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Download MBBS Ophthalmology PPT 32 Anterior Uveitis Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Ophthalmology PPT 32 Anterior Uveitis Lecture Notes

This post was last modified on 07 April 2022

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Introduction

Uveitis :
inflammation of uveal tract (iris, ciliary body & choroid) and of neighbouring

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structures(retina, vitreous, optic nerve)




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IUSG classification

Group

SubGroup

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Infectious

Bacterial

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Fungal

Viral

Parasitic

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Others

Non Infectious

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Known Systemic Association

No Known Systemic Association

Masquerade

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Neoplastic

Non Neoplastic

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Anatomical classification

Type

Primary Site

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Includes

Anterior Uveitis

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Anterior Chamber

Iritis,

Iridocyclitis

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Anterior cyclitis

Intermediate Uveitis Vitreous

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Pars Planitis

Posterior cyclitis

Hyalitis

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Posterior Uveitis

Retina or Choroid

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Focal,Multi Focal or

Diffuse Choroiditis

Chorioretinitis

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Retinitis

Retinochoroiditis

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Neuroretinitis

Pan Uveitis

Anterior Chamber,Vitreous

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and Retina or choroid



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Pathological Classification

Granulomatous

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Non granulomatous

Large greasy mutton fat KPs

Confluent, fine white coloured

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Iris nodules-Koeppe & Busacca

small(lymphocyte,plasma cells

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pigments)

Descriptors of Clinical Behaviour

Type

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Descriptor

Definition

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Onset

Sudden

Insidious

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Duration

Limited

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3 Months

Persistent

3Months

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Course

Acute

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Sudden Onset+Limited Duration

Recurrent

Repeated Episodes,inactive periods 3 months off

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treatment

Chronic

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Persistent,Relapse in <3 months off treatment




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Approach to patient of Uveitis

Symptoms

Anterior : photophobia, redness,

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watering, pain,VA; may be

asymptomatic

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Intermediate: floaters, photopsia, VA

Posterior: VA,Photopsia, floaters,

scotomata

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POH

Previous episodes and investigation;

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surgery/trauma

PMH

Arthropathies (e.g. Ankylosing

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sponylitis), Chronic infections (e.g.

HSV, tuberculosis), systemic

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inflammation(e.g.sarcoid,Behcet,s

disease)

SR

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Detailed review of all systems

Approach to patient of Uveitis

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FH

Family members with Uveitis or related

diseases

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SH

Travel/residence abroad, pets IV drugs,

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sexual Hx

DX

Including any systemic

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immunosuppresion

AX

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Allergies or relevant drug

contraindictions

Visual acuity

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Best-corrected/pin-hole;near

Visual Function

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Check for RAPD, colour vision

Conjunctiva

Circumcorneal injection

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Cornea

Band keratopathy, keratic precipitates

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(distribution,size, pigment)




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Approach to patient of Uveitis

AC

Flare/ cells, fibrin, hypopyon

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Gonioscopy

PAS (consider if IOP)

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Iris

Loss of pattern,Transillumination

defects/sectoral atrophy, miosis,

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posterior synechiae, heterochromia,

Koeppe or Busacca nodules ,NVI

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Lens

Pigment on ALS,cataract, aphakia/

pseudophakia

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Tonometry
Dilated fundoscopy

(non-contact handheld lens

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?indirect/indenting)

Vitreous

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Haze, cells, snowballs, opacities,

subhyaloid precipitates (KP-like but on

posterior vitreous face)

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Optic disc

Disc swelling, glaucomatous changes,

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atrophy

Approach to patient of Uveitis

Vessels

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Inflammation (sheathing, leakage),

ischaemia (BRAO, B/CRVO, retinal

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oedema), occlusion

Retina

CMO, uni/multifocal retinitis (blurred

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white lesions may progress

oedema,)occlusion

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Choroid

Uni/multifocal choroiditis (deeper

yellow-white lesions), associated

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exudative retinal detachment



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Ocular Signs

Anatomical location Condition
Forehead & Adnexa

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Vesicles

Herpes Zoster Ophthalmicus

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Poliosis

VKH

Nodules

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Sarcoid, Leprosy

Madarosis

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Leprosy

Conjunctiva

Granulomas

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Foreign body granulomas Sarcoid

Cornea

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Dendritic keratitis, SPK Viral uveitis

Sclero Kerato uveitis Syphilis, tuberculosis, Hansen's & viral

Exposure and neurotrophic keratitis

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Leprosy

Band Keratopathy

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Juvenile rheumatoid arthritis,

Sarcokdosis

Ocular signs

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Anatomical location

Condition

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Iris/Pupil
Miotic and irregular pupils

posterior synechiae (but the response

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of the pupil to light and near is

symmetric),Festooned pupil,seclusio

pupillae,occlusio pupillae,ectropion

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pupillae

Relative Afferent Pupillary Defect

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Asymmetric disc involvement as a

result of disc edema due to uveitis or

optic atrophy as a result of chronic

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uveitis

Sectoral iris atrophy

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Herpetic uveitis (irregular constriction

of pupil)

