ICEID EYE CENTRE

UVEITIS CLINICAL ASSESSMENT & WORKUP

Clinician-administered history, examination, classification and investigation form

A. PATIENT INFORMATION

Name

Patient ID

DOB

Age

Phone number

Date of reporting

Address

B. SYSTEMS REVIEW

Skin

Oral

Oral ulcer Oral abscess

Pulmonary

Gastrointestinal

Genitourinary

Recurrent UTI Genital ulcer

Axial / Peripheral Arthritis

Exposure / Pets

Exposure to cats Exposure to unfiltered water Improperly cooked meat

Social History

Smoking

Travel — where/when

Occupation

Drug use — specify

C. PAST MEDICAL, OCULAR & DRUG HISTORY

Current medications History details / notes

D. SLIT LAMP & OCULAR EXAMINATION

Record findings separately for right (OD) and left (OS) eyes.

Examination finding	OD	OS
Conjunctiva - nodule / granules
Corneal epithelium - dendrites
Corneal stroma - infiltrates / cells
KPs - size, colour, distribution
IOP (mmHg)
Anterior chamber depth / angle
Anterior chamber cells
Anterior chamber flare
Structural changes - PAS / rubeosis
Iris colour / contour / atrophy
Anterior / posterior synechiae
Koeppe / Busacca nodules
Iris bombe
Lens - cataract
Vitreous cells / vitritis grade
Retina - exudates / haemorrhage
Macula - CME / atrophy
Optic nerve
Choroid - lesions / haemorrhage
Sclera / para-scleral exudates

E. UVEITIS CLASSIFICATION & WORKING DIAGNOSIS

Anatomic classification Time course Broad aetiologic category

Infectious Aetiology Checklist

Viral - HSV / VZV / CMV / EBV Bacterial - Syphilis / TB / Lyme / Bartonella / Rickettsial Fungal Protozoal - Toxoplasmosis Helminthic - Toxocariasis / DUSN / Onchocerciasis / Cysticercosis

Masquerade Syndrome

Neoplastic masquerade suspected Non-neoplastic masquerade suspected

Details

F. INVESTIGATIONS / WORKUP

Core ICEID workup: Every uveitis requiring work-up should be assessed for sarcoidosis, tuberculosis and syphilis.

Investigation	Status / Result
Sarcoidosis assessment/testing
Tuberculosis testing
Syphilis testing
Chest X-ray (CXR)
ACE
CT chest
Cultures if infection suspected
PCR if infection suspected
Tissue biopsy if neoplasia suspected
OCT
VFT
Fundus Photo

G. CLINICIAN DIAGNOSTIC SUMMARY

Most likely diagnosis Anatomic diagnosis Suspected aetiology / associated systemic condition Key positive findings Key negative findings Differential diagnoses

H. PLAN & FOLLOW-UP

Additional investigations required Referral / co-management required Specialty / clinician Treatment / Management Plan Follow-up interval Urgent review / escalation Reason

CLINICIAN DETAILS

Clinician name

Date