DIS - Anterior Uveitis I - Week 3 Flashcards
Is uveitis associated with other diseases or does it occur in isolation? Explain (3).
It may be associated with systemic disease, immune/auto-immune disorders, or occur in isolation
What is the optometrist’s role in uveitis (4)?
Detection
Diagnosis
Primary care/management
Referral
True or false
Acute iritis is a relatively rare form of uveitis
False, it is the most common form of uveitis
Define uveitis. Is it intra- or extraocular only?
Inflammation of any part of the uveal tract
-intraocular only
What four factors affect the classification of uveitis?
Location
Clinical behaviour
Aetiology
Pathology
Define endophthalmitis in the context of uveitis and areas of inflammation (3).
Uveitis with inflammation of intraocular cavities but excluding the sclera
Define panophthalmitis/panuveitis in the context of uveitis and areas of inflammation (4).
Endophthalmitis with inflammation of the sclera, tenons capsule, and orbital tissue
Define vitritis in the context of uveitis (2). What is it usually due to?
Infiltration of inflammatory cells into the vitreous due to uveitis
List the two forms of anterior uveitis. What percentage of all uveitis cases do they make up?
Iritis
Iridocyclitis
they make up 80% of all uveitis cases
List the two forms of intermediate uveitis.
Pars planitis
Chronic cyclitis
List the three forms of posterior uveitis. At what anatomical point is the uveitis considered to be posterior?
Choroiditis
Chorioretinitis/retinochoroiditis
Retinitis
-beyond the vitreous base
List the two forms of diffuse uveitis.
Endophthalmitis
Panuveitis/panophthalmitis
Describe three characteristics of acute uveitis.
Sudden onset
Very symptomatic
Resolves completely in <3 months
List three characteristics of chronic uveitis.
Often insidious
Often asymptomatic
Many months to recover or longer >3/12
What must chronic uveitis be distinguished from?
Recurrent acute uveitis
What can poorly treated acute uveitis lead to?
Chronic uveitis
What is meant by subacute uveitis (2)?
Healing or going to chronic
List three examples of exogenous causes of uveitis. Give two examples.
External injury
Invasion of microorganisms
Other agents from outside the eye
-anterior segment surgery
-infective ulcer, abrasion
List two systemic disorders that can result in uveitis.
Arthritis
Sarcoidosis
Give two examples of parasitic infections that can cause uveitis.
Toxoplasma
Lyme disease
Give three examples of viruses that can cause uveitis.
CMV
HSV
HZO
Give an example of a fungus that can cause uveitis.
Candida
List three examples of endogenous causes of uveitis.
Microorganisms/inflammatory agents from within the body
Systemic disorders
Idiopathic
Distinguish between acute and chronic uveitis in terms of whether they are granulomatous or non-granulomatous.
Acute - non-granulomatous
Chronic - granulomatous
Distinguish between acute and chronic uveitis by injection and pain.
Acute
-grade 4 injection
-grade 3+ pain
Chronic
-grade 1 injection
-grade 1 pain, sometimes none
Distinguish between acute and chronic uveitis by the presence of nodules.
Acute - no nodules
Chronic - grade 2 nodules
Distinguish between acute and chronic uveitis by the appearance of keratic precipitates.
Acute - small/fine
Chronic - mutton fat appearance
Distinguish between acute and chronic uveitis by the main cell types present (2 each).
Acute
-neutrophils
-lymphocytes
Chronic
-macrophages
-giant cells
List the three classifications of uveitis (by cause).
Infectious
Non-infectious
Masquerade
List the 5 sub-classifications of infectious uveitis.
Bacterial
Viral
Fungal
Parasitic
Other
List the 3 sub-classifications of non-infectious uveitis.
Systemic associations
No known systemic associations
Immune related
List the 2 sub-classifications of masquerade uveitis.
Neoplastic
Non-neoplastic
List three ocular drugs that may induce uveitis.
Latanoprost
Brimonidine
Metipranolol
List seven systemic drugs that can induce uveitis.
Cidofovir
-CMV/HIV drug
Bisphosphonates
Oral contraceptives
Systemic sulphonamides
Influenza vaccine
BCG vaccine for TB
Cancer-related chemotherapy
Is drug induced uveitis usually common or uncommon? Are they mild or severe? Granulomatous or non-granulomatous?
Uncommon
Mild
Non-granulomatous
What three other conditions may sometimes occur alongside drug induced uveitis?
Vitritis
Optic neuritis
Panuveitis
What three things does drug induced uveitis respond to?
Withdrawal of the drug
Topical steroids
Topical cycloplegics
At what age does prevalence of uveitis increase?
