Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Ophthalmology PPT 43 Posterior Uveitis Lecture Notes
POSTERIOR UVEITIS
Definition & Classification of Uveitis-
? Inflammation of uveal tract is uveitis.
? CLASSIFICATION:
? I. ANATOMICAL CLASSIFICATION
? II. CLINICAL CLASSIFICATION
? III. ETIOLOGICAL CLASSIFICATION
? IV. PATHOLOGICAL CLASSIFICATION
A. Anatomical Classification ? (IUSG)
International Uveitis Study Group
1) Anterior Uveitis ? Inflammation of iris and anterior
part of ciliary body.
2) Intermediate Uveitis ? Involvement of posterior
part of ciliary body and extreme periphery of retina.
(Pars planitis)
3) Posterior uveitis ? Retinochoroiditis, choroiditis,
retinitis, chorioretinitis
4) Diffuse or pan uveitis ? Involvement of entire uveal
tract
B. Clinical Classification -
? 1) Acute ? sudden symptomatic onset. Persists
for 3 weeks or less.
? 2) Chronic ? Frequently insidious and
asymptomatic. Persists for months or years.
? 3) Recurrent
C. Etiological Classification
? 1) Exogenous-
Introduction of organism into the eye through a perforating
wound or ulcer. Acute iridocyclitis of suppurative type, pan-
ophthalmitis.
? 2) Secondary infection-
Due to direct spread from adjoining structures-
-- Cornea
-- Sclera
-- Retina
D. Pathological Classification
1) Granulomatous
2) Non-granulomatous
POSTERIOR UVEITIS
? Posterior uveitis refers to inflammation of the
choroid (choroiditis).
? Since the outer layers of retina are in close
contact with the choroid and also depend on it
for the nourishment, the choroidal inflammation
almost always involves the adjoining retina and
the resultant lesion is called chorioretinitis.
Clinical types
? I. Suppurative choroiditis (Purulent
inflammation of the choroid)
? I . Non-suppurative choroiditis
? 1. Diffuse choroiditis.
? 2. Disseminated choroiditis.
? 3. Circumscribed/localised/focal choroiditis.
i. Central choroiditis.
i . Juxtacaecal or juxtapapil ary choroiditis.
i i. Anterior peripheral choroiditis.
iv. Equatorial choroiditis.
Symptoms
? 1. Defective vision.
? 2. Photopsia.
? 3. Black spots floating in front of the eyes.
? 4. Metamorphopsia.
? 5. Micropsia
? 6. Macropsia
? 7. Positive scotoma
Signs
? 1. Vitreous opacities
? 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.
This results due to exudation and cellular
infiltration of the choroid which hide the
choroidal vessels. The lesion is typically
deeper to the retinal vessels. The overlying
retina is often cloudy and oedematous.
Signs
? i . In atrophic stage or healed stage, when
active inflammation subsides, the affected area
becomes more sharply defined and delineated
from the rest of the normal area. The involved
area shows white sclera below the atrophic
choroid and black pigmented clumps at the
periphery of the lesion.
Complications
These include extension of the inflammation to
anterior uvea,
complicated cataract,
vitreous degeneration,
macular oedema,
secondary periphlebitis retinae and
retinal detachment.
Treatment
? It is broadly on the lines of anterior uveitis.
? 1. Non-specific therapy: In the form of topical
and systemic steroids.
? 2. Specific treatment is required for the
causative disease.
PURULENT UVEITIS
? Purulent uveitis is suppurative inflammation of
the uveal tract occurring as a result of direct
invasion by the pyogenic organisms.
? Purulent iridocylitis
? Purulent choroiditis
? Endophthalmitis
? Panophthalmitis
ENDOPHTHALMITIS
? Endophthalmitis is defined as an inflammation
of the inner structures of the eyeball i.e., uveal
tissue and retina associated with pouring of
exudates in the vitreous cavity, anterior
chamber and posterior chamber.
? Etiologically endophthalmitis may be infectious
or non-infectious (sterile).
A. Infective endophthalmitis
? Exogenous infections.
? Endogenous or metastatic endophthalmitis.
? Secondary infections from surrounding
structures.
Causative organisms
? 1. Bacterial endophthalmitis.
