Anterior Uveitis Flashcards
What is anterior uveitis?
it’s a pathologic inflammation of any of the structures of the uveal tract, that disrupts the blood-ocular barrier with leukocytes and protein leakage.
What are the types of inflammation of the anterior chamber?
Iritis, Iridocyclitis, Anterior cyclytis
How long does anterior uveitis usually last?
6-12 weeks with/without therapy
Is anterior uveitis granulomatous or non-granulomatous?
non-granulomatous
What are the cells in granuloma?
predominantly macrophages and few lymphocytes
What are the common inciting granulomatous agents?
Bacteria, Fungi, exogenous foreign body, lipid, dermoid cyst or sarcoid
T/F Is TB a non-caseating granulomatous?
False. it’s a caseating granulomatous
What is panuveitis?
it’s inflammation involving two or more sites.
How can you describe uveitis?
By anatomic location, type of inflammation(granulomatous or non-granulomatou), laterality, duration (acute or chronic), causative factors, endogenous vs. exogenous (infectious, autoimmune, systemic or neoplastic).
T/F The relapse of chronic uveitis is more than 3 months.
False. Less than 3 months
How many times does it need the uveitis to come back in order to classify it as recurrent?
3 times
In what age group does uveitis most occur?
most prevalent in 20-50yrs, highly diagnostic in 15-20yrs. uncommon 70 yrs and beyond.
What are some causes to uveitis?
Trauma, infections, pars planitis, fuch’s heterochromic iridocyclitis and gastrointestinal disease are common among all age groups
Which ethnicity has a high frequency of ankylosing spondylitis, reiter’s syndrome and HLA-B27 diseases?
white
T/F Asians have highest incidence of Vogt-Koyanagi-Harada Syndrome and Bechet’s disease.
True
Which race have high incidence of Behcet’s disease?
Asians and Mediterranean
T/F Blacks, especially in female have a 20-30x higher incidence of uveitis due to sarcoidosis?
False. only 10-15x higher
Does stress increase the risk of uveitis?
Yes
What kind of ocular history questions you want to ask the patient with uveitis?
If they have any diseases, injury, surgery and if this is the first time they have uveitis
What are the clinical signs and inflammation of uveitis?
Rubor (redness), Tumor (swelling), Calor (heat), Dolor (pain). “RTCD”
T/F Acute uveitis is usually called the uveitis salute.
True. Because patients would put their hand on the head due to the pain
What are the exogenous uveitis?
trauma, ocular infection or allergic reaction
What are the endogenous uveitis?
Ocular disease (pars planitis, fuch’s heterochromic iridocyclytis, posner-schlossman glaucomatocyclitic crisis), and systemic diseases as well
Fuch’s heterochromic iridocyclitis is 90% _________.
Unilateral
The syndromes of fuch’s heterochromic iridocylitis are ______, ______, ______, and _____.
recurrent chronic uveitis, heterochromia (loss of iris pigment), cataract and glaucoma
What uveitis is Pars Planitis?
It’s a intermediate uveitis. you can see cells and opacities in the vitreous base (snow banking).
T/F Pars Planitis is not at risk for cystoid macular edema.
False
What kind of steroids the patient need to treat pars planitis?
combination of oral and topical. sometimes, depot steroid shots if topical is unsuccessful
T/F In Possner-Schlossman Syndrome/Glaucomatocyclitic Crisis, the larger pupil is in the non-affected eye.
False. In the affected eye.
Lens induced uveitis (post surgical) can cause both _____ and _____.
granulomatous (phaco-anaphylactic uveitis), non-granulomatous (Phakogenic uveitis)
What are the types of hypersensitivity reactions that cause uveitis?
Type 1. immediate IgE
Type 2. Cytotoxicity IgG, IgM +/- complement
Type 3. Immune complex IgG, IgM and complement
Type 4. Cell mediated
Which specific human leukocyte antigen (HLA) is anterior uveitis link to?
HLA-B27
What are some signs and symptoms of uveitis that can differentiate itself from conjunctivitis or keratitis?
- topical anesthetics don’t help
- no itching or burning
- uveitis salute
- hyperemia(red) specially around cornea
Symptoms of uveitis include: _____, _____, _____ and _____,
pain, photophobia, tearing and vision loss.
What are the signs and symptoms of the lid in uveitis patients?
blepharospasm (uncontrolled muscle contraction), congestion and edema, erythema (redness of skin), pseudoptosis.
What are the signs and symptoms of the conjunctiva in uveitis patients?
circumcorneal flush, inflammation most noticeable around the cornea, cu-de-sac is white and quiet, inflammation may be sectional or sectoral with the greatest inferiorly or inferior temporally with more than 90 degree in size.
What are some signs of uveitis?
Edema, Band Keratopathy, Cells and flare in the anterior chamber, Iris membranes, Keratic precipitates, Hypopion, Synechiae, Iris atrophy, Iris granulomas, Iris nodules, Pupil involvement, IOP changes, Cataracts, spillover of cells in the vitreous, Cystoid macular edema, and Bilateral uveitis.
T/F Striate keratitis can be seen in advanced and chronic cases and secondary to corneal edema.
True
T/F Band Keratopapthy may develop in acute cases.
False. in recurrent/advanced or chronic cases
Band Keratopathy is comprise of ______.
calcium salt
T/F Band Keratopathy is located under the corneal epithelium.
True
What is the Still’s Triad in juvenile rheumatoid arthritis?
- Cataract
- Band Keratopathy
- Chronic uveitis
“CBC”
What is the grading if you see 1 - 5 cells in 30-60 sec in the anterior chamber?
Grade 0-1+
What is the grading if you see 5-10 cells in the beam at once?
Grade 1-2+
What is the grading if you see cells scattered throughout beam?
Grade 2-3+
What is the grading if you see dense cells in beam?
Grade 3-4+
Flare is protein leak from ____.
Inflamed blood vessels. More noticeable in chronic granulomatous uveitis.
What is the grade for trace flare?
0-1+
What is the grade for obvious flare (by bilateral comparison)?
1-2+
What is the grade for hazy aqueous flare?
2-3+
What is the grade for dense or plasmoid aqueous flare?
3-4+
Dense or plasmoid aqueous flare can be seen in _____.
severe acute uveitis
What is keratic precipitates (KP)?
It’s inflammatory cellular deposit on the corneal endothelium
What are the types of KP?
Fine, granulomatous and pigmented
T/F Fine KP has a 2D appearance.
False. 3D
What is the size of fine KP?
Less than 0.5mm
“mutton fat” is describing which KP?
Granulomatous Keratic Precipitates
How does Granulomatous KP look like?
Chronic types are large, flat, greasy, wavy and grainy looking. May accumulate pigment with age.
Arlt’s triangle or Krukenberg’s spindle are _______ keratic precipitates.
Pigmented
How does Arlt’s triangle form?
Due to temperature differential between lens and cornea, causing convection current (cells up to the lens and drop down to the cornea endothelium)
Granulomatous uveitis is associated with which diseases?
TB, Sarcoidosis, Syphilis, Cat Scratch Fever, and Fungal Infections
Non-granulomatous uveitis is associated with which diseases?
Juvenile Rheumatoid Arthritis and Fuch’s Heterochromic Iridocyclitis
Fine Keratitis Precipitates is granulomatous or non-granulomatous?
Non-granulomatous
Hypopion consists of a dense accumulation of _________.
White blood cells, usually PolyMorphoNuclear (PMN) cells
Hypopion is most common in which diseases?
Behcet’s Leprosy, Endopthalmitis, Sarcoid, and post surgical uveitis
What is peripheral Anterior Synechiae?
It’s a fibrous adhesions between peripheral cornea and iris
Which is more common? Anterior or Posterior synechiae?
Posterior. Adhesions is between the pupillary border and the anterior lens capsule
T/F Seclusio Pupillae is a immobile pupil with a 180 posterior synechiae.
False. 360 posterior synechiae
Iris Atrophy occurs in acute or chronic uveitis?
Chronic. Like in Fuch’s Heterochromic Iridocyclytis and Herpetic uveitis
What are some signs of Iris Atrophy?
- Iris pigment may be reduced
- Smooth velvety appearance (edema)
- Dense flare in anterior chamber
Iris Granulomas are common in ______.
Sarcoid
What are the two types of Iris granulomas?
Koeppe nodules (on pupil border) and Bussaca nodules (away from the pupil border, in the internal iris stroma)
What is the Henkind test?
Shinning a light in the non-affected pupil will cause pain in the other eye’s pupil
Which cataract is most common in uveitis?
Posterior sub-capsular cataract
What are the types of cataract form in uveitis?
Epi-capsular stars (can happen in both acute and chronic), Posterior sub-capsular cataract (most common) and mature cataracts (Still’s disease- Rheumatoid arteritis)
Unilateral uveitis is more common in which conditions?
Sarcoid, Behcet’s foreign body, post-surgical events and fuchs.
Who can you refer a chronic uveitis patient to?
Internist, Rheumatologist, Virologist and Uveitis specialist
Ankylosing Spondylitis limits the motion of the _____ spine, and causes calcification of the ________ joint.
Lumbar, sacroiliac
Most of the Ankylosing Spondylitis patients have which gene?
HLA-B27
T/F Males are 4x more affected with ankylosing Spondylitis than female.
True
Behcet’s syndrome is associated with which gene?
HLA-B5
Who are more affected with Behcet’s?
young adults, Asian, and women 2x more than man
T/F Behcet’s syndrome is not associated with hypopion.
False
Behcet’s affects where?
mouth, genital, and skin
What is the clinical triad for Reactive Arthritis/Reiter’s Syndrome?
Arthritis, Urethritis and conjunctivitis with anterior uveitis
How can you differentiate the ulcers between Behcet’s and Reiter’s?
Reiter’s ulcers aren’t as deep as Behcet’s
Which disease is called the great mimicker?
Syphilis
What is the primary, secondary and tertiary symptoms of syphilis?
Primary: Chancre (21 days after infection)
Secondary: Plantar/Palmar rash
Tertiary: Cardiac and neurologic effects Gumma (3-5 years after infection)
What are some ocular findings of syphilis?
- Granulomatous anterior or posterior uveitis
- Interstitial keratitis
- Argyll-Robertson Pupil
- Chorio-retinitis (salt and pepper fundus)
- Great Masquerader
What are the Hutchinson’s Triad for congenital syphilis?
Eye (interstitial keratitis), Ears (eighth nerve deafness) and Teeth(notched incisor teeth)
How to treat syphilis?
penicillin, and oral and topical steroids for the interstitial keratitis
Which gender does Crohn’s disease affect more?
How about ulcerative colitis?
Male
Female
How long does it take to diagnose Juvenile Rheumatoid Arthritis?
6 weeks of chronic observed synovitis
Which gender does JRA affect more?
Females are 4x more than males
What are the signs and symptoms of Psoriaritis Arthritis?
Silver red scaly patches on the skin, nails affected as well as few joints on fingers and toes
What do we find in the eyes of kids who have Juvenile Xanthogranuloma (JXG)?
Anterior uveitis, Epibulbar mass and spontaneous hyphema.
What is the Triad for Systemic Lupus Erythematosus? (LUPUS)
Joint pain, Fever, Rash (malar rash - on face), Discoid rash (on face or skin)
LUPUS and Sarcoid are _____system disease.
multi
T/F Pulmonary nodes are most common in Sarcoid patients.
True
Which race and gender does Sarcoid most commonly found?
Young black female
What are the ocular signs of TB?
Any part of the eye can be affected, Phlyctenular conjunctivitis (vesicle surround by a reddened zone) and anterior uveitis
What drugs would you prescribe to a TB patient?
Systemic isoniazid, Ethambutol (anti-mycobacterial), Rifampin (bactericidal antibiotic), Streptomycin (anti-mycobacterial)
What organism cause Lyme disease?
Borrelia burgdorferi
What organism cause syphilis?
Treponema pallidium
How does Lyme disease look like on the skin?
“bull’s eye lesion”
What antibiotic is use to treat Lyme disease?
Doxycycline
T/F Herpes family is a granulomatous uveitis disease.
False, non-granulomatous
45% of all herpes infections in the eye presents as ________.
iridocyclytis (inflammation of the iris and ciliary body)
Chicken pox can cause which kind of herpes in the eye?
Varicella
What do you see in the corneal epithelium of a herpes simplex patient?
- PED, dendrites, geographic ulcer
- decreased sensitivity and scarring
- End-bulbs, stain with Rose Bengal
What is the Acyclovir concentration for treating herpes simplex uveitis?
- Oral Acyclovir 400mg p.o. 5x a day for 7-10days for treatment
- long term oral antiviral prophylaxis 400mg p.o. Acyclovir 2x a day
Herpes Zoster dermatomal pain is associated with CN5 V___.
1
What is the Acyclovir concentration for treating herpes zoster uveitis?
Acyclovir 800mg p.o. 5x a day
Herpes simplex affects _______ patients and zoster affects ______ patients.
younger, older
What is vogt-Harada-Koyanagi syndrome (VKH)?
Autoimmune disease with inflammation of melanocytes
Where are the places in the body VKH can affect?
hair (alopecia and poliosis), eye, ear (tinnitus) and brain (seizures, loss of consciousness)
T/F Uveitis from rubella is not always congenital.
False, it’s always congenital
Which organism cause Leprosy?
mycobacteria
When do you require a lab workout for uveitis patients?
When the uveitis is recurrent, bilateral or granulomatous
What kind of disease is associated with an elevated hemoglobin level?
Lung disease: TB, Sarcoidosis, Smokers, High altitudes, Leukemia
- Elevated hemoglobin is associated with _________.
- Increased platelet size is associated with _________.
- Neutrophils is associated with ________.
- Lymphocytes is associated with ________.
- Monocytes is associated with __________.
- Eosinophils is associated with _________.
- Basophils is associated with ________.
- Lung disease
- Inflammatory Bowel disease
- Bacterial infection, arthritis
- Viral infection, Allergies
- Systemic infections
- Allergies
- Leukemia
Which white blood cells are associated with allergies?
Eosinophils and Lymphocytes
What does it mean to the infection if VDRL titer falls as disease gets better?
indicates active infection
Which venereal test give many false positives?
RPR
What is the significance of the different CD4 count with HIV positive patients?
<100 cells/cubic mm – risk for CMV retinitis, Herpes Zoster retinitis and Crytococcal choroiditis
Purified Protein Derivative (PPD)/Mantoux test is to test for what?
TB
What are the cycloplegic and mydriatic agents to prescript to uveitis patients?
0.25% scopolamine b.i.d.
5% Homatropine q.i.d.
1% Atropine b.i.d. (not the best choice - encourage snechiae formation)
What was the steroid medication recommended by Dr. Neiberg in treating uveitis?
Pred Forte
Should we use prostaglandins in the treatment of uveitis?
NO, prostaglandin is a pro-inflammatory agent
