? Inflammation of uveal tract is uveitis.
? CLASSIFICATION:
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? I. ANATOMICAL CLASSIFICATION? II. CLINICAL CLASSIFICATION
? III. ETIOLOGICAL CLASSIFICATION
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? IV. PATHOLOGICAL CLASSIFICATION
A. Anatomical Classification ? (IUSG)
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International Uveitis Study Group
1) Anterior Uveitis ? Inflammation of iris and anterior
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part of ciliary body.2) Intermediate Uveitis ? Involvement of posterior
part of ciliary body and extreme periphery of retina.
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(Pars planitis)
3) Posterior uveitis ? Retinochoroiditis, choroiditis,
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retinitis, chorioretinitis4) Diffuse or pan uveitis ? Involvement of entire uveal
tract
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B. Clinical Classification -
? 1) Acute ? sudden symptomatic onset. Persists
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for 3 weeks or less.? 2) Chronic ? Frequently insidious and
asymptomatic. Persists for months or years.
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? 3) Recurrent
C. Etiological Classification
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? 1) Exogenous-
Introduction of organism into the eye through a perforating
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wound or ulcer. Acute iridocyclitis of suppurative type, pan-ophthalmitis.
? 2) Secondary infection-
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Due to direct spread from adjoining structures-
-- Cornea
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-- Sclera-- Retina
D. Pathological Classification
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1) Granulomatous
2) Non-granulomatous
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POSTERIOR UVEITIS
? Posterior uveitis refers to inflammation of the
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choroid (choroiditis).? Since the outer layers of retina are in close
contact with the choroid and also depend on it
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for the nourishment, the choroidal inflammation
almost always involves the adjoining retina and
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the resultant lesion is called chorioretinitis.Clinical types
? I. Suppurative choroiditis (Purulent
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inflammation of the choroid)
? I . Non-suppurative choroiditis
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? 1. Diffuse choroiditis.? 2. Disseminated choroiditis.
? 3. Circumscribed/localised/focal choroiditis.
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i. Central choroiditis.
i . Juxtacaecal or juxtapapil ary choroiditis.
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i i. Anterior peripheral choroiditis.iv. Equatorial choroiditis.
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Symptoms? 1. Defective vision.
? 2. Photopsia.
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? 3. Black spots floating in front of the eyes.
? 4. Metamorphopsia.
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? 5. Micropsia? 6. Macropsia
? 7. Positive scotoma
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Signs
? 1. Vitreous opacities
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? 2. Features of a patch of choroiditis.i. In active stage it looks as a pale-yellow or
dirty white raised area with il -defined edges.
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This results due to exudation and cellular
infiltration of the choroid which hide the
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choroidal vessels. The lesion is typicallydeeper to the retinal vessels. The overlying
retina is often cloudy and oedematous.
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Signs
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? i . In atrophic stage or healed stage, when
active inflammation subsides, the affected area
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becomes more sharply defined and delineatedfrom the rest of the normal area. The involved
area shows white sclera below the atrophic
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choroid and black pigmented clumps at the
periphery of the lesion.
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Complications
These include extension of the inflammation to
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anterior uvea,complicated cataract,
vitreous degeneration,
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macular oedema,
secondary periphlebitis retinae and
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retinal detachment.Treatment
? It is broadly on the lines of anterior uveitis.
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? 1. Non-specific therapy: In the form of topical
and systemic steroids.
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? 2. Specific treatment is required for thecausative disease.
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PURULENT UVEITIS? Purulent uveitis is suppurative inflammation of
the uveal tract occurring as a result of direct
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invasion by the pyogenic organisms.
? Purulent iridocylitis
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? Purulent choroiditis? Endophthalmitis
? Panophthalmitis
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ENDOPHTHALMITIS
? Endophthalmitis is defined as an inflammation
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of the inner structures of the eyeball i.e., uvealtissue and retina associated with pouring of
exudates in the vitreous cavity, anterior
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chamber and posterior chamber.
? Etiologically endophthalmitis may be infectious
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or non-infectious (sterile).A. Infective endophthalmitis
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? Exogenous infections.? Endogenous or metastatic endophthalmitis.
? Secondary infections from surrounding
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structures.
