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Ocular Disease > Anterior Uveitis - part 1 > Flashcards

Anterior Uveitis - part 1 Flashcards

1
Q

what is anterior uveitis?

A

pathological inflammation of any structure of the uveal tract (iris, ciliary body, choroid)

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2
Q

what are the 3 events that occur in uveitis?

A

inflammation, disruption of blood-ocular barrier, and infiltration of leukocytes and protein leakage

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3
Q

what are the 3 categories of anterior uveitis?

A

anterior uveitis, posterior uveitis, and pan uveitis

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4
Q

describe the duration and onset of acute anterior uveitis

A

sudden onset, limited duration, 1st and 2nd episodes are usually acute, lasts less than 6-12 weeks

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5
Q

what is the pain level with anterior uveitis?

A

moderate to severe pain

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6
Q

is anterior uveitis generally granulomatous or non-granulomatous?

A

non-granulomatous with fine keratic precipitates (on corneal endothelium)

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7
Q

what is a granulomatous?

A

occurs when neutrophils are unable to remove an inciting agent - granulomas form with chronic inflammation

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8
Q

what are the predominant cells in granulomas?

A

macrophages (macrophages may fuse to form multinucleated giant cells) *few lymphocytes are present

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9
Q

what are 5 common inciting agents in granulomas?

A

bacteria (mycobacterial in TB/Leprosy), fungi, exogenous FB, endogenous altered material (lipid- chalazion, or dermoid cyst) and sarcoid

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10
Q

what are 3 examples of non-caseating granulomas?

A

chalazion, epidermoid/dermois cyst, sarcoidosis

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11
Q

what is an example of a caseating granuloma

A

TB granuloma

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12
Q

what is posterior uveitis?

A

inflammation of choroid and retina

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13
Q

what is panuveitis?

A

inflammation involving two or more sites = anterior chamber, vitreous, retina, choroid inflammation not predominant at any one site

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14
Q

describe chronic uveitis

A

persistent and relapse in less than 3 months after discontinuing treatment

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15
Q

describe recurrent uveitis

A

3rd episode re-classifies as recurrent, requires complete medical evaluation, and repeated episodes with inactivity longer than 3 months

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16
Q

which ages is uveitis most prevalent?

A

20-50 years old

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17
Q

why is uveitis uncommon as a primary diagnosis beyond age 70?

A

immunity decreases with age (not as hypersensitive)

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18
Q

list the order of causes for uveitis for under age 20:

A

trauma, unknown, pars planitis, infection, JRA, Fuch’s heterochromic iridocyclytis, sarcoidosis, gastrointestinal disease

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19
Q

list the order of causes for uveitis ages 20-50:

A

unknown, trauma, pars planitis, sarcoidosis, HLA, infection, Fuch’s heterochomic iridocyclytis, and gastrointestinal disease

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20
Q

list the order of causes for uveitis for 50+:

A

unknown, trauma, HLA, infection, gastrointestinal disease, Fuch’s heterochromic iridocycliytis and pars planitis

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21
Q

what 3 things cause males to have uveitis?

A

trauma, ankylosing spondylitis, and Reiter’s syndrome (reactive arthritis)

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22
Q

what type of uveitis doubles in females due to sarcoidosis?

A

granulomatrous type

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23
Q

what are 5 things that cause uveitis to be greater in females?

A

(Still’s disease) chronic JRA, hepatomegaly,splenomegaly, lymphadenopathy, and rash

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24
Q

what 3 syndromes are caucasians higher at risk for?

A

ankylosing spondylitis, Reiter’s syndrome and HLA-B27 diseases

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25
Q

what causes blacks have a higher incidence of uveitis?

A

10-15x higher risk due to sarcoidosis (especially females and in SE USA)

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26
Q

what are 2 syndromes that are more prevalent in Asians?

A

Vogt-Koyanagi-Harada syndrome and Behcet’s disease

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27
Q

what race has the highest incidence of Behcet’s disease?

A

Mediterranean

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28
Q

which region is sarcoid not common? what about non-existent?

A

south pacific

south african blacks

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29
Q

which 3 regions should you consider sarcoid?

A

southeastern US, swedish and norwegians

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30
Q

which venereal diseases are associated with uveitis?

A

syphilis, chlamydia and HIV

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31
Q

which type of uveitis is associated with type A personality and stress?

A

pars planitis

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32
Q

what are the 4 clinical signs of inflammation?