S. epidermidis and S.aureus,
Streptococci,
Pseudomonas,
Pneumococci,
Cornebacterium.
Propionio bacterium acnes and actinomyces are
gram-positive organisms capable of producing
slow grade endophthalmitis.
? 2. Fungal endophthalmitis is caused by
aspergil us, fusarium, candida etc.
B. Non-infective
(sterile)endophthalmitis
? Sterile endophthalmitis refers to inflammation of
inner structures of eyeball caused by certain
toxins/toxic substances. It occurs in following
situations.
? 1. Postoperative sterile endophthalmitis
? 2. Post-traumatic sterile endophthalmitis
? 3. Intraocular tumour
? 4. Phacoanaphylactic endophthalmitis
Symptoms.
? Acute bacterial endophthalmitis usually
occurs within 7 days of operation and is
characterized by severe ocular pain, redness,
lacrimation, photophobia and marked loss of
vision.
Signs
? Lid swelling
? Conjunctival chemosis and
congestion
? Corneal edema
? Wound gape & necrosis
? Hypopyon
? Iris becomes edematous and
muddy
? Yellow reflex
? IOP may or may not be raised
Treatment
? Intravitreal antibiotics , S/C injections, Topical
fortified antibiotic drops & oral antibiotics.
? Cycloplegics
? Antiglaucoma therapy
? Vitrectomy
PANOPHTHALMITIS
? It is an intense purulent inflammation of the
whole eyeball including the Tenon's capsule.
? Symptoms.
? Severe ocular pain and headache
? Complete loss of vision
? Watering & discharge
? Marked redness and swelling of the eyes
Signs
? Lids swelling.
? Eyeball is slightly proptosed, ocular
movements are limited & painful.
? Ciliary as well as conjunctival
congestion.
? Cornea is cloudy and oedematous.
? Anterior chamber is full of pus.
? Vision is completely lost
? Intraocular pressure is markedly
raised.
? Complications include
? Orbital cellulitis
? Cavernous sinus thrombosis
? Meningitis or encephalitis
Treatment
? 1. Anti-inflammatory and analgesics
? 2. Broad spectrum antibiotics
? 3. Evisceration
Non-suppurative Uveitis
? I. UVEITIS ASSOCIATED WITH CHRONIC
SYSTEMIC BACTERIAL INFECTIONS:
1. Tubercular uveitis
2. Syphilitic uveitis
3. Leprotic uveitis
? UVEITIS ASSOCIATED WITH NONINFECTIOUS
SYSTEMIC DISEASES
1. Uveitis in sarcoidosis
2. Behcet's disease.
Non-suppurative Uveitis
? III. UVEITIS ASSOCIATED WITH ARTHRITIS
1. Uveitis with Ankylosing spondylitis
2. Reiter's syndrome
3. Stil 's disease
? IV. PARASITIC UVEITIS
1. Toxoplasmosis
2. Toxocariasis
3. Onchocerciasis
4. Amoebiasis
Non-suppurative Uveitis
? V. FUNGAL UVEITIS
1. Presumed ocular histoplasmosis syndrome
2. Candidiasis
? VI. VIRAL UVEITIS
1. Herpes simplex uveitis
2. Herpes zoster uveitis
3. Acquired cytomegalovirus uveitis
4. Uveitis in acquired immune deficiency
syndrome (AIDS)
Non-suppurative Uveitis
? VII. LENS INDUCED UVEITIS
1. Phacotoxic uveitis
2. Phacoanaphylactic endophthalmitis
? VIII. TRAUMATIC UVEITIS
? IX. UVEITIS ASSOCIATED WITH MALIGNANT
INTRAOCULAR TUMOURS
Non-suppurative Uveitis
? IDIOPATHIC SPECIFIC UVEITIS SYNDROMES
1. Fuchs' uveitis syndrome
2. Intermediate uveitis (pars planitis)
3. Sympathetic ophthalmitis
4. Glaucomatocyclitic crisis.
5. Vogt-Koyanagi-Harada's syndrome.
6. Bird shot retinochoroidopathy.
7. Acute multifocal placoid pigment
epitheliopathy (AMPPE)
8. Serpiginous choroidopathy.
VOGT-KOYANAGI-HARADA (VKH) SYNDROME
? It is an idiopathic multisystem disorder which includes
cutaneous, neurological and ocular lesions, more
common in Japanese who are usually positive for HLA-
DR4 and DW15.
