Block 16: Anterior Uveitis Flashcards
What is anterior uveitis?
Inflammation of the anterior-most portion of the uveal tract (iris + anterior part of ciliary body)
What is the anterior part of the ciliary body called?
Pars plicata
Inflammation of all uveal structures is called ____?
Panuveitis
What are two other names sometimes used when referring to anterior uveitis?
- Iritis
2. Iridocyclitis
What is the most common cause of anterior uveitis?
Idiopathic (50%)
What is the second most common cause/association of anterior uveitis?
Non-infections, associated with being HLA-B27 positive
What is the cause of a clinical presentation that looks like anterior uveitis, but is not “true anterior chamber inflammation”
Masquerade
How can the onset of anterior uveitis be described? (2 answers)
- Sudden
- Insidious (chronic/slow development)
What is the time frame that denotes whether anterior uveitis is limited or persistent.
3 months - anything lasting longer than 3 months is persistent
If the course of anterior uveitis is described as having a sudden onset with limited duration, this is known as ____?
Acute Anterior Uveitis
If the course of anterior uveitis is described as repeated episodes of inflammation separated by untreated periods without inflammation, this is known as ____?
Recurrent Anterior Uveitis
If the course of anterior uveitis is described as lasting longer than 3 months and recurring within 3 months if left untreated, this is known as _____?
Chronic Anterior Uveitis
Which is the most common onset of anterior uveitis? (acute or chronic?)
Acute
How is the pain frequently described in anterior uveitis?
Dull/achy
Anterior uveitis can be asymptomatic until complications such as ______ develop
Cataracts
Where is the redness mostly concentrated in an eye with anterior uveitis?
Perilimbal or Circumlimbal Injection
In anterior uveitis, “ciliary flush” or “ciliary body flush” refers to ____?
Perilimbal injection (redness around limbus/corneal margin)
What is a common difference in a red eye due to conjunctivitis versus a red eye due to anterior uveitis?
(Referring to the location of the redness…)
- Conjunctivitis is often more red further away from limbus, especially in fornices.
- Anterior Uveitis is more red around limbus
Is the pupil often constricted or dilated in anterior uveitis?
What causes this?
- Constricted (miosis)
- Due to spasm of iris sphincter muscle from the inflammation
A constricted pupil in anterior uveitis predisposes to _____?
Posterior synechiae
Which feature is KEY in both diagnosing anterior uveitis and grading the severity?
Cells in anterior chamber
What is the convection current in the eye?
The increasing warmth towards the back of the eye causes cells in anterior chamber to float upward further back in the AC (towards the lens) and downward further forward in the AC (towards cornea)
The presence of white inflammatory cells settling in the bottom of the anterior chamber is called ____?
This indicates anterior uveitis that is _____? (how severe?)
- Hypopyon
- Moderate to severe uveitis
Which surface of the cornea to keratic precipitates form on in anterior uveitis?
Posterior surface
Keratic precipates forming in a triangle that is wider inferiorly in anterior uveitis is called ____?
Arlt’s Triangle
What is the reason that keratic precipates often occur more inferiorly on cornea?
Convection current - cells move downward towards front of anterior chamber
What causes hazy flare in anterior uveitis?
Increased amounts of inflammation causing a leakage of protein from blood vessels. (Protein = flare)
Inflammatory cell precipitates forming on surface of the iris near the pupillary margin are called ____?
Koeppe Iris Nodules
Inflammatory cell precipates forming on peripheral surface of iris are called _____?
Busacca
Where do Koeppe iris nodules form?
Surface of iris at pupillary margin
Where do Busacca iris nodules form?
Peripheral surface of iris
If you dilate a patient with anterior uveitis and notice a small, pigmented ring on the pupil, what does this indicate?
Posterior synechiae - pigmented ring is where iris was stuck to anterior surface of lens
What can help break up posterior synechiae?
Dilation
Using retroillumination in a patient with anterior uveitis can help determine the presence or absence of ____?
Iris atrophy
Is iris atrophy more common in acute or long-standing inflammation?
Long-standing
How can anterior uveitis affect IOP?
Can be high or low
Is IOP usually high or low initially in anterior uveitis?
