Download MBBS Ophthalmology PPT 32 Anterior Uveitis Lecture Notes

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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