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