Low IOP
What causes IOP to be low in initial and active anterior uveitis?
Inflamed ciliary body cannot produce and secrete aqueous humor as well. But the drainage system (through the trabecular meshwork) is unaffected.
Aqueous humor exits at normal rate, but is produced at a slower rate = decreased IOP
How may persistent anterior uveitis affect IOP?
Why?
Increase IOP
Because the inflammatory cells can clog the trabecular meshwork and slow the drainage of aqueous from the eye
How often should you dilate a patient with anterior uveitis?
Why?
- 100% of the time
- Checking for posterior segment inflammation
When would further investigation of anterior uveitis NOT be needed?
- First episode of mild to moderate acute anterior uveitis with no indication of underlying ocular/systemic disease (or underlying disease is already known)
List 3 indications for further investigation in anterior uveitis.
- Acute anterior uveitis that is recurrent, severe, or bilateral
- Any anterior uveitis that is chronic, granulomatous, resistant to treatment
- Suggestion of underlying disease based on ocular or systemic findings
Acute anterior uveitis has a strong association with which HLA?
HLA-B27
HLA-B27 is often associated with anterior uveitis that is chronic or acute?
Acute
What is a disadvantage of blood tests when investigating anterior uveitis?
Never 100% specific/sensitive
When a specific disorder is suspected to be associated with anterior uveitis, what is the best action an optometrist should make in determining the disorder?
Consult with appropriate specialist
What is a CBC finding with parasitic infections?
Eosinophilia
What does a CBC finding with exceptionally high leukocytosis usually indicate?
Malignancy
A chest Xray helps detect which two associated conditions of anterior uveitis?
- TB
2. Sarcoidosis
An X-ray of _______ can help detect seronegative ankylosing spondylitis
Sacroiliac joint
What is a common X-ray finding in a patient with TB?
Hilar adenopathy
What treatment is used in most cases of anterior uveitis to suppress inflammation?
Topical steroid: Prednisone Acetate 1%
How often should a patient use a topical steroid in most cases of anterior uveitis?
Frequent initial doses - hourly
Cycloplegic drops are used in most cases of anterior uveitis for ______? (2 answers)
- Preventing and/or breaking up posterior synechiae
2. Promoting comfort by relaxing ciliary muscle
What needs to be monitored when using a treatment to suppress inflammation in most cases of anterior uveitis?
IOP
What are 2 alternatives to topical steroids when trying to suppress inflammation in anterior uveitis?
- Steroid injections or pills
2. NSAIDs/anti-metabolites
An example of a drop used in most cases of anterior uveitis to promote comfort by relaxing ciliary muscle is ____?
Homatropine 5%
Any joint disease of the vertebral column is called a ______?
Spondyloarthropathy
3 common features of spondyloarthropathies are _____?
- HLA-B27 positive
- Rheumatoid factor seronegative
- Enthesitis
How should chronic anterior uveitis that is associated with a spondyloarthropthy be treated?
Second-line systemic immunosuppressant (biological blocker) - handled by sub-specialist
What is an “Enthesis”
Point where ligament or tendon attaches to bone
Inflammation of the point where a ligament or tendon attaches to bone is called ____?
Enthesitis
Ankylosing Spondylitis most commonly presents in what types of patients? (3 features)
- Men
- 20-30 years old
- HLA-B27 +
Radiology demonstrates early changes ______ with Ankylosing Spondylitis
Sacroiliac joint
Late ankylosing spondylitis is often described as____?
“Bamboo spine”
What is the correlation between eye and joint involvement in ankylosing spondylitis? (little or high?)
Little correlation
Bony fusion of the spine refers to ____?
Ankylosing spondylitis
Reactive arthritis is known as ____?
Reiter’s Syndrome
What are the 3 characterizations of Reiter’s Syndrome?
- Urethritis
- Conjunctivitis
- Arthritis
What percent of patients are HLA-B27 positive in Reiter’s Syndrome?
75%
What can cause Reactive Arthritis?
Triggering infection by various organisms
Acute anterior uveitis occurs in what percent of patients with Reactive Arthritis?
