BCSC 9. Intraocular Inflammation and Uveitis

Question 1

Cell type that dominates acute infection

Answer 1

Neutrophils

Question 2

Initial recognition, transport, presentation of antigenic substances to adaptive immune system constitute this phase of immune response arc

Answer 2

Afferent - APCs migrate via afferent lymphatics to lymph node.

Question 3

Mast cells bind this immunoglobulin (Ig) type to their cell surface

Answer 3

Immunoglobulin E (IgE)

Question 4

Regional immunity

Answer 4

Many organs and tissue sites possess modificaitons to the classic immune response arc. Affect all 3 phases of response arc - afferent, processing, and effector.

Question 5

AIRE (autoimmune regulator) deficient mice develop spontaneous uveitis because

Answer 5

Autoreactive T cells escape deletion. AIRE (autoimmune regulator) is a transcription factor used by thmus in process of establishing thymic tolerance. Early in life, thymus expresses many cell-type-specific proteins; T-cell clones reactive to these proteins are deleted. Autoreactive T cells escape deletion and mice spontaneously develop posterior uveitits.

Question 6

The fluocinolone acetonide implant releases therapeutic levels of corticosteroids to the vitreous cavity for approximately how long?

Answer 6

30 months - 0.59-mg fluocinolone implant is effective for median of 30 months. Treatment for chronic noninfectious uveitis affecting posterior segment.

Question 7

What inhibitor of tumor necrosis factor alpha is least effective for uveitis

Answer 7

Etanercept - tumor necrosis factor alpha (TNF-a) decoy receptor is used in polyarticular juvenile idiopathic arthritis (JIA) adn adult RA. Less effective than infliximab and adalimumab for uveitis and is not preferred biologic for uveitis.

Question 8

Mechanism of action of methotrexate

Answer 8

Extracellular release of adenosine. Folic acid analogue and inhibitor of dihydrofolate reductase, inhibits DNA replication.

Question 9

Most common noninfectious systemic disease associated with scleritis

Answer 9

Rheumatoid arthritis - 40% of scleritis cases are associated with systemic disease.

Question 10

White dot lesions of which disease are leas apparent on fluorescein angiography

Answer 10

Birdshot uveitis - inconsistent findings depending on age of lesions.

Question 11

FA pattern in APMPPE - Acute posterior multifocal placoid pigment epitheliopathy

Answer 11

Block early, stain late

Question 12

FA pattern in Punctate inner choroiditis (PIC)

Answer 12

early hyperfluorescence with late staining

Question 13

FA pattern in serpiginous choroiditis

Answer 13

Choroidal flush in early stage and staining of active edge of lesion in later stage

Question 14

FA pattern of choroidal neovascular membranes, and which white dot is this seen in

Answer 14

Early hyperfluorescence with late leakage - PIC

Question 15

What finding can suggest a diagnosis of multiple evanescent white dot syndrome after the white dots have disappeared

Answer 15

Granular pigment changes in the fovea (pathognomonic for MEWDS). Do not typically develop peripheral punched-out lesions or peripapillary scarring

Question 16

Entity can present with marked visual symptoms but minimal findings on clinical exam

Answer 16

Acute zonal occult outer retinopathy (AZOOR). Marked abnormalities on electroretinography, multifocal ERG and visual field testing.

Question 17

Association with antibodies directed against proteinase 3 in patient with necrotizing scleritis

Answer 17

Granulomatosis with polyangiitis - testing for antineutrophil cytoplasmic antibodies (ANCA) (c-ANCA and p-ANCA) PR3-ANCA are associated with c-ANCA and MPO-ANCA are associated with p-ANCA

Question 18

PR3-ANCA

Answer 18

c-ANCA - sensitive and specific for granulomatosis with polyangiitis

Question 19

MPO-ANCA

Answer 19

p-ANCA - microscopic polyangiitis

Question 20

Stage of Vogt-Koyanagi-Harada syndrome associated with exudative RDs

Answer 20

Acute uveitic stage

Question 21

Convalescent stage of VKH

Answer 21

Occurs weeks to months after the exudative RDs have resolved after acute uveitic stage, patients develop gradual depigmentation in the fundus such as vitiligo, alopecia, and poliosis.

