DIS - Posterior Uveitis II - Week 4 Flashcards
What is cytomegalovirus also known as?
Human herpesvirus type 5
Is cytomegalovirus widespread among adults, children, or rare in humans? Explain why.
Affects most of the adult population
Post infection, it remains latent in the host
-possible reactivation
What percentage of adults are seropositive to cytomegalovirus? What about people with HIV?
Normal - 50%
HIV - 95-100%
What kind of syptoms are associated with systemic cytomegalovirus (2)?
Mononucleosis-like symptoms or none
-asymptomatic
Is cytomegalovirus retinitis common or rare? In wha four populations is it particularly more common?
Uncommon/rare in normals
Prospers with immunodeficiency:
-HIV
-elderly
-leukaemia
-immunosuppression via steroid, chemotherapy, etc
When did cytomegalovirus come into prominence?
With the rise of HIV/AIDS
When does cytomegalovirus retinitis tend to occur relative to HIV? What is the prognosis like from the first sign of infection (for life, not visual prognosis)?
Relatively late occurence
Short average time to death from the first sign of CMV infection
What cells does HIV target?
CD4+
What is the most common intraocular infection in HIV/AIDS?
CMV retinitis
What type of vision loss does untreated cytomegalovirus retinitis result in and when?
Progressive visual loss creeping
-when CD4+ count drops to 50-100 cells/uL
What eventually results from cytomegalovirus retinitis (2)?
Eventual blindness from full thickness retinal necrosis and retinal detachment
In what percentage of patients is cytomegalovirus retinitis bilateral? In what percentage is the macula involved?
Bilateral in 10-20%
Macular involvement in 50%
Describe what full thickness retinitis/retinal necrosis appears like (including colour). What is it often adjacent to? What else would you expect to see and what can its appearance be likened to?
Multiple yellow/white geographic lesions
Often adjacent to vessels
Vascilitis often present
Looks like ketchup on cottage cheese
Is vitritis seen with cytomegalovirus retinitis? Explain.
Yes, mild vitritis
What is the management for cytomegalovirus retinitis?
IV Gancyclovir
List three other general AIDS-related retinal disorders, aside from CMV.
HIV retinopathy
Candidiasis
Other causes of posterior uveitis
-syphilis, TB, candida, pneumocystitis, etc
List four other viral AIDS-related retinal disorders.
Acute retinal necrosis
-necrotising retinitis
HSV1 (younger)
HSV2 and VSV (older)
Progressive outer retinal necrosis
What is the interaction between progressive outer retinal necrosis and VZV?
Aggressive reaction
What is kaposi’s sarcoma aused by and in what condition is it usually seen?
Human herpes virus type 8
How is syphilis generally transmitted?
Sexually transmitted infection (STI/STD)
What causes syphilis? What shape is it?
Trepenoma pallidum
-spirochaete
Briefly describe primary (1), secondary (1), and tertiary (3) syphilis.
Primary - initial STD
Secondary - rash and systemic symptoms
Tertiary
-neurosyphilis
-cardiovascular
-gummatous (granulomas)
Can syphilis be contracted from blood transfusion or open skin lesions?
Yes, occasionally
What effect has improved HIV survivability had on syphilis prevalence?
Increased prevalence of syphilis
What kind of keratitis occurs with congenital syphilis?
Interstitial keratitis
What kind of uveitis can occur with syphilis and at what stage?
Anterior or posterior, at any stage
Is anterior uveitis from syphilis often granulomatous or non-granulomatous?
Often non-granulomatous
List the four types of postrior uveitis that may be seen with syphilis.
Chorioretinitis
-disseminated
-posterior placoid
Retinitis
Retinal vasculitis
Describe the appearance of disseminated chorioretinitis. What classic appearance does it have when congenital? Is vitritis present?
Multiple yellow/grey lesions
-vitritis often present
Classic salt/pepper appearance when congenital
Describe the appearance of posterior placoid chorioretinitis. Where is it generally found? Is vitritis present?
Around the disc
-yellow/grey lesions with pale centres
-vitritis often present
Describe retinal vasculitis and what it often resembles.
Isolated retinal vessel inflammation
-mild leakage to extreme
-often resembles BVO
What is responsible for tuberculosis?
Mycobacterium tuberculosis
In what patients and countries is ocular TB often seen?
HIV patients
Endemic countries
What is a typical feature of posterior segment TB? List 5 additional things you may see.
Choroidal granuloma
-granulomatous
Also:
Vasculitis
Keratitis
Scleritis
Anterior uveitis
Retinitis
What can hypersensitivity to TB organisms result in (2)?
Occlusion of vessels, leading to ischaemia
What is sympathetic ophthalmia and what does it generally follow? What can occur in the fellow eye and why?
Bilateral granulomatous uveitis
Follows penetrating trauma
Trauma to the first eye also excites inflammation in the fellow eye
After what surgery is sympathetic ophthalmia most common? Comment in rarity after cataract surgery, malignant melanoma, and cyclo-cryotherapy.
