DIS - Overview of Ocular Inflammation - Week 6 Flashcards
Define uveitis. Is it intraocular only?
Inflammation of any part of the uveal tract
Intraocular only
Between granulomatous and non-granulomatous uveitis, which is chronic and acute?
Non-granulomatous - acute
Granulomatous - chronic
What is injection like between granulomatous and non-granulomatous uveitis?
Non-granulomatous - high grade
Granulomatous - low grade
What is pain like between granulomatous and non-granulomatous uveitis?
Non-granulomatous - high grade
Granulomatous - low grade to none
What is the presence of nodules like between granulomatous and non-granulomatous uveitis?
Non-granulomatous - none
Granulomatous - present
What is the appearance of keratic precipitates like between granulomatous and non-granulomatous uveitis?
Non-granulomatous - small/fine
Granulomatous - mutton fat
What is the appearance of fundus pathology like between granulomatous and non-granulomatous uveitis?
Non-granulomatous - diffuse
Granulomatous - nodular lesions
What are the main cell types present in granulomatous (2) and non-granulomatous uveitis (2)?
Non-granulomatous
-neutrophils
-lymphocytes
Granulomatous
-macrophages
-giant cells
What cells appear first in most forms of inflammation?
Neutrophils
Are the capillaries of the iris fenestrated?
No
What junctions are found between endothelial cells of the iris capillaries?
Tight junctions
Does the iris stroma have a surface epithelium?
No
-capillary leakage is directly into the aqueous
What junctions are present in the pigmented and non-pigmented epithelium of the iris?
Non-pigmented - tight junctions
Pigmented - gap junctions
What happens to tight junctions during inflammation and what happens after the inflammation resolves?
Destroyed with inflammation
Replaced after it resolves
What is the key marker for inflammation?
Cells
Is there a potential for permanent damage to the blood aqueous barrier with constant inflammation?
Yesd
What are four common causes of uveitis in young individuals (including adolescents)?
JIA
Leukaemia/lymphoma
Retinoblastoma
Toxocariasis
What are eleven common causes of uveitis in young to middle aged individuals?
Behcets disease
Fuchs disease
HLA B27+
Pars planitis
Psoriatic arthritis
Reiters
Sarcoidosis
SLE
Birdshot
Rheumatoid arthritis
VKH
What are three common causes of uveitis in geriatric individuals?
Temporal arteritis
Ischaemia
Leukaemia/lymphoma
What are four common causes of uveitis in males?
Ankylosing spondylitis
Behcets disease
Psoriatic arthritis
Reiters syndrome
What are four common causes of uveitis in females?
JIA
MS
Scleroderma
Sjogrens syndrome
SLE
Rheumatoid arthritis
What are four common causes of uveitis in white people?
Ankylosing spondylitis
Psoriatic arthritis
Reiters syndrome
Birdshot retinopathy
What are three common causes of uveitis in asians?
Behcets disease
VKH
TB
What is a common cause of uveitis in black people?
Sarcoidosis
What is a common cause of uveitis in eurasians?
Eales disease
What should you always do if you suspect uveitis and to differentiate it from what? Name two other diseases it should be differentiated from.
Always stain in AAU to differentiate from dry eye
-also scleritis and episcleritis
Does acute anterior uveitis require quick attention?
Yes
Can posterior uveitis be relatively advanced at diagnosis?
Yes
Does posterior uveitis easily spread to the macula?
Yes
Do posterior uveitis symptoms tend to be vague or clearcut?
Vague
What is the most common cause of posterior uveitis?
Toxoplasmosis
List four viral causes of posterior uveitis.
CMV
HSV
HZV
Rubella
List five bachterial causes of posterior uveitis.
Syphilis
Tuberculosis
Streptococcus
Staphylococcus
Lyme disease
List four fungal causes of posterior uveitis.
Candida
Aspergilla
Histoplasmosis
Cryptococcus
List three parasitic causes of posterior uveitis.
Toxoplasmosis
Toxocariasis
Onchocerciasis
List 9 distinct inflammatory diseases of unknown aetiology that can result in posterior uveitis.
AMPPPE
VKH
Behcets disease
Birdshot chorioretinopathy
Sarcoidosis
Serpiginous choroiditis
Sympathetic ophthalmia
MEWDS
SLE
What are four active inflammatory things that cause visual loss in posterior uveitis?
