Ciliary Body: Anterior Uveitis Flashcards
other names for anterior uveitis
- iritis
- anterior cyclitis
- iridocyclitis
anterior uveitis
inflammation of the pars plicata and/or iris
anterior uveitis etiology/associations
- idiopathic in ~50% of cases
- post-operative ocular surgery (cataract surgery)
- trauma
- autoimmune, inflammatory systemic disease; most common diseases include: sarcoidosis, SLE, JIA, IBD, Reiter’s, ankylosing spondylitis, psoriatic arthritis, GPA, PAN, Behcet’s
- HLA-B27 positivity: with or without related systemic disease (UCRAP conditions)
- systemic infection; most common infections include herpes simplex, herpes zoster, lyme, syphilis, TB; rare infections include mumps, influenza, adenovirus, measles, chlamydia
- inflammation elsewhere in the globe (cornea, sclera, retina, choroid)
- anterior segment ischemia (ex: carotid insufficiency, tight scleral buckle, or previous EOM surgery)
- retinal detachment
- lens-induced (ex: rupture of hypermature cataract, incomplete cataract extraction)
- drug induced (ex: rifabutin, cidofovir)
- masquerading syndrome (cancer, metastasis)
anterior uveitis demographics
depends on etiology- think about the demographics of the underlying systemic condition!
anterior uveitis laterality
- depends on etiology
- systemic disease typically causes bilateral uveitis; exception: herpes is typically unilateral
anterior uveitis symptoms
- red eye(s)
- eye pain; severe»_space; mild; may have tearing
- photophobia
- blurred vision
anterior uveitis signs
- injection of the conjunctiva and/or around the limbus (ciliary flush/ circumlimbal flush/ circumlimbal injection)- may range from faint/mild to severe; may not be present if chronic
- anterior chamber reaction: cells and flare
- keratic precipitates (KPs)
- Busacca or Koeppe nodules
- WBCs in the anterior vitreous
- peripheral anterior synechia (PAS)
- posterior synechia (PS)
- pupillary miosis
- low IOP more common in acute phase
- high IOP more common in chronic phase
- iris atrophy if chronic
anterior chamber reaction: cells
- WBCs in the AC
- moves with the convection current of aqueous
- if severe, hypopyon (layer of WBCs in the AC) can form; hypopyon more common in Behcet’s disease and HLA-B27 positive patients
anterior chamber reaction: flare
- protein in the AC
- fibrinous/plasmoid aqueous is more common in HLA-B27 positive patients
grade the severity of the AC rxn by ____
estimating the # of cells and severity of flare in a 1 mm by 1 mm slit beam
keratic precipitates (KPs)
- WBCs on the K endothelium
- typically inferior in Arlt’s triangle
- if chronic, can become pigmented and irregular
- fine KPs: small, punctate, white
- Mutton-fat KPs: large, greasy, yellow
Busacca and Koeppe nodules
- WBCs on the iris
- Busacca nodules in the midperiphery
- Koeppe nodules at the pupillary margin
WBCs in the anterior vitreous
- due to inflammatory spillover into the vitreous
- cells can accumulate and create a hypopyon
- hypopyon is more common in Behcet’s disease and HLA-B27 positive patients
peripheral anterior synechia (PAS)
peripheral iris stuck to peripheral cornea
posterior synechia (PS)
iris pupillary zone stuck to lens
pupillary miosis
- more common in chronic uveitis; due to inflammatory mediators; sluggish, minimal, or non-reactive to light
- pupil may be normal in acute uveitis
- pupil may also be irregular in shape; more common in recurrent or chronic uveitis; due to synechiae or iris atrophy
____ IOP more common in acute phase; if herpetic etiology, may have ____ IOP due to concurrent trabeculitis
low;
high
____ IOP more common in chronic phase; due to ____
high;
inflammatory debris obstructing the TM, > 180 degree PS blocking the pupil, > 180 degree PAS blocking the angle, or steroid use
anterior uveitis classifications: onset
sudden or insidious
anterior uveitis classifications: duration
limited (< 3 months) or persistent (> 3 months)
anterior uveitis classifications: clinical course
- acute (sudden and limited) or chronic (insidious and persistent)
- recurrent
anterior uveitis classifications: non-granulomatous
- tends to be due to antigens that ____
- main cells involved are ____
- tends to be ____ uveitis
the immune system believes it can clear completely –> immune system drives an aggressive inflammatory response;
lymphocytes and plasma cells;
an acute
anterior uveitis classifications: granulomatous
- tends to be due to antigens that ____
- main cells involved are ____
- tends to be ____ uveitis
- tends to occur in ____
- granulomatous sings include ____
have learned to evade the immune system –> immune cells build a wall around the antigens (granuloma) to prevent further growth or spread;
non-phagocytic macrophages called epithelioid cells that fuse together to form giant cells;
a chronic;
sarcoidosis, lyme, syphilis, TB;
mutton-fat KPs and Busacca or Koeppe nodules
anterior uveitis complications
- posterior subcapsular cataract (PSC)
- cystoid macular edema (CME)
- band keratopathy
- secondary glaucoma
anterior uveitis complications: posterior subcapsular cataract (PSC)
due to chronic anterior uveitis or steroid use
anterior uveitis complications: cystoid macular edema (CME)
- due to chronic anterior uveitis with inflammatory spillover into the macula
- dilate your uveitis patients!!
- can visualize on OCT
- the macular may appear elevated or irregular on your DFE
- may improve with topical steroids, may require retinal specialist referral for intra-vitreal anti-VEGF
anterior uveitis complications: band keratopathy
- linear band of calcium that deposits in the cornea at the level of Bowman’s layer and anterior stroma
- due to chronic anterior uveitis
anterior uveitis complications: secondary glaucoma
- inflammatory etiology
- Posner-Schlossman Syndrome aka glaucomatocyclitic crisis
- due to self-limited, recurrent, prolonged elevated IOP in tandem with anterior chamber inflammation (non-granulomatous)
anterior uveitis management
- if posterior synechiae, break with 10% phenyl or 1% atropine; may require synechialysis, commonly done in tandem with cataract surgery
- topical cycloplegic: for ocular comfort, reduces ciliary spasm
- topical steroid: for persistent severe inflammation, consider oral steroids or subconj steroid injection
always obtain a baseline ____ before starting steroid treatment
IOP
RTC may vary based on severity and treatment regimetn:
- more severe = _____
- more mild = _____
1-2 day RTC;
3-7 day RTC
intermediate uveitis
inflammation of pars plana, peripheral retina, and vitreous
posterior uveitis
- inflammation of choroid and/or retina
- can also involve blood vessels (vasculitis) and/or teh ON (optic neuritis)
panuveitis
anterior + intermediate + posterior uveitis with no predominant site
when to order lab work
if bilateral, chronic, recurrent, granulomatous, worsening, or in conjunction with an intermediate or posterior uveitis and etiology is unknown, order lab work based on the most likely etiologies
if systemic etiology, ____
refer out for systemic treatment
____ is most common form of uveitis
anterior uveitis
cannot clinically distinguish between inflammation of the ____ and ____
iris; pars plicata