? Clinical features
? 1. Cutaneous lesions include: alopecia, poliosis and
vitiligo.
? 2. Neurological lesions are in the form of
meningism,encephalopathy, tinnitus, vertigo and
deafness.
? 3. Ocular features are bilateral chronic granulomatous
panuveitis and exudative retinal detachment.
? Treatment. It comprises steroids administered
topically, periocularly and systemically.
SYMPATHETIC OPHTHALMITIS
? It is a rare bilateral granulomatous panuveitis.
? Occurs following penetrating ocular trauma
associated with incarceration of uveal tissue
in the wound.
? The injured eye is called `exciting eye'
and the fellow eye which also develops uveitis
is called `sympathizing eye'.
? A. Predisposing factors
? 1. It almost always follows a penetrating wound.
? 2. Wounds in the ciliary region
? 3. Wounds with incarceration of the iris, ciliary
body or lens capsule are more vulnerable.
? 4. It is more common in children than in adults.
? 5. It does not occur when actual suppuration
develops in the injured eye.
? Dalen-Fuchs' nodules are formed due to
proliferation of the pigment epithelium (of the iris,
ciliary body and choroid) associated with invasion
by the lymphocytes and epitheloid cells.
Clinical picture
? I. Exciting (injured) eye. It shows clinical features of
persistent low grade plastic uveitis, which include
ciliary congestion, lacrimation and tenderness.
? 2. Sympathizing (sound) eye.
It is usually involved after 4-8 weeks of injury in the
other eye. Can occur upto 1 year after injury.
? Retrolental flare is first clinical sign.
? If not prevented loss of sight is inevitable
? Prophylaxis
? Treatment.
Ocular Toxoplasmosis
Clinical features
Unilateral focal chorio-retinitis adjacent to healed
chorioretinal scar
a. Healed scars may be multiple, but usually only
one reactivates at a time.
b. Atypical forms of extensive chorio-retinitis can
occur in immunocompromised individuals.
c. Active chorio-retinitis is yellow-white, slightly
elevated, with a relatively well-defined border.
Clinical features: Intraocular inflammation
a. Iritis. Often granulomatous & may be associated with
ocular hypertension
b. Vitritis. Often intensified over the lesion
c. Vasculitis. Variably present; Often arteritis, but
also periphlebitis and the vasculitis can be remote from
the chorio-retinitis
d. Optic neuritis or neuro-retinitis.
Appropriate Laboratory Testing
1. Conformation of exposure to toxoplasmosis by serum ab. titer;
high sensitivity and low specificity because of high prevalence
of positive antibody titers in general population
2. Determination of toxoplasmosis IgG or IgA titers in aqueous
humor useful in cases with atypical features
3. PCR of aqueous humor for toxoplasmosis DNA useful in older
patients with large lesions or in immunocompromised patients
Risk of congenital infection
Acquired toxoplasmosis infection in a pregnant woman
a. Most severe effects on fetus if acquired during first trimester
b. Risk of transmission greatest if acquired during third trimester
Seroconversion treated with antibiotic therapy
Prenatal treatment reduces fetal effects.
Differential Diagnosis
1. Toxocariasis
2. Cytomegalovirus retinitis
3. Necrotizing herpetic retinitis
4. Syphilis
5. Focal fungal or bacterial infections
6. Intraocular lymphoma
Treatment
Decision to treat based on proximity to macula and
optic nerve, amount of inflammation, and vision
1. Sight-threatening infections almost always treated.
2. Small, peripheral lesions often observed.
3. Infection is self-limited in most cases in healthy patients.
Treatment
1. Pyrimethamine is most common agent combined with
sulfadiazine or triple-sulfa, azithromycin, or clindamycin
Usually given with leukovorin to mitigate hematologic toxicity
2. Trimethoprim-sulfamethoxazole increasing in use combined
with clindamycin for increased efficacy
3. Monotherapy-generally reserved for non-sight-
threatening disease; Doxycycline or minocycline
Anti-inflammatory Treatment
Topical corticosteroids
Oral corticosteroids
Indicated for vision threatening inflammation
Low to moderate doses for 2 to 3 weeks
Not given alone because of risk of worsened infection
without antibiotic coverage
Periocular steroids felt to be contraindicated
because of reports of uncontrolled infection after injection
Generally not used in immunocompromised patients
INTERMEDIATE UVEITIS (PARS
PLANITIS)
? It denotes inflammation of pars plana part of
ciliary body and most peripheral part of the
retina.