Vitrectomy - most common antecedent event
Rarely occurs in the others
Are rates of sympathetic ophthalmia increasing or decreasing?
Increasing
What is the typical onset for sympathetic ophthalmia post-exciting and what is the range?
Typically 3 months
-days to decades
List 3 anterior features of sympathetic ophthalmia.
Mild anterior uveitis
-granulomatous
Mutton fat keratic precipitates
List 4 posterior features of sympathetic ophthalmia.
Vitritis
-moderate to severe
Posterior uveitis
-multiple peripheral yellow/white lesions
papillitis
Circumpapillary choroidal lesions
What is the treatment for sympathetic ophthalmia (2)?
Systemic steroids
-high dose, tapered over 3/12
Immunosuppression
-cyclosporin
Define white dot syndrome.
Distinct inflammatory disorders of uncertain aetiology
Describe the lesions in white dot syndrome, including colour, size, and position.
Some are yellow rather than white
Often larger than dots
More superficial dots tend to be white and probably represent retinitis
List 5 examples of diseases that can be considered white dot syndrome.
Acute multifocal posterior pigment placoid epitheliopathy
-AMPPPE
Multiple evansecent white dot syndrome
-MEWDS
Birdshot retino-choroidopathy
Acute retinal pigment epitheliitis
Punctate inner choroidopathy
What will you often see with acute multifocal posterior pigment placoid epitheliopathy and what is it thought to be secondary to?
Choroidal vasculitis secondary to RPE dysfunction
What may you see in acute multifocal posterior pigment placoid epitheliopathy with recent viral illness?
Hypersensitivity-induced occlusive vasculitis of choroidal lobules
What appearance do lesions have in acute multifocal posterior pigment placoid epitheliopathy? Include colour, position, and layer.
Multiple large plaque-like lesions
-cream-coloured
-initially at the posterior pole
-RPE level
What kind of vision loss (VA and VF) is present with acute multifocal posterior pigment placoid epitheliopathy? What will patients often initially experience?
VA - 6/12 to 6/120
Central/paracentral scotoma
Sudden onset of blurred vision or photopsia
-possible flashing lights up to a few weeks before
What age does acute multifocal posterior pigment placoid epitheliopathy tend to occur?
<30
What event does acute multifocal posterior pigment placoid epitheliopathy tend to follow?
Viral illness
Is acute multifocal posterior pigment placoid epitheliopathy usually uni- or bilateral?
Bilateral
True or false
Anterior uveitis and vitritis may be seen with acute multifocal posterior pigment placoid epitheliopathy
True
Describe the typical angiography pattern for acute multifocal posterior pigment placoid epitheliopathy (2).
Initial dark hypo-fluorescence
late slow hyperfluorescence
What eventually happens with acute multifocal posterior pigment placoid epitheliopathy?
Slow spontaneous recovery
What age and gender does multiple evanescent white dot syndrome tend to occur?
Young women
Is multiple evanescent white dot syndrome usually uni- or bilateral?
Unilateral
Describe the lesions in multiple evanescent white dot syndrome including size, colour, layer, and position (2). Are cells present in the vitreous?
multiple small discrete white lesions in deep layers (RPE)
Found at the posterior pole
-perifoveal but not foveal
Cells in the vitreous
Describe what vision loss is opften like with multiple evanescent white dot syndrome. Is RAPD present?
Sudden drop in VA (up to 6/60)
Possible RAPD
Is multiple evanescent white dot syndrome self-limiting or does it require urgent treatment?
Self-limiting ~2 months
What is the visual outcome following multiple evanescent white dot syndrome expected to be?
6/6 to 6/12
Describe the appearance of birdshot retinochoroidopathy.
Scattered lesions like shotgun scatter
Is birdshot retinochoroidopathy typically uni- or bilateral? Is it inflammatory? Is it chronic or acute?
Bilateral chronic inflammatory disease
Is birdshot retinochoroidopathy common or uncommon?
Uncommon
What age does birdshot retinochoroidopathy typically occur? What race and gender?
6th to 7th decade
-white
-female
List four symptoms of birdshot retinochoroidopathy. Is pain often present?
Blurred vision
Dsturbed colour vision
Night vision difficulty
Floaters
No pain
Is vitritis present with birdshot retinochoroidopathy?
Yes (diffuse)
True or false
Snowbanking is present with birdshot retinochoroidopathy.
False
What is VA like with birdshot retinochoroidopathy?
6/12 to 6/18
Describe the lesions seen in birdshot retinochoroidopathy including shape, colour, size, and position (2).
Round ovoid subretinal lesions
Cream coloured
Small
Numerous
-macula and midperiphery
-mostly macula
Would you see vasculitis with birdshot retinochoroidopathy?
Yes, significant
What would you expect to see on fluorescein angiography with birdshot retinochoroidopathy?
Hyperfluorescence/leakage
What percentage of patients will recover from birdshot retinochoroidