DIS - Anterior Uveitis II - Week 3 Flashcards by B H

When assessing acute anterior uveitis, what two things should you always do and why?

Stain, to look for corneal involvement
Dilate, to look for posterior signs

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List 8 common differential diagnoses for acute anterior uveitis. What would make you especially suspicious?

Conjunctivitis
Allergy/hypersensitivity
Angle closure glaucoma
Corneal foreign body
Corneal ulceration
Corneal abrasion
Keratitis
Episcleritis
-beware unilateral red eye

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List four common diseases that can cause uveitis in order of how common they are.

Ankylosing spondylitis
Reiters disease
Psoriatic disease
Inflammatory bowel disease

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List four questions that can be asked of a patient, whom you suspect to have uveitis, to work up ankylosing spondylitis as a possible cause.

Joint pain (how many)
Diagnosis of arthritis
Back pain/stiffness
-especially in the morning - buttocks
Limited motion of hips

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List three questions that can be asked of a patient, whom you suspect to have uveitis, to work up inflammatory bowel disease as a possible cause.

Recurrent diarrhoea
Bloody diarrhoea
Abdominal cramps/pain

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List four questions that can be asked of a patient, whom you suspect to have uveitis, to work up reactive arthritis as a possible cause.

Ulcers/painful lesions in the mouth/genital area
Pus in urine
Blood in urine
Pain with micturition

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What question can be asked of a patient, whom you suspect to have uveitis, to work up psoriasis as a possible cause.

Any lesions on your scalp, elbow, knees, other lesions

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List three questions that can be asked of a patient, whom you suspect to have uveitis, to work up sarcoidosis and TB as a possible cause.

Difficulty breathing
Chronic cough
Recent febrile illness

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What question can be asked of a patient, whom you suspect to have uveitis, to work up lyme disease and TB as a possible cause (3)?

Travel overseas
-USA
-Asia
-Africa

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What is ankylosing spondylitis? What area of the body does it involve and is it degenerative? Is it acute or chronic?

A chronic spinal joint disease
-inflammatory arthritis of the bone-ligament interface
Isnt degenerative

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What occurs in ankylosing spondylosis that causes it to manifest its symptoms (list 2 main ones)?

Healing by bony deposition across the joint
-causes fusion (ankylosis)
-loss of spine flexibility

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In what age range and gender does ankylosing spondylitis typically occur? After what age is onset rare?

20 to 40 year old males
-rare onset after 45

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Is ankylosing spondylitis seropositive or -negative?

Negative (rheumatoid factor)

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What broad aspect of the skeleton does ankylosing spondylitis affect? What part specifically? List four joints that are affected.

Axial skeleton
The spine mostly
Sacro-iliac joint
Facet joints of the spine
-articular processes of the vertebrae
Costal-vertebral joint
Peripheral joints/tendon insertions

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List 6 early signs of ankylosing spondylitis.

Ache/stiffness
Lower back/buttock pain/stiffness
Referred pain at night or morning
Accentuated by rest/inactivity
Improves with activity/exertion
Intermittent > constant

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What can the referred pain in ankylosing spondylitis be likened to?

Sciatica

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List 4 later features of ankylosing spondylitis.

Fixed flexion deformity of the spine
Rigid spine (poker spine)
Bending from hips instead of vertebrae
Limited reach in attempting to bend forward

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How long does acute anterior uveitis last in ankylosing spondylitis and in what form? Is it generally recurrent? Is it granulomatous? What may be seen on the lens?

Acute iridocyclitis lasing <6 to 8 weeks
Recurrent
Non-granulomatous
Posterior synechiae are common

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When do symptoms of acute iridocyclitis in ankylosing spondylitis begin relative to signs?

1 to 2 days before signs

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In what percentage of cases is acute iridocyclitis seen in ankylosing spondylitis?

20 to 25%

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What is an important feature to look out for with acute iridocyclitis in ankylosing spndylitis?

Cells and flare

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What is reiters syndrome also known as?

Reactive arthritis

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List the triad of reactive arthritis. Do people commonly have all three?

Urethritis
Conjunctivitis
Sero-negative arthritis
Many cases dont have all three

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What percentage of reactive arthritis cases will develop acute anterior uveitis?

12%

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Are posterior synechiae common in reactive arthritis?

Yes

List two types of infectious agents that can trigger an immune response to result in reactive arthritis. What would you expect to see in both types?

STD or enteric infections -painless mouth ulcers in both types

What major feature of reactive arthritis occurs first and what may it result in (2)?

