Download MBBS Ophthalmology PPT 43 Posterior Uveitis Lecture Notes

POSTERIOR UVEITIS

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Definition & Classification of Uveitis-
? 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, chorioretinitis

4) 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 typically

deeper 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 delineated

from 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 the

causative 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., uveal

tissue 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 are

gram-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 usually

occurs 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 raised


Treatment

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? Intravitreal antibiotics , S/C injections, Topical

fortified 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 conjunctival

congestion.

? 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 markedly

raised.

? Complications include

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? Orbital cellulitis

? Cavernous sinus thrombosis

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? Meningitis or encephalitis


Treatment

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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 DISEASES

1. 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. Amoebiasis

Non-suppurative Uveitis

? V. FUNGAL UVEITIS

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1. Presumed ocular histoplasmosis syndrome

2. Candidiasis

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? VI. VIRAL UVEITIS

1. 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 UVEITIS

1. Phacotoxic uveitis

2. Phacoanaphylactic endophthalmitis

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? VIII. TRAUMATIC UVEITIS

? IX. UVEITIS ASSOCIATED WITH MALIGNANT

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INTRAOCULAR TUMOURS

Non-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 ophthalmitis

4. 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 invasion

by 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 the

other 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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? Treatment.

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Ocular Toxoplasmosis
Clinical features

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Unilateral focal chorio-retinitis adjacent to healed

chorioretinal 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 can

occur 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 with

ocular 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-retinitis

d. 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 aqueous

humor 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 woman

a. 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. Toxocariasis

2. Cytomegalovirus retinitis

3. Necrotizing herpetic retinitis

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4. Syphilis

5. Focal fungal or bacterial infections

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6. Intraocular lymphoma

Treatment

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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Treatment

1. 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 efficacy

3. 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 corticosteroids

Indicated 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 contraindicated

because 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 the

retina.

? 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 come

with 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 exudates

present 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 painful

diminution 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 floaters

with 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. On

clinical 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 trauma

followed 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 is

your diagnosis?

? A. Sympathetic ophthalmitis

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? B. Posterior uveitis

? C. Endophthalmitis

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? D. Panophthalmitis


MCQ

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? 8. What is the most common cause of loss of

vision in pars planitis?

? A. Panuveitis

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? B. Posterior uveitis

? C. Cystoid macular edema

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? D.Floaters

MCQ

9. Snow banking is seen in:

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A. Panuveitis

B. Posterior uveitis

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C. Endophthalmitis

D. 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. Panophthalmitis

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