DIS - Anterior Uveitis II - Week 3 Flashcards
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
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
List four common diseases that can cause uveitis in order of how common they are.
Ankylosing spondylitis
Reiters disease
Psoriatic disease
Inflammatory bowel disease
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
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
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
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
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
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
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
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
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
Is ankylosing spondylitis seropositive or -negative?
Negative (rheumatoid factor)
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
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
What can the referred pain in ankylosing spondylitis be likened to?
Sciatica
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
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
When do symptoms of acute iridocyclitis in ankylosing spondylitis begin relative to signs?
1 to 2 days before signs
In what percentage of cases is acute iridocyclitis seen in ankylosing spondylitis?
20 to 25%
What is an important feature to look out for with acute iridocyclitis in ankylosing spndylitis?
Cells and flare
What is reiters syndrome also known as?
Reactive arthritis
List the triad of reactive arthritis. Do people commonly have all three?
Urethritis
Conjunctivitis
Sero-negative arthritis
Many cases dont have all three
What percentage of reactive arthritis cases will develop acute anterior uveitis?
12%
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
