Download MBBS Ophthalmology PPT 32 Anterior Uveitis Lecture Notes

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