Question 22

Chronic recurrent stage of VKH

Answer 22

Repeated bouts of anterior uveitis that can lead to significant structural damage

Question 23

Factor associated with vision loss in patients with ocular sarcoidosis

Answer 23

delay of more than 1 year in presentation to a uveitis specialist

Question 24

Test useful in diagnosis of tubular interstitial nephritis and uveitis

Answer 24

urine Beta2-microglobulin level

Question 25

Class of infectious organisms associated with glaucomatocyclitic crisis (Posner-Schlossman syndrome)

Answer 25

Viruses such as cytomegalovirus (CMV

Question 26

Lyme disease-associated intermediate uveitis occurs most commonly in what stage of disease

Answer 26

Stage 2, disseminated disease

Question 27

Ocular manifestation of early stage 1 lyme disease (LD)

Answer 27

Follicular conjunctivitis

Question 28

CDC recommended testing protocol for LD in patient with intermediate uveitis and h/o recent tick bite

Answer 28

Enzyme-linked immunosorbent assay for Lyme IgM and IgG antibodies followed by western blot testing. (Both must be positive)

Question 29

Pars planitis

Answer 29

idiopathic intermediate uveitis with snowbank or snowball formation (in the absence of an associated infection or systemic disease) For example if the patient has MS, the term intermediate uveitis should be used

Question 30

Treatment strategy for JIA associated uveitis which occurs m/c with oligoarticular-onset JIA, girls who test positive for ANA

Answer 30

short-term treatment with topical corticosteroids to eliminate inflammation in the eye; early consideration of systemic IMT such as with methotrexate.

Question 31

Suspect intraocular inflammation related to toxoplasmosis and wish to perform Goldmann-Witmer test using these two tissues

Answer 31

Aqeuous and serum. GW = (xIgG in aqeous/total IgG in aqeous)/(xIgG in serum/total IgG in serum)

Question 32

65 yo M found to have unilateral decline in vision as well as occlusive arteritis, vitritis, multifocal yellow-white peripheral retinitis. Diagnosis and treatment

Answer 32

Acute retinal necrosis - acute unilateral vision loss, photophobia, floaters, PAIN. Significant AS inflammation with KP, posterior synechiae, elevated IOP, heavy vitreous cellular infiltration. IV acyclovir 10 mg/kg q8hrs for 10-14 days is effective against HSV and VZV. Start systemic corticosteroids (prednisone 1mg/kg/day) to treat active inflammation and tapered over weeks

Question 33

Triad of occlusive retinal arteriolitis, vitritis, multifocal yellow-white peripheral retinitis

Answer 33

Acute Retinal Necrosis (ARN)

Question 34

Widespread necrosis of midperipheral retina, multiple posterior retinal breaks, proliferative vitreoretinopathy predispose to combined tractional-rhgematogenous retinal detachments in 75% of patients

Answer 34

ARN

Question 35

Patient with ARN fails to respond to systemic acyclovir

Answer 35

IV ganciclovir (0.2-2.0mg/0.1mL) and foscarnet (1.2-2.4mg/0.1mL) to achieve rapid injduction combination

Question 36

Most common cause of endogenous fungal infection

Answer 36

Candidia

Question 37

Organism aside from propionibacterium acnes should be suspected in case of chronic, indolent, intraocular inflammation after cataract surgery

Answer 37

Candida parapsilosis

Question 38

Suspect ciliary body melanoma, with fibrin and PAS, pigmented mass on gonio. Next step?

Answer 38

B-scan or Ultrasound biomicroscopy or anterior segment optical coherence tomography

Question 39

Treatment for visually significant calcific band keratopathy

Answer 39

epithelial debridement and chelation with ethylenediaminetetraacetic acid (EDTA)

Question 40

How long must uveitis resolve prior to cataract surgery

Answer 40

3 months

Question 41

Intraocular infection is m/c associated with immune recovery uveitis in patient with AIDS whose immune function has improved with antiretroviral therapy

Answer 41

CMV retinitis - a/w minimal inflammatory response in AIDS patients - reconstituted immune system’s response to CMV antigens.