Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Ophthalmology PPT 32 Anterior Uveitis Lecture Notes
Introduction
Uveitis :
inflammation of uveal tract (iris, ciliary body & choroid) and of neighbouring
structures(retina, vitreous, optic nerve)
IUSG classification
Group
SubGroup
Infectious
Bacterial
Fungal
Viral
Parasitic
Others
Non Infectious
Known Systemic Association
No Known Systemic Association
Masquerade
Neoplastic
Non Neoplastic
Anatomical classification
Type
Primary Site
Includes
Anterior Uveitis
Anterior Chamber
Iritis,
Iridocyclitis
Anterior cyclitis
Intermediate Uveitis Vitreous
Pars Planitis
Posterior cyclitis
Hyalitis
Posterior Uveitis
Retina or Choroid
Focal,Multi Focal or
Diffuse Choroiditis
Chorioretinitis
Retinitis
Retinochoroiditis
Neuroretinitis
Pan Uveitis
Anterior Chamber,Vitreous
and Retina or choroid
Pathological Classification
Granulomatous
Non granulomatous
Large greasy mutton fat KPs
Confluent, fine white coloured
Iris nodules-Koeppe & Busacca
small(lymphocyte,plasma cells
pigments)
Descriptors of Clinical Behaviour
Type
Descriptor
Definition
Onset
Sudden
Insidious
Duration
Limited
3 Months
Persistent
3Months
Course
Acute
Sudden Onset+Limited Duration
Recurrent
Repeated Episodes,inactive periods 3 months off
treatment
Chronic
Persistent,Relapse in <3 months off treatment
Approach to patient of Uveitis
Symptoms
Anterior : photophobia, redness,
watering, pain,VA; may be
asymptomatic
Intermediate: floaters, photopsia, VA
Posterior: VA,Photopsia, floaters,
scotomata
POH
Previous episodes and investigation;
surgery/trauma
PMH
Arthropathies (e.g. Ankylosing
sponylitis), Chronic infections (e.g.
HSV, tuberculosis), systemic
inflammation(e.g.sarcoid,Behcet,s
disease)
SR
Detailed review of all systems
Approach to patient of Uveitis
FH
Family members with Uveitis or related
diseases
SH
Travel/residence abroad, pets IV drugs,
sexual Hx
DX
Including any systemic
immunosuppresion
AX
Allergies or relevant drug
contraindictions
Visual acuity
Best-corrected/pin-hole;near
Visual Function
Check for RAPD, colour vision
Conjunctiva
Circumcorneal injection
Cornea
Band keratopathy, keratic precipitates
(distribution,size, pigment)
Approach to patient of Uveitis
AC
Flare/ cells, fibrin, hypopyon
Gonioscopy
PAS (consider if IOP)
Iris
Loss of pattern,Transillumination
defects/sectoral atrophy, miosis,
posterior synechiae, heterochromia,
Koeppe or Busacca nodules ,NVI
Lens
Pigment on ALS,cataract, aphakia/
pseudophakia
Tonometry
Dilated fundoscopy
(non-contact handheld lens
?indirect/indenting)
Vitreous
Haze, cells, snowballs, opacities,
subhyaloid precipitates (KP-like but on
posterior vitreous face)
Optic disc
Disc swelling, glaucomatous changes,
atrophy
Approach to patient of Uveitis
Vessels
Inflammation (sheathing, leakage),
ischaemia (BRAO, B/CRVO, retinal
oedema), occlusion
Retina
CMO, uni/multifocal retinitis (blurred
white lesions may progress
oedema,)occlusion
Choroid
Uni/multifocal choroiditis (deeper
yellow-white lesions), associated
exudative retinal detachment
Ocular Signs
Anatomical location Condition
Forehead & Adnexa
Vesicles
Herpes Zoster Ophthalmicus
Poliosis
VKH
Nodules
Sarcoid, Leprosy
Madarosis
Leprosy
Conjunctiva
Granulomas
Foreign body granulomas Sarcoid
Cornea
Dendritic keratitis, SPK Viral uveitis
Sclero Kerato uveitis Syphilis, tuberculosis, Hansen's & viral
Exposure and neurotrophic keratitis
Leprosy
Band Keratopathy
Juvenile rheumatoid arthritis,
Sarcokdosis
Ocular signs
Anatomical location
Condition
Iris/Pupil
Miotic and irregular pupils
posterior synechiae (but the response
of the pupil to light and near is
symmetric),Festooned pupil,seclusio
pupillae,occlusio pupillae,ectropion
pupillae
Relative Afferent Pupillary Defect
Asymmetric disc involvement as a
result of disc edema due to uveitis or
optic atrophy as a result of chronic
uveitis
Sectoral iris atrophy
Herpetic uveitis (irregular constriction
of pupil)
Argyl Robinson pupil
Neurosyphilis
Ocular signs
Anatomical Location
Condition
Gonioscopic evaluation
Peripheral Anterior Synechiae
Sarcoid, Tuberculosis
Iris nodules
Sarcoid, Tuberculosis
Hyphema
Herpetic
Foreign body
Trumatic uveitis
Grading of AC cel s
Grade
Description
0
None
1+
Faint (just detactable)
2+
Moderate (iris+lens clear)
3+
Marked (iris+lens hazy)
4+
Intense (fibrin or plastic aqueous)
Grading of AC Flare
Activity
Cells
0
<1
0.5+
1-5
1+
6-15
2+
16-25
3+
26-50
4+
>50
Signs
Signs
KP: fibrous deposits on the posterior
surface of the cornea, usually
associated with uveitis.
