Day 9 (3): Common Clinical Presentation of the Uveitis Patient Flashcards
What is uveitis?
Any inflammation of the uvea with OR without involvement of adjacent structures
How is uveitis classified anatomically?
What to look for: INFLAMMATORY CELLS!!!
Anterior Uveitis
- anterior chamber (iris, pars plicata or both)
- iritis, anterior cyclitis, iridocyclitis,
Intermediate Uveitis
- vitreous base, pars plana or peripheral retinal complex
- hyalitis, pars planitis, posterior cyclitis
- note: pars planitis is a diagnosis of exclusion where no underlying etiology can be identified inspite of exhaustive labs
Posterior Uveitis
- retina or choroid or both
- choroiditis, retinitis, chorioretinitis, retinochoroiditis, neuroretinitis
Panuveitis
- NO predominant site of inflammation
- may involve any combination of the above
- the severity of each affected segment must be COMPARABLE
- if one segment is more affected than the other, it is NOT panuveitis but just a spillover effect
REMEMBER:
1. Anatomic classification DOES NOT include STRUCTURAL complications such as macular edema, neovascularization and optic disc swelling.
How is uveitis classified according to onset and disease course?
- ACUTE
- sudden onset
- LIMITED duration: < / = 3 months - CHRONIC
- insidious onset
- PERSISTENT disease: > 3 months
- RELAPSE in < 3 months after discontinuation of therapy - RECURRENT
- REPEATED episodes of acute attacks separated by periods of inactivity
- off treatment for > / = 3 months
How is uveitis classified according to etiologic agent?
- INFECTIOUS
- HSV
- VZV
- CMV
- Syphilis
- Tuberculosis
- Toxoplasmosis
- HIV - NON-INFECTIOUS
- WITH associated systemic disease
+ Ankylosing Spondylitis
+ Behcet’s Disease
+ Juvenile Idiopathic Arthritis
+ Reactive Arthritis
+ Inflammatory Bowel Disease
+ Sarcoidosis
+ Immune Recovery Uveitis: pts with HIV develop s/sx of uveitis after initiating HAART
- WITHOUT associated systemic disease
+ Idiopathic disease: NO identified disease of precipitant
+ Sympathetic Ophthalmia
+ Drug-related - MASQUERADE: resemble uveitis in presentation but are actually secondary to lymphoma or other malignancies
What are the signs and symptoms of anterior uveitis?
Involvement: anterior chamber (iris, ciliary body or both)
Disease entities: iritis, anterior cyclitis, iridocyclitis,
SYMPTOMS
If Acute/Limited:
- sudden onset with DEFINITE start date (pt can clearly remember)
- classic triad:
1. pain
2. redness
3. photophobia: sensitivity to bright light
- vision may NOT be affected
- self-limited
If Chronic/Persistent:
- insidious onset with a less precise history
- may be ASYMPTOMATIC
- floaters
- decreased vision with time
- prolonged
SIGNS
1. Eye redness
2. Keratic precipitates
3. Cells and Flare
4. Adhesions (PS, PAS)
5. Iris nodules (Koappe, Busacca)
6. Pupillary changes
7. IOP changes
Describe the eye redness seen anterior uveitis.
Limbal congestion/Perilimbal flush
- ciliary congestion because CB located adjacent to the limbus
- involves deeper vessels arranged RADIALLY
- dusky red
- DDX: keratitis, angle-closure glaucoma
What are keratic precipitates?
- deposition of inflammatory cells in the corneal endothelium
- classified according to:
- Size
+ small to medium:
- fine, stellate
- PMNs, lymphocytes, plasma cells
- e.g. Fuch’s Heterochromic Uveitis, Non-granulomatous Uveitis
+ large:
- mutton fat-like; yellowish and greasy
- macrophages, epithelioid cells
- e.g. Granulomatous Uveitis - Pigmentation: indication of chronicity
+ non-pigmented: acute
+ pigmented: chronic - Distribution
+ Arlt’s Triangle:
- mutton-fat KPs which clump in a triangular or wedge-shaped region on the central to inferior corneal endothelium
- due to gravity and convection current
- clinical sign characteristic of granulomatous uveitis
+ Diffuse
What are cells and flare?