Initial bacterial infection -urethritis -dysentery/enteric infection

What is often the cause of urethritis in reactive arthritis?

Non-gonococcal bacteria -often chlamydia

What generally occurs three weeks after urethritis in reactive arthritis? How long does it last and what happens after (3)? Is there permanent damage?

Acute arthritis 3 weeks after urethritis Lasts 10 to 30 days Becomes chronic, progressive, and recurrent Usually no permanent damage

When does conjunctivitis typically occur relative to other components in the triad of reactive arthritis? In what percentage of cases does it occur?

After urethritis, but before arthritis Occurs in 30-60% of cases

Is the conjunctivitis in reactive arthritis mucopurulent or serous? Are follicles present?

Mucopurulent, without follicles

Whatis the prevalence of psoriatic arthritis?

1-2%

What causes psoriasis?

Hyper-proliferation of the epidermis

What areas of the body are generally affected by psoriasis (8)?

Scalp, joint, lower back, groin, legs, feet, nails

Do a large or small percentage of psoriasis patients develop arthritis?

Small

What percentage of psoriasis patients will develop acute anterior uveitis?

7% of the arthritic group

What two things do patients with acute anteior uveitis associated with psoriatic arthritis respond well to?

Steroid Cycloplegia

Define crohns disease (2). Where does it most often affect?

Inflammation of any part of the bowel or any part of the bowel wall Most often the small intestine

Define ulcerative colitis.

Inflammation of the colon, usually the lining -often with ulcers

List four symptoms of inflammatory bowel disease.

Abdominal pain/cramping Diarrhoea (multiple times per day) Bloody stools Weight loss

What is behcets disease considered to be?

Idiopathic multi-system disease

What is the ratio of behcets disease between male and female?

3:2 m/f

Describe the cause of behcets disease.

Abnormal circulating immune complexes resulting in obstructive vasculitis

What may behcets disease be precipitated by (2)?

Viral or streptococcal infection

In what two world regions, gender, and age group is behcets disease typical?

Young males from the east mediterranean and japan

What is behcets disease sometimes called?

Silk road disease

List 5 features of behcets disease.

Recurrent mouth ulcers (v. painful) Genital ulcers Skin lesions Uveitis -anterior and posterior Multiple systemic complications

List the requirements of diagnosing behcets disease (2).

Requires 3 major features or 2 major features and 2 minor features

What are genital ulcerations in women with behcets disease commonly misdiagnosed as?

Herpetic cause

What is often the first sign of behcets disease?

Recurrent oral ulcers

List 6 minor features of behcets disease.

Thrombophlebitis Arthritis Colitis/peptic ulcers CNS lesions -including EOM palsies Cardiovascular lesions -sterial occlusions/pericarditis Positive family history

What kind of anterior uveitis is present with behcets disease? Is it recurrent? How severe or mild is it?

Anterior iridocyclitis It is acute, recurrent, and severe

How long does acute anterior uveitis last with behcets disease?

2 to 4 weeks

What four ocular signs may you see with uveitis in behcets disease?

Vitritis Keratitis Episcleritis Conjunctivitis

What may acute anterior uveitis evolve into in behcets disease? What is there a risk of?

Chronic anterior uveitis -risk of phthysis

What is commonly seen with uveitis in behcets disease?

Hypopyon

What are the three main forms of posterior uveitis seen in behcets disease?

Diffuse vascular leakage Retinal vasculitis Retinitis

What is the visual prognosis of behcets disease like if there are posterior changes?

Poor

What three diseases are sometimes associated with acute anterior uveitis? Are they more or less commonly associated with chronic anterior uveitis?

Sarcoidosis Syphilis Tuberulosis More likely to be associated with CAU

Is the incidence of syphilis rising or declining the past few years?

Rising

What is the most common ocular finding in syphilis?

Posterior uveitis -can also cause anterior uveitis

What is the GP referral criteria for acute anterior uveitis (2)?

Any repeat attacks to review medical status Any patient who reports medical complications

What is the ophthalmologist referral criteria for acute anterior uveitis (7)?

Any posterior cause Complicated IOP response Hypopyon Plastic AC/AAU Uniocular patients Very young/old patients with the first episode Patients with protracted response

Is juvenile idiopathic arthritis seropositive or -negative?

Seronegative

When is the onset of juvenile idiopathic arthritis?

<16yoa

List the three subgroups of juvenile idiopathic arthritis.

Systemic JIA Polyarticular JIA Pauciarticular JIA

In which type of uvenile idiopathic arthritis may uveitid develop (2)? Is it dependent or independent to the activity of arthritis?