Both the size and
distribution of keratic
White, yel owish greasy precipitates of
precipitates are helpful in
inflammatory cel s
the differential diagnosis.
Typical y distributed in a wedge-shaped region
on the inferior corneal endothelium, known as
Arlt's triangle
AS
Fibrin clot and posterior synechiae in a patient with
acute, anterior uveitis and ankylosing spondylitis .
Signs
Iris atrophy in a patient with herpes simplex virus?associated anterior uveitis.
Etiology of anterior uveitis
?Acute
? Idipathic
? HLA-B27 associated
v
Ankylosing Spondylitis
v
Reiter's syndrome
v
IBD
v
Psoariasis
? Herpetic anterior uveitis(HSV and VZV)
? Posner Schlossman Syndrome
? Systemic diseases associated
v Diabetes
v Sarcoidosis
v TINU, IgA Nephropathy
?Chronic
?Non Infective
?Immune mediated
Traumatic
Neoplastic
Idiopathic
Etiology of anterior uveitis
?Chronic
? Fuch's Heterochromic uveitis
? JIA
Systemic signs
Systemic sign
Differentials
Poliosis
VKH, Sympathetic ophthalmia
Loss of Hair
SLE, VKH and Syphillis
Hypo-pigmentation of the skin
Leprosy,Sympathetic ophthalmia, VKH
harada's
Rash
Vascuitic disease, SLE, Behcet's Disease,
Syphilis
Erythema nodosum-tender violaceous
I BD, sarcoidosis, TB, Behcet's
subcutaneous nodules in lower extremities
Scaling of the skin
SLE, Psoriatic arthritis, Syphilis and Reiter's
syndrome
Discoid lesions
SLE, Psoriatic arthritis, Syphilis, Reiter's
Nail abnormalities
Psoriatic arthritis, reiter's,Vasculitis
Oral ulcers alone
SLE& IBD
Urethral discharge
Reiter's s, Syphilis, HSV, Gonococcal
Urethritis
Systemic sign
Differentials
Epididymitis
Behcet's , TB
Prostatitis
Reiter's , AS and Gonococcal
Nephritis
Vasculitis (Wegener's, SLE,
Behcet's),Sarcoidosis,TB
Arthritis
Sero negative spondyloarthropathies,
JRA, Behcet's, Sarcoidosis, SLE,
Leprosy, Relapsing polychondritis
Cartilage loss
Relapsing polychondritis,Syphilis,
Gonococcal, Wegener's
Nasopharyngeal manifestation
Wegener's , Sarcoidosis, Whipple's,
Mucormycosis
Cystitis
Whipple's, Reiter's
Lymph nodes
TB, Sarcoidosis, Lymphoma
Neuropathy
Leprosy, HZV, Sarcoidosis, MS, Syphilis
Systemic sign
Differentials
Hearing loss
VKH, Sarcoidosis
Respiratory Symptoms
TB, Sarcoidosis, Wegener's
Bowel disease
Whipple's, Crohn's, Ulcerative colitis
Fever
Collagen vascular disease, TB,
Leptospirosis
Nongranulomatous Vs
granulomatous Uveitis
Non-granulomatous
Granulomatous
Onset
Acute
Insidious
Evolution
Spontaneous regression
Chronic
(mostly)
Keratic precipitates
Confluent, fine white
Non confluent, large
coloured
mutton fat keratic
small(lymphocyte,plasma precipitates (epithelioid
cells pigments)
cells, hystiocytes)
Iris
Occasionally Koeppe's
Frequent Koeppe's and
nodules
Busacca's nodules
Flare
Intense
Mild
Synecthiae
Easy to break with
Dens broad based,
mydriatics in early stages. difficult to break
Vitreous exudates
Fine punctuate opacities Heavy vitreous exudates
in vitreous
Differential Dignosis
Feature
Acute
Acute
Acute congestive
conjunctivitis
iridocyclitis
glaucoma
Onset
Gradual
Usually gradual
Sudden
Pain
Mild discomfort
Moderate in eye
Severe in eye and
and along the first the entire
division of
trigeminal area
trigeminal nerve
Discharge
Mucopurulent
Watery
Watery
Coloured halos
May be present
Absent
Present
Vision
Good
Slightly impaired
Markedly impaired
Congestion
Superficial
Deep ciliary
Deep ciliary
Conjunctival
Tenderness
Absent
Marked
Marked
Pupil
Normal
Small and
Large and
irregular
vertically oval
Differential dignosis
Anterior
Normal
May be deep
Very shallow
chamber
Iris
Normal
Muddy
Oedematous
Intraocular
Normal
Usually normal
Raised
pressure
Media
Clear
Hazy due to KPs,
Hazy due to
aqueous flare and oedematous
pupillary exudates
Constitutional
Absent
Little
Prostration and
symptoms
vomiting
When to Investigate
In general, Investigations may be performed for:
Diagnosis : by identifying causative or associated systemic disease;by
identifying a definite aetiology
Management:monitoring disease activity/complication(e.g.OCT for
macular oedema);monitoring potential side-effects of treatment (e.g.
