Download MBBS Ophthalmology PPT 1 Anterior Uveitis Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Ophthalmology PPT 1 Anterior Uveitis Lecture Notes




Anterior uveitis

Ophthalmology

DEFINITION:-

The inflammation of uveal tract.
Classification-

n I. ANATOMICAL CLASSIFICATION
n II. CLINICAL CLASSIFICATION
n III. ETIOLOGICAL CLASSIFICATION
n IV. PATHOLOGICAL CLASSIFICATION

A. Anatomical Classification ?

(IUSG) International Uveitis Study

Group

n

1) Anterior Uveitis ? Inflammation of iris

and anterior part of ciliary body.

n

2) Intermediate Uveitis ? Involvement of

posterior part of ciliary body and extreme

periphery of retina. (Pars planitis)

n

3) Posterior uveitis ? Retinochoroiditis,

choroiditis, retinitis, chorioretinitis

n

4) Diffuse or pan uveitis ? Involvement of

entire uveal tract


B. Clinical Classification -

n 1) Acute ? sudden symptomatic onset.

Persists for 3 weeks or less.

n 2) Chronic ? Frequently insidious and

asymptomatic. Persists for months or

years.

n 3) Recurrent

C. Etiological Classification

One of the most difficult problems in ophthalmology.

In most of the cases, probably, al ergy is the cause.
n 1) Exogenous-

Introduction of organism into the eye through a

perforating wound or ulcer.

n 2) Secondary infection-

Due to direct spread from adjoining structures-

n

Cornea

n

Sclera

n

Retina




3) Endogenous

4) Al ergic inflammation: Result of an antigen-antibody

reaction occurring in the eye due to previous

sensitization of uveal tissue to some al ergen. The

al ergen is a foreign protein.

n Most of the cases of iridocyclitis do not have any

specific cause and are probably al ergic in nature.

5) Auto-immune -

Immune disorders

e.g. rheumatoid arthritis, SLE, ankylosing spondylitis,

Reiter's syndrome, Behcet's Syndrome.
D. Pathological Classification

Granulomatous

Non-

granulomatous

1. Aetiology

Organismal

Antigen-antibody

invasion

reaction

2. Course

a) Onset

Insidious

Acute

b) Duration

Chronic

Short

c) Inflammation

Moderate

Severe

Granulomatous

Non-

granulomatous

3. Pathology

a) Lesion

Circumscribed

Diffuse

b) Iris

Focal reaction

Diffuse reaction

c) Keratic

Mutton fat

Fine plenty

precipitates
d) Iris adhesions Coarse, few, thick Fine, plenty, thin

4.

May be positive

Negative

Investigations


PATHOLOGY AND

CLINICAL SIGNS-

Inflammation of iris and ciliary body

Dilatation of blood vessels

Iris stromal edema.

SIGNS - Iris pattern altered.Iris colour

altered. Iris thickened.Also

accompanied by, ciliary congestion,

conjunctival hyperaemia and chemosis

of conjunctiva.

SIGNS ?
n Iris pattern and colour altered.
n Iris thickened accompanied by, ciliary

congestion, conjunctival hyperaemia

and chemosis of conjunctiva.


Exudation of fibrin-rich fluid and

inflammatory cells in the tissues

Exudates escape into anterior chamber

n Plasmoid aqueous
n SIGNS - Aqueous flare (like the beam

of projector in smokey theatre)

Nutrition of corneal endothelium is

affected due to toxins

Corneal endothelium becomes sticky

and edematous

Cells desquamated at places


Inflammatory cells stick to endothelial

layer as cellular deposits .

SIGN ? Keratic precipitates

In very intense cases, polymorphs pour

out to sink to bottom of anterior

chamber

SIGN ? Hypopyon


Exudates cover the iris as a thin film and

spread over pupil ary area

SIGN ? Irritation of iris musculature

constrictor being more powerful than

dilator, spasm results in miosis.

If exudate is profuse

SIGN ? Plastic iritis

Blockage of pupil

SIGN ? impairment of sight.

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

layer of iris left permanently upon anterior capsule of

lens (valuable evidence of previous iritis)

Later on, the organization of the adhesion leads to formation of

fibrous bands between pupil ary margin of iris and lens capsule

(atropine cannot rupture them)

SIGN ? Posterior synechiae (more in lower part of pupil

due to effect of gravity)


When adhesions are localized and a

mydriatic is instil ed, it causes

intervening portions of circle of pupil to

dilate.

SIGN? Festooned pupil

(due to irregular dilatation

and is a sign of present or

past iritis.)



Pigment epithelium on

posterior surface is pul ed

around pupil ary margin so

that patches of pigment on

anterior surface of iris are

seen.

SIGN ? Ectropion of

uveal pigment (due to

contraction of

organizing exudates

upon iris)




With recurrent attacks or severe cases, the

whole circle of pupil ary margin gets tied

to lens capsule.



SIGNS ? Annular or ring synechiae or

Seclusio pupillae

Col ection of aqueous behind iris since

aqueous drainage is hampered.

Iris is hence bowed forwards like sail.

SIGN ? Iris Bombe (anterior chamber is

funnel shaped i.e. deepest in centre,

shallowest at periphery)


As iris bulges forward and comes into contact with

cornea

Adhesions of iris to cornea at periphery develop

SIGNS ? Peripheral anterior synechiae

Obliteration of filtration angle (Hypertensive

iridocyclitis)

SIGNS ? Rise in IOP (secondary glaucoma)

When exudate is more extensive

Organization of exudate across entire pupil ary

area

Film of opaque fibrous tissue in pupil ary area

SIGNS ? Occlusio pupillae or Blocked pupil

Exudates fil up posterior chamber if there is

much of cyclitis

When these adhesions organize, the iris adheres

to lens capsule.

SIGNS ? Total posterior synechiae


When these adhesions organize, the iris

adheres to lens capsule.

SIGNS ? Total posterior synechiae

Retraction of peripheral part of iris

Anterior chamber is abnormal y deep at

periphery

In worst cases of plastic iridocyclitis

Cyclitic membrane formed

behind lens

Final y, degenerative

changes in ciliary body

Vitreous becomes fluid

Nutrition of lens impaired

Phthisis bulbi wil be the SIGNS ? Complicated

eventuality.

cataract


In final stages, there is

interference with

secretion of aqueous

Fal in IOP

Eye shrinks (development

of soft eye is an

ominous sign)

SIGNS ? Phthisis bulbi

Clinical Features

SYMPTOMS

SIGNS

n Pain

n

Signs of vascular

n Diminished vision

congestion

n Redness of eye

n

Signs of exudation

n lacrimation

n

Signs of pupil ary

changes

n photophobia
Clinical Features

SIGNS

n

Lid oedema

n

Circumcorneal congestion

n

Corneal signs

n

Anterior chamber signs

n

Iris signs

n

Pupil ary signs

n

Lenticular changes

n

Changes in the vitreous

Clinical Features

SIGNS

n

Corneal signs

Corneal oedema

Keratic precipitates (KPs)

Mutton fat, granular, red & old KPs

Posterior corneal opacity
Clinical Features

SIGNS

n

Anterior chamber signs

n 1. Aqueous cel s. It is an early feature of

iridocyclitis.

n ? = 0 cel s,
n ? = 1?5 cel s,
n +1 = 6?10 cel s,
n +2 = 11-20 cel s,
n +3 = 21?50 cel s, and
n +4 = over 50 cel s

Clinical Features

n 2. Aqueous flare. It is due to leakage of protein

particles into the aqueous humour from damaged

blood vessels. It is demonstrated on the slit lamp

examination by a point beam of light passed obliquely to

the plane of iris.

n Grade :
n 0 = no aqueous flare,
n +1 = just detectable;
n +2 = moderate flare with clear iris details;
n +3 = marked flare (iris details not clear);
n +4 = intense flare (fixed coagulated aqueous

with considerable fibrin).


