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UVEITIS

CONGENITAL DISEASES OF THE IRIS

Congenital aniridia represents the bilateral absence of the

iris
Pseudo-polycoria the stroma of the iris presents some
halls, giving the false impression of more pupils
Congenital coloboma defect in the iris structure causing an
irregular pupil
Corectopia displacement of the eyes pupil from its normal
central position
Anisocoria unequal pupil size

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Congenital aniridia

Polycoria

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Congenital coloboma

Corectopia

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Anisocoria

Uveitis is an Inflammatory eye

disease affecting the iris, ciliary body
and the choroid
Its prevalence is higher (38/100
000) in younger people
(mean age 39)
Frecquently, etiology is unknown
Progress of the disease towards
complications may induce even
blindess
Structure of the eye

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1. ANATOMICAL CLASSIFICATION
Anterior uveitis
the iris, ciliary body, cornea or sclera
non-infectious and often idiopathic
the most common form (28-61%) of all cases

Intermediate uveitis
the anterior vitreous and pars plana
often idiopathic etiology (61%)
known causes: sarcoidosis (22,2%),
multiple sclerosis (8%)
the most rare form (3-17%) of all cases
Posterior uveitis
Types of uveitis the retina and choroid
infectious etiology (toxoplasma, CMV)
9,3-38% of all cases
Panuveitis
involving all three sections of the uveal tract
7-38% of all cases

Bloch-Michel E, Nussenblatt RB. International Uveitis Study Group recommendations for the evaluation
of intraocular inflammatory disese Am. J. Ophtalmol. 1987: 103: 234-5

2. CLINICAL CLASSIFICATION

Acute uveitis
The onset is sudden and it usually lasts for less than 3 weeks

Chronic uveitis
The onset is insidious and the duration is more than 3 weeks

Recurrent uveitis
The uveitis keeps recurring periodically

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3. PATHOLOGICAL CLASSIFICATION

Granulomatous uveitis
It is infected in nature with minimal clinical features

Non Granulomatous uveitis

It is usually due to allergic or immune related reaction

4. ETIOLOGICAL CLASSIFICATION

Infective uveitis

Toxic uveitis

Traumatic uveitis

Idiopathic uveitis

Uveitis associated with non infective systemic diseases

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MAIN CAUSES OF UVEITIS

Rheumatic conditions
Spondyloarthritis (SA, Psa, ReA, nSpA): 32,7%1
Juvenile idiopathic arthritis: 20%2
Sarcoidosis, Behcet disease
Infections
bacteria: specific: Mycobacteriun tuberculosis,Treponema pallidum
nonspecific: Streptococcus, Stafiloccoccus
parasites: Toxoplasma gondi, Toxocara canis, Borellia burgdorferi
viruses: Herpes virus, Cytomegalus virus
fungi: Candida albicans
Inflammatory bowel diseases (5%):
Crohn disease, ulcerative colitis, Whipple disease
Renal diseases:
Tubulointerstitial nephritis
Trauma
Unknown causes: 50%
1. Zeboulon N, Dougados M, Gossec L. Prevalence and characteristics of uveitis in the spondyloarthropaties: a
systematic literature review, Ann Rheum Dis 2008; 67: 955-959
2. Kotaliemi K, Arketa-Kautiainen M, Haapasaari J , et al. Uveitis in young adults with juvenile idiopathic arthritis : a
clinical evaluation of 123 patients, Ann Rheum Dis 2005;64: 871-874

CLINICAL FEATURES (I)

-anterior uveitis-
Symptoms:
photophobia, pain, redness,
decreased vision, lacrimation

Signs:
ciliary injection, keratic precipitates
iris nodules, miosis
pathological changes of the aqueous humour serous
- purulent hypopyon (pus)
- fibrinous

Kanski J.J. Uveitis. From: Kanski J.J. Clinical Ophthalmology A Systematic Approach Fifth Edition. Ed. Butterworth
Heinemann;2003.X:271-317.

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Cilliary injection

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Keratic precipitates

Koeppes nodules

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Busaccas nodules

Hypopyon

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Intermediate uveitis
Affects the pars plana of the cilliary body and the peripheral
retina

Etiology
Is unknown; it is an idiopathic inflammatory disease

Incidence
Both eyes are affected in about 80% of cases
Females are commonly affected than males

CLINICAL FEATURES (II)

-intermediate uveitis-

Symptoms:
1. insidious onset of blurred vision
(usually unilateral and subsequently bilateral)
2. vitreous floaters and later impairment of visual acuity

Kanski J.J. Uveitis. From: Kanski J.J. Clinical Ophthalmology A Systematic Approach Fifth Edition. Ed. Butterworth
Heinemann;2003.X:271-317.

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CLINICAL FEATURES (II)

-intermediate uveitis-

Signs:
1. anterior vitritis
2. peripheral retinal periphlebitis
3. snow banking grey white plaques involving the inferior pars plana, which
make coalesce together giving the appearance of a snow bank

Kanski J.J. Uveitis. From: Kanski J.J. Clinical Ophthalmology A Systematic Approach Fifth Edition. Ed. Butterworth
Heinemann;2003.X:271-317.

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Snow banking

CLINICAL FEATURES (II)

-intermediate uveitis-

Treatment:
Approximately 80% of cases do not need any treatment.

Corticosteroid and immunosupressants agents may be given in chronic

cases.

Kanski J.J. Uveitis. From: Kanski J.J. Clinical Ophthalmology A Systematic Approach Fifth Edition. Ed. Butterworth
Heinemann;2003.X:271-317.

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CLINICAL FEATURES (III)

-posterior uveitis-
Symptoms:
floaters, impairment of visual acuity

Signs:
vitritis, vitreous opacities, choroiditis
Coarse vitreous opacities
retinitis
retinal periphlebitis & retinal periarteritis

Retinal periphlebitis Old multifocal choroiditis

Kanski J.J. Uveitis. From: Kanski J.J. Clinical Ophthalmology A Systematic Approach Fifth Edition. Ed. Butterworth
Heinemann;2003.X:271-317.

COURSE & PROGNOSIS

Anterior uveitis
Acute: with appropriate treatment the inflammation tends to completely
resolve within 5-6 weeks with excellent visual prognosis
Chronic: the inflammation persists for longer than 3 months and in some
cases even years
remissions and exacerbations of inflammatory activity are common

Intermediate uveitis
Most patients have a severe disease with a longer course and episodes of
exacerbations (the prognosis in not so good)
Few patients have a benign course which may NOT require treatment
(the prognosis is positive)

Posterior uveitis
The prognosis is relatively poor, 60% of patients having an important decrease of
the visual acuity due to complications

Kanski J.J. Uveitis. From: Kanski J.J. Clinical Ophthalmology A Systematic Approach Fifth Edition. Ed. Butterworth
Heinemann;2007.X:442-508.

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COMPLICATIONS
Anterior uveitis
Posterior synechiae, band keratopathy
Cataract, glaucoma
Macular oedema

Intermediate uveitis
Cataract, cystoid macular oedema
Tractional retinal detachment

Posterior uveitis
Cystoid macular oedema,
Choroidal neovascularization
Retinal detachement, Vascular oclusion

Kanski J.J. Uveitis. From: Kanski J.J. Clinical Ophthalmology A Systematic Approach Fifth Edition. Ed. Butterworth
Heinemann;2003.X:271-317.

TREATMENT
-targets-

Treatment of uveitis aims at:

Preserving visual acuity;
Relieving ocular pain;
Preventing formation of synechiae;
Identifying the source of ocular inflammation and/or
eliminating it;
Managing intraocular pressure

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TREATMENT OPTIONS

Mydriatics
Corticosteroids
Immunomodulatory drugs
Biological therapy

TREATMENT OPTIONS (I)

Mydriatics are used for several reasons:

To relieve spasm of the ciliary muscle and pupillary sphincter
To prevent formation of posterior synechiae
To break down recently formed posterior synechiae
The most useful preparations in clinical practice are:
Tropicamide
Phenylephrine
Atropine

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TREATMENT OPTIONS (II)

Corticosteroids, aproved by FDA, are administred :
Topically: as drops or ointments primarily useful for anterior
uveitis or as adjunct therapy along with systemic treatment for
panuveitis;
Locally: as local injections (retrobulbar or intravitreal) of long-
acting steroids (triamcinolone) with therapeutic concentration in
the posterior segment injections
Systemically: -oral Prednison 1-2 mg/kg/day until inflammation
abates, then doses are tapered gradually to 10 mg/kg/day
-pulse intravenous Methylprednisolone 1-3 g for 3
days, then switched to lower doses of oral Prednison

Nguyen QD, Current Medical Therapy for Non-infectious Uveitis and ocular inflammation Disease, US Opthalmic Review
2007: 14-15

Immunomodulatory drugs are used

in combination with corticosteroids ( to eliminate the need for high
doses ofTREATMENT
systemic steroid), in OPTIONS
order to decrease(III)
the side effects
Antimetabolites
Methotrexate: 20 mg/week: Juvenile Idiopathic Arthritis
Azathioprine: 2.5 mg/kg/day Behcet Disease
T-cell inhibitors/calcineurin inhibitors
Cyclosporine, Tacrolimus
Alkylating agents:
Chlorambucil, Cyclophoaphamide
Nguyen QD, Current Medical Therapy for Non-infectious Uveitis and ocular inflammation Disease, US
Opthalmic Review 2007: 14-15

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