20%
Arthritis develops in 40% of patients affected with ____?
Psoriasis
What race and age group is most likely to develop Psoriatic Arthritis?
- Caucasians
- Middle age
25% of males with acute anterior uveitis have ____?
Ankylosing spondylitis
The most common form of psoriasis is ___?
Plaque-type (well-demarcated raised silvery inflamed plaques on scalp, trunk, arms, legs)
Acute anterior uveitis occurs in what percent of patients with Psoriatic arthritis?
7%
What are 2 examples of inflammatory bowel disease?
- Ulcerative colitis
2. Crohn’s disease
What age group do both ulcerative colitis and crohn’s disease often present?
10-30 years old
What percent of patients with Ulcerative colitis or Crohn’s disease develop acute anterior uveitis?
- Ulcerative Colitis: 5%, especially if HLA-B27 positive and/or have arthritis
- Crohn’s Disease: 3%
Long-standing abdominal cramps + bloody diarrhea are common symptoms of ______ and may develop _____ cancer.
- Ulcerative colitis
- Colon cancer
Crohn’s disease is _____ (type?) inflammation of the ________ (location?)
Granulomatous inflammation of intestinal wall
Biological blockers have been endorsed by the American Uveitis Society for the treatment of what type of anterior uveitis?
- Chronic
- Vision-threatening
- Associated Spondyloarthropathy
Treating anterior uveitis with an associated spondyloarthropathy with _____ (drug?) has serious side effects and should be handled by ______ (person?)
- Biological blockers
- Sub-specialist
How is acute anterior uveitis treated when associated with a spondyloarthropathy?
Treated same as normal acute cases…
- Most use topical steroid to suppress inflammation
- Most use cycloplegic drops for post synechiae and promote comfort
A chronic, usually unilateral ocular inflammation of unknown cause is known as ____?
Fuchs Uveitis Syndrome
Describe the symptoms in fuchs uveitis syndrome
Minima - usually incidental finding
How is the anterior chamber reaction labeled in fuchs uveitis syndrome? (absent, mild, severe?)
Mild cells
How is the hyperemia described in fuchs uveitis syndrome? (absent, mild, severe?)
Absent
The majority of patients with Fuchs Uveitis Syndrome eventually develop _____?
Glaucoma
What is a very common finding in the lens with Fuchs Uveitis Syndrome?
Cataract
What age does Fuchs Uveitis Syndrome typically present?
40
What finding is always absent in Fuchs Uveitis Syndrome?
Hyperemia
How is the iris affected in Fuchs Uveitis Syndrome?
What is the appearance of an affected brown eye vs blue eye?
- Iris atrophy/heterochromia
- Affected eye becomes hypochromic (loses pigmentation)
- Change is subtle in brown eyes
- Blue eyes may appear brownish due to posterior pigment layer showing through
What type of treatment is usually NOT indicated in Fuchs Uveitis Syndrome?
Steroids
What type of treatment may be considered in a case of severe Fuchs Uveitis Syndrome?
(this tx is generally NOT indicated for average cases)
Steroid drops (gtt)
Regular, long-term monitoring for _____ is necessary in Fuchs Uveitis Syndrome?
Glaucoma
An arthritis of unknown cause that occurs before age 16 and lasts at least 6 weeks is called _____?
Juvenile Idiopathic Arthritis
Juvenile Idiopathic Arthritis is usually chronic or acute? Unilateral or bilateral?
Chronic and bilateral
What are 4 potential causes of significant compromise in Juvenile Idiopathic Arthritis?
- Band keratopathy
- Cataract
- Glaucoma
- Maculopathies
What is a key cause of morbidity in juvenile idiopathic arthritis?
Anterior uveitis
Anterior uveitis is most common in what form of juvenile idiopathic arthritis?
Oligoarticular
Why is detection of anterior uveitis in juvenile idiopathic arthritis often delayed?
Because it is often asymptomatic and has no injection/redness (even with severe AC reactions)
Describe endothelium during acute exacerbations of anterior uveitis in juvenile idiopathic arthritis?
Entire endothelium shows “dusting” by hundreds of cells
The most common systemic disease associated with childhood anterior uveitis is _____?