n Aqueous Flare

Clinical Features

SIGNS

n

Anterior chamber signs

3. Hypopyon. When exudates are heavy and thick,

they settle down in lower part of the anterior chamber

as hypopyon (sterile pus in the anterior chamber)

4. Hyphaema (blood in the anterior chamber): It may
be seen in haemorrhagic type of uveitis.


n Hypopyon in anterior uveitis

Clinical Features

SIGNS

n

Iris signs

1. Loss of normal pattern.

2. Changes in iris colour.

3. Iris nodules

4. Posterior synechiae.

5. Neovascularsation of iris
Clinical Features

SIGNS

n

Pupil ary signs

1. Narrow pupil.

2. Irregular pupil shape.

3. Ectropion pupil ae

4. Sluggish pupil ary reaction

5. Occlusio pupil ae

Clinical Features

SIGNS

n

Lenticular signs

1. Pigment dispersal over anterior lens capsule

2. Exudates

3. Complicated cataract
n Change in the vitreous

Anterior vitreous may show exudates and

inflammatory cel s after an attack of acute

iridocyclitis.
n Fuch's heterochromic iridocylitis

n Posner Schlossman syndrome.

Fuch's heterochromic

iridocylitis

n Fuchs' heterochromic iridocyclitis is a

chronic nongranulomatous type of low

grade anterior uveitis.

n It typical y occurs unilateral y in middle-

aged persons.
Fuch's heterochromic

iridocylitis

n The disease is characterised by:
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,

n (vi) a fairly common rubeosis iridis,

sometimes associated with

neovascularisation of the angle of anterior

chamber

n (vi )comparatively early development of

complicated cataract and secondary

glaucoma (usual y open angle type).

n Treatment. Topical corticosteroids .
Posner Schlossman syndrome.

n Recurrent attacks of acute rise of intraocular

pressure (40-50 mm of Hg) without

shal owing of anterior chamber associated

with,

n fine KPs at the back of cornea, without any

posterior synechiae,

n epithelial oedema of cornea,
n a dilated pupil, and a white eye (no

congestion).

Posner Schlossman syndrome.

n The disease typical y affects young adults, 40

percent of whom are positive for HLA-BW54.

n Treatment. It includes medical

treatment to lower IOP along with a short

course of topical steroids.
Differential Diagnosis

Character

Conjunctivitis Iridocyclitis

Glaucoma

Infection

Superficial

Deep

----

Secretion

Mucopurulent

Watery

Watery

Pupil

Normal

Smal ,

Large, Oval

irregular

Character Conjunctivitis Iridocyclitis Glaucoma

Media

Clear

Sometimes Corneal

pupil

oedema

opaque

Tension

Normal

Usual y

High

normal

Pain

Mild

Moderate Severe and

with first

entire

division of trigeminal

trigeminal
Character

Conjunctivitis Iridocyclitis Glaucoma

Tenderness

Absent

Marked

Marked

Vision

Good

Fair

Poor

Onset

Gradual

Usual y

Sudden

gradual

Systemic

Absent

Little

Prostration

complications

and

vomiting

Complications of Uveitis

n

Hypertensive uveitis ? Secondary glaucoma

n

Endothelial opacities in cornea due to formation of keratic

precipitates

n

Hypopyon and hyphaema

n

Suppurative uveitis may progress to end-ophthalmitis or

pan-ophthalmitis

n

Toxic matter goes into lens ? complicated cataract.

n

Post inflammatory atrophy of zonules ? subluxation of

lens

n

Vitreous ? opacification of vitreous, liquification of gel,

shrinkage of gel, retinal detachment

Contd.
...
n

macular edema

n

optic neuritis ? undergoes atrophy ? optic nerve

atrophy

n

occlusive pupil ae

n

seclusion pupil ae

n

Ectropion of uveal pigment

n

Hypotony ? atrophic bulbi

n

Secondary squint

n

Iris atrophy

Investigations

n

Local

n

Vision, refraction, fundus examination

n

IOP by Schiotz Tonometer

n

Slit Lamp examination

n

Focal ?

