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Uveitis

Uveitis

• Inflammation of one or all parts of


the uveal tract.
• Components of the uveal tract
include the iris, the ciliary body, and
the choroid.
Classification of Uveitis

• Anatomical
• Clinical
• Etiological
• Pathological
Anatomical Classification
• Anterior uveitis
– Iritis
– Iridocyclitis
• Intermediate
uveitis
• Posterior uveitis
• Panuveitis
Clinical Classification

• Acute uveitis
• Chronic uveitis
Etiological Classification

• Exogenous uveitis
• Endogenous uveitis
– Associated with systemic disease
– Infections with bacteria, fungi, viruses,
protozoans, or roundworms
– Idiopathic specific uveitis entities
– Idiopathic non specific uveitis entities
Pathological Classification

• Granulomatous
• Non- granulomatous
When to investigate?
• One of the most pressing questions that arises in
the mind of every ophthalmologist who sees a
new case of uveitis is "what is the cause of this
disease?" In evaluating patients with uveitis, the
ophthalmologist must consider that a lengthy list
of infections, autoimmune systemic diseases,
distinctive inflammatory conditions and
masquerade syndromes may all cause uveal
inflammation. Despite this array of potential
diagnoses, the vast majority of patients have
disease that defies categorisation.
Clinical Features of Uveitis

• Anterior uveitis
– Signs: Photophobia, pain, redness,
decreased vision, and lacrimation
– Injections
– Keratic precipitates
• Endothelial dusting
• Medium KP
• Large KP
• Old KP
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• Iris nodules
– Koeppe
– Busacca
• Aqueous cells
– 5-10 cells= +1
– 11-20 cells= +2
– 21-50 cells= +3
– >50 cells= +4
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• Aqueous flare
– Faint- just detectable= +1
– Moderate- iris details clears= +2
– Marked- iris details hazy= +3
– Intense- with severe fibrinous
exudates= +4
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Complications

• Posterior synechiae
– Seclusio pupillae
– Iris bombe
• Anterior vitreous cells
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Intermediate Uveitis

• Symptoms: intially floaters and later


impairment of visual acuity
• Signs: Cellular infiltration of vitreous
• Complications: cystoid macular
edema, cyclitic membrane formation,
cataract and tractional retinal
detachment
Posterior Uveitis
• Symptoms:
– Floaters
– Impaired vision
• Signs:
– Vitreous opacities
– Choroiditis
– Inactive lesions
– Retinitis
– Vasculitis
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• Three main types of posterior uveitis:
– Unifocal
– Multifocal
– Geographical
Treatment

• Mydriatics
• Steroids
• Immunosuppresants
Mydriatics
Mydriatics

• Indications
– To provide comfort
– To prevent formation of posterior
synechiae
– To break down recently formed
synechiae
Steroids

• Mainstay of treatment
• Dexamethasone, Bethamethasone,
Prednisolone
Steroids
Complications

• Glaucoma
• Cataract
• Corneal complications
• Systemic side effects
Immunosuppressive Agents
Uveitis associated with
Arthritis
• Ankylosing spondylitis
– 2nd and 3rd decade of life
– Gradual onset of chronic backache and
stiffness
– HLA-B27
– Ocular features: acute, recurrent, non
granulomatous iritis
Ankylosing Spondylitis
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Uveitis associated with
Arthritis
• Reiter’s syndrome
– Episode of arthritis of more than 1
month duration
– (+) HLA-B27
– Triad: Urethritis, conjunctivitis &
seronegative arthritis
– 3rd decade of life
• Ocular features
– Bilateral mucopurulent conjunctivitis
– Acute anterior iritis
– Punctate epithelial keratitis
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Psoriatic arthritis

• Idiopathic, seronegative, chronic,


anodular, erosive arthritis
• HLA-B27, HLA-B17
• Ocular features:
– Conjunctivitis
– Acute iritis
– Keratitis
– Secondary Sjorgen’s syndrome
Psoriatic Arthritis
Juvenile Idiopathic Arthritis

