Diagnóstico y tratamiento inicial de la uveítis por médicos no oftalmólogos
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Toro Arango, O., De la Torre, A., Pachón Suárez, D., Salazar Muñoz, J., & Parra Morales, A. (2017). Diagnóstico y tratamiento inicial de la uveítis por médicos no oftalmólogos. NOVA, 15(28), 99 - 114. https://doi.org/10.22490/24629448.2085
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Autores
O Toro Arango
A De la Torre
D Pachón Suárez
J Salazar Muñoz
A M Parra Morales
Resumen
Objetivos: Describir los principales signos y síntomas, así como el tratamiento inicial de un paciente con diagnóstico de uveítis con el propósito de evitar retardo en la remisión y el inicio del manejo oportuno de esta patología. Métodos: Se realizó una revisión sistemática de la literatura en la cual se identificaron los principales signos y síntomas que deben ser tenidos en cuenta para sospechar el diagnóstico de uveítis y su tratamiento indicado. Se llevó a cabo una búsqueda en PubMed durante el periodo del 2010-2015, se eligieron 439 artículos, los cuales fueron sometidos a dos procesos de filtrado manual, eligiendo por un grupo de investigadores los resúmenes que respondieran nuestra pregunta de investigación. Posteriormente un grupo de oftalmólogos expertos y médicos con experiencia en oftalmología realizaron una segunda revisión. Resultados: Posterior al primer proceso de filtrado se obtuvieron 73 artículos que se sometieron a un segundo proceso de selección donde se obtuvieron 30 artículos. De la selección final de artículos: seis fueron estudios observacionales o ensayos clínicos; los artículos restantes fueron revisiones de la literatura. Los estudios observacionales y ensayos clínicos aleatorizados se evaluaron con la herramienta GRADE siendo la mayoría de evidencia alta. Se hizo una revisión de los treinta artículos seleccionados, por parte de nuestros investigadores, dando como resultado recomendaciones para el diagnóstico y tratamiento de la uveítis para el personal médico no oftalmólogo. Conclusiones: Existen un conjunto de signos y síntomas que pueden hacer sospechar al médico no oftalmólogo el diagnóstico de uveítis. Ante un paciente que presenta dolor ocular asociado a disminución de la agudeza visual, fotofobia, ojo rojo sin secreción conjuntival, miosis pupilar, depósitos retroquératicos y hallazgos al fondo de ojo como vitreitis o coriorretinitis se debe sospechar una uveítis. El manejo precoz de la uveítis anterior no infecciosa puede ser instaurado por el médico no oftalmólogo con corticoides tópicos, sin embargo, en caso de uveítis intermedia y posterior es importante remitir al oftalmólogo cuanto antes. Proponemos un algoritmo para ayudar al diagnóstico de la uveítis y recomendaciones para su manejo inicial.
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NOVA por http://www.unicolmayor.edu.co/publicaciones/index.php/nova se distribuye bajo una Licencia Creative Commons Atribución-NoComercial-SinDerivar 4.0 Internacional.
Así mismo, los autores mantienen sus derechos de propiedad intelectual sobre los artículos.
Referencias
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Yanoff M, Duker J. Anatomy of the Uvea. Edinburgo: Elsevier; 2009. 775-776 p.
Foxman EFE, Zhang M, Hurst SD, Muchamuel T, Shen D, Wawrousek EF, et al. Inflammatory mediators in uveitis: differential induction of cytokines and chemokines in Th1- versus Th2-mediated ocular inflammation. J Immunol [Internet]. 2002;168(5):2483–92. Available from: http://www.jimmunol.org/content/168/5/2483.shortnhttp://www.ncbi.nlm.nih.gov/pubmed/11859142
Li Z, Lim WK, Mahesh SP, Liu B, Nussenblatt RB. Cutting edge: in vivo blockade of human IL-2 receptor induces expansion of CD56(bright) regulatory NK cells in patients with active uveitis. J Immunol [Internet]. 2005;174(9):5187–91. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15843513
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Chipont BE, Cunningham E. Manejo del paciente con uveítis anterior aguda. Arch Soc Esp Oftalmol [Internet]. 2002;4. Available from: http://www.oftalmo.com/seo/2002/04abr02/04.htm
Weinberg R. Anterior uveitis. Ophtalmol clin North Am.1993;6:23–8.
