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)
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
3
Q
what are the 3 categories of anterior uveitis?
A
anterior uveitis, posterior uveitis, and pan uveitis
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
5
Q
what is the pain level with anterior uveitis?
A
moderate to severe pain
6
Q
is anterior uveitis generally granulomatous or non-granulomatous?
A
non-granulomatous with fine keratic precipitates (on corneal endothelium)
7
Q
what is a granulomatous?
A
occurs when neutrophils are unable to remove an inciting agent - granulomas form with chronic inflammation
8
Q
what are the predominant cells in granulomas?
A
macrophages (macrophages may fuse to form multinucleated giant cells) *few lymphocytes are present
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
10
Q
what are 3 examples of non-caseating granulomas?
A
chalazion, epidermoid/dermois cyst, sarcoidosis
11
Q
what is an example of a caseating granuloma
A
TB granuloma
12
Q
what is posterior uveitis?
A
inflammation of choroid and retina
13
Q
what is panuveitis?
A
inflammation involving two or more sites = anterior chamber, vitreous, retina, choroid inflammation not predominant at any one site
14
Q
describe chronic uveitis
A
persistent and relapse in less than 3 months after discontinuing treatment
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
16
Q
which ages is uveitis most prevalent?
A
20-50 years old
17
Q
why is uveitis uncommon as a primary diagnosis beyond age 70?
A
immunity decreases with age (not as hypersensitive)
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
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
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
21
Q
what 3 things cause males to have uveitis?
A
trauma, ankylosing spondylitis, and Reiter’s syndrome (reactive arthritis)
22
Q
what type of uveitis doubles in females due to sarcoidosis?
A
granulomatrous type
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
24
Q
what 3 syndromes are caucasians higher at risk for?
A
ankylosing spondylitis, Reiter’s syndrome and HLA-B27 diseases
25
what causes blacks have a higher incidence of uveitis?
10-15x higher risk due to sarcoidosis (especially females and in SE USA)
26
what are 2 syndromes that are more prevalent in Asians?
Vogt-Koyanagi-Harada syndrome and Behcet's disease
27
what race has the highest incidence of Behcet's disease?
Mediterranean
28
which region is sarcoid not common? what about non-existent?
south pacific
south african blacks
29
which 3 regions should you consider sarcoid?
southeastern US, swedish and norwegians
30
which venereal diseases are associated with uveitis?
syphilis, chlamydia and HIV
31
which type of uveitis is associated with type A personality and stress?
pars planitis
32
what are the 4 clinical signs of inflammation?
rubor (redness), tumor (swelling), calor (hear) and dolor (pain)
33
why does the eye have immune privilege?
it is somewhat immunosuppressed - if it reacted to everything that got in the eye we would go blind
34
why is the eye so vulnerable to Herpes Simplex?
due to its immune privilege - it leaves the eye vulnerable to pathogens that would usually be eliminated by T cells
35
the release of these chemicals cause the breakdown of the blood aqueous barrier. what are they?
histamine, bradykinin and serotonin
36
what happens after proteins diffuse from ciliary processes and iris stroma into aqueous during red eye?
IgM and IgA are detectable - complement components rise and significant amount of coagulation factors and fibrinolysis occurs
37
is there always swelling with acute anterior uveitis?
healthy cornea = minimal swelling
if the patient has Fuch's endothelial dystrophy = severe swelling
38
what type of swelling occurs with chronic anterior uveitis?
corneal edema
39
what is the uveitis salute?
patients in the waiting room will have their hand over the effected eye(s) - inflamed eye is hot to touch and usually painful
40
what are 4 exogenous etiologies of uveitis?
unknown, trauma, ocular infection, allergic reaction
41
what are 3 endogenous etiologies of uveitis?
unknown, ocular disease (pars planitis, fuch's heterochromia iridocyclytis, posner-schlossman glaucomatocyclitic crisis) and systemic disease
42
what are some characteristics of Fuch's heterochromia iridocyclitis?
unknown etiology, 2-3% of all uveitis and 90% unilateral
affecte eye = OD
43
what are the 4 parts to Fuch's heterochromia iridocyclitis syndrome?
recurrent chronic uveitis, heterochromia, cataract, glaucoma - difficult to control
44
what is the hallmark sign of pars planitis?
cells and opacities in vitreous base (snow banking)
45
how often does pars planitis occur? is it unilateral or bilateral?
10% of all uveitis and 70% bilateral
46
when would you refer a patient with pars planitis?
if they are at risk of CME, reduced VA 20/40 or worse, may need oral and topical steroids, may need depot steroid shot
47
what is possner-schlossman syndrome/glaucomatocyclitic crisis?
mild idiopathic anterior chamber inflammation, monocular and in young adults (resolves in middle age)
48
what are the signs of possner-schlossman syndrome?
elevated IOP (over 30mmHg), intermittent attacks lasting 3-10 days, KP, corneal edema, heterochromia with anisocoria and the larger pupil is affected eye
49
what causes elevated IOP in possner-schlossman syndrome?
