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 eye’s pupil from its normal
central position
 Anisocoria – unequal pupil size
Congenital aniridia
Polycoria
Congenital coloboma
Corectopia
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
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
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

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.
Cilliary injection
Keratic precipitates
Koeppe’s nodules
Busacca’s nodules
Hypopyon
 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.
 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.
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.
 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 Old multifocal choroiditis

 Kanski J.J. – Uveitis. From: Kanski J.J. Clinical Ophthalmology A Systematic Approach Fifth Edition. Ed. Butterworth
periphlebitis
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
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
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
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
TREATMENT OPTIONS (III)
 Immunomodulatory drugs are used
in combination with corticosteroids ( to eliminate the need for high
doses of systemic steroid), in order to decrease 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