LeHoang P. The gold standard of noninfectious uveitis: Corticosteroids. New Treat Noninfectious Uveitis. 2012;51:7–28.
Gomes Bittencourt M, Sepah YJ, Do D V, Agbedia O, Akhtar A, Liu H, et al. New treatment options for noninfectious uveitis. Dev Ophthalmol [Internet]. 2012 [cited 2016 Sep 8];51:134–61. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22517211
Durrani OM, Meads CA, Murray PI. Uveitis: a potentially blinding disease. Ophthalmol J Int d’ophtalmologie Int J Ophthalmol Zeitschrift für Augenheilkd [Internet]. [cited 2016 Sep 8];218(4):223–36. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15258410
Pato E, Muñoz-Fernández S, Francisco F, Abad MA, Maese J, Ortiz A, et al. Systematic review on the effectiveness of immunosuppressants and biological therapies in the treatment of autoimmune posterior uveitis. Semin Arthritis Rheum [Internet]. 2011 Feb [cited 2016 Sep 8];40(4):314–23. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20656330
Jabs DA, Rosenbaum JT, Foster CS, Holland GN, Jaffe GJ, Louie JS, et al. Guidelines for the use of immunosuppressive drugs in patients with ocular inflammatory disorders: recommendations
of an expert panel. Am J Ophthalmol [Internet]. 2000 Oct [cited 2016 Sep 8];130(4):492–513. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11024423
Larson T, Nussenblatt RB, Sen HN. Emerging drugs for uveitis. Expert Opin Emerg Drugs [Internet]. 2011 Jun [cited 2016 Sep 8];16(2):309–22. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21210752
Hedayatfar A, Hashemi H, Asgari S, Chee S-P. Comparison of efficacy and ocular surface toxicity of topical preservative-free methylprednisolone and preserved prednisolone in the treatment
of acute anterior uveitis. Cornea. 2014;33(4):366–72.
Gallego-Pinazo R, Dolz-Marco R, Martínez-Castillo S, Arévalo JF, Díaz-Llopis M. Update on the principles and novel local and systemic therapies for the treatment of non-infectious uveitis. Inflamm Allergy Drug Targets [Internet]. 2013;12(October 2015):38–45. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23441991
Kruh J, Stephen Foster C. The philosophy of treatment of uveitis: Past, present and future. New Treat Noninfectious Uveitis. 2012;51:1–6.
Siddique SS, Shah R, Suelves AM, Foster CS. Road to remission: a comprehensive review of therapy in uveitis. Expert Opin Investig Drugs [Internet]. 2011;20(11):1497–515. Available
from: http://www.ncbi.nlm.nih.gov/pubmed/21936708
Lee K, Bajwa A, Freitas-Neto CA, Metzinger JL, Wentworth BA, Foster CS. A comprehensive review and update on the biologic treatment of adult noninfectious uveitis: Part II. Expert Opin Biol Ther [Internet]. 2014;14(11):1651–66. Available from: http://www.embase.com/search/results?subaction=viewrecord&from=export&id=L600509390nhttp://dx.doi.org/10.1517/14712598.2014.947957nhttp://sfx.library.uu.nl/utrecht?sid=EMBASE&issn=17447682&id=-doi:10.1517/14712598.2014.947957&atitle=A+comprehensive+rev
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Jap A, Chee S-P. Viral anterior uveitis. Curr Opin Ophthalmol. 2011;22(6):483–8.
Barisani-Asenbauer T, Maca SM, Mejdoubi L, Emminger W, Machold K, Auer H. Uveitis- a rare disease often associated with systemic diseases and infections- a systematic review of 2619 patients. Orphanet J Rare Dis. 2012;7(1):57.
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sticas clÃnicas e epidemioló-gicas das uveÃtes em um serviço de urg&. Arq Bras Oftalmol [Internet]. 2014;2(1):3. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&npid=S0004-2749201400010003
Pan J, Kapur M, McCallum R. Noninfectious immune-me diated uveitis and ocular inflammation. Curr Allergy Asthma Rep. 2014;14(1):1–8.
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Cohen AE, Assang C, Patane MA, From S, Korenfeld M. Evaluation of dexamethasone phosphate delivered by ocular iontophoresis for treating noninfectious anterior uveitis. Ophthalmology
[Internet]. 2012;119(1):66–73. Available from: http://dx.doi.org/10.1016/j.ophtha.2011.07.006
Sheppard JD, Toyos MM, Kempen JH, Kaur P, Foster CS. Difluprednate 0.05% versus prednisolone acetate 1% for endogenous anterior uveitis: A phase III, multicenter, randomized
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DOI: http://dx.doi.org/10.22490/24629448.2085
Tasman W, Jaeger. EA. Duane’s Ophthalmology. Journal of Chemical Information and Modeling. 2009.
Yanoff M, Duker J. Opthalmology. Mechanisms of Uveitis. 2nd ed. Edinburgo: Elsevier; 2009. 778-780 p.
Borges S. Oftalmología [Internet]. 1 ed La habana. [cited 2012 Mar 8]. Available from: http://www.hospitalameijeiras.sld.cu/hha/mpm/documentos/OFTALMOLOGIA/PA/UVEITIS.pdf
Rathinam SR, Namperumalsamy P. Global variation and pattern changes in epidemiology of uveitis. Indian J Ophthalmol [Internet]. 2007;55(3):173–83. Available from: http://www.ijo.in/article.asp?issn=0301-4738;year=2007;volume=55;issue=3;spage=173;epage=183;aulast=Rathinamnhttp://www.
ncbi.nlm.nih.gov/pubmed/17456933
De-la-Torre A, Lopez-Castillo CA, Rueda JC, Mantilla RD, Gomez-Marin JE, Anaya JM. Clinical patterns of uveitis in two ophthalmology centres in Bogota, Colombia. Clin Exp Ophthalmol. 2009;37(5):458–66.
Yanoff M, Duker J. Anatomy of the Uvea. Edinburgo: Elsevier; 2009. 775-776 p.
Foxman EFE, Zhang M, Hurst SD, Muchamuel T, Shen D, Wawrousek EF, et al. Inflammatory mediators in uveitis: differential induction of cytokines and chemokines in Th1- versus Th2-mediated ocular inflammation. J Immunol [Internet]. 2002;168(5):2483–92. Available from: http://www.jimmunol.org/content/168/5/2483.shortnhttp://www.ncbi.nlm.nih.gov/pubmed/11859142
Li Z, Lim WK, Mahesh SP, Liu B, Nussenblatt RB. Cutting edge: in vivo blockade of human IL-2 receptor induces expansion of CD56(bright) regulatory NK cells in patients with active uveitis. J Immunol [Internet]. 2005;174(9):5187–91. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15843513
Chan CC, Li Q. Immunopathology of uveitis. Br J Ophthalmol [Internet]. 1998 Jan [cited 2016 Sep 8];82(1):91–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9536890
Whitcup SM, Chan CC, Li Q, Nussenblatt RB. Expression of cell adhesion molecules in posterior uveitis. Arch Ophthalmol (Chicago, Ill 1960) [Internet]. 1992 May [cited 2016 Sep 8];110(5):662–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/1374609
Chan C-C, Gery I. Mechanisms of uveitis. 3rd ed. Elsevier; 1992.
Rosa, JR R. 2015-2016 Basic and Clinical Science Course (bcsc): Ophthalmic Pathology and Intraocular Tumors. Section 4. Ophthalmology AA of, editor. 2015.