TM is congested by inflammatory debris, open angles
50
what are some symptoms of lens induced uveitis?
pain, redness, photophobia (non-infectious hypopion or hyphema)
51
what causes lens induced uveitis and when does it occur?
reaction to lens protein that occurs after disruption of lens capsule - 1 day to 59 years after surgery
52
what is the treatment for lens induced uveitis?
topical or periocular steroids injected, removal of lens fragment
53
why must lens induced uveitis be differentiated from enophthalmitis?
endophthalmitis will need antibiotics ASAP
54
what is phaco-anaphylactic uveitis?
granulomatous reaction, autoimmune/immune complex - not a true type 1 hypersensitivity reaction
55
what is phakogenic uveitis?
non-granulomatous reaction
56
what is an example of type 1 hypersensitivity uveitis?
immediate IgE = atopic iritis shellfish allergy
57
what is an example of type 2 hypersensitivity uveitis?
cytotoxicity IgG, IgM, +/- complement = microbial iritis
58
what is an example of type 3 hypersensitivity uveitis?
immune complex IgG, IgM, and complement = autoimmune lens induced sympathetic ophthalmia
59
what is an example of type 4 hypersensitivity uveitis?
cell mediated = sensitized T lymphocytes may have relationship with chronic uveitis
60
how might a person have a genetic predisposition to uveitis?
linked to human leukocyte antigen (HLA) - present on many cells in body used to determine self from non-self
61
which specific HLA is associated to uveitis?
HLA-B27
62
how do you differentiate uveitis from conjunctivitis and keratitis?
pain is deeper and won't respond to anesthetic, no itching or burning, uveitis salute, circumlimal hyperemia
63
is pain associated with acute or chronic uveitis? does the level of pain predict the severity?
acute = severe and debilitating
chronic = may be asymptomatic
doesn't predict severity
64
why does light cause pain in uveitis?
changes the pupil size - iris movement causes pain
65
what is the henkind test?
take light and shine it in the eye without uveitis and it will also have pain
66
what type of discharge is associated with uveitis?
hyper-lacrimation = watery eyes (no other discharge present)
67
how is vision affected in acute uveitis?
vision is usually normal to hazy
68
how is vision affected in chronic uveitis?
vision may be worse than symptoms - depends on degree
69
what type of vision will increase pain?
near vision/accommodation = pupil constricts causing pain
70
what are 4 signs and symptoms with lids?
blepharospasm, congestion and edema, erythema, and pseudoptosis
71
what does the hyperemia on the conjunctiva look like in uveitis?
peri-limbal/circumcorneal flush (deep scleral or episcleral radiating vessel pattern) and cul-de-sacs are white and quiet
72
what type of inflammation is there and where is it greatest?
most noticeable around the cornea - may be sectoral or sectional greatest inferior and usually more 90 degrees in size
73
what type of edema is present in chronic or advanced uveitis?
microcystic edema, stromal edema, and striate keratitis
74
what is band keratopathy?
forms under the corneal epithelium, comprised of calcium salts
75
what type of uveitis is band keratopathy present in?
recurrent/advanced or chronic cases
76
how is band keratopathy removed?
EDTA chelation
77
what is the Still's traid in JRA?
cataract, band keratopathy and uveitis (chronic)
78
what type of cells are seen in the anterior chamber in uveitis?
\*classic sign usually WBC (leukocytes) that have leaked from ciliary body (occasionally RBC or pigment cells)
79
how do you grade cells seen in uveitis?
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
what causes flare in uveitis? and when is it more noticeable?
protein leaking from inflamed blood vessels
chronic granulomatous uveitis
81
does flare ever go away?
it can get better but may persist indefinitely
82
how do you grade the flare seen in uveitis?