CELLS
- discrete inflammatory cells
- MOST important indicator of ACTIVE inflammation
- maybe located in the anterior chamber or in the vitreous
- HYPOPYON: exudate rich in WBCs seen in the inferior anterior chamber
FLARE
- haziness of the anterior chamber
- due to protein exudation into the AC resulting from damage to the Blood-Aqueous Barrier (tight junctions between the cells of the INNER NON-pigmented epithelium of the ciliary body and POSTERIOR PIGMENTED epithelium of the iris)
- may persist even in the absence of acute inflammation
What are the two kinds of adhesions seen in cases of anterior uveitis?
- Posterior Synechia
- between the posterior aspect of iris and anterior capsule of the lens
- may be thick and broad-based (granulomatous) or thin and stringy (non-granulomatous) - Peripheral Anterior Synechia
- between the peripheral anterior iris and the cornea at the iridocorneal angle
What are the two kinds of iris nodules?
- Koeppe nodules
- pupillary border
- BOTH granulomatous and non-granulomatous uveitis - Busacca nodules
- iris stroma (near the collarette)
- in granulomatous uveitis
What are some associated pupillary changes in anterior uveitis?
- Miosis
- due to spasm of the circular muscle of the ciliary body and contraction of the iris sphincter - Irregularly-shaped pupil: due to posterior synechia
- Presence of fibrous membranes
- Abnormal pupillary reflexes
Describe the changes in IOP associated with anterior uveitis.
IOP may be low, high or even normal.
LOW
- due to decreased production of aqueous humor from ciliary body inflammation
HIGH
- usually seen in chronic cases of uveitis with long-standing inflammation
- mechanisms:
1. angle closure: due to PAS or pupillary block
2. inflammation of the trabecular meshwork: causes decreased aqueous drainage
3. steroid-related: mainstay of treatment
- examples:
1. Herpetic Uveitis
2. Fuch’s Heterochromic Iridocyclitis
3. Posner-Schlossman Syndrome
What is Posner-Schlossman Syndrome?
Glaucomatocyclitic Crisis
- episodes of ocular hypertension and non-granulomatous anterior uveitis
- pathophysiology still unknown
- characteristics:
1. unilateral
2. recurrent
3. self-limited: several hours to weeks
4. periods of inactivity: NO signs of uveitis between attacks
5. mild discomfort or blurring of vision
6. normal or increased IOP WITH open angles
7. mild anterior chamber reaction or fine white KPs
8. normal visual fields and optic discs
- treatment goals:
1. controlling the IOP
2. decreasing inflammation
- while usually without sequelae, repeated attacks over time may lead to long-term glaucomatous damage
Differentiate granulomatous from non-granulomatous uveitis.
Granulomatous
- MINIMAL inflammation
- involvement: anterior, posterior or panuveitis
- etiology: infectious
- onset: insidious
- duration: chronic
- minimal to absent redness, pain and photophobia
- associated with floaters and decreased vision (from panuveitis)
- (+) large mutton-fat KPs
- (+) Koeppe and Busacca nodules
- (+) thick broad-based posterior synechia
Non-granulomatous
- SEVERE inflammation
- involvement: anterior
- etiology: non-infectious
- onset: sudden
- duration: acute BUT tends to recur
- marked redness, pain and photophobia
- minimal blurring of vision (usually affects anterior uvea only)
- (+) small to medium, fine or stellate KPs
- (+) Koeppe nodules ONLY
- (+) beginning pupillary membrane
What are the signs and symptoms of intermediate uveitis?
Involvement: vitreous base, pars plana or peripheral retinal complex
Disease entities: hyalitis, pars planitis, posterior cyclitis
Symptoms:
1. ASYMPTOMATIC: in mild cases
2. Floaters: opacities in the anterior vitreous
3. Blurring of vision:
- scattering of light due to vitreous haze or macular edema (most common cause)
Signs:
1. Vitreous haze:
- hazy or cloudy appearance of the vitreous
- due to protein exudation from the breakdown of the BAB
2. Inflammatory cells in the peripheral retina
- Snowbanks: grey-white fibrovascular plaques inferiorly
- Snowballs: inflammatory cell aggregates within the vitreous
- Perivascular Sheathing: aggregation of WBCs along vessel walls
Note:
Pars planitis: diagnosis of exclusion where no underlying etiology can be identified inspite of exhaustive labs
