Anterior uveitis
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OphthalmologyDEFINITION:-
The inflammation of uveal tract.
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Classification-n I. ANATOMICAL CLASSIFICATION
n II. CLINICAL CLASSIFICATION
n III. ETIOLOGICAL CLASSIFICATION
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n IV. PATHOLOGICAL CLASSIFICATIONA. Anatomical Classification ?
(IUSG) International Uveitis Study
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Group
n
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1) Anterior Uveitis ? Inflammation of irisand anterior part of ciliary body.
n
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2) Intermediate Uveitis ? Involvement of
posterior part of ciliary body and extreme
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periphery of retina. (Pars planitis)n
3) Posterior uveitis ? Retinochoroiditis,
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choroiditis, retinitis, chorioretinitis
n
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4) Diffuse or pan uveitis ? Involvement ofentire uveal tract
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B. Clinical Classification -n 1) Acute ? sudden symptomatic onset.
Persists for 3 weeks or less.
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n 2) Chronic ? Frequently insidious and
asymptomatic. Persists for months or
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years.n 3) Recurrent
C. Etiological Classification
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One of the most difficult problems in ophthalmology.
In most of the cases, probably, al ergy is the cause.
n 1) Exogenous-
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Introduction of organism into the eye through a
perforating wound or ulcer.
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n 2) Secondary infection-Due to direct spread from adjoining structures-
n
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Cornea
n
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Scleran
Retina
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3) Endogenous
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4) Al ergic inflammation: Result of an antigen-antibody
reaction occurring in the eye due to previous
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sensitization of uveal tissue to some al ergen. Theal ergen is a foreign protein.
n Most of the cases of iridocyclitis do not have any
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specific cause and are probably al ergic in nature.
5) Auto-immune -
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Immune disorderse.g. rheumatoid arthritis, SLE, ankylosing spondylitis,
Reiter's syndrome, Behcet's Syndrome.
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D. Pathological ClassificationGranulomatous
Non-
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granulomatous
1. Aetiology
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OrganismalAntigen-antibody
invasion
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reaction
2. Course
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a) OnsetInsidious
Acute
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b) Duration
Chronic
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Shortc) Inflammation
Moderate
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Severe
Granulomatous
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Non-granulomatous
3. Pathology
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a) Lesion
Circumscribed
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Diffuseb) Iris
Focal reaction
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Diffuse reaction
c) Keratic
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Mutton fatFine plenty
precipitates
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d) Iris adhesions Coarse, few, thick Fine, plenty, thin4.
May be positive
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Negative
Investigations
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PATHOLOGY AND
CLINICAL SIGNS-
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Inflammation of iris and ciliary bodyDilatation of blood vessels
Iris stromal edema.
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SIGNS - Iris pattern altered.Iris colour
altered. Iris thickened.Also
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accompanied by, ciliary congestion,conjunctival hyperaemia and chemosis
of conjunctiva.
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SIGNS ?
n Iris pattern and colour altered.
n Iris thickened accompanied by, ciliary
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congestion, conjunctival hyperaemiaand chemosis of conjunctiva.
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Exudation of fibrin-rich fluid andinflammatory cells in the tissues
Exudates escape into anterior chamber
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n Plasmoid aqueous
n SIGNS - Aqueous flare (like the beam
of projector in smokey theatre)
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Nutrition of corneal endothelium is
affected due to toxins
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Corneal endothelium becomes stickyand edematous
Cells desquamated at places
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Inflammatory cells stick to endothelial
layer as cellular deposits .
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SIGN ? Keratic precipitates
In very intense cases, polymorphs pour
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out to sink to bottom of anteriorchamber
SIGN ? Hypopyon
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Exudates cover the iris as a thin film and
spread over pupil ary area
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SIGN ? Irritation of iris musculature
constrictor being more powerful than
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dilator, spasm results in miosis.If exudate is profuse
SIGN ? Plastic iritis
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Blockage of pupil
SIGN ? impairment of sight.
