Uveitiden rechtfertigen: Jede Verzögerung des Therapiebeginns vermehrt die infektiöse und entzündliche Gewebsschädigung, erhöht das Risiko einer Affektion des Partnerauges und anderer Organe, wohingegen der Einsatz höherer Steroiddosen, Immunsuppressiva und Biologika zu unkontrollierter Erregerproliferation und zu Rezidiven führen kann.
Abstract
Acute posterior and panuveitis mostly affect younger patients and affect both eyes in more than half of cases. Because of the severe consequences in the clinical course, rapid and broad differential diagnosis are critical steps. Permanent loss of vision after a delay in starting therapy and the initiation of ineffective treatment are both serious risks. The initial diagnostic classification is based on clinical presentation (anatomical localisation and type of inflammation) and clinical course and, secondarily, on the response to acute therapy. The aetiology is acute in as many as one third of cases. The most frequent acute posterior uveitis in immunocompetent persons is acute viral retinal necrosis. It is difficult to distinguish this clinically from Behçet uveitis, as long as there are no systemic manifestations. In patients with disease threatening the macula, high dose steroid therapy must be started no later than 24 hours after the start of antiviral and anti-parasitic acute therapy. Thus, misdiagnosis has therapeutic consequences. Moreover, the prognosis is favourably affected by aggressive treatment of acute posterior uveitis. Any delay in starting therapy increases infectious and inflammatory tissue damage, and increases the risk of involvement of the other eye and of other organs. On the other hand, the use of high doses of steroids, immunosuppressives and biological agents can lead to uncontrolled proliferation of the pathogen and relapses.
-
Literatur
- 1 Wakefield D, Chang JH. Epidemiology of uveitis. Int Ophthalmol Clin 2005; 45: 1-13
- 2 You C, Sahawneh HF, Ma L. et al. A review and update on orphan drugs for the treatment of noninfectious uveitis. Clin Ophthalmol 2017; 11: 257-265
- 3 Al-Dhibi HA, Al-Mahmood AM, Arevalo JF. A systematic approach to emergencies in uveitis. Middle East Afr J Ophthalmol 2014; 21: 251-258
- 4 Lee JH, Agarwal A, Mahendradas P. et al. Viral posterior uveitis. Surv Ophthalmol 2017; 62: 404-445
- 5 Deschenes J, Murray PI, Rao NA. et al. International Uveitis Study Group (IUSG): clinical classification of uveitis. Ocul Immunol Inflamm 2008; 16: 1-2
- 6 Tsirouki T, Dastiridou A, Symeonidis C. et al. A focus on the epidemiology of uveitis. Ocul Immunol Inflamm 2018; 26: 2-16
- 7 Barisani-Asenbauer T, Maca SM, Mejdoubi L. et al. Uveitis – a rare disease often associated with systemic diseases and infections – a systematic review of 2619 patients. Orphanet J Rare Dis 2012; 7: 57
- 8 Tran VT, Auer C, Guex-Crosier Y. et al. Epidemiology of uveitis in Switzerland. Ocul Immunol Inflamm 1994; 2: 169-176
- 9 Guex-Crosier Y. [Epidemiology of uveitis]. Rev Prat 1999; 49: 1989-1994
- 10 Lee JH, Mi H, Lim R. et al. Ocular Autoimmune Systemic Inflammatory Infectious Study – Report 3: Posterior and Panuveitis. Ocul Immunol Inflamm 2017; DOI: 10.1080/09273948.2017.1358377.
- 11 Nazari Khanamiri H, Rao NA. Serpiginous choroiditis and infectious multifocal serpiginoid choroiditis. Surv Ophthalmol 2013; 58: 203-232
- 12 Chen EJ, Bin Ismail MA, Mi H. et al. Ocular Autoimmune Systemic Inflammatory Infectious Study (OASIS) – Report 1: epidemiology and classification. Ocul Immunol Inflamm 2018; 26: 732-746
- 13 Adán-Civera AM, Benítez-Del-Castillo JM, Blanco-Alonso R. et al. Burden and direct costs of non infectious uveitis in Spain. Reumatol Clin 2016; 12: 196-200
- 14 Reznicek L, Seidensticker F, Stumpf C. et al. Systematic analysis of wide-field fundus autofluorescence (FAF) imaging in posterior uveitis. Curr Eye Res 2014; 39: 164-171
- 15 Alberdi-Saugstrup M, Enevold C, Zak M. et al. Non-HLA gene polymorphisms in juvenile idiopathic arthritis: associations with disease outcome. Scand J Rheumatol 2017; 46: 369-373
- 16 Márquez A, Cordero-Coma M, Martín-Villa JM. et al. New insights into the genetic component of non-infectious uveitis through an Immunochip strategy. J Med Genet 2017; 54: 38-46