Causative organisms
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? 1. Bacterial endophthalmitis.S. epidermidis and S.aureus,
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Streptococci,
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Pseudomonas,Pneumococci,
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Cornebacterium.
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Propionio bacterium acnes and actinomyces aregram-positive organisms capable of producing
slow grade endophthalmitis.
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? 2. Fungal endophthalmitis is caused by
aspergil us, fusarium, candida etc.
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B. Non-infective(sterile)endophthalmitis
? Sterile endophthalmitis refers to inflammation of
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inner structures of eyeball caused by certain
toxins/toxic substances. It occurs in following
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situations.? 1. Postoperative sterile endophthalmitis
? 2. Post-traumatic sterile endophthalmitis
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? 3. Intraocular tumour
? 4. Phacoanaphylactic endophthalmitis
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Symptoms.
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? Acute bacterial endophthalmitis usuallyoccurs within 7 days of operation and is
characterized by severe ocular pain, redness,
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lacrimation, photophobia and marked loss of
vision.
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Signs? Lid swelling
? Conjunctival chemosis and
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congestion
? Corneal edema
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? Wound gape & necrosis? Hypopyon
? Iris becomes edematous and
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muddy
? Yellow reflex
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? IOP may or may not be raisedTreatment
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? Intravitreal antibiotics , S/C injections, Topicalfortified antibiotic drops & oral antibiotics.
? Cycloplegics
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? Antiglaucoma therapy
? Vitrectomy
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PANOPHTHALMITIS? It is an intense purulent inflammation of the
whole eyeball including the Tenon's capsule.
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? Symptoms.
? Severe ocular pain and headache
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? Complete loss of vision? Watering & discharge
? Marked redness and swelling of the eyes
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Signs
? Lids swelling.
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? Eyeball is slightly proptosed, ocular
movements are limited & painful.
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? Ciliary as well as conjunctivalcongestion.
? Cornea is cloudy and oedematous.
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? Anterior chamber is full of pus.
? Vision is completely lost
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? Intraocular pressure is markedlyraised.
? Complications include
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? Orbital cellulitis
? Cavernous sinus thrombosis
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? Meningitis or encephalitisTreatment
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? 1. Anti-inflammatory and analgesics? 2. Broad spectrum antibiotics
? 3. Evisceration
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Non-suppurative Uveitis
? I. UVEITIS ASSOCIATED WITH CHRONIC
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SYSTEMIC BACTERIAL INFECTIONS:1. Tubercular uveitis
2. Syphilitic uveitis
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3. Leprotic uveitis
? UVEITIS ASSOCIATED WITH NONINFECTIOUS
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SYSTEMIC DISEASES1. Uveitis in sarcoidosis
2. Behcet's disease.
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Non-suppurative Uveitis
? III. UVEITIS ASSOCIATED WITH ARTHRITIS
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1. Uveitis with Ankylosing spondylitis
2. Reiter's syndrome
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3. Stil 's disease? IV. PARASITIC UVEITIS
1. Toxoplasmosis
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2. Toxocariasis
3. Onchocerciasis
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4. AmoebiasisNon-suppurative Uveitis
? V. FUNGAL UVEITIS
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1. Presumed ocular histoplasmosis syndrome
2. Candidiasis
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? VI. VIRAL UVEITIS1. Herpes simplex uveitis
2. Herpes zoster uveitis
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3. Acquired cytomegalovirus uveitis
4. Uveitis in acquired immune deficiency
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syndrome (AIDS)Non-suppurative Uveitis
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? VII. LENS INDUCED UVEITIS1. Phacotoxic uveitis
2. Phacoanaphylactic endophthalmitis
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? VIII. TRAUMATIC UVEITIS
? IX. UVEITIS ASSOCIATED WITH MALIGNANT
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INTRAOCULAR TUMOURSNon-suppurative Uveitis
? IDIOPATHIC SPECIFIC UVEITIS SYNDROMES
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1. Fuchs' uveitis syndrome
2. Intermediate uveitis (pars planitis)
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3. Sympathetic ophthalmitis4. Glaucomatocyclitic crisis.
5. Vogt-Koyanagi-Harada's syndrome.
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6. Bird shot retinochoroidopathy.
7. Acute multifocal placoid pigment
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epitheliopathy (AMPPE)8. Serpiginous choroidopathy.