Zhou R, Caspi RR. Ocular immune privilege. F1000 Biol Rep [Internet]. 2010 [cited 2016 Sep 8];2. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20948803
Taylor AW, Kaplan HJ. Ocular immune privilege in the year 2010: ocular immune privilege and uveitis. Ocul Immunol Inflamm [Internet]. 2010 Dec [cited 2016 Sep 8];18(6):488– 92. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21091058
Smith JR, Jabs DA, Briceland DJ, Holland GN. Education in the ophthalmic discipline of uveitis. Am J Ophthalmol [Internet]. 2008 Dec [cited 2016 Sep 8];146(6):799–801. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19027419
Nussenblatt RB, Whitcup SM. Uveitis: Fundamentals and Clinical Practice. 4rd ed. Chicago: Elsevier; 2010.
FT K. Uveitis Infecciosa: Una Revisión. Arch Soc Esp Oftalmol [Internet]. 2000; Available from: http://www.oftalmo.com/seo/2000/04abr00/04.htm
McCluskey PJ, Towler HM, Lightman S. Management of chronic uveitis. BMJ [Internet]. 2000 Feb 26 [cited 2016 Sep 8];320(7234):555–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10688564
De Smet MD, Taylor SRJ, Bodaghi B, Miserocchi E, Murray PI, Pleyer U, et al. Understanding uveitis: The impact of research on visual outcomes. Prog Retin Eye Res [Internet]. 2011;30(6):452–70. Available from: http://dx.doi.org/10.1016/j.preteyeres.2011.06.005
Herbort CP. Uveitis update: An overview by the society for Ophthalmo-Immunoinfectiology in Europe. Middle East Afr J Ophthalmol [Internet]. 2009 Oct [cited 2016 Sep 8];16(4):157–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20404983
Chipont BE, Cunningham E. Manejo del paciente con uveítis anterior aguda. Arch Soc Esp Oftalmol [Internet]. 2002;4. Available from: http://www.oftalmo.com/seo/2002/04abr02/04.htm
Weinberg R. Anterior uveitis. Ophtalmol clin North Am.1993;6:23–8.
LeHoang P. The gold standard of noninfectious uveitis: Corticosteroids. New Treat Noninfectious Uveitis. 2012;51:7–28.
Gomes Bittencourt M, Sepah YJ, Do D V, Agbedia O, Akhtar A, Liu H, et al. New treatment options for noninfectious uveitis. Dev Ophthalmol [Internet]. 2012 [cited 2016 Sep 8];51:134–61. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22517211
Durrani OM, Meads CA, Murray PI. Uveitis: a potentially blinding disease. Ophthalmol J Int d’ophtalmologie Int J Ophthalmol Zeitschrift für Augenheilkd [Internet]. [cited 2016 Sep 8];218(4):223–36. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15258410
Pato E, Muñoz-Fernández S, Francisco F, Abad MA, Maese J, Ortiz A, et al. Systematic review on the effectiveness of immunosuppressants and biological therapies in the treatment of autoimmune posterior uveitis. Semin Arthritis Rheum [Internet]. 2011 Feb [cited 2016 Sep 8];40(4):314–23. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20656330
Jabs DA, Rosenbaum JT, Foster CS, Holland GN, Jaffe GJ, Louie JS, et al. Guidelines for the use of immunosuppressive drugs in patients with ocular inflammatory disorders: recommendations
of an expert panel. Am J Ophthalmol [Internet]. 2000 Oct [cited 2016 Sep 8];130(4):492–513. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11024423
Larson T, Nussenblatt RB, Sen HN. Emerging drugs for uveitis. Expert Opin Emerg Drugs [Internet]. 2011 Jun [cited 2016 Sep 8];16(2):309–22. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21210752
Hedayatfar A, Hashemi H, Asgari S, Chee S-P. Comparison of efficacy and ocular surface toxicity of topical preservative-free methylprednisolone and preserved prednisolone in the treatment
of acute anterior uveitis. Cornea. 2014;33(4):366–72.