n

ENT, Dental, Genito-urinatory

examination for septic focus.
n

For associated systemic disorders ?

n

CBC, ESR, MT, X-ray chest ? Tuberculosis

n

Urine, Blood examination-Diabetes

n

VDRL, Kahn Test ? syphilis

n

Urethral smear ? gonorrhoeae

n

Urine culture ? for UTI

n

Blood culture ? Septicemia

n

ASLO Titre, C-reactive protein ? for

rheumatic disorders

n

Screening test for auto immune disorders

Treatment

1.

Of iridocyclitis

2.

Of complications and sequelae.


Treatment of Iridocyclitis

n

Drugs used ?

n

Mydriatics

n

Steroids

n

Cytotoxic agents

n

Cyclosporin

Essentials of treatment of

anterior uveitis

Dilatation of pupil with atropine
n Hot application
n Control of acute phase of inflammation

with steroids


Atropine

n

Acts in 3 ways

n

by keeping the iris and ciliary body at rest

n

by diminishing hyperaemia

n

by preventing formation of posterior

synechiae and breaking down any already

formed.

Method of administration and

dose:

n Atropine may be used in form of drops or

ointment (1%) ,every four hours is usual y

sufficient.

n When pupil is wel dilated, twice a day

suffices.

n If atropine irritation ensues, one or the other

substitutes for this drug may be used.

e.g. Homatropine, Cyclopentolate.


Mydriasis -the sub-conjunctival injection

of 0.3 ml. of mydricaine, a mixture of

atropine, procaine and adrenaline.

To avoid relapse-Atropine, or its

equivalent -continued for at least 10

days to a fortnight after the eye

appears to be quiet.

n

Hot application

n

extremely soothing to patient by

diminishing the pain.

n

of therapeutic service in increasing the

circulation.


Corticosteroids

n

Administered as drops or ointment, or more

effectively as subconjunctival injections are

of great value in control ing the

inflammation in the acute phase.

n

Occasional y, results are dramatic and eye

becomes white with great rapidity.

n

Minimize damages of antigen antibody

reaction.

Aspirin

n

Is very useful in relieving pain but if it

is intense, stronger preparation are

required.
n

Cyclosporin

-T-cel immunosuppressive drug. Used in

resistant cases.

n

Broad spectrum antibiotic

- In case of suppurative uveitis.
n

Specific Chemotherapy for Tuberculosis,

syphilis, gonorrhoea.

n

Increasing body resistance by multi-vitamins.

Treatment of complications

and sequelae-

n

Secondary glaucoma-

n

Before formation of posterior or

peripheral synechiae,- intensify

atropinisation in order to al ay the

inflammatory congestion.

n

Corticosteroids - topical y and

acetazolamide - systematical y are

very useful in such cases..
Annular synechiae-

n

Iridectomy `

n

( No operative procedure of this kind must be

undertaken during an acute attack of iritis if it can

be avoided. Reason ? operation wil set up a

traumatic iritis which wil result in the opening

getting fil ed with exudates.)

n

preventive iridectomy- Since ring synechiae is

the result of recurrent attacks, iridectomy can be

performed during quiescent interval.

n

Difficulty ? iris is atrophied, friable. Haemorrhage is

common. Synechiae can be broken with YAG Laser.

n

Hypopyon and Hyphaema may need

evacuation and A.C. Wash.

n

End-ophthalmitis ? intravitreal injection of

Decadron and Gentamicin

n

Pan ophthalmitis ? Evisceration

n

Iris Bombe

Medical ? 1. Atropine

2. Diamox

Surgical ? 1. 4-dot Iridotomy

n

using von Graefe's knife

n

YAG Laser for breaking posterior synechiae


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This post was last modified on 07 April 2022