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In early stages, there is adhesion of iris to lens capsule(Atropine may free the iris)
SIGN ? Spots of exudate or pigment derived from posterior
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layer of iris left permanently upon anterior capsule of
lens (valuable evidence of previous iritis)
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Later on, the organization of the adhesion leads to formation offibrous bands between pupil ary margin of iris and lens capsule
(atropine cannot rupture them)
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SIGN ? Posterior synechiae (more in lower part of pupil
due to effect of gravity)
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When adhesions are localized and a
mydriatic is instil ed, it causes
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intervening portions of circle of pupil todilate.
SIGN? Festooned pupil
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(due to irregular dilatation
and is a sign of present or
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past iritis.)Pigment epithelium on
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posterior surface is pul ed
around pupil ary margin so
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that patches of pigment onanterior surface of iris are
seen.
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SIGN ? Ectropion of
uveal pigment (due to
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contraction oforganizing exudates
upon iris)
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With recurrent attacks or severe cases, the
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whole circle of pupil ary margin gets tied
to lens capsule.
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SIGNS ? Annular or ring synechiae or
Seclusio pupillae
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Col ection of aqueous behind iris since
aqueous drainage is hampered.
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Iris is hence bowed forwards like sail.SIGN ? Iris Bombe (anterior chamber is
funnel shaped i.e. deepest in centre,
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shallowest at periphery)
As iris bulges forward and comes into contact with
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cornea
Adhesions of iris to cornea at periphery develop
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SIGNS ? Peripheral anterior synechiaeObliteration of filtration angle (Hypertensive
iridocyclitis)
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SIGNS ? Rise in IOP (secondary glaucoma)
When exudate is more extensive
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Organization of exudate across entire pupil aryarea
Film of opaque fibrous tissue in pupil ary area
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SIGNS ? Occlusio pupillae or Blocked pupil
Exudates fil up posterior chamber if there is
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much of cyclitisWhen these adhesions organize, the iris adheres
to lens capsule.
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SIGNS ? Total posterior synechiae
When these adhesions organize, the iris
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adheres to lens capsule.
SIGNS ? Total posterior synechiae
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Retraction of peripheral part of irisAnterior chamber is abnormal y deep at
periphery
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In worst cases of plastic iridocyclitis
Cyclitic membrane formed
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behind lensFinal y, degenerative
changes in ciliary body
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Vitreous becomes fluid
Nutrition of lens impaired
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Phthisis bulbi wil be the SIGNS ? Complicatedeventuality.
cataract
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In final stages, there is
interference with
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secretion of aqueous
Fal in IOP
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Eye shrinks (developmentof soft eye is an
ominous sign)
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SIGNS ? Phthisis bulbi
Clinical Features
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SYMPTOMSSIGNS
n Pain
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n
Signs of vascular
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n Diminished visioncongestion
n Redness of eye
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n
Signs of exudation
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n lacrimationn
Signs of pupil ary
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changes
n photophobia
Clinical Features
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SIGNS
n
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Lid oedeman
Circumcorneal congestion
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n
Corneal signs
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nAnterior chamber signs
n
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Iris signs
n
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Pupil ary signsn
Lenticular changes
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n
Changes in the vitreous
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Clinical FeaturesSIGNS
n
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Corneal signs
Corneal oedema
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Keratic precipitates (KPs)Mutton fat, granular, red & old KPs
Posterior corneal opacity
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Clinical FeaturesSIGNS
n
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Anterior chamber signs
n 1. Aqueous cel s. It is an early feature of
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iridocyclitis.n ? = 0 cel s,
n ? = 1?5 cel s,
n +1 = 6?10 cel s,
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n +2 = 11-20 cel s,n +3 = 21?50 cel s, and
n +4 = over 50 cel s
Clinical Features
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n 2. Aqueous flare. It is due to leakage of protein
particles into the aqueous humour from damaged
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blood vessels. It is demonstrated on the slit lampexamination by a point beam of light passed obliquely to
the plane of iris.
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n Grade :
n 0 = no aqueous flare,
n +1 = just detectable;
n +2 = moderate flare with clear iris details;
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n +3 = marked flare (iris details not clear);n +4 = intense flare (fixed coagulated aqueous
with considerable fibrin).
