Evaluation of a Standardized Strategy for Uveitis Etiological Diagnosis (ULISSE)

Uveitis: Medico-economical and Clinical Evaluation of a Standardized Strategy for an Etiological Diagnosis

The Uveitis, the inflammation of the uvea, is a rare disease with an incidence of 52/100,000 inhabitants per year and a prevalence of 115 / 100,000 inhabitants per year. The causes of uveitis are numerous and include infectious diseases, systemic and neurological diseases, ophthalmic entities, neoplasia, and drug-related reactions. The etiological diagnosis is important both for prognosis and therapeutics. However, clinical evaluations to establish etiological diagnosis are not standardized. Some authors suggest a minimalist examination, common to all kinds of uveitis. On the other hand, others propose an evaluation guided by the anatomo-clinical type of uveitis. We conducted a retrospective study to assess the contribution of complementary examinations to etiological determination. In this study, we found that most patients benefited from a wide paraclinical evaluation compared to what is usually described in the literature. Complementary examinations were mostly systematic, without any clinical or ophthalmological elements of orientation. This study highlighted the lack of contribution of some examinations. Using these results, and the literature analysis, we designed a diagnostic algorithm adapted to the anatomo-clinical type of uveitis. Moreover, we found that the average cost per patient was estimated at €290.51 with the algorithm compared to €560.83 without it. We would like to carry out a new study to estimate the efficiency as well as the medico-economic impact of the use of a standardized strategy for the etiological diagnosis of uveitis, compared with a free strategy. Hypothesis: The standardized strategy for the diagnostic of uveitis is at least as efficient as the free one, and costs half as much. The examinations prescribed, except for those from the standardized strategy, do not contribute to etiological determination.

Free strategy followed in order to make the etiological diagnosis, which means, investigators are free to perform any examination they thought necessary.

Etiological diagnosis made by following a standardized two-stage strategy: first-line assessment (listed examinations and then examinations directed by the clinical or para-clinical elements of orientation) and second or third-line assessment (examinations directed by the anatomo-clinical type of uveitis).

Free strategy followed in order to make the etiological diagnosis, which means, investigators are free to perform any examination they thought necessary.

Etiological diagnosis made by following a standardized two-stage strategy: first-line assessment (listed examinations and then examinations directed by the clinical or para-clinical elements of orientation) and second or third-line assessment (examinations directed by the anatomo-clinical type of uveitis).

The primary outcome is the percentage of patients having an etiological diagnosis 6 months after the beginning of the study for both strategies.

Note: Only diagnoses made at the end of the standardized strategy will be numbered in this arm of the study; all diagnoses made after by the free authorized examinations in this same arm will lead to standardized strategy failure.

Percentage of patients having an established etiological diagnosis at the end of the first diagnostic stage and at the end of the second diagnostic stage. (Second or third-line assessment). Ratio of the standardized strategy's first stage examinations having contributed to the etiological diagnosis. Ratio of the standardized strategy's second stage examinations, directed by the anatomo-clinical type of the uveitis (Second or third-line assessment) having contributed to an etiological diagnosis. Ratio of free complementary examinations having contributed to an etiological diagnosis.

Description and ratio of the examinations that have not allowed the doctor to make an etiological diagnosis. Description and ratio of the complementary examinations not included in the standardized strategy.

For each patient: The standardized strategy's average cost of diagnosis distinguishing between first diagnostic stage costs and second diagnostic stage costs (made up of the second or third-line assessment directed by the anotomo-clinical type of the uveitis). Average cost of the complementary examinations not included in the standardized strategy but allowed at the end of it (subsequent free assessment). Average cost for each patient of the whole free strategy.

- Quality of life, estimated with the standard quality of life questionnaire (SF-36) and the one specific to ophthalmology (NEI VFQ-25), will be compared between these groups: Uveitis diagnosis versus no diagnosis Free strategy versus standardized strategy.

Inclusion Criteria: Uveitis Patient consulting one of the study's sites Age > 18 years old Affiliation to the French national health insurance program Patient agreeing to participate in the study Exclusion Criteria: Positive HIV serology Postsurgical or posttraumatic uveitis or endophthalmitis Toxoplasmic uveitis Pathology likely to be the cause of the known uveitis Ophthalmic entities only diagnosed by the ophthalmic examination Age < 18 years old Patient under law protection or guardianship Pregnant women or those planning to be pregnant during the study Severe uveitis (VA < 20/200) with retinal vascularitis requiring an emergency treatment and assessment.

de Parisot A, Kodjikian L, Errera MH, Sedira N, Heron E, Perard L, Cornut PL, Schneider C, Riviere S, Olle P, Pugnet G, Cathebras P, Manoli P, Bodaghi B, Saadoun D, Baillif S, Tieulie N, Andre M, Chiambaretta F, Bonin N, Bielefeld P, Bron A, Mouriaux F, Bienvenu B, Vicente S, Bin S, Broussolle C, Decullier E, Seve P; ULISSE group. Randomized Controlled Trial Evaluating a Standardized Strategy for Uveitis Etiologic Diagnosis (ULISSE). Am J Ophthalmol. 2017 Jun;178:176-185. doi: 10.1016/j.ajo.2017.03.029. Epub 2017 Mar 31.