65 and over
Is uveitis common in the very young? What about the very old?
Less common in both
What two components contribute to the formation of the blood-aqueous barrier? What does inflammation lead to?
Tight junctions in the ciliary epithelium and endothelium of iris capillaries
-inflammation leads to a breakdown in these junctions
What is they key aspect of uveitis?
Breakdown of the blood aqueous barrier
On breakdown of the blood aqueous barrier, what two macromolecules fill the aqueous? What does this result in?
Proteins like albumin
Fibrin/fibrinogen
-passive and due to leakage
Results in flare
Do cells normally leave blood vessels? Explain in the context of uveitis (2).
Normally do not
-only with the breakdown of the blood aqueous barrier and the presence of a chemoattractant
What does the presence of cells in the anterior chamber indicate?
Active inflammation
Capillaries of what two structures form the blood aqueous barrier?
Iris
Ciliary body
List and describe the three types of capillaries. Give an example of an organ where they can be found.
Non-fenestrated
-continuous basal lamina and endothelium
-iris BV
Fenestrated
-continuous basal lamina and fenestrated endothelium
-choroid
Sinusoidal
-fenestrated basal lamina and endothelium
-liver
True or false
The iris stroma has no surface epithelium
What consequence does this have on any capillary leakage?
True
Any capillary leakage is directly into the aqueous
Do iris capillaries normally restrict all cells entry into the anterior chamber?
Yes
What protein percentage do iris capillaries maintain in the anterior chamber?
They restrict protein outflow so there is <1% in the aqueous
Do iris capillaries allow the flow of amino acids into/out of the anterior chamber?
Yes, concentration is equal in aqueous and blood
Are ciliary body capillaries fenestrated, non-fenestrated, or sinusoidal? Where in the ciliary body is it found?
Fenestrated
-ciliary body stroma
What is the non-pigmented epithelium of the ciliary bodies a continuation of?
Neuroepithelium
Do ciliary body capillaries have tight junctions?
Yes
How many layers tick is the epithelium of the ciliary body?
2
What is the outer layer of the ciliary body adjacent to and is it pigmented or non-pigmented?
Adjacent to the stroma
Pigmented
What is the pigmented epithelium of the ciliary body a continuation of?
The RPE
Does the pigmented epithelium of the ciliary body have gap junctions? What does this allow for?
Yes
Allows lateral diffusion between cells
What kind of junctions are destroyed in inflammation (uveitis)? Where are these present (2)?
Tight junctions
-ciliary body - non-pigmented epithelium
-iris - capillary endothelium
What happens to IOP with uveitis? Explain why.
Reduction
Reduced osmotic difference between the blood and aqueous giving less aqueous formation
What causes red eye in uveitis and via what structure?
Inflammatory cytokines drain via the trabecular meshwork into conjunctival veins to give a vascular response
Are tight junctions permanently destroyed with uveitis?
No, they are replaced
What is a key marker for inflammation in uveitis?
Cells
Is flare considered significant for uveitis? Does it suggest inflammation? Explain.
Flare is generally persistent, less significant, and less suggestive of inflammation
What can prolonged/uncontrolled inflammation lead to?
Permanent damage to the blood aqueous barrier
List four symptoms of acute anterior uveitis.
Redness
Pain
Photophobia
Lacrimation without discharge
Is acute anterior uveitis typically uni- or bilateral?
Usually unilateral
What is vision like with acute anterior uveitis?
Normal
What is the onset of acute anterior uveitis like?
Rapid
List 12 key signs of acute anterior uveitis.
Hyperaemia
Cells
Flare
Miotic pupil
Keratic precipitates
Hypopyon
Synechiae (anterior/posterior)
Vitreous cells
IOP
Pseudo-ptosis
Normal VA
Iris nodules
What is the cause of iris miosis with anterior uveitis? What does this cause induce to result in miosis?
Substance P - an inflammatory cytokine
Induces sphincter contraction
What ocular drug has less effect in the presence of substance P?
Atropine
What else does substance P contribute to?
Hyperaemia
where is redness greatest with uveitis?
Next to the limbus
Does a decrease in the number of cells present in the anterior chamber with uveitis indicate improvement?
Yes
What can cells and fibrin in uveitis form?
Keratic precipitates
What does flare represent?
Turbidity created by increased concentration of plasma proteins and fibrinogen
Are cytokines needed for flare?
No
Is flare a good or poor indicator of inflammation?
Poor
True or false
Flare may persist after active inflammation subsides
True
What activates fibrinogen and to form what? What is the activator released from?