A

rubor (redness), tumor (swelling), calor (hear) and dolor (pain)

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33
Q

why does the eye have immune privilege?

A

it is somewhat immunosuppressed - if it reacted to everything that got in the eye we would go blind

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34
Q

why is the eye so vulnerable to Herpes Simplex?

A

due to its immune privilege - it leaves the eye vulnerable to pathogens that would usually be eliminated by T cells

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35
Q

the release of these chemicals cause the breakdown of the blood aqueous barrier. what are they?

A

histamine, bradykinin and serotonin

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36
Q

what happens after proteins diffuse from ciliary processes and iris stroma into aqueous during red eye?

A

IgM and IgA are detectable - complement components rise and significant amount of coagulation factors and fibrinolysis occurs

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37
Q

is there always swelling with acute anterior uveitis?

A

healthy cornea = minimal swelling

if the patient has Fuch’s endothelial dystrophy = severe swelling

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38
Q

what type of swelling occurs with chronic anterior uveitis?

A

corneal edema

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39
Q

what is the uveitis salute?

A

patients in the waiting room will have their hand over the effected eye(s) - inflamed eye is hot to touch and usually painful

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40
Q

what are 4 exogenous etiologies of uveitis?

A

unknown, trauma, ocular infection, allergic reaction

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41
Q

what are 3 endogenous etiologies of uveitis?

A

unknown, ocular disease (pars planitis, fuch’s heterochromia iridocyclytis, posner-schlossman glaucomatocyclitic crisis) and systemic disease

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42
Q

what are some characteristics of Fuch’s heterochromia iridocyclitis?

A

unknown etiology, 2-3% of all uveitis and 90% unilateral

affecte eye = OD

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43
Q

what are the 4 parts to Fuch’s heterochromia iridocyclitis syndrome?

A

recurrent chronic uveitis, heterochromia, cataract, glaucoma - difficult to control

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44
Q

what is the hallmark sign of pars planitis?

A

cells and opacities in vitreous base (snow banking)

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45
Q

how often does pars planitis occur? is it unilateral or bilateral?

A

10% of all uveitis and 70% bilateral

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46
Q

when would you refer a patient with pars planitis?

A

if they are at risk of CME, reduced VA 20/40 or worse, may need oral and topical steroids, may need depot steroid shot

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47
Q

what is possner-schlossman syndrome/glaucomatocyclitic crisis?

A

mild idiopathic anterior chamber inflammation, monocular and in young adults (resolves in middle age)

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48
Q

what are the signs of possner-schlossman syndrome?

A

elevated IOP (over 30mmHg), intermittent attacks lasting 3-10 days, KP, corneal edema, heterochromia with anisocoria and the larger pupil is affected eye

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49
Q

what causes elevated IOP in possner-schlossman syndrome?

A

TM is congested by inflammatory debris, open angles

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50
Q

what are some symptoms of lens induced uveitis?

A

pain, redness, photophobia (non-infectious hypopion or hyphema)

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51
Q

what causes lens induced uveitis and when does it occur?

A

reaction to lens protein that occurs after disruption of lens capsule - 1 day to 59 years after surgery

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52
Q

what is the treatment for lens induced uveitis?

A

topical or periocular steroids injected, removal of lens fragment

53
Q

why must lens induced uveitis be differentiated from enophthalmitis?

A

endophthalmitis will need antibiotics ASAP

54
Q

what is phaco-anaphylactic uveitis?

A

granulomatous reaction, autoimmune/immune complex - not a true type 1 hypersensitivity reaction

55
Q

what is phakogenic uveitis?

A

non-granulomatous reaction

56
Q

what is an example of type 1 hypersensitivity uveitis?

A

immediate IgE = atopic iritis shellfish allergy

57
Q

what is an example of type 2 hypersensitivity uveitis?

A

cytotoxicity IgG, IgM, +/- complement = microbial iritis

58
Q

what is an example of type 3 hypersensitivity uveitis?

A

immune complex IgG, IgM, and complement = autoimmune lens induced sympathetic ophthalmia

59
Q

what is an example of type 4 hypersensitivity uveitis?

A

cell mediated = sensitized T lymphocytes may have relationship with chronic uveitis

60
Q

how might a person have a genetic predisposition to uveitis?

A

linked to human leukocyte antigen (HLA) - present on many cells in body used to determine self from non-self

61
Q

which specific HLA is associated to uveitis?