• Idiopathic, inflammatory arthritis of


at least 6 wks duration
• Seronegative for IgM rheumatoid
factor
• Systemic onset: transient
maculopapular rash, generalized
lymphadenopathy,
hepatosplenomegaly and serositis
• Pauciarticular onset
• Ocular findings:
– Asymptomatic
– Uninjected white eye even in the
presence of severe uveitis
– KPs are usually small to medium
– Posterior synechiae
• Treatment: topical steroids
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Uveitis in Non- Infectoius
systemic disease
Sarcoidosis

– Common, idiopathic multisystem


disorder
– Non caseating granulomata
– Presentation:
• Acute onset
• Insidious onset
Sarcoidosis

• Diagnostic tests:
– Chest x-ray
– Biopsy
• Ocular features:
– Eyelid lesions- violaceous sarcoid
plaques
– Anterior segment lesions-
keratoconjunctivitis sicca
Sarcoidosis

• Anterior uveitis
– Acute anterior uveitis- acute onset
sarcoid
– Chronic granulomatous anterior uveitis-
older patients with pulmonary sarcoid
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Sarcoidosis

• Intermediate uveitis
– Vitreous cells and opacities
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Sarcoidosis
• Posterior uveitis
– Retinal phlebitis
– Choroidal granulomas
– Retinal granulomas
– Preretinal granulomas
– Optic disc granulomas
– Peripheral retinal granulomas
• Tx: Steroids
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Behcet disease

• Idiopathic disease that typically


affects men from the eastern
Mediterranian and Japan
• Third to fourth decade of life
Behcet disease

• Ocular findings:
– Acute recurrent anterior uveitis
– Retinits
– Retinal vasculitis
– General vascular leakage
– Vitritis
Behcet disease

• Ocular features:
– Acute recurrent iridocyclitis
• Posterior segment
– Diffuse vascular leakage
– Peripheblitis
– Retinitis
– Vitritis
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Behcet disease

• Treatment of posterior uveitis


– Systemic steroids
– Chlorambucil
– Cyclosporin
– Plasma exchange
Vogt-Koyanagi-Harada
Syndrome
• Idiopathic, granular, granulomatous
panuveitis
• Vogt- koyanagi: Skin & hair changes with
anterior uveitis
– Alopecia, vitiligo
• Harad disease: Neurological features and
retinal detachment
– Irritation
– encephalopathy
– Auditory symptoms
– CSF lymphocytosis
Vogt-Koyanagi-Harada
Syndrome
• 3 phases:
1. Uveitic phase
- Bilateral anterior uveitis- granulomatous
- Bilateral posterior uveitis- disc edema &
multifocal retinal detachments
2. Convalascent- numerous residual, small
mottled atrophic scars
3. Chronic recurrent- chronic
granulomatous anterior uveitis
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Vogt-Koyanagi-Harada
Syndrome
• Tx:
– Steroids
– Immunosuppresants
Viral Uveitis
Herpes Zoster

• VZV
• Remains latent in the primary
sensory ganglia
• Herpes zoster ophthalmicus
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Signs
Complications

• Iris atrophy
• Secondary glaucoma
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Cytomegalovirus Retinitis
• Most common ocular infection in AIDS
patients
• Clinical features:
1. Indolent retinits- mild granular opacification
2. Fulminating retinitis- dense white geogrphical
area of opcification associated with vasculitis
& mild vitritis
3. Regression- fewer hemorhrrages, less
opacification, diffuse atrophic and
pigmentary changes
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• Tx:
– Systemic Gancylcovir
– Intravitreal Gancyclovir
– Foscarnet
– Cidofovir
Mycobacterial Uveitis
Tuberculosis

• Chronic granulomatous infection


caused by M. Bovis and
M.tuberculosis
• Clinical features:
– Chronic iridocyclitis
– Choroiditis
– Periphlebitis
– Paneuvieitis
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Leprosy

• Caused by M. Leprae
• 2 types:
– Leprematous
– Tuberculoid
• Ocular findings:
– Acute iritis
– Chronic iritis
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