Thromboxane to form fibrin
Thromboxane is released from arachidonic acid of inflammed cell membranes
Does the aqueous clot due to the presence of fibrin? Explain.
It does not because platelets are absent
What do fibrin strands form? What does it mean?
Forms plastic iritis
-stagnation of cells
What does the presence of fibrin suggest? What does it promote the formation of?
Suggests more serious inflammation
Promotes synechial formation
What inhibits fibrin formation?
Steroid
-by inhibiting thrombin
What does hypopyon indicate of the blood aqueous barrier?
Severe breakdown
Is hypopyon short- or longlived?
Shortlived
What may usually be present in the contents of hypopyon (3)?
Cells
Protein
Fibrin
What is usually found in hypopyon with acute anterior uveitis? Is it dense or mobile? Does it resorb quickly or slowly?
High fibrin content
Dense and immobile
Resorbs slowly
What is usually found in hypopyon with behcets disease? Is it dense or mobile? Does it resorb quickly or slowly?What
Minimal fibrin
Moves easily with head movement
May disappear quickly
What are keratic precipitates formed by?
Lymphocytes or macrophages
Where on the cornea are keratic precipitates found?
Sticky on the corneal endothelium
How do new and old keratic precipitates appear in terms of colour and regularity?
New - white/round
Old - irregular/pigmented
Where are keratic precipitates generally distributed and why? what does a generalised distribution across the chamber indicate?
Inferior distribution due to aqueous convention currents
-if generalised, indicates chronic inflammation
If you see mutton fat appearing keratic precipitates, what should you think?
Granulomatous
What is posterior synechiae? What is it promoted by?
Adhesion of the iris to the lens (pupil border)
Promoted by fibrin and inflammatory mediators
What does posterior synechiae increase the risk of?
Pupil block
What does posterior synechiae develop with? Is it slow or rapid?
Develop rapidly with severe inflammation
Do posterior synechiae tend to rupture? Explain.
May rupture with iris movement
What minimises the formation of posterior synechiae?
Active iris
What may pigment on the lens indicate?
Previous synechial event
What is peripheral anterior synechiae?
Iris-corneal adhesion
How many clock hours of peripheral anterior synechiae will cause aqueous outflow impediment?
> 4 clock hours
Are cells in the vitrous common in acute anterior uveitis?
Yes
What causes cells in the vitreous?
Spillover from inflamed tissue
Describe how you may distinguish between iritis. iridocyclitis, and posterior uveitis based on cells in the anterior chamber and vitreous.
Iritis - AC cells»_space; vitreous cells
Iridocyclitis - AC cells = vitreous cells
Posterior uveitis - AC cells «_space;vitreous cells
What is it like to look at the vitreous in posterior uveitis?
Like looking through fog
How do cells appear in the vitreous in posterior uveitis?
Headlamps through fog
If you suspect acute anterior uveitis, but IOP is increased, what would you think (2)?
Inflamed TM and draining poorly
-trabeculitis
TM may also be obstructed with inflammatory debris
In what type of uveitis is IOP the key aspect? What can it be described as?
Posner-schlossman syndrome
Glaucomato-cyclitic crisis
Describe posner-schlossman syndrome. Is it uni- or bilateral? What age does it occur? Is it self-limiting?
Unilateral, recurrent, non-granulomatous trabeculitis in 30-60 year olds
Very high IOP with open angle during attack
Self-limiting
What may individuals with posner-schlossman syndrom develop with age?
Open angle glaucoma
What are three other important features of uveitis?
Cystoid macular oedema
Corneal oedema
Iris atrophy
If you suspect uveitis, what should you always consider as a possible cause of decreased VA?
Cystoid macular oedema
What is cystoid macular oedema mainly caused by in uveitis (2)?
Severe or recurrent uveitis
What kind of corneal oedema may you see in uveitis (2)?
Stromal/endothelial
What is iris atrophy mainly caused by in uveitis?
Recurrent anterior uveitis
In what four diseases is chronic anterior uveitis often seen in?
Fuchs iridocyclitis
Juvenile idiopathic arthritis
HZV
HZO
List three symptoms of chronic anterior uveitis (4).
Mild ache
Lacrimation
Photophobia
-often asymptomatic
What are pupils like with chronic anterior uveitis?
Normal
What are iris nodules? What are they called if seen at the pupil margin? What about the iris stroma?
Accumulations of inflammatory cells on the iris
-a granuloma
Pupil margin - koeppe nodule
Iris stroma - bussaca nodule
Are iris nodules common in acute anterior uveitis? Explain why.
No, because nodules indicate high probability of granulomatous disease
What iris change can Fuchs iridocyclitis cause?
Heterochromia
