Download MBBS Ophthalmology PPT 1 Anterior Uveitis Lecture Notes

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Ophthalmology

DEFINITION:-

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 CLASSIFICATION

A. Anatomical Classification ?

(IUSG) International Uveitis Study

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Group

n

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1) Anterior Uveitis ? Inflammation of iris

and 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 of

entire 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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Sclera

n

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. The

al 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 disorders

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

Reiter's syndrome, Behcet's Syndrome.

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D. Pathological Classification

Granulomatous

Non-

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granulomatous

1. Aetiology

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Organismal

Antigen-antibody

invasion

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reaction

2. Course

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a) Onset

Insidious

Acute

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b) Duration

Chronic

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Short

c) 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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Diffuse

b) Iris

Focal reaction

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Diffuse reaction

c) Keratic

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Mutton fat

Fine plenty

precipitates

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

4.

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 body

Dilatation 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 hyperaemia

and chemosis of conjunctiva.

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Exudation of fibrin-rich fluid and

inflammatory 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 sticky

and 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 anterior

chamber

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 of

fibrous 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 to

dilate.

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 on

anterior surface of iris are

seen.

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SIGN ? Ectropion of

uveal pigment (due to

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contraction of

organizing 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 synechiae

Obliteration 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 ary

area

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 cyclitis

When 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 iris

Anterior 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 lens

Final 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 ? Complicated

eventuality.

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 (development

of soft eye is an

ominous sign)

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SIGNS ? Phthisis bulbi

Clinical Features

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SYMPTOMS

SIGNS

n Pain

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n

Signs of vascular

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n Diminished vision

congestion

n Redness of eye

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n

Signs of exudation

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n lacrimation

n

Signs of pupil ary

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changes

n photophobia
Clinical Features

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SIGNS

n

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Lid oedema

n

Circumcorneal congestion

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n

Corneal signs

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n

Anterior chamber signs

n

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Iris signs

n

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Pupil ary signs

n

Lenticular changes

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n

Changes in the vitreous

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Clinical Features

SIGNS

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 Features

SIGNS

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 lamp

examination 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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SIGNS

n

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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SIGNS

n

Iris signs

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1. Loss of normal pattern.

2. Changes in iris colour.

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3. Iris nodules

4. Posterior synechiae.

5. Neovascularsation of iris

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Clinical Features

SIGNS

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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SIGNS

n

Lenticular signs

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1. Pigment dispersal over anterior lens capsule

2. Exudates

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3. Complicated cataract
n Change in the vitreous

Anterior vitreous may show exudates and

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inflammatory cel s after an attack of acute

iridocyclitis.
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 heterochromic

iridocylitis

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 anterior

chamber

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) without

shal 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 Iridocyclitis

Glaucoma

Infection

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Superficial

Deep

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----

Secretion

Mucopurulent

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Watery

Watery

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Pupil

Normal

Smal ,

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Large, Oval

irregular

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Character Conjunctivitis Iridocyclitis Glaucoma

Media

Clear

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Sometimes Corneal

pupil

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oedema

opaque

Tension

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Normal

Usual y

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High

normal

Pain

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Mild

Moderate Severe and

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with first

entire

division of trigeminal

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trigeminal
Character

Conjunctivitis Iridocyclitis Glaucoma

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Tenderness

Absent

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Marked

Marked

Vision

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Good

Fair

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Poor

Onset

Gradual

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Usual y

Sudden

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gradual

Systemic

Absent

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Little

Prostration

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complications

and

vomiting

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Complications of Uveitis

n

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Hypertensive uveitis ? Secondary glaucoma

n

Endothelial opacities in cornea due to formation of keratic

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precipitates

n

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Hypopyon and hyphaema

n

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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n

optic neuritis ? undergoes atrophy ? optic nerve

atrophy

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n

occlusive pupil ae

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n

seclusion pupil ae

n

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Ectropion of uveal pigment

n

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Hypotony ? atrophic bulbi

n

Secondary squint

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n

Iris atrophy

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Investigations

n

Local

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n

Vision, refraction, fundus examination

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n

IOP 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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n

Urine, Blood examination-Diabetes

n

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VDRL, Kahn Test ? syphilis

n

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Urethral smear ? gonorrhoeae

n

Urine culture ? for UTI

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n

Blood culture ? Septicemia

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n

ASLO Titre, C-reactive protein ? for

rheumatic disorders

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n

Screening test for auto immune disorders

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Treatment

1.

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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n

Cytotoxic agents

n

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Cyclosporin

Essentials of treatment of

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anterior uveitis

Dilatation 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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n

by 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 posterior

synechiae 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 or

ointment (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 other

substitutes 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 10

days to a fortnight after the eye

appears to be quiet.

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n

Hot application

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n

extremely 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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n

Administered 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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n

Occasional 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 in

resistant 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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n

Increasing 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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n

Difficulty ? 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 ? Evisceration

n

Iris Bombe

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Medical ? 1. Atropine

2. Diamox

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Surgical ? 1. 4-dot Iridotomy

n

using von Graefe's knife

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n

YAG Laser for breaking posterior synechiae

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