BCSC 9. Intraocular Inflammation and Uveitis Flashcards
Cell type that dominates acute infection
Neutrophils
Initial recognition, transport, presentation of antigenic substances to adaptive immune system constitute this phase of immune response arc
Afferent - APCs migrate via afferent lymphatics to lymph node.
Mast cells bind this immunoglobulin (Ig) type to their cell surface
Immunoglobulin E (IgE)
Regional immunity
Many organs and tissue sites possess modificaitons to the classic immune response arc. Affect all 3 phases of response arc - afferent, processing, and effector.
AIRE (autoimmune regulator) deficient mice develop spontaneous uveitis because
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.
The fluocinolone acetonide implant releases therapeutic levels of corticosteroids to the vitreous cavity for approximately how long?
30 months - 0.59-mg fluocinolone implant is effective for median of 30 months. Treatment for chronic noninfectious uveitis affecting posterior segment.
What inhibitor of tumor necrosis factor alpha is least effective for uveitis
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.
Mechanism of action of methotrexate
Extracellular release of adenosine. Folic acid analogue and inhibitor of dihydrofolate reductase, inhibits DNA replication.
Most common noninfectious systemic disease associated with scleritis
Rheumatoid arthritis - 40% of scleritis cases are associated with systemic disease.
White dot lesions of which disease are leas apparent on fluorescein angiography
Birdshot uveitis - inconsistent findings depending on age of lesions.
FA pattern in APMPPE - Acute posterior multifocal placoid pigment epitheliopathy
Block early, stain late
FA pattern in Punctate inner choroiditis (PIC)
early hyperfluorescence with late staining
FA pattern in serpiginous choroiditis
Choroidal flush in early stage and staining of active edge of lesion in later stage
FA pattern of choroidal neovascular membranes, and which white dot is this seen in
Early hyperfluorescence with late leakage - PIC
What finding can suggest a diagnosis of multiple evanescent white dot syndrome after the white dots have disappeared
Granular pigment changes in the fovea (pathognomonic for MEWDS). Do not typically develop peripheral punched-out lesions or peripapillary scarring
Entity can present with marked visual symptoms but minimal findings on clinical exam
Acute zonal occult outer retinopathy (AZOOR). Marked abnormalities on electroretinography, multifocal ERG and visual field testing.
Association with antibodies directed against proteinase 3 in patient with necrotizing scleritis
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
PR3-ANCA
c-ANCA - sensitive and specific for granulomatosis with polyangiitis
MPO-ANCA
p-ANCA - microscopic polyangiitis
Stage of Vogt-Koyanagi-Harada syndrome associated with exudative RDs
Acute uveitic stage
Convalescent stage of VKH
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.
Chronic recurrent stage of VKH
Repeated bouts of anterior uveitis that can lead to significant structural damage
Factor associated with vision loss in patients with ocular sarcoidosis
delay of more than 1 year in presentation to a uveitis specialist
Test useful in diagnosis of tubular interstitial nephritis and uveitis
urine Beta2-microglobulin level
Class of infectious organisms associated with glaucomatocyclitic crisis (Posner-Schlossman syndrome)
Viruses such as cytomegalovirus (CMV
Lyme disease-associated intermediate uveitis occurs most commonly in what stage of disease
Stage 2, disseminated disease
Ocular manifestation of early stage 1 lyme disease (LD)
Follicular conjunctivitis
CDC recommended testing protocol for LD in patient with intermediate uveitis and h/o recent tick bite
Enzyme-linked immunosorbent assay for Lyme IgM and IgG antibodies followed by western blot testing. (Both must be positive)
Pars planitis
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
Treatment strategy for JIA associated uveitis which occurs m/c with oligoarticular-onset JIA, girls who test positive for ANA
short-term treatment with topical corticosteroids to eliminate inflammation in the eye; early consideration of systemic IMT such as with methotrexate.
Suspect intraocular inflammation related to toxoplasmosis and wish to perform Goldmann-Witmer test using these two tissues
Aqeuous and serum. GW = (xIgG in aqeous/total IgG in aqeous)/(xIgG in serum/total IgG in serum)
65 yo M found to have unilateral decline in vision as well as occlusive arteritis, vitritis, multifocal yellow-white peripheral retinitis. Diagnosis and treatment
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
Triad of occlusive retinal arteriolitis, vitritis, multifocal yellow-white peripheral retinitis
Acute Retinal Necrosis (ARN)
Widespread necrosis of midperipheral retina, multiple posterior retinal breaks, proliferative vitreoretinopathy predispose to combined tractional-rhgematogenous retinal detachments in 75% of patients
ARN
Patient with ARN fails to respond to systemic acyclovir
IV ganciclovir (0.2-2.0mg/0.1mL) and foscarnet (1.2-2.4mg/0.1mL) to achieve rapid injduction combination
Most common cause of endogenous fungal infection
Candidia
Organism aside from propionibacterium acnes should be suspected in case of chronic, indolent, intraocular inflammation after cataract surgery
Candida parapsilosis
Suspect ciliary body melanoma, with fibrin and PAS, pigmented mass on gonio. Next step?
B-scan or Ultrasound biomicroscopy or anterior segment optical coherence tomography
Treatment for visually significant calcific band keratopathy
epithelial debridement and chelation with ethylenediaminetetraacetic acid (EDTA)
How long must uveitis resolve prior to cataract surgery
3 months
Intraocular infection is m/c associated with immune recovery uveitis in patient with AIDS whose immune function has improved with antiretroviral therapy
CMV retinitis - a/w minimal inflammatory response in AIDS patients - reconstituted immune system’s response to CMV antigens.
