Uveitis

By Reshida Mohammed(MD)
Ophthalmology resident
2023

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  Introduction
– “Uvea” = “Grape” (Latin).
– Uveal Tract = Three parts --- Iris + Ciliary body + Choroid.

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 – Ciliary body --- two parts:
– Pars plicata --- anterior part.
– Pars plana --- posterior part.

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  Uveitis
– It is an inflammation of the uvea --- and, it can affect:
– Any part of the uveal tract:
• Iris ---> iritis.
• Choroid ---> choroiditis.
• Ciliary body --- cyclitis.
• Pars plicata ---> anterior cyclitis
• Pars plana ---> pars planitis (intermediate uveitis).

– More than one part of the uveal tract:

• Iris and ciliary body ---> iridocyclitis.
• Whole uveal tract ---> panuveitis.

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  Classification of Uveitis
– Anatomical (the most widely accepted) – Etiologic
– Anterior uveitis – Infectious
– Intermediate uveitis – Traumatic
– Posterior uveitis – Neoplastic
– Panuveitis – Autoimmune
– Idiopathic
– Mode of onset & course
– Acute uveitis (<3 months) – Type of inflammation
– chronic uveitis (>3 months) – Granulomatous
– Recurrent uveitis – Non-granulomatous

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• The classification of uveitis, established
by the SUN (Standardization of Uveitis
Nomenclature) Working Group is
– Based on the primary site of inflammation.
– Anterior uveitis (red) -- involves the iris and
anterior ciliary body
– Intermediate uveitis (blue)-- involves the
posterior ciliary body and the pars plana and/or
the peripheral retina
– Posterior uveitis (green)-- involves the choroid,
either primarily or secondarily from the retina

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 • Anterior Uveitis
– The inflammation involves the iris and anterior part of the ciliary body.
» Iritis
» Iridocyclitis
» Keratouveitis

– Anterior uveitis is further divided into acute and chronic.

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 – Causes of anterior uveitis:
– Arthritis --- JRA, ankylosing spondylitis, Reiter’s syndrome, psoriasis
– Sarcoidosis
– Behcet’s disease

– Infections --- HSV, HZV, Syphilis, TB, Lyme disease

– Trauma
– Surgery --- esp. associated with lens
– Idiopathic (unknown cause)

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 – Acute Anterior Uveitis --- AAU
– Has classic presentation
• Pain, redness and photophobia, blurred vision

– Signs
• Conjunctival injection
• Perilimbal (ciliary flush) --- in early cases
• Diffuse --- in severe cases

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 • Miosis --pupillary sphincter spasm predisposes to the formation of posterior synechiae
• Endothelial dusting or Keratic precipitates (KP’s)--composed of inflammatory cells such
as lymphocytes, plasma cells and macrophages
• Inflamm. cells and flare (protein influx) in A/C
• Sometimes inflamm. membrane covering pupil
• Posterior synechiae

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 – Chronic Anterior Uveitis --- CAU
– Gradual onset, persistent inflammation, lasts > 3months.
– Symptoms:
• Variable --- redness, discomfort, photophobia.
• Sometimes --- asymptomatic until complications develop --- E.g., cataract.

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 – Signs:
• Aqueous cells and flare
• Old KP’s (endothelial aggregates of inflammatory cells)
• Posterior synechiae
• Iris atrophy or nodules

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 • Intermediate Uveitis
– Inflammation of the middle portion of the uvea.
– Presentation:
– Insidious onset of blurred vision and floaters.
– Externally, the eye looks quiet and normal.
– Anterior vitreous cells.
– Snow ball --- aggregation of inflammatory cells in the
anterior part of vitreous.
– Snow banking --- grey-white fibrovascular plaque in the
inferior peripheral retina

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 • Posterior Uveitis
– Inflammation affecting the choroid, retina, and/or retinal vessels.
– Clinical Presentations:
– The eye may look quiet or may have AC inflammation.
– Symptoms --- blurry / loss of vision, scotoma, floaters.
– Signs --- infiltrates within the vitreous, retina or choroid; signs of RD.

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 • Panuveitis --- Diffuse Uveitis
– Inflammation of the entire inner eye.
– Presentation --- findings of the anterior and posterior uveitis.

– Endophthalmitis
– A type of panuveitis which is of infectious cause --- usually unilateral.

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  Investigation for Uveitis
– Diagnosis often made on clinical grounds --- as in:
– Mild unilateral acute anterior uveitis.
– Systemic diagnosis already made --- E.g., sarcoidosis.
– Distinct features --- E.g., toxoplasmosis, CMV retinitis, sympathetic ophthalmia.

– When investigations is needed, it should be done based on the most likely cause
clinically.

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 – General investigations:
– CBC, ESR, CRP
– Serology for syphilis --- VDRL, RPR, FTA-abs
– Chest x-ray

– Specific workups:
– Infectious workup --- HIV test, toxoplasma IgG/IgM, Sputum AFB
– ANA --- for children with arthritis

– Serum ACE, lysozyme

– Biopsy --- from conj., aqueous, vitreous, retina, choroid
– Imaging tests --- Ultrasound, Fluorescein angiography, OCT, CT scan, MRI

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  Treatment of Uveitis
– Steps of management:
– Proper workup and diagnosis.
• Especially, differentiate infectious from the non infectious causes.

– Treatment of the underlying cause, if any.

– Supportive management.

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 – Treatment of underlying causes:
– TB --- initiate proper anti-TB
– CMV retinitis --- Gancyclovir, Foscarnet
– HSV --- Acyclovir

– Toxoplasmosis:
• 1st line --- pyrimethamine, sulfadiazine, folinic acid, and prednisolone.
• 2nd Line --- Clindamycin.
• 3rd Line --- trimethoprim and sulfamethoxazole.

– Systemic inflammatory d’ses:

• Systemic corticosteroids
• Immunomodulatory agents

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 – Supportive treatment:
– Important for both infectious & non infectious causes.
– Include:
• Cycloplegics
• Uses --- relieve pain, prevent synechiae.
• Tropicamide, cyclopentolate, atropine.

• Corticosteroids --- to control inflammation.

• Immunosuppressive drugs --- indications being:
• Sight threatening uveitis despite steroid use.
• Steroid resistant or steroid dependent cases.
• Intolerable side effects of steroids.
• If corticosteroid use is contraindicated.

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 – Possible routes for corticosteroids:
– Topical --- for treatment of anterior uveitis.
– Sub-Tenon injection --- for intermediate or posterior uveitis.

– Intravitreal --- as injection or implant --- for posterior uveitis.

– Systemic --- for:
• Vision threatening uveitis --- posterior uveitis, panuveitis.
• Simultaneous treatment of underlying systemic inflammatory d’ses.

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 •Thank you

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