UVEITIS

Definition
An inflammation of the uveal tract
Uveal tract: iris, ciliary body, choroid

Intraocular inflammation, not only theuvea,

but also adjacent structures

Classification

Aetiological: exogenous, endogenous

Pathological: granulomatous, nongranulomatous

Medical history

Systemic Evaluation
Skin
Joints
Lung
Neurologic
GI

GU
etc

Symptoms
and Signs
Symptoms
Redness
Pain
Photophobia

Signs
Injection
Keratic precipitate (KP)
Iris nodule
Koeppe, Busacca

Lacrimation

Cells (AC or Vitreous)

Floaters

Flares

Decreased vision

Posterior synechiae (PS)

Choroiditis
Retinitis
Vasculitis

Fig. 11.2 Signs of acute

anterior uveitis. (A) Ciliary
injection; (B) miosis; (C)
endothelial dusting by cells;
(D) aqueous flare and cells;
(E) fibrinous exudate; (F)
hypopyon

Posterior
synechia

Keratic precipitates. (A)

Aggregate of inflammatory
cells on the corneal
endothelium; (B) large
mutton-fat keratic
precipitates; (C) ghost
keratic precipitates; (D) old
pigmented keratic
precipitates

Signs of
posterior uveitis.
(A) Retinitis; (B)
Choroiditis; (C)
vasculitis

Iris nodules in granulomatous anterior

uveitis. (A) Koeppe nodules; (B) Busacca
nodules

Cells & Flare

Cells: active inflammation

Flare: leakage of protein

Special investigations
Indications
Granulomatous inflammation.
Recurrent uveitis.
Bilateral disease.
Systemic manifestations without a specific

diagnosis.
Confirmation of a suspected ocular picture
which depends on the test result as part of the
criteria for diagnosis such as HLA-A29 testing
for birdshot chorioretinopathy.

Skin test

(A) Positive tuberculin skin reaction; (B)

strongly positive tuberculin skin reaction;
(C) positive pathergy test in Behet
syndrome

Other tests
Imaging:
Fluorescein angiography (FA), Indocyanine green
angiography (ICGA), Optical coherence
tomography (OCT)
Radiology
Chest X-ray, Sacroiliac joint X-ray, CT and MR

Biopsy
HLA type

Treatment
Mydriatics
Steroids
topical, periocular injection, systemic

Calcineurin inhibitors:
Cyclosporin, Tacrolimus

Antimetabolites:
Azathioprine, MTX,

Anterior uveitis
Acute
HLA-B27 related diseases
Behcet syndrome
Glaucomatocyclitic crisis
Lens-associated uveitis

HLA-B27 Related
Diseases
Seronegative spondyloarthropathies
Ankylosing spondylitis
Reiter syndrome
Inflammatory bowel disease
(enteropathic arthritis)

Psoriatic arthritis

Ankylosing Spondylitis
Acute iritis, Sacroiliitis and spondylitis
HLA-B27
General population: 5%
Acute iritis: 45%
AS: 90%

Both AS & acute iritis: 95%

c. Circinate balanitis
d. Keratoderma blennorrhagicum

Reiter Syndrome
Young adult male
Classic triad
Urethritis
Polyarthritis
Conjunctivitis (the most common) or acute iritis

Behcet Syndrome (1)

Generalized occlusive vasculitis

Posterior involvement > Anterior

retinal vasculitis, hemorrhage, necrosis,

macular edema, ischemic optic neuropathy

(A) Major aphthous

ulceration; (B)
genital ulceration; (C)
superficial
thrombophlebitis; (D)
dermatographia

Behcet Syndrome (2)

Skin lesion: erythema nodosum
HLA-B51
Young adults
Recurrence
Poor prognosis

Glaucomatocyclitic Crisis
(Posner- Schlossman Syndrome)
Unilateral mild iritis: (low grade cells, flare)
Markedly elevated IOP
Recurrence are common
A diagnosis of exclusion

Lens-Associated Uveitis
Phacoantigenic glaucoma
Lens capsule injury (immune response to lens
protein)
Mutton-fat KP, dense cells & flare, PS
Phacolytic glaucoma
Intact capsule, hypermature cataract
Acute increase of IOP (clogging of TM by lens
protein & engorged macrophages)
Lack of KP, PS

Chronic Iridocyclitis
Juvenile rheumatoid arthritis
Most common systemic disorder associated with
iridocyclitis in the pediatric
Female/Male: 3/2
Risk factors for iridocyclitis:
female, pauciarticular onset, ANA (+)
Often white & uninflamed in appearance
Complications:
cataract (84%), band keratopathy (70%), macular
edema, vitreous debris, glaucoma, phthisis

Intermediate Uveitis
Anterior vitreous cells:
snowballs, snowbanking

Retinal phlebitis
Associated with sarcoidosis, multiple

sclerosis, Lyme disease, toxocariasis,

syphilis, tuberculosis, connective tissue
disease

Pars Planitis
Most common form of intermediate uveitis
< 40 y/o
Bilateral (80%)
Vitreous condensation, cellular
infiltration in vitreous base
Fluorescein angiography: diffuse peripheral
venular leaking
Major cause of visual loss: cystoid macular

edema

Posterior segment
signs in intermediate
uveitis. (A)
Peripheral
periphlebitis and a
few snowballs
inferiorly; (B) inferior
snowbanking and
snowballs; (C)
severe snowbanking,
neovascularization
and inferior retinal
detachment

Posterior Uveitis
Infectious
Viral: Herpes, CMV, Rubella, Measles, HIV..
Fungal: Histoplasmosis, Candidiasis
Protozoal: Toxoplasmosis
Helminthic: Toxocariasis, Cysticercosis
Immunologic
Collagen vascular dz: SLE, PAN, Wegener
granulomatosis
Retinochoroidopathies
Masquerade conditions
Endophthalmitis: Nocadia asteroids

Cytomegalovirus retinitis
Active toxoplasma retinitis.

Toxocara granuloma

Acute retinal necrosis (ARN)

Classic triad
Vitritis
Occlusive retinal arteriolitis & periphlebitis
Multifocal yellow-white peripheral retinitis
Pts: typically healthy & not debilitated
Varicella-zoster, herpes simplex, CMV
Posterior pole tends to be spared

Multiple posterior retinal breaks &

traction/RRD
Ischemic optic neuropathy
Poor prognosis

Ocular Complications in
AIDS
Up to 70% of individuals with AIDS
May be the first sign of disseminated systemic inf.
Microangiopathy of retina
Various opportunistic infections
Kaposi sarcoma
Lymphoma
Squamous cell carcinoma of conjunctiva
HIV retinopathy: most common
Retinal hemorrhage, microaneurysm, cotton-wool spots
CMV retinitis: most common opportunistic ocular

inf.

Panuveitis
Infectious
Bacterial: Syphilis, Tuberculosis, Lyme dz,
Helminthic: Onchocerciasis
Immunologic & granulomatous
Sarcoidosis
Sympathetic opthalmia
Vogt-Koyanagi-Harada (VKH) syndrome
Masquerade syndrome
Neoplasms

Sympathetic Ophthalmia
Bilateral granulomatous panuveitis occurring after

penetrating trauma
The traumatized :exciting eye and the fellow eye:
sympathizing eye
Diffuse and massive lymphocytic infiltration of the
choroid
65% of cases is between 2 weeks and 3 months after
initial injury and 90% of all cases occur within the first
year.
Treatment:
Enucleation
Topical treatment of the anterior uveitis with steroids and

cycloplegics resistant to this form of therapy (diagnostic

clue)
Systemic steroids, immunomodulatory therapy

Sympathetic Ophthalmia