A

HLA-B27

62
Q

how do you differentiate uveitis from conjunctivitis and keratitis?

A

pain is deeper and won’t respond to anesthetic, no itching or burning, uveitis salute, circumlimal hyperemia

63
Q

is pain associated with acute or chronic uveitis? does the level of pain predict the severity?

A

acute = severe and debilitating

chronic = may be asymptomatic

doesn’t predict severity

64
Q

why does light cause pain in uveitis?

A

changes the pupil size - iris movement causes pain

65
Q

what is the henkind test?

A

take light and shine it in the eye without uveitis and it will also have pain

66
Q

what type of discharge is associated with uveitis?

A

hyper-lacrimation = watery eyes (no other discharge present)

67
Q

how is vision affected in acute uveitis?

A

vision is usually normal to hazy

68
Q

how is vision affected in chronic uveitis?

A

vision may be worse than symptoms - depends on degree

69
Q

what type of vision will increase pain?

A

near vision/accommodation = pupil constricts causing pain

70
Q

what are 4 signs and symptoms with lids?

A

blepharospasm, congestion and edema, erythema, and pseudoptosis

71
Q

what does the hyperemia on the conjunctiva look like in uveitis?

A

peri-limbal/circumcorneal flush (deep scleral or episcleral radiating vessel pattern) and cul-de-sacs are white and quiet

72
Q

what type of inflammation is there and where is it greatest?

A

most noticeable around the cornea - may be sectoral or sectional greatest inferior and usually more 90 degrees in size

73
Q

what type of edema is present in chronic or advanced uveitis?

A

microcystic edema, stromal edema, and striate keratitis

74
Q

what is band keratopathy?

A

forms under the corneal epithelium, comprised of calcium salts

75
Q

what type of uveitis is band keratopathy present in?

A

recurrent/advanced or chronic cases

76
Q

how is band keratopathy removed?

A

EDTA chelation

77
Q

what is the Still’s traid in JRA?

A

cataract, band keratopathy and uveitis (chronic)

78
Q

what type of cells are seen in the anterior chamber in uveitis?

A

*classic sign usually WBC (leukocytes) that have leaked from ciliary body (occasionally RBC or pigment cells)

79
Q

how do you grade cells seen in uveitis?

A

0-1+ = 1-5 cells in 30-60 seconds

1-2+ = 5-10 cells in beam

2-3+ = cells scattered

3-4+ = dense cells

80
Q

what causes flare in uveitis? and when is it more noticeable?

A

protein leaking from inflamed blood vessels

chronic granulomatous uveitis

81
Q

does flare ever go away?

A

it can get better but may persist indefinitely

82
Q

how do you grade the flare seen in uveitis?

A

0-1+ = trace flare

1-2+= obvious flare

2-3+ = hazy aqueous

3-4+ = dense or plasmoid aqueous

83
Q

what is plasmoid aqueous comprised of?

A

dense accumulation of fibrin cells producing translucent to cloudy strands or sheets with lumps or protein material

84
Q

when is plasmoid aqueous seen?

A

severe acute uveitis - can be mistaken for lens material from ruptured lens capsule after blunt trauma

85
Q

what are keratic precipitates (KP)?

A

inflammatory cellular deposits on corneal endothelium

86
Q

what types of KP are seen in anterior uveitis?

A

fine, granulomatous, and pigmented

87
Q

describe the size and composition of fine keratic precipitates

A

whitish-gray fibrin or epitheloid cells adherent to posterior cornea - small/discrete and always less than 0.5mm (3D appearance)

88
Q

describe granulomatous keratic precipitates

A

large, flat confluent looking, greasy/waxy, grainy - look like mutton fat

89
Q

describe Arlt’s triangle seen in pigmented KP

A

base down, formed by convection current, gravity causes colder particles in front of cornea to drop (colder climates they don’t drop as close to cornea)

90
Q

what 4 things are in mutton fat KP?

A

epitheloid cells, giant cells (histocytes cluster/fuse), plasma cells, lymphocytes

91
Q

what 3 things are in fine KP?

A

epitheloid cells/fibrin, plasma cells, and lymphocytes

92
Q

name the 5 syndromes that have granulomatous uveitis (mutton fat KP)

A

tuberculosis, sarcoidosis, syphilis, cat scratch fever, fungal infections

93
Q

what are 2 syndromes that are non-granulomatous uveitis (fine KP)?