Argyl Robinson pupil

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Neurosyphilis



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Ocular signs

Anatomical Location

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Condition

Gonioscopic evaluation

Peripheral Anterior Synechiae

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Sarcoid, Tuberculosis

Iris nodules

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Sarcoid, Tuberculosis

Hyphema

Herpetic

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Foreign body

Trumatic uveitis

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Grading of AC cel s

Grade

Description

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0

None

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1+

Faint (just detactable)

2+

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Moderate (iris+lens clear)

3+

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Marked (iris+lens hazy)

4+

Intense (fibrin or plastic aqueous)

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Grading of AC Flare

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Activity

Cells

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0

<1

0.5+

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1-5

1+

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6-15

2+

16-25

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3+

26-50

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4+

>50

Signs

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Signs

KP: fibrous deposits on the posterior

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surface of the cornea, usually

associated with uveitis.

Both the size and

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distribution of keratic

White, yel owish greasy precipitates of

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precipitates are helpful in

inflammatory cel s

the differential diagnosis.

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Typical y distributed in a wedge-shaped region

on the inferior corneal endothelium, known as

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Arlt's triangle

AS

Fibrin clot and posterior synechiae in a patient with

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acute, anterior uveitis and ankylosing spondylitis .



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Signs

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Iris atrophy in a patient with herpes simplex virus?associated anterior uveitis.

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Etiology of anterior uveitis

?Acute

? Idipathic

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? HLA-B27 associated

v

Ankylosing Spondylitis

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v

Reiter's syndrome

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v

IBD

v

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Psoariasis

? Herpetic anterior uveitis(HSV and VZV)
? Posner Schlossman Syndrome

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? Systemic diseases associated

v Diabetes

v Sarcoidosis

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v TINU, IgA Nephropathy

?Chronic
?Non Infective

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?Immune mediated
Traumatic
Neoplastic
Idiopathic

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Etiology of anterior uveitis

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?Chronic

? Fuch's Heterochromic uveitis
? JIA

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Systemic signs

Systemic sign

Differentials

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Poliosis

VKH, Sympathetic ophthalmia

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Loss of Hair

SLE, VKH and Syphillis

Hypo-pigmentation of the skin

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Leprosy,Sympathetic ophthalmia, VKH

harada's

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Rash

Vascuitic disease, SLE, Behcet's Disease,

Syphilis

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Erythema nodosum-tender violaceous

I BD, sarcoidosis, TB, Behcet's

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subcutaneous nodules in lower extremities
Scaling of the skin

SLE, Psoriatic arthritis, Syphilis and Reiter's

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syndrome

Discoid lesions

SLE, Psoriatic arthritis, Syphilis, Reiter's

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Nail abnormalities

Psoriatic arthritis, reiter's,Vasculitis

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Oral ulcers alone

SLE& IBD

Urethral discharge

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Reiter's s, Syphilis, HSV, Gonococcal

Urethritis

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Systemic sign

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Differentials

Epididymitis

Behcet's , TB

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Prostatitis

Reiter's , AS and Gonococcal

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Nephritis

Vasculitis (Wegener's, SLE,

Behcet's),Sarcoidosis,TB

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Arthritis

Sero negative spondyloarthropathies,

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JRA, Behcet's, Sarcoidosis, SLE,

Leprosy, Relapsing polychondritis

Cartilage loss

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Relapsing polychondritis,Syphilis,

Gonococcal, Wegener's

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Nasopharyngeal manifestation

Wegener's , Sarcoidosis, Whipple's,

Mucormycosis

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Cystitis

Whipple's, Reiter's

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Lymph nodes

TB, Sarcoidosis, Lymphoma

Neuropathy

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Leprosy, HZV, Sarcoidosis, MS, Syphilis

Systemic sign

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Differentials

Hearing loss

VKH, Sarcoidosis

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Respiratory Symptoms

TB, Sarcoidosis, Wegener's

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Bowel disease

Whipple's, Crohn's, Ulcerative colitis

Fever

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Collagen vascular disease, TB,

Leptospirosis

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Nongranulomatous Vs

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granulomatous Uveitis

Non-granulomatous

Granulomatous

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Onset

Acute

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Insidious

Evolution

Spontaneous regression

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Chronic

(mostly)

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Keratic precipitates

Confluent, fine white

Non confluent, large

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coloured

mutton fat keratic

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small(lymphocyte,plasma precipitates (epithelioid

cells pigments)

cells, hystiocytes)