- 17 Huang XF, Lin D, Lin KH. et al. Genotype-phenotype association study reveals CFI-Rs13104777 to be a protective genetic marker against acute anterior uveitis. Ocul Immunol Inflamm 2018; 26: 51-56
- 18 Davoudi S, Navarro-Gomez D, Shen L. et al. NOD2 genetic variants and sarcoidosis-associated uveitis. Am J Ophthalmol Case Rep 2016; 3: 39-42
- 19 Hsu YR, Huang JC, Tao Y. et al. Noninfectious uveitis in the Asia-Pacific region. Eye (Lond) 2019; 33: 66-77 doi:10.1038/s41433-018-0223-z
- 20 Verhagen FH, Bekker CPJ, Rossato M. et al. A disease-associated microRNA cluster links inflammatory pathways and an altered composition of leukocyte subsets to noninfectious uveitis. Invest Ophthalmol Vis Sci 2018; 59: 878-888
- 21 Wen X, Hu X, Miao L. et al. Epigenetics, microbiota, and intraocular inflammation: new paradigms of immune regulation in the eye. Prog Retin Eye Res 2018; 64: 84-95
- 22 Chang JH, McCluskey PJ, Wakefield D. Toll-like receptors in ocular immunity and the immunopathogenesis of inflammatory eye disease. Br J Ophthalmol 2006; 90: 103-108
- 23 Guymer R, Robman L. Chlamydia pneumoniae and age-related macular degeneration: a role in pathogenesis or merely a chance association?. Clin Exp Ophthalmol 2007; 35: 89-93
- 24 Drancourt M, Bodaghi B, Lepidi H. et al. Intraocular detection of Bartonella henselae in a patient with HLA-B27 uveitis. J Clin Microbiol 2004; 42: 1822-1825
- 25 Drancourt M, Berger P, Terrada C. et al. High prevalence of fastidious bacteria in 1520 cases of uveitis of unknown etiology. Medicine (Baltimore) 2008; 87: 167-176
- 26 Fukushima H, Numaga J, Yoshimoto M. et al. An ocular cat-scratch disease patient positive for cytoplasmic anti-neutrophil cytoplasmic antibody. Graefes Arch Clin Exp Ophthalmol 2001; 239: 882-885
- 27 Habot-Wilner Z, Trivizki O, Goldstein M. et al. Cat-scratch disease: ocular manifestations and treatment outcome. Acta Ophthalmol 2018; 96: e524-e532
- 28 Sahlberg AS, Granfors K, Penttinen MA. HLA-B27 and host-pathogen interaction. Adv Exp Med Biol 2009; 649: 235-244
- 29 Kaneko F, Togashi A, Saito S. et al. Behçetʼs disease (Adamantiades-Behçetʼs disease). Clin Dev Immunol 2011; 2011: 681956 doi:10.1155/2011/681956
- 30 Lin P. The role of the intestinal microbiome in ocular inflammatory disease. Curr Opin Ophthalmol 2018; 29: 261-266
- 31 Lee JH, Agarwal A, Mahendradas P. et al. Viral posterior uveitis. Surv Ophthalmol 2017; 62: 404-445
- 32 Akinsoji E, Goldhardt R, Galor A. A glimpse into uveitis in the aging eye: pathophysiology, clinical presentation and treatment considerations. Drugs Aging 2018; 35: 399-408
- 33 Pleyer U, Pohlmann D, Stübiger N. [Treatment of posterior non-infectious uveitis: current situation and future developments]. Ophthalmologe 2016; 113: 380-390
- 34 Abaño JM, Galvante PR, Siopongco P. et al. Review of epidemiology of uveitis in Asia: pattern of uveitis in a tertiary hospital in the Philippines. Ocul Immunol Inflamm 2017; 25 (Suppl. 01) S75-S80
- 35 Garweg JG, Tappeiner C. Zur Differentialdiagnose der infektiösen posterioren Uveitis. Klin Monatsbl Augenheilkd 2011; 228: 268-272
- 36 Pleyer U, Chee SP. Current aspects on the management of viral uveitis in immunocompetent individuals. Clin Ophthalmol 2015; 9: 1017-1028
- 37 de Parisot A, Kodjikian L, Errera MH. et al. Randomized Controlled Trial Evaluating a Standardized Strategy for Uveitis Etiologic Diagnosis (ULISSE). Am J Ophthalmol 2017; 178: 176-185
- 38 Patel AK, Newcomb CW, Liesegang TL. et al. Risk of retinal neovascularization in cases of uveitis. Ophthalmology 2016; 123: 646-654
- 39 Dick AD, Rosenbaum JT, Al-Dhibi HA. et al. Guidance on noncorticosteroid systemic immunomodulatory therapy in noninfectious uveitis: Fundamentals Of Care for UveitiS (FOCUS) Initiative. Ophthalmology 2018; 125: 757-773
- 40 Davis JL. Diagnostic dilemmas in retinitis and endophthalmitis. Eye (Lond) 2012; 26: 194-201
- 41 Tajunisah I, Reddy SC, Tan LH. Acute retinal necrosis by cytomegalovirus in an immunocompetent adult: case report and review of the literature. Int Ophthalmol 2009; 29: 85-90