May develop with any type -but especially pacuiarticular JIA -independent to activity of arthritis

Is uveitis in juvenile idiopathic arthritis acute or chronic? Is it uni- or bilateral? Is it granulomatous?

Chronic Bilateral Non-granulomatous

What percentage of uveitis in juvenile idiopathic arthritis cases are female?

75%

What is the onset of uveitis in juvenile idiopathic arthritis always like?

Asymptomatic

What five ocular signs may you see at the onset of uveitis in juvenile idiopathic arthritis?

Cells Keratic precipitates Posterior synechaie CMO Band keratopathy

What is the review and screening for uveitis like when examining a patient with juvenile idiopathic arthritis (3)?

At or within 6 weeks of diagnosis 2 monthly for 6 months 4 monthly until 11yoa

What kind of uveitis occurs in fuchs uveitis syndrome? What else is it called?

Anterior uveitis Fuchs heterochromic iridocyclitis

What age group does fuchs uveitis syndrome typically affect?

Young adult

Is fuchs uveitis syndrome typically symptomatic or asymptomatic?

Asymptomatic

Is there good or poor visiion with fuchs uveitis syndrome?

Good

Can fuchs uveitis syndrome result in chronic uveitis? Explain (2).

Yes Chronic non granulomatous and unilateral

Is iris heterochromia a reliable indicator of fuchs uveitis syndrome? Which eye does it typically affect? Explain the eye colours.

It is an inconsistent feature Affected eye is hypochromic -brown eyes are less brown -blue eyes are more saturated

Aside from heterochromia, what other features of the iris are present in fuchs uveitis syndrome (4)?

Iris crypts lost Stromal atrophy Patchy iris pigment loss Iris vessels visible

What anterior condition relating to the iris may be present in fuchs uveitis syndrome (aside from heterochromia and atrophy)?

Rubeosis

What two conditions complicate chronic fuchs uveitis syndrome?

Cataract and primary open angle glaucoma

Who can best manage fuchs uveitis syndrome?

Ophthalmologists

Are steroids typically used for fuchs uveitis syndrome?

No, useless

What can sarcoidosis be described as?

Multi-system granulomatous, idiopathic inflammation

Does sarcoidosis have consistent or variable racial prevalence? Explain (2).

Variable -higher in afro-americans and swedes

What is sarcoidosis characterised by?

Non-caseating granulomas

What five organs does sarcoidosis commonly involve? List 5 less commonly involved organs.

Common -lungs -lymph nodes -skin -liver -eyes Less common -spleen -CNS -bone -joints -heart

When does ocular sarcoidosis often occur?

4th to 6th decade

What kind of keratic precipitates can often be seen with ocular sarcoidosis? List another thing you may see.

Mutton fat KP very large Iris nodules

Is ocular sarcoidosis often uni- or bilateral?

Bilateral

What 3 diseases does ocular sardcoidosis increase the risk of?

Cataract Glaucoma Phthysis

In what percentage of ocular sarcoidosis does uveitis occur and what kind?

Chronic anterior uveitis in 60% of ocular sarcoidosis cases

How long after skin lesions emerge does uveitis occur in herpes zoster ophthalmicus?

1 to 2 weeks

What can be seen of the iris in HZO?

Patchy atrophy

What three things can be seen of the cornea in HZO?

Dendritic keratitis Stromal keratitis Exposure keratitis

Describe glaucoma associated with HZO.

Often severe with high IOP

Is phthysis present in HZO?

Yes

What is the ocular management for HZO (4)?

Topical antiviral Topical steroid Cycloplegia Glaucoma medications

What is the oral management for HZO?

Oral acyclovir

Is uveitis in syphilis generally granulomatous?

Generally granulomatous but not always

What type of uveitis is more likely with TB (2)?

Chronic anterior uveitis -acute is possible

Is TB hard or easy to catch?

Hard to catch

What are the three essentials of therapeutic management for acute anterior uveitis?

Determining the underlying cause Controlling inflammation Controlling complications

What is a difficulty with long term treatment/management of chronic anterior uveitis?

Substantial risk of tissue damage

What is the purpose of cycloplegia with acute anterior uveitis (2)?

Pain and synechiae control

In what 6 cases of uveitis is periocular injections of steroids considered?

Severe anterior uveitis Intermediate uveitis Chronic uveitis Poorly compliant patients At surgery Poor response to topical drugs

What is usually the treatment for posterior uveitis (2)?

Systemic/oral steroids