Juvenile Idiopathic Arthritis
Hypopyon is often present or absent in juvenile idiopathic arthritis?
Absent
Posterior synechiae is common or uncommon in long-standing, undetected cases of anterior uveitis in juvenile arthritis?
Common
What are 3 examples of signs parents may eventually notice in anterior uveitis with juvenile idiopathic arthritis?
- Strabismus
- Abnormal appearance of eye due to….
- Band keratopathy
- Cataract
How often should children known to have juvenile idiopathic arthritis be screened?
Every 3-4 months until age 12
What type of treatment is proven effective in most cases of anterior uveitis in juvenile idiopathic arthritis?
Topical steroids
What can be used to prevent posterior synechiae in anterior uveitis (with juvenile idiopathic arthritis)?
Mydriasis
Why should mydriasis be short acting and discontinued ASAP in anterior uveitis with juvenile idiopathic arthritis?
Increased risk of amblyopia
An immune response to lens proteins is called ____?
Lens-induced (phacogenic) uveiits
What are 3 potential causes of lens induced phacogenic uveitis?
- Incomplete cataract extraction
- Trauma
- Capsular degeneration in mature cataract (rare)
A chronic disorder of unknown cause that manifests with non-caseating granulomatous inflammatory foci is _____?
Sarcoidosis
The most common ocular sign of Sarcoidosis is ___?
Granulomatous anterior uveitis
“Mutton fat” in sarcoidosis refers to _____?
Keratic precipitates or iris nodules
Chest X-ray often shows _____ in Sarcoidosis?
Bilateral hilar lymphadenopathy
A patient with Sarcoidosis will have a positive or negative TB test?
Negative
What is commonly used to treat ocular sarcoidosis?
Steroids
Is sarcoidosis usually unilateral or bilateral?
Bilateral
An idiopathic multi system syndrome characterized by recurrent oral ulcers, genital ulceration, and uveitis is ____?
Bechet’s Disease
What is the main cause of visual impairment in Bechet’s disease?
-Retinal vascular disease
A common sign of anterior uveitis in Bechet’s disease is ___
Bilateral mobile hypopyon in relatively white eye
Anterior uveitis affects what percent of patients with herpes zoster ophthalmicus?
50%
When is the onset of anterior uveitis in HZV?
1-3 weeks after acute skin rash
How is the iris often affected in HZV anterior uveitis?
Sectoral iris ischemia and atrophy
How is corneal sensation often affected in HZV anterior uveitis?
Reduced corneal sensation
What are 3 common components to treatment in HZV anterior uveitis?
- Topical steroids
- Mydriatics/Cycloplegics
- Oral antiviral within 72 hours of rash onset
A relatively quiet eye with a few keratic precipitates, high repeated IOP spikes, and absence of heterochromia/iris atrophy and cataract formation is known as ____?
This may be confused for ____?
- Positive Schlussmann Syndrome or Glaucomatocyclitic Crisis
- Can be confused for Fuchs Uveitis Syndrome
What is a key difference in iris atrophy in anterior uveitis caused by a virus versus other causes?
Virus-Related anterior uveitis causes patchy/sectorial iris atrophy
(rather than even distribution in other cases)
A chief complaint of blurred vision is common in HZV and HSV anterior uveitis due to ___?
Corneal edema
Diffuse keratic precipitate (rather than Arlt’s triangle where they settle inferiorly) typically indicates anterior uveitis caused by ____?
Virus
How can you differentiate a dendritic pattern on cornea due to HSV Anterior Uveitis versus HSV Keratitis?
HSV Anterior Uveitis: Ulcer is actually keratic precipitates forming on endothelium of cornea. If you stain this cornea, it would be clear
HSV Keratitis: Ulcer is due to epithelial defect and staining would show dendritic ulcer
Redness that is more intense toward fornices and less intense near limbus is most likely ____?
Conjunctivitis
A “bulls-eye rash” + anterior uveitis indicates ______ as the probable cause of anterior uveitis?
Lyme’s disease
Anterior uveitis + VDRL positive test indicates ____ as the probably cause of anterior uveitis?
Syphilis