Gallego-Pinazo R, Dolz-Marco R, Martínez-Castillo S, Arévalo JF, Díaz-Llopis M. Update on the principles and novel local and systemic therapies for the treatment of non-infectious uveitis. Inflamm Allergy Drug Targets [Internet]. 2013;12(October 2015):38–45. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23441991
Kruh J, Stephen Foster C. The philosophy of treatment of uveitis: Past, present and future. New Treat Noninfectious Uveitis. 2012;51:1–6.
Siddique SS, Shah R, Suelves AM, Foster CS. Road to remission: a comprehensive review of therapy in uveitis. Expert Opin Investig Drugs [Internet]. 2011;20(11):1497–515. Available
from: http://www.ncbi.nlm.nih.gov/pubmed/21936708
Lee K, Bajwa A, Freitas-Neto CA, Metzinger JL, Wentworth BA, Foster CS. A comprehensive review and update on the biologic treatment of adult noninfectious uveitis: Part II. Expert Opin Biol Ther [Internet]. 2014;14(11):1651–66. Available from: http://www.embase.com/search/results?subaction=viewrecord&from=export&id=L600509390nhttp://dx.doi.org/10.1517/14712598.2014.947957nhttp://sfx.library.uu.nl/utrecht?sid=EMBASE&issn=17447682&id=-doi:10.1517/14712598.2014.947957&atitle=A+comprehensive+rev
Pleyer U, Stübiger N. New pharmacotherapy options for noninfectious posterior uveitis. Expert Opin Biol Ther [Internet]. 2014;14(12):1783–99. Available from: http://www.scopus.com/inward/record.url?eid=2-s2.0-84910074151&partnerID=tZOtx3y1
Dhoot DS, Martin DF, Srivastava SK. Pediatric infectious posterior uveitis. Int Ophthalmol Clin [Internet]. 2011;51(1):113–28. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21139480
Mandelcorn ED. Infectious causes of posterioruveitis. Can J Ophthalmol [Internet]. 2013;48(1):31–9. Available from: http://dx.doi.org/10.1016/j.jcjo.2012.11.013
Jap A, Chee S-P. Viral anterior uveitis. Curr Opin Ophthalmol. 2011;22(6):483–8.
Barisani-Asenbauer T, Maca SM, Mejdoubi L, Emminger W, Machold K, Auer H. Uveitis- a rare disease often associated with systemic diseases and infections- a systematic review of 2619 patients. Orphanet J Rare Dis. 2012;7(1):57.
Camilo ENR, Moura GL, Arantes TE, ª, e nio F. Clinical and epidemiological characteristics of patients with uveitis in an emergency eye care center in Brazil^ien; CaracterÃ
sticas clÃnicas e epidemioló-gicas das uveÃtes em um serviço de urg&. Arq Bras Oftalmol [Internet]. 2014;2(1):3. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&npid=S0004-2749201400010003
Pan J, Kapur M, McCallum R. Noninfectious immune-me diated uveitis and ocular inflammation. Curr Allergy Asthma Rep. 2014;14(1):1–8.
Velu J, Agarwal S, Gupta V, Sharma K, Sharma A, Gupta A. Hypopyon uveitis-a rare presentation of intraocular tuberculosis. Ocul Immunol Inflamm [Internet]. 2013;21(3):251– 3. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23617801
Cohen AE, Assang C, Patane MA, From S, Korenfeld M. Evaluation of dexamethasone phosphate delivered by ocular iontophoresis for treating noninfectious anterior uveitis. Ophthalmology
[Internet]. 2012;119(1):66–73. Available from: http://dx.doi.org/10.1016/j.ophtha.2011.07.006
Sheppard JD, Toyos MM, Kempen JH, Kaur P, Foster CS. Difluprednate 0.05% versus prednisolone acetate 1% for endogenous anterior uveitis: A phase III, multicenter, randomized
study. Investig Ophthalmol Vis Sci. 2014;55(5):2993–3002.
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DOI: http://dx.doi.org/10.22490/24629448.2085
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