Blood tests for some immunosuppressants.)
Role of investigation
Monitoring disease
? OCT
? FFA
? EDTs
? Visual fields
Role of Investigation
Monitoring
? Regular BP
? Weight
? BM
? Urinalysis
? Blood test
Investigations in diagnosis of
Uveitis types
Investigation
Consider
Base-line FBC, ESR
Syphilis serology
Syphilis
ANA (in children)
JIA
Urinalysis
TINU (Protein),diabetes (glucose)
CXR
TB, sarcoidosis
ACE
Sarcoidosis
ANCA
Wegener's(PR3)
Toxoplasma serology
Toxoplasmosis
Toxocara ELISA
Toxoplasmosis
Borrelia serology
Lyme disease
HLA-B27
B27-associated disease
HLA-A29
Birdshot retinochoroidopathy
Mantoux test
TB, sarcoidosis
Fundus Fluorescein angiography
Investigations in diagnosis of
uveitis type
Electrophysiology
Ultrasound B-scan
High- resolution CT thorax
Sarcoidosis
CT orbits
MRI head scan
Demyelination, sarcodosis, lymphoma
Gallium scan
Sarcoidosis
Lumbar puncture
Demyelination,Lymphoma
Conjunctival biopsy
Sarcoidosis
PCR of intraocular fluid
Infection
Vitreous biopsy
Infection, Lymphomia
Choroidal biopsy
Lymphoma
Complications
? Band keratopathy
? Cataract
? CMO
? Glaucomaous optic neuropathy
? Vitreous debris
? Retinal detachment
? Non-glaucomatous optic Neuropathy
? Choroidal neovascularization
? Subretinal fibrosis
Treatment
Medical or surgical
Medical therapy
? Corticosteroid
i.
Topically
ii.
Perioculary
iii. Intravitreally
iv.
Systemically
? Cycloplegics
? Systermic immunosuppressants
-Resistant,sight-threatening cases
? The use of anti-VEGF agents
-Macular oedema
Secondary IOP
i. Topical therapies
-Avoid those causing uveitis and CMO
Surgery
?Cataract, glaucoma
?Vitreoretinal procedures
Fuchs heterochromic uveitis
Rare , chronic ,young adults
Unknown cause , no systemic association
Mild ant uveitis,no signs of conjunctival inflamation, no ant synechia
KPs diffusely distributed over the cornea
Heterochromic iris due to loss of pigment epithelial cells.
Inflamed vitreous
70% catarct
Steroids are not effective and not prescribed,cataract surgery is done when
indicated,and patients usually respond well
Immune-mediated systemic
disorders
Spondyloarthritides such as ankylosing spondylitis and
reactive arthritis ,are the most common systemic immune
disorders associated with uveitis
v20-40 %
vMale >female
vtypically unilateral,
vtends to resolve within three months of its onset.
vRecurrences are common, and can occur in the
contralateral eye.
vThe prognosis for this form of uveitis is generally
excellent provided that acute attacks are treated early
and vigorously
Immune-mediated systemic
disorders
7% psoriatic arthritis and 2 to 9 % of patients
with IBD may develop uveitis,
vis frequently bilateral,
vposterior to the lens,
vinsidious in onset,
vchronic in duration
vmore common in females than males
Immune-mediated systemic
disorders
Juvenile idiopathic arthritis (JIA) may be associated with
uveitis, particularly in the subset of patients with
pauciarticular disease and a positive antinuclear antibody.
vmajority of patients asymptomatic.(white eye but with
signs of uveitis present )
v usually bilateral
v insidious in onset,
vchronic in duration,
vanterior.
v commonly associated with complications such as band
keratopathy, posterior synechiae , cataract formation, and
glaucoma.
Immune-mediated systemic
disorders
80 percent of patients with Behcet's disease develop uveitis
vtypically bilateral.
vfrequently episodic,
vgenerally does not resolve completely between episodes
vRetinal vasculitis is a frequent manifestation
Behcet
Male,young,bilateral , hypopyon
This post was last modified on 07 April 2022