0-1+ = trace flare
1-2+= obvious flare
2-3+ = hazy aqueous
3-4+ = dense or plasmoid aqueous
83
what is plasmoid aqueous comprised of?
dense accumulation of fibrin cells producing translucent to cloudy strands or sheets with lumps or protein material
84
when is plasmoid aqueous seen?
severe acute uveitis - can be mistaken for lens material from ruptured lens capsule after blunt trauma
85
what are keratic precipitates (KP)?
inflammatory cellular deposits on corneal endothelium
86
what types of KP are seen in anterior uveitis?
fine, granulomatous, and pigmented
87
describe the size and composition of fine keratic precipitates
whitish-gray fibrin or epitheloid cells adherent to posterior cornea - small/discrete and always less than 0.5mm (3D appearance)
88
describe granulomatous keratic precipitates
large, flat confluent looking, greasy/waxy, grainy - look like mutton fat
89
describe Arlt's triangle seen in pigmented KP
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
what 4 things are in mutton fat KP?
epitheloid cells, giant cells (histocytes cluster/fuse), plasma cells, lymphocytes
91
what 3 things are in fine KP?
epitheloid cells/fibrin, plasma cells, and lymphocytes
92
name the 5 syndromes that have granulomatous uveitis (mutton fat KP)
tuberculosis, sarcoidosis, syphilis, cat scratch fever, fungal infections
93
what are 2 syndromes that are non-granulomatous uveitis (fine KP)?
JRA and Fuch's heterochromia iridocyclitis
94
which type of uveitis granulomatous or non-granulomatous has iris nodules?
granulomatous
95
when might you see a hypopion in uveitis?
severe acute anterior unveitis - Behcet's, leprosy, endopthalmitis, sarcoid and post surgical uveitis (BLES)
96
what does a hypopion consist of?
dense accumulation of WBCs (usually polymorphonuclear - PMN cells)
97
where do you see peripheral anterior synechiae (PAS)?
fibrous adhesions between peripheral cornea and iris (view with gonio)
98
where do posterior synechiae form?
adhesions between pupillary border and anterior lens capsule
99
what causes posterior synechiae to form?
forms readily in all types of uveitis - especially with flare (may occur with iris nodules)
100
which type of synchiae is more common and what is it mistaken as?
posterior synechiae - persistent pupillary membrane
101
what is seclusio pupillae?
immobile pupil with a 360 posterior synechiae - usually in chronic uveitis
102
what types of uveitis does iris atrophy occur?
chronic - Fuch's heterochromic iridocyclytis and herpetic uveitis
103
what are 3 signs of iris atrophy?
decrease in iris pigment (TIDs), iris may swell, and iris crypts may lose their definition
104
what can iris atrophy be associated with?
dense flare
105
where can iris granulomas form?
on pupil border, anterior surface of iris or angle locations
106
what do iris granulomas look like?
fleshy, whitish, pink, vascularized masses
107
what are the two types of iris granulomas?
Koeppe and Bussaca nodules
108
what are koeppe iris nodules?
round/oval tissue, cellular aggregates, located at pupil border and may accumulate over time
109
what are busacca nodules?
whitish-yellow lumps away from pupil border - in internal iris stroma
110
what size and shape pupil can we expect in uveitis?
miotic, irregular (posterior synechiae), sluggish reaction, and may be fixed in seclusio pupillae
111
what happens to IOP in the early stages of uveitis?
may be 3-6mm lower compared to other eye - due to reduced aqueous production of ciliary body
112
what happens to IOP in untreated acute or chronic forms of uveitis?
prolonged hypotony in chronic conditions could lead to phtisis bulbi - chronic IOP below 5mmHg is at risk
113
what causes an elevation of IOP in uveitis?
TM congestion may reduce outflow or an iatrogenic cause due to steroid use
114
what are 3 types of cataracts associated with uveitis?
epi-capsular stars, posterior sub-capsular cataract (PSC) and mature cataracts
115
when would a patient develop an epi-capsular cataract with uveitis?
acute or chronic cases - pigment clumps may persis
116
which type of cataract is the most common and what is it associated with?
PSC (posterior sub-capsular cataract) - topical/oral steroids and fuch's heterochromic iridocyclytis
117
which uveitis conditions get mature cataracts?
Still's disease (JRA)
118
what might you see in the vitreous with uveitis?
cells attached to vitreous strands - anterior chamber cells may spill over into vitreous (need to dilate patient)
119
when might you see CME (cystoid macular edema) in patients?
if inflammation is chronic
120
when do you see bilateral presentations of uveitis?
most cases it becomes bilateral - endogenous and chronic types (especially granulomatous)
121
what types of uveitis are unilateral?
sarcoid, behcet's FB, and post-surgical events
122
Name 5 signs of Uveitis seen in photo:
Posterior synechaie, cornealimbal hyperemia, corneal edema, conjunctival swelling, watering
123
Which is the affected eye and what syndrome do they have?
right - Fuch's heterochromia iridocyclitis
124
What type of synechiae is seen in photo:
Posterior syneciae (iris to lens)
125
What type of synechiae is seen in photo:
Peripheral anterior synechiae (PAS) - iris to cornea
126
What is seen in photo:
fine keratic precipitates
127
What is seen in photo:
granulomatous KP - Mutton fat
128
What is this photo showing?
iris membrane
129
What type of uveitis is this showing?
pars planitis - "snow banking"