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n Aqueous Flare
Clinical Features
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SIGNSn
Anterior chamber signs
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3. Hypopyon. When exudates are heavy and thick,
they settle down in lower part of the anterior chamber
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as hypopyon (sterile pus in the anterior chamber)4. Hyphaema (blood in the anterior chamber): It may
be seen in haemorrhagic type of uveitis.
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n Hypopyon in anterior uveitis
Clinical Features
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SIGNSn
Iris signs
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1. Loss of normal pattern.
2. Changes in iris colour.
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3. Iris nodules4. Posterior synechiae.
5. Neovascularsation of iris
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Clinical FeaturesSIGNS
n
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Pupil ary signs
1. Narrow pupil.
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2. Irregular pupil shape.3. Ectropion pupil ae
4. Sluggish pupil ary reaction
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5. Occlusio pupil ae
Clinical Features
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SIGNSn
Lenticular signs
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1. Pigment dispersal over anterior lens capsule
2. Exudates
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3. Complicated cataractn Change in the vitreous
Anterior vitreous may show exudates and
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inflammatory cel s after an attack of acuteiridocyclitis.
n Fuch's heterochromic iridocylitis
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n Posner Schlossman syndrome.Fuch's heterochromic
iridocylitis
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n Fuchs' heterochromic iridocyclitis is a
chronic nongranulomatous type of low
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grade anterior uveitis.n It typical y occurs unilateral y in middle-
aged persons.
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Fuch's heterochromiciridocylitis
n The disease is characterised by:
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n (i) heterochromia of iris,n (i ) diffuse stromal iris atrophy,
n (i i) fine KPs at back of cornea,
n (iv) faint aqueous flare,
n (v) absence of posterior synechiae,
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n (vi) a fairly common rubeosis iridis,
sometimes associated with
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neovascularisation of the angle of anteriorchamber
n (vi )comparatively early development of
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complicated cataract and secondary
glaucoma (usual y open angle type).
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n Treatment. Topical corticosteroids .Posner Schlossman syndrome.
n Recurrent attacks of acute rise of intraocular
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pressure (40-50 mm of Hg) withoutshal owing of anterior chamber associated
with,
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n fine KPs at the back of cornea, without any
posterior synechiae,
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n epithelial oedema of cornea,n a dilated pupil, and a white eye (no
congestion).
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Posner Schlossman syndrome.n The disease typical y affects young adults, 40
percent of whom are positive for HLA-BW54.
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n Treatment. It includes medical
treatment to lower IOP along with a short
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course of topical steroids.Differential Diagnosis
Character
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Conjunctivitis IridocyclitisGlaucoma
Infection
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Superficial
Deep
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----Secretion
Mucopurulent
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Watery
Watery
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PupilNormal
Smal ,
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Large, Oval
irregular
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Character Conjunctivitis Iridocyclitis GlaucomaMedia
Clear
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Sometimes Corneal
pupil
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oedemaopaque
Tension
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Normal
Usual y
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Highnormal
Pain
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Mild
Moderate Severe and
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with firstentire
division of trigeminal
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trigeminal
Character
Conjunctivitis Iridocyclitis Glaucoma
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Tenderness
Absent
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MarkedMarked
Vision
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Good
Fair
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PoorOnset
Gradual
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Usual y
Sudden
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gradualSystemic
Absent
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Little
Prostration
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complicationsand
vomiting
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Complications of Uveitis
n
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Hypertensive uveitis ? Secondary glaucoman
Endothelial opacities in cornea due to formation of keratic
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precipitates
n
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Hypopyon and hyphaeman
Suppurative uveitis may progress to end-ophthalmitis or
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pan-ophthalmitis
n
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Toxic matter goes into lens ? complicated cataract.n
Post inflammatory atrophy of zonules ? subluxation of
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lens
n
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Vitreous ? opacification of vitreous, liquification of gel,shrinkage of gel, retinal detachment
Contd.