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Iris

Occasionally Koeppe's

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Frequent Koeppe's and

nodules

Busacca's nodules

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Flare

Intense

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Mild

Synecthiae

Easy to break with

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Dens broad based,

mydriatics in early stages. difficult to break

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Vitreous exudates

Fine punctuate opacities Heavy vitreous exudates

in vitreous

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Differential Dignosis

Feature

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Acute

Acute

Acute congestive

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conjunctivitis

iridocyclitis

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glaucoma

Onset

Gradual

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Usually gradual

Sudden

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Pain

Mild discomfort

Moderate in eye

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Severe in eye and

and along the first the entire

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division of

trigeminal area

trigeminal nerve

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Discharge

Mucopurulent

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Watery

Watery

Coloured halos

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May be present

Absent

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Present

Vision

Good

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Slightly impaired

Markedly impaired

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Congestion

Superficial

Deep ciliary

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Deep ciliary

Conjunctival

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Tenderness

Absent

Marked

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Marked

Pupil

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Normal

Small and

Large and

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irregular

vertically oval

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Differential dignosis

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Anterior

Normal

May be deep

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Very shallow

chamber
Iris

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Normal

Muddy

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Oedematous

Intraocular

Normal

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Usually normal

Raised

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pressure
Media

Clear

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Hazy due to KPs,

Hazy due to

aqueous flare and oedematous

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pupillary exudates

Constitutional

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Absent

Little

Prostration and

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symptoms

vomiting

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When to Investigate

In general, Investigations may be performed for:

Diagnosis : by identifying causative or associated systemic disease;by

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identifying a definite aetiology

Management:monitoring disease activity/complication(e.g.OCT for

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macular oedema);monitoring potential side-effects of treatment (e.g.

Blood tests for some immunosuppressants.)


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Role of investigation

Monitoring disease

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? OCT
? FFA
? EDTs
? Visual fields

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Role of Investigation

Monitoring
? Regular BP
? Weight

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? BM
? Urinalysis
? Blood test


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Investigations in diagnosis of

Uveitis types

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Investigation

Consider

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Base-line FBC, ESR
Syphilis serology

Syphilis

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ANA (in children)

JIA

Urinalysis

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TINU (Protein),diabetes (glucose)

CXR

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TB, sarcoidosis

ACE

Sarcoidosis

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ANCA

Wegener's(PR3)

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Toxoplasma serology

Toxoplasmosis

Toxocara ELISA

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Toxoplasmosis

Borrelia serology

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Lyme disease

HLA-B27

B27-associated disease

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HLA-A29

Birdshot retinochoroidopathy

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Mantoux test

TB, sarcoidosis

Fundus Fluorescein angiography

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Investigations in diagnosis of

uveitis type

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Electrophysiology
Ultrasound B-scan
High- resolution CT thorax

Sarcoidosis

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CT orbits
MRI head scan

Demyelination, sarcodosis, lymphoma

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Gallium scan

Sarcoidosis

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Lumbar puncture

Demyelination,Lymphoma

Conjunctival biopsy

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Sarcoidosis

PCR of intraocular fluid

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Infection

Vitreous biopsy

Infection, Lymphomia

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Choroidal biopsy

Lymphoma

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Complications

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? Band keratopathy
? Cataract
? CMO
? Glaucomaous optic neuropathy
? Vitreous debris

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? Retinal detachment
? Non-glaucomatous optic Neuropathy
? Choroidal neovascularization
? Subretinal fibrosis

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Treatment

Medical or surgical

Medical therapy

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? Corticosteroid

i.

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Topically

ii.

Perioculary

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iii. Intravitreally

iv.

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Systemically

? Cycloplegics

? Systermic immunosuppressants

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-Resistant,sight-threatening cases

? The use of anti-VEGF agents

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-Macular oedema




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Secondary IOP
i. Topical therapies
-Avoid those causing uveitis and CMO

Surgery

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?Cataract, glaucoma
?Vitreoretinal procedures

Fuchs heterochromic uveitis

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Rare , chronic ,young adults
Unknown cause , no systemic association

Mild ant uveitis,no signs of conjunctival inflamation, no ant synechia

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KPs diffusely distributed over the cornea

Heterochromic iris due to loss of pigment epithelial cells.

Inflamed vitreous

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70% catarct

Steroids are not effective and not prescribed,cataract surgery is done when

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indicated,and patients usually respond well




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Immune-mediated systemic

disorders

Spondyloarthritides such as ankylosing spondylitis and

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reactive arthritis ,are the most common systemic immune

disorders associated with uveitis
v20-40 %

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vMale >female
vtypically unilateral,
vtends to resolve within three months of its onset.
vRecurrences are common, and can occur in the

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contralateral eye.

vThe prognosis for this form of uveitis is generally

excellent provided that acute attacks are treated early

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and vigorously

Immune-mediated systemic

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disorders

7% psoriatic arthritis and 2 to 9 % of patients

with IBD may develop uveitis,

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vis frequently bilateral,
vposterior to the lens,
vinsidious in onset,
vchronic in duration

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vmore common in females than males




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Immune-mediated systemic

disorders

Juvenile idiopathic arthritis (JIA) may be associated with

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uveitis, particularly in the subset of patients with

pauciarticular disease and a positive antinuclear antibody.

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vmajority of patients asymptomatic.(white eye but with

signs of uveitis present )

v usually bilateral

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v insidious in onset,
vchronic in duration,
vanterior.
v commonly associated with complications such as band

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keratopathy, posterior synechiae , cataract formation, and

glaucoma.

Immune-mediated systemic

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disorders

80 percent of patients with Behcet's disease develop uveitis
vtypically bilateral.

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vfrequently episodic,
vgenerally does not resolve completely between episodes
vRetinal vasculitis is a frequent manifestation


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Behcet

Male,young,bilateral , hypopyon