Vitritis
CMO
Disc oedema
Obliterative retinal vasculitis
What are five active non-inflammatory things that cause visual loss in posterior uveitis?
Cataract
Vitreous debris
Chronic macular problem
Glaucoma
Optic atrophy
List 5 chronic macular problems with non-inflammatory causes that can cause visual loss in posterior uveitis.
Permanent CMO
RPE disturbance
ERM
SRNVM
Macular hole
-full/partial
What should you always keep in mind when you confirm a case as uveitis?
Systemic associations
-always return to history taking even if you have already inquired
What drug is often used to treat uveitis in primary care and what three things should you always do before prescribing this drug?
Steroids
-be very sure there is no infection in anterior uveitis
-look at anterior/posterior segment thoroughly and history
Determine if the corneal epithelium is intact
Keep high IOP in mind
What does high IOP in suspected anterior uveitis suggest?
Viral aetiology
Is it advisable to give steroids if you confirm anterior or posterior uveitis?
No steroids without antibiotic control
Describe the mimickry theory for HLA inflammation.
HLA B27 moecules dhare short peptide sequences with proteins from gram negative enteric bacteria
-this may result in fragemnts of certain bacteria combining with HLA molecules
Give three pieces of evidence for the mimickry theory for HLA inflammation.
20% of HLA B27 patients develop spondyloarthropathy after exposure to certain gram negative bacteria
Some patients with recurrent AAU have elevated levels of bacterial antibodies
Patients with AS had specific antibodies to klebsiella during active AS
List two idiopathic forms of anterior uveitis that have similar clinical presentations to anterior uveitis secondary to infectious agents (notw which two). What may this indicate? Also note what these typical features are (4).
Fuchs uveitis syndrome
Posner schlossman syndrome
-small keratic precipitates
-iris atrophy
-unilateral
-elevated IOP
Indicates these two diseases may have an infectious cause (HSV and HZO, among possible others)
Some studies suggest that CMV may explain a third of idiopathic cases of idiopathic anterior uveitis. Why are antivirals not given for CMV even though antiviral drugs for it exist (2)?
It is impractical because it is too expensive and never eliminates the virus
Why should uveitis be treated aggressively?
Risk of blindness
What is the general starting dose for acute anterior uveitis (2 drugs, note name, dose).
Pred forte q1h
Aropine tid
Should primary care be given to the first attack of acute anterior uveitis (note the two views)? What about recurring cases?
If it looks isolated, treat AAU with primary care
Refer every case of recurrent AAU
or
Refer every first attack to detect any possible underlying diseases
-subsequent recurrences dont need referrals because underlying condition is already found (?)
What 7 things should definitely warrant a referral if you suspect acute anterior uveitis?
Severe attacks
Grade 3p4 cells/flare
Hypopyon
Plastic A/C
Uni-ocular patients
Young patients (<15)
Slow/no imrpovement
-no change to cells/flare/injection for 5-6 days
-no change in symptoms for 6-7 days
What percentage of uveitis cases cause glaucoma? What percentage of those develop severe chronic glaucoma?
10-20%
-46% of these develop sevre chronic glaucoma
List three causes of glaucoma from uveitis.
Steroids from treatment
Posterior synechiae, leading to pupil block and secondary angle closure
Clogging of TB meshwork with inflammatory cells
How should cases of uveitis and glaucoma be managed?
Co-treat uveitis and glaucoma with sterouds and aqueous suppressants
What drugs should be stopped if uveitis is diagnosed (2)?
Miotics
Prosaglandins
Is there a role for ALT/SLT in managing uveitic glaucoma?
No, pro-inflammatory
List four surgical options for uveitic glaucoma.
Drainage implant
Trabeculectomy
Surgical iridectomy
Surgical synechiolysis
What is generally required to do cataract surgery in a patient with uveitis?
3 months of quietness
-aggressive control of inflammation before the surgery
What three things make cataract surgery more difficult with uveitis?
Posterior synechiae
Uveitic membranes
Poor pupil dilation
Is macular oedema common or rare in uveitis? What is the management (3)?
Common
-steroids (beware cataract and glaucoma)
-NSAIDs - limited probability on their own
-carbonic anhydrase inhibitors