? Etiology. It is an idiopathic disease usually
affecting both eyes of young adults.
? Symptoms. Most of the patients present with
history of floaters. Some patients may come
with defective vision due to associated cystoid
macular oedema.
Signs
? Fundus examination with indirect
ophthalmoscope reveals the whitish exudates
present near the ora serrata in the inferior
quadrant. These typical exudates are referred
as snow ball opacities. These may coalesce to
form a grey white plaque called snow banking.
Complications
? Cystoid macular oedema,
? Complicated cataract and
? Tractional retinal detachment
? Treatment
1. Corticosteroids ( Topical or systemic)
2. Immunosuppressive drugs may be helpful in
steroid resistant cases.
3. Peripheral cryotherapy is also reported to be
effective.
MCQ
1. A 60 yr old female having h/o cataract surgery 1 yr
back. She had complain of sudden onset painful
diminution of vision and was diagnosed as a case of
late onset endophthalmitis. Organism most
commonly implicated is?
? A. Pseudomonas aeruginosa
? B. Staphylococcus epidermidis
? C. Candida albicans
? D. Propionibacterium acnes
MCQ
2. Al of the following are involved in
endophthalmitis except?
? A. Retina
? B. Vitreous
? C. Sclera
? D. Uvea
MCQ
? 3. A 30 yr old female had complains of floaters
with blurring of vision. On indirect ophthalmoscopy
pt had clear central fundus but there was
inflammation of the pheripheral part. What is your
diagnosis?
? A. Panuveitis
? B. Posterior uveitis
? C. Endophthalmitis
? D. Pars planitis
MCQ
? 4. A 50 yr old female having h/o cataract surgery 1
week back. She had complains of sudden onset
painful diminution of vision, redness & watering. On
clinical examination she had hypopyon, AC cells
and flare with vitreous exudates on USG. What is
your diagnosis?
? A. Panuveitis
? B. Posterior uveitis
? C. Endophthalmitis
? D. Panophthalmitis
?
MCQ
? 5. A 30 yrs old male had history of trauma
followed by loss of vision, severe pain, redness
and watering. On clinical examination he had
inflammation of all ocular structures including
tenon's capsule. What is your diagnosis?
? A. Panuveitis
? B. Posterior uveitis
? C. Endophthalmitis
? D. Panophthalmitis
MCQ
? 6. A 50 yr old female having h/o cataract surgery 1
week back. She had complains of sudden onset
painful diminution of vision, redness & watering.
On clinical examination she had hypopyon, AC
cells and flare with vitreous exudates on USG.
Which is the most common organism responsible
for the condition?
? A. Pseudomonas aeruginosa
? B. Staphylococcus epidermidis
? C. Candida albicans
? D. Propionibacterium acnes
MCQ
? 7. A 15 yrs old male had history of penetrating
trauma to right eye followed by loss of vision,
severe pain, redness and watering in the left eye 3
months after trauma . On clinical examination he
retrolental flare with signs of panuveitis. What is
your diagnosis?
? A. Sympathetic ophthalmitis
? B. Posterior uveitis
? C. Endophthalmitis
? D. Panophthalmitis
MCQ
? 8. What is the most common cause of loss of
vision in pars planitis?
? A. Panuveitis
? B. Posterior uveitis
? C. Cystoid macular edema
? D.Floaters
MCQ
9. Snow banking is seen in:
A. Panuveitis
B. Posterior uveitis
C. Endophthalmitis
D. Pars planitis
MCQ
? 10. Dalen-Fuchs' nodules are seen in:
? A. Sympathetic ophthalmitis
? B. Posterior uveitis
? C. Endophthalmitis
? D. Panophthalmitis
THANK YOU
This post was last modified on 07 April 2022