Uveitis Ppt

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 lesionskeratoconjunctivitis sicca

Sarcoidosis • Anterior uveitis – Acute anterior uveitis- acute onset sarcoid – Chronic granulomatous anterior uveitisolder 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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