6 - Epi/Sclera/Uvea Flashcards
Episcleritis
- who
- pathophys
Young adults (peak 2nd-4th decades) Hx of frequent recurrences (60-67%)
#1 cause = IDIOPATHIC Associated systemic condns (~30%): UCRAP, RA, LUPUS (collagen vascular/inflammatory dz) -others: —spirochetes (syphilis, lyme) —virus (herpes s/z, mumps) —metabolic (gout) —vasculitic dz (temporal arteritis, wegener’s, behcet’s, polyartertis nodosa) —dermatologic (acne rosacea)
Episcleritis
-signs/symp
Signs: SECTORAL (70%) injection, simple (80%) or nodular (20%)
- nodule can be moved slightly (unlike scleritis)
- blanches with phenyl 2.5%
Symp: acute UNILATERAL (2/3rds) red eye, mild pain
Scleritis
- who
- pathophys
Female, 40-60yo
Much less common than epi
GRANULOMATOUS inflammation of sclera
50% assoc with underlying systemic condns: 30% of those from collagen vascular dz - #1 RHEUMATOID ARTHRITIS, #2 wegener’s
Scleritis
-divisons/subtypes
Non-necrotizing
- diffuse (60%): MOST COMMON + benign, diffuse hyperemia
- nodular (25%): deep, focal, painful, injected, IMMOBILE nodule
Necrotizing
- with inflammation (5%): WORST, 33% die of severe autoimmune dz, ocular concerns are peripheral corneal melt -> secondary glaucoma
- without inflammation (10%): Sleromalacia Perforans, result of CHRONIC RHEUMATOID ARTHRITIS, NO PAIN, BLUE SCLERA
Scleritis
-signs/symp
Signs: DIFFUSE inflammation of large, deep vessels (immobile), edematous or THIN SCLERA -> BLUE, frequently BILATERAL
-recall: scleral thinning due to age assoc with hyaline plaques
Symp: SEVERE BORING PAIN - can radiate to forehead/brow/jaw, gradual onset redness/decr in vision
-scleromalacia p is virtually symptom-free
What to think of when see blue sclera (2)
Scleritis
Drugs - minocycline, topical steroids
Axenfeld’s nerve loop
Congenital anomaly
Focal, pigmented, elevated area where LPCNs are visible in the sclera
Can be painful
Anterior uveitis
-who
Affects 15/100k, 45k new cases/year
Most often young adults (peak 2nd-4th decades)
-rarely in indiv older than 70: if so, commonly due to toxoplasmosis, herpes zoster
Anterior uveitis
-pathophys
Secondary to BREAKDOWN OF BAB
50% with acute are HLA-B27(+) (UCRAP)
-50% of new-onset acute have associated spondyloarthopathy (80% of those ANKYLOSING SPONDYLITIS)
Anterior uveitis
- breakdown of divisions/subtypes
- most common uveitis
Granulomatous = sarcoid, TB (also syph, herpes)
Non-granulomatous = IDIOPATHIC (70%) or UCRAP (30%)
Most common uveitis: anterior unilateral acute non-granulomatous
Anterior uveitis
-acute vs chronic
A: self-limited, <3mo, may be recurrent
C: persists >3mo, may have periods of exacerbations but never fully resolves
Anterior uveitis
-symp
Pain*, redness, PHOTOPHOBIA, lacrimation, mildly decr vision (esp with cme)
*pain is due to congestion and irritation of anterior ciliary nerves
Anterior uveitis
-signs
—dx based on
—main threats to vision
Presence of WBCs in anterior chamber (cells)
Posterior synechiae* (iris-lens)
Peripheral anterior synechiae* (iris-angle -> secondary glauc)
CME
Cataract formation (esp PSC) - assoc with chronic cases
*think fat + sticky iris
Anterior uveitis
-signs
—IOP
—cyclitic membrane
IOP:
- early = decr (CB inflammation -> decr active secretion)
- later = may be elevated due to trabeculitis/chronic TM damage, PS, PAS, significant inflamm, topical steroids, prostaglandin production
Cyclitic membr: chronic uveitis, fibrovascular membranes extending from CB -> posterior chamber, may involve lens
Anterior uveitis
-signs
—most common corneal findings
KERATIC PRECIPITATES
- fine KP= non-granulomatous etiology
- mutton-fat KP, iris stromal nodules (Koeppe, Busacca) = granulomatous (infectious (tb, syph), chronic course, incr predilection for posterior chamber)
Keratic precipitates
- what are they (in general)
- mutton-fat
- koeppe nodules
- busacca nodules
WBCs on endothelium
MF: macrophages, greasy app, mid-lower cornea
KN: wbcs on pupillary margin, assoc with gran + non-gran
BN: wbcs in any part of iris stroma except pupillary margin, PATHOGNOMONIC for granulomatous etiology
Keratic precipitates
- non-granulomatous
- stellate
- granulomatous
NG = fine
- 70% idiopathic
- 30% UCRAP
Stellate: Fuchs, Herpes
Gran: sarcoid, tb, busacca, koeppe
-granulomatous = macrophages
Acute non-granulomatous anterior uveitis
- # 1 cause (besides trauma)
- describe glaucomatocyclitic crisis
- other causes
Ankylosing spondylitis (30yo male, lower back pain, improves with exercise)
aka Posner-Schlossman
- UNILATERAL, mild iritis, recurrent, self-limiting
- high IOP: 30-40’s, secondary to TRABECULITIS
- fine KPs, OPEN ANGLE on gonio
IBD, reactive arth, psoriatic arth, behcets, lyme
3 major condns that present with unilateral AC cells with acutely elev IOP
Posner-Schlossman: TM INFLAMMATION
Herpes zoster/simplex trabeculitis
Fuchs heterochromic iridocyclitis: TM DAMAGE -> NVA
Chronic granulomatous anterior uveitis
-causes
Sarcoid: idiopathic inflamm, females, AAs, bilateral
- chest radiograph, incr ACE levels
- periphlebitis (candle wax exudates)
TB: night sweats, chest x-ray, PPD
Herpes s/z: incr IOP in involved eye, STELLATE KPs, epi defects
Syphilis: associated INTERSTITIAL KERATITIS, maculopapular rash (palms, soles), (+)VDRL/RPR, (+)FTA-ABS/MHA-TP
-salt + pepper fundus
Interstitial keratitis
- what
- cause
1 cause = congenital syphilis* (90%)
Stromal inflammation WITHOUT primary involvement of epi or endo
-stromal NV
-progression -> diffuse vasularization, often into line of sight
Late stages: stromal vessels partially clear -> ghost vessels, corneal scarring, irregular astig
- also tb, hsv
- cong syph triad: Hutchinson’s teeth, deafness, interstitial keratitis
Chronic non-granulomatous anterior uveitis
-causes
JIA/JRA: kids, bilateral, (-)RF, (+)ANA
Fuchs: esp pts with blue eyes, UNILATERAL (90%), CHRONIC, fine STELLATE KPs, nva, iris heterochromia
- assoc with glaucoma, cataracts
- often asymptomatic
Pars planitis
Chronic, intermediate uveitis
Inflammation over pars plana = “SNOWBANKING”
No systemic assoc
Posterior uveitis
- what it is (generally)
- presentation
Breakdown in BAB
Inflammation of retina, choroid, or both
-retinitis, retinochoroiditis, choroiditis, chorioretinitis, neuroretinitis
May present with or without WBCs in vitreous (vitritis): depends on primary site of inflamm
- retinal inflamm: results in breakdown of BRB -> WBCs in vitreous -> floaters, decr vison
- choroidal inflamm: BRB not affected, no vitritis, asymptomatic unless macular involvement
Posterior uveitis
-causes/assoc conditions
Toxoplasmosis
Sarcoid
Syphilis
Cytomegalovirus
Toxoplasmosis
- who
- pathophys
Most common cause of posterior uveitis in usa
Think 25yo with unilateral vitritis
PARASITIC infection by toxoplasma gondii: obligate intracellular intestinal parasite
Toxoplasmosis
-congenital vs acquired
C: 90%, transplacental - if mother is affected prior to pregnancy fetus is unaffected
-of these, 90% born normal with chorioretinal scar, 10% born with cerebral calcifications (mentally handicapped)
A: inhalation via cat feces, eating undercooked meat
Toxoplasmosis
-signs/symp
Recurrence of an old, stable, congenital ocular lesion is most common cause of infectious retinitis
Unilateral redness, photophobia, floaters, uveitis, vitritis, decr vision
Avg age 25
FOCAL, FLUFFY, YELLOW-WHITE retinal lesions adjacent to old c.r. scar with overlying VITRITIS (“headlights in the fog”)
Toxo vs histo
T:
- one eye, one lesion
- retinovitritis
- parasite
H:
- bilateral, multiple lesions (histo spotS)
- choroiditis
- fungal
Sarcoid
- retinal vitritis
- retinal vasculitis
Vit: “cotton ball opacities” - diffuse white, fluffy opacities in inferior vitreous (snow banking, exudative clumps)
Vasc: “candle wax drippings” - sheathing around reintal veins + yellow-white exudates leaking (periphlebitis)
Cytomegalovirus
- app
- CD4
- ddx
White patches of necrotic retina with HEMORRHAGIC retinitis + vascular sheathing
<50
Toxo: less intravitreal hemorrhage + more vitritis than CMV
PORN: less intravitreal hemorrhage; minimal vitritis (similar to CMV),
Iris coloboma
- pathophys
- signs
- associations
Imcomplete closure of embryonic fissure
Typically INFERIOR NASAL
Complete: full-thickness, may extend margin -> peripheral cornea (“keyhole” pupil) or only pupillary margin (oval-shaped pupil)
Incomplete: partial-thickness, visible as TID on retro
Assoc with other colobomas: CB, zonular, choroidal, retinal, optic nerve
Iris malignancy
- pathophys
- signs
- high risk characteristics that = need for evaluation
Malignant tumor arising from abnormal profleration of melanoCYTES, esp within STROMA
-most are thought to arise from iris nevi
Pigmented or amelanotic, irregular feathery margins, diameter >3mm
80% in INFERIOR quadrant
Hyphema, ectropion uvea, angle involvement, inferior location, diffuse feathery margins
