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KMK Ocular Disease > 6 - Epi/Sclera/Uvea > Flashcards

6 - Epi/Sclera/Uvea Flashcards

1
Q

Episcleritis

  • who
  • pathophys
A 
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)
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2
Q

Episcleritis

-signs/symp

A

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

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3
Q

Scleritis

  • who
  • pathophys
A

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

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4
Q

Scleritis

-divisons/subtypes

A

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
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5
Q

Scleritis

-signs/symp

A

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

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6
Q

What to think of when see blue sclera (2)

A

Scleritis

Drugs - minocycline, topical steroids

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7
Q

Axenfeld’s nerve loop

A

Congenital anomaly
Focal, pigmented, elevated area where LPCNs are visible in the sclera
Can be painful

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8
Q

Anterior uveitis

-who

A

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

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9
Q

Anterior uveitis

-pathophys

A

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)

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10
Q

Anterior uveitis

  • breakdown of divisions/subtypes
  • most common uveitis
A

Granulomatous = sarcoid, TB (also syph, herpes)

Non-granulomatous = IDIOPATHIC (70%) or UCRAP (30%)

Most common uveitis: anterior unilateral acute non-granulomatous

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11
Q

Anterior uveitis

-acute vs chronic

A

A: self-limited, <3mo, may be recurrent

C: persists >3mo, may have periods of exacerbations but never fully resolves

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12
Q

Anterior uveitis

-symp

A

Pain*, redness, PHOTOPHOBIA, lacrimation, mildly decr vision (esp with cme)
*pain is due to congestion and irritation of anterior ciliary nerves

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13
Q

Anterior uveitis
-signs
—dx based on
—main threats to vision

A

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

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14
Q

Anterior uveitis
-signs
—IOP
—cyclitic membrane

A

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

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15
Q

Anterior uveitis
-signs
—most common corneal findings

A

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)
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16
Q

Keratic precipitates

  • what are they (in general)
  • mutton-fat
  • koeppe nodules
  • busacca nodules
A

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

17
Q

Keratic precipitates

  • non-granulomatous
  • stellate
  • granulomatous
A

NG = fine

  • 70% idiopathic
  • 30% UCRAP

Stellate: Fuchs, Herpes

Gran: sarcoid, tb, busacca, koeppe
-granulomatous = macrophages

18
Q

Acute non-granulomatous anterior uveitis

  • # 1 cause (besides trauma)
  • describe glaucomatocyclitic crisis
  • other causes
A

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

19
Q

3 major condns that present with unilateral AC cells with acutely elev IOP

A

Posner-Schlossman: TM INFLAMMATION

Herpes zoster/simplex trabeculitis

Fuchs heterochromic iridocyclitis: TM DAMAGE -> NVA

20
Q

Chronic granulomatous anterior uveitis

-causes

A

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

21
Q

Interstitial keratitis

  • what
  • cause
A

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
22
Q

Chronic non-granulomatous anterior uveitis

-causes

A

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
23
Q

Pars planitis

A

Chronic, intermediate uveitis
Inflammation over pars plana = “SNOWBANKING”
No systemic assoc

24
Q

Posterior uveitis

  • what it is (generally)
  • presentation
A

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
25
Q

Posterior uveitis

-causes/assoc conditions

A

Toxoplasmosis
Sarcoid
Syphilis
Cytomegalovirus

26
Q

Toxoplasmosis

  • who
  • pathophys
A

Most common cause of posterior uveitis in usa
Think 25yo with unilateral vitritis

PARASITIC infection by toxoplasma gondii: obligate intracellular intestinal parasite

27
Q

Toxoplasmosis

-congenital vs acquired

A

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

28
Q

Toxoplasmosis

-signs/symp

A

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”)

29
Q

Toxo vs histo

A

T:

  • one eye, one lesion
  • retinovitritis
  • parasite

H:

  • bilateral, multiple lesions (histo spotS)
  • choroiditis
  • fungal
30
Q

Sarcoid

  • retinal vitritis
  • retinal vasculitis
A

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)

31
Q

Cytomegalovirus

  • app
  • CD4
  • ddx
A

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),

32
Q

Iris coloboma

  • pathophys
  • signs
  • associations
A

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

33
Q

Iris malignancy

  • pathophys
  • signs
  • high risk characteristics that = need for evaluation
A

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

KMK Ocular Disease (17 decks)

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