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...n
macular edema
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noptic neuritis ? undergoes atrophy ? optic nerve
atrophy
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n
occlusive pupil ae
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nseclusion pupil ae
n
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Ectropion of uveal pigment
n
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Hypotony ? atrophic bulbin
Secondary squint
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n
Iris atrophy
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Investigationsn
Local
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n
Vision, refraction, fundus examination
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nIOP by Schiotz Tonometer
n
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Slit Lamp examination
n
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Focal ?n
ENT, Dental, Genito-urinatory
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examination for septic focus.
n
For associated systemic disorders ?
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n
CBC, ESR, MT, X-ray chest ? Tuberculosis
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nUrine, Blood examination-Diabetes
n
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VDRL, Kahn Test ? syphilis
n
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Urethral smear ? gonorrhoeaen
Urine culture ? for UTI
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n
Blood culture ? Septicemia
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nASLO Titre, C-reactive protein ? for
rheumatic disorders
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n
Screening test for auto immune disorders
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Treatment1.
Of iridocyclitis
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2.
Of complications and sequelae.
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Treatment of Iridocyclitis
n
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Drugs used ?n
Mydriatics
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n
Steroids
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nCytotoxic agents
n
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Cyclosporin
Essentials of treatment of
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anterior uveitisDilatation of pupil with atropine
n Hot application
n Control of acute phase of inflammation
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with steroids
Atropine
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n
Acts in 3 ways
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nby keeping the iris and ciliary body at rest
n
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by diminishing hyperaemia
n
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by preventing formation of posteriorsynechiae and breaking down any already
formed.
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Method of administration and
dose:
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n Atropine may be used in form of drops orointment (1%) ,every four hours is usual y
sufficient.
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n When pupil is wel dilated, twice a day
suffices.
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n If atropine irritation ensues, one or the othersubstitutes for this drug may be used.
e.g. Homatropine, Cyclopentolate.
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Mydriasis -the sub-conjunctival injection
of 0.3 ml. of mydricaine, a mixture of
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atropine, procaine and adrenaline.
To avoid relapse-Atropine, or its
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equivalent -continued for at least 10days to a fortnight after the eye
appears to be quiet.
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n
Hot application
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nextremely soothing to patient by
diminishing the pain.
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n
of therapeutic service in increasing the
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circulation.Corticosteroids
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nAdministered as drops or ointment, or more
effectively as subconjunctival injections are
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of great value in control ing the
inflammation in the acute phase.
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nOccasional y, results are dramatic and eye
becomes white with great rapidity.
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n
Minimize damages of antigen antibody
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reaction.Aspirin
n
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Is very useful in relieving pain but if it
is intense, stronger preparation are
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required.n
Cyclosporin
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-T-cel immunosuppressive drug. Used inresistant cases.
n
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Broad spectrum antibiotic
- In case of suppurative uveitis.
n
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Specific Chemotherapy for Tuberculosis,
syphilis, gonorrhoea.
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nIncreasing body resistance by multi-vitamins.
Treatment of complications
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and sequelae-
n
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Secondary glaucoma-n
Before formation of posterior or
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peripheral synechiae,- intensify
atropinisation in order to al ay the
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inflammatory congestion.n
Corticosteroids - topical y and
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acetazolamide - systematical y are
very useful in such cases..
Annular synechiae-
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n
Iridectomy `
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n( No operative procedure of this kind must be
undertaken during an acute attack of iritis if it can
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be avoided. Reason ? operation wil set up a
traumatic iritis which wil result in the opening
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getting fil ed with exudates.)n
preventive iridectomy- Since ring synechiae is
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the result of recurrent attacks, iridectomy can be
performed during quiescent interval.
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nDifficulty ? iris is atrophied, friable. Haemorrhage is
common. Synechiae can be broken with YAG Laser.
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n
Hypopyon and Hyphaema may need
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evacuation and A.C. Wash.n
End-ophthalmitis ? intravitreal injection of
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Decadron and Gentamicin
n
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Pan ophthalmitis ? Eviscerationn
Iris Bombe
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Medical ? 1. Atropine
2. Diamox
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Surgical ? 1. 4-dot Iridotomyn
using von Graefe's knife
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n
YAG Laser for breaking posterior synechiae
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