A

JRA and Fuch’s heterochromia iridocyclitis

94
Q

which type of uveitis granulomatous or non-granulomatous has iris nodules?

A

granulomatous

95
Q

when might you see a hypopion in uveitis?

A

severe acute anterior unveitis - Behcet’s, leprosy, endopthalmitis, sarcoid and post surgical uveitis (BLES)

96
Q

what does a hypopion consist of?

A

dense accumulation of WBCs (usually polymorphonuclear - PMN cells)

97
Q

where do you see peripheral anterior synechiae (PAS)?

A

fibrous adhesions between peripheral cornea and iris (view with gonio)

98
Q

where do posterior synechiae form?

A

adhesions between pupillary border and anterior lens capsule

99
Q

what causes posterior synechiae to form?

A

forms readily in all types of uveitis - especially with flare (may occur with iris nodules)

100
Q

which type of synchiae is more common and what is it mistaken as?

A

posterior synechiae - persistent pupillary membrane

101
Q

what is seclusio pupillae?

A

immobile pupil with a 360 posterior synechiae - usually in chronic uveitis

102
Q

what types of uveitis does iris atrophy occur?

A

chronic - Fuch’s heterochromic iridocyclytis and herpetic uveitis

103
Q

what are 3 signs of iris atrophy?

A

decrease in iris pigment (TIDs), iris may swell, and iris crypts may lose their definition

104
Q

what can iris atrophy be associated with?

A

dense flare

105
Q

where can iris granulomas form?

A

on pupil border, anterior surface of iris or angle locations

106
Q

what do iris granulomas look like?

A

fleshy, whitish, pink, vascularized masses

107
Q

what are the two types of iris granulomas?

A

Koeppe and Bussaca nodules

108
Q

what are koeppe iris nodules?

A

round/oval tissue, cellular aggregates, located at pupil border and may accumulate over time

109
Q

what are busacca nodules?

A

whitish-yellow lumps away from pupil border - in internal iris stroma

110
Q

what size and shape pupil can we expect in uveitis?

A

miotic, irregular (posterior synechiae), sluggish reaction, and may be fixed in seclusio pupillae

111
Q

what happens to IOP in the early stages of uveitis?

A

may be 3-6mm lower compared to other eye - due to reduced aqueous production of ciliary body

112
Q

what happens to IOP in untreated acute or chronic forms of uveitis?

A

prolonged hypotony in chronic conditions could lead to phtisis bulbi - chronic IOP below 5mmHg is at risk

113
Q

what causes an elevation of IOP in uveitis?

A

TM congestion may reduce outflow or an iatrogenic cause due to steroid use

114
Q

what are 3 types of cataracts associated with uveitis?

A

epi-capsular stars, posterior sub-capsular cataract (PSC) and mature cataracts

115
Q

when would a patient develop an epi-capsular cataract with uveitis?

A

acute or chronic cases - pigment clumps may persis

116
Q

which type of cataract is the most common and what is it associated with?

A

PSC (posterior sub-capsular cataract) - topical/oral steroids and fuch’s heterochromic iridocyclytis

117
Q

which uveitis conditions get mature cataracts?

A

Still’s disease (JRA)

118
Q

what might you see in the vitreous with uveitis?

A

cells attached to vitreous strands - anterior chamber cells may spill over into vitreous (need to dilate patient)

119
Q

when might you see CME (cystoid macular edema) in patients?

A

if inflammation is chronic

120
Q

when do you see bilateral presentations of uveitis?

A

most cases it becomes bilateral - endogenous and chronic types (especially granulomatous)

121
Q

what types of uveitis are unilateral?

A

sarcoid, behcet’s FB, and post-surgical events

122
Q

Name 5 signs of Uveitis seen in photo:

A

Posterior synechaie, cornealimbal hyperemia, corneal edema, conjunctival swelling, watering

123
Q

Which is the affected eye and what syndrome do they have?

A

right - Fuch’s heterochromia iridocyclitis

124
Q

What type of synechiae is seen in photo:

A

Posterior syneciae (iris to lens)

125
Q

What type of synechiae is seen in photo:

A

Peripheral anterior synechiae (PAS) - iris to cornea

126
Q

What is seen in photo:

A

fine keratic precipitates

127
Q

What is seen in photo:

A

granulomatous KP - Mutton fat

128
Q

What is this photo showing?

A

iris membrane

129
Q

What type of uveitis is this showing?

A

pars planitis - “snow banking”

Ocular Disease (10 decks)

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