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VOGT-KOYANAGI-HARADA (VKH) SYNDROME? It is an idiopathic multisystem disorder which includes
cutaneous, neurological and ocular lesions, more
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common in Japanese who are usually positive for HLA-
DR4 and DW15.
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? Clinical features? 1. Cutaneous lesions include: alopecia, poliosis and
vitiligo.
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? 2. Neurological lesions are in the form of
meningism,encephalopathy, tinnitus, vertigo and
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deafness.? 3. Ocular features are bilateral chronic granulomatous
panuveitis and exudative retinal detachment.
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? Treatment. It comprises steroids administered
topically, periocularly and systemically.
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SYMPATHETIC OPHTHALMITIS? It is a rare bilateral granulomatous panuveitis.
? Occurs following penetrating ocular trauma
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associated with incarceration of uveal tissue
in the wound.
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? The injured eye is called `exciting eye'and the fellow eye which also develops uveitis
is called `sympathizing eye'.
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? A. Predisposing factors? 1. It almost always follows a penetrating wound.
? 2. Wounds in the ciliary region
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? 3. Wounds with incarceration of the iris, ciliary
body or lens capsule are more vulnerable.
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? 4. It is more common in children than in adults.? 5. It does not occur when actual suppuration
develops in the injured eye.
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? Dalen-Fuchs' nodules are formed due to
proliferation of the pigment epithelium (of the iris,
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ciliary body and choroid) associated with invasionby the lymphocytes and epitheloid cells.
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Clinical picture? I. Exciting (injured) eye. It shows clinical features of
persistent low grade plastic uveitis, which include
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ciliary congestion, lacrimation and tenderness.
? 2. Sympathizing (sound) eye.
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It is usually involved after 4-8 weeks of injury in theother eye. Can occur upto 1 year after injury.
? Retrolental flare is first clinical sign.
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? If not prevented loss of sight is inevitable
? Prophylaxis
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Ocular ToxoplasmosisClinical features
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Unilateral focal chorio-retinitis adjacent to healedchorioretinal scar
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a. Healed scars may be multiple, but usually only
one reactivates at a time.
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b. Atypical forms of extensive chorio-retinitis canoccur in immunocompromised individuals.
c. Active chorio-retinitis is yellow-white, slightly
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elevated, with a relatively well-defined border.
Clinical features: Intraocular inflammation
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a. Iritis. Often granulomatous & may be associated withocular hypertension
b. Vitritis. Often intensified over the lesion
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c. Vasculitis. Variably present; Often arteritis, but
also periphlebitis and the vasculitis can be remote from
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the chorio-retinitisd. Optic neuritis or neuro-retinitis.
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Appropriate Laboratory Testing
1. Conformation of exposure to toxoplasmosis by serum ab. titer;
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high sensitivity and low specificity because of high prevalence
of positive antibody titers in general population
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2. Determination of toxoplasmosis IgG or IgA titers in aqueoushumor useful in cases with atypical features
3. PCR of aqueous humor for toxoplasmosis DNA useful in older
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patients with large lesions or in immunocompromised patients
Risk of congenital infection
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Acquired toxoplasmosis infection in a pregnant womana. Most severe effects on fetus if acquired during first trimester
b. Risk of transmission greatest if acquired during third trimester
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Seroconversion treated with antibiotic therapy
Prenatal treatment reduces fetal effects.
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Differential Diagnosis
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1. Toxocariasis2. Cytomegalovirus retinitis
3. Necrotizing herpetic retinitis
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4. Syphilis
5. Focal fungal or bacterial infections
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6. Intraocular lymphomaTreatment
Decision to treat based on proximity to macula and
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optic nerve, amount of inflammation, and vision
1. Sight-threatening infections almost always treated.
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2. Small, peripheral lesions often observed.3. Infection is self-limited in most cases in healthy patients.
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Treatment1. Pyrimethamine is most common agent combined with
sulfadiazine or triple-sulfa, azithromycin, or clindamycin
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Usually given with leukovorin to mitigate hematologic toxicity
2. Trimethoprim-sulfamethoxazole increasing in use combined
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with clindamycin for increased efficacy3. Monotherapy-generally reserved for non-sight-
threatening disease; Doxycycline or minocycline
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Anti-inflammatory Treatment
Topical corticosteroids
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Oral corticosteroidsIndicated for vision threatening inflammation
Low to moderate doses for 2 to 3 weeks
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Not given alone because of risk of worsened infection
without antibiotic coverage
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Periocular steroids felt to be contraindicatedbecause of reports of uncontrolled infection after injection
Generally not used in immunocompromised patients
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INTERMEDIATE UVEITIS (PARS
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PLANITIS)
? It denotes inflammation of pars plana part of
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ciliary body and most peripheral part of theretina.
? Etiology. It is an idiopathic disease usually
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affecting both eyes of young adults.
? Symptoms. Most of the patients present with
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history of floaters. Some patients may comewith defective vision due to associated cystoid
macular oedema.
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Signs
? Fundus examination with indirect
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ophthalmoscope reveals the whitish exudatespresent near the ora serrata in the inferior
quadrant. These typical exudates are referred
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as snow ball opacities. These may coalesce to
form a grey white plaque called snow banking.
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Complications
? Cystoid macular oedema,
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? Complicated cataract and? Tractional retinal detachment
? Treatment
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1. Corticosteroids ( Topical or systemic)
2. Immunosuppressive drugs may be helpful in
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steroid resistant cases.3. Peripheral cryotherapy is also reported to be
effective.
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MCQ
1. A 60 yr old female having h/o cataract surgery 1 yr
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back. She had complain of sudden onset painfuldiminution of vision and was diagnosed as a case of
late onset endophthalmitis. Organism most
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commonly implicated is?
? A. Pseudomonas aeruginosa
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? B. Staphylococcus epidermidis? C. Candida albicans
? D. Propionibacterium acnes
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MCQ
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2. Al of the following are involved in
endophthalmitis except?
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? A. Retina? B. Vitreous
? C. Sclera
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? D. Uvea
MCQ
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? 3. A 30 yr old female had complains of floaterswith blurring of vision. On indirect ophthalmoscopy
pt had clear central fundus but there was
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inflammation of the pheripheral part. What is your
diagnosis?
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? A. Panuveitis? B. Posterior uveitis
? C. Endophthalmitis
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? D. Pars planitis
MCQ
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? 4. A 50 yr old female having h/o cataract surgery 1
week back. She had complains of sudden onset
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painful diminution of vision, redness & watering. Onclinical examination she had hypopyon, AC cells
and flare with vitreous exudates on USG. What is
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your diagnosis?
? A. Panuveitis
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? B. Posterior uveitis? C. Endophthalmitis
? D. Panophthalmitis
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?
MCQ
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? 5. A 30 yrs old male had history of traumafollowed by loss of vision, severe pain, redness
and watering. On clinical examination he had
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inflammation of all ocular structures including
tenon's capsule. What is your diagnosis?
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? A. Panuveitis? B. Posterior uveitis
? C. Endophthalmitis
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? D. Panophthalmitis
MCQ
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? 6. A 50 yr old female having h/o cataract surgery 1
week back. She had complains of sudden onset
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painful diminution of vision, redness & watering.On clinical examination she had hypopyon, AC
cells and flare with vitreous exudates on USG.
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Which is the most common organism responsible
for the condition?
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? A. Pseudomonas aeruginosa? B. Staphylococcus epidermidis
? C. Candida albicans
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? D. Propionibacterium acnes
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MCQ? 7. A 15 yrs old male had history of penetrating
trauma to right eye followed by loss of vision,
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severe pain, redness and watering in the left eye 3
months after trauma . On clinical examination he
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retrolental flare with signs of panuveitis. What isyour diagnosis?
? A. Sympathetic ophthalmitis
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? B. Posterior uveitis
? C. Endophthalmitis
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? D. PanophthalmitisMCQ
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? 8. What is the most common cause of loss ofvision in pars planitis?
? A. Panuveitis
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? B. Posterior uveitis
? C. Cystoid macular edema
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? D.FloatersMCQ
9. Snow banking is seen in:
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A. Panuveitis
B. Posterior uveitis
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C. EndophthalmitisD. Pars planitis
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MCQ? 10. Dalen-Fuchs' nodules are seen in:
? A. Sympathetic ophthalmitis
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? B. Posterior uveitis
? C. Endophthalmitis
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? D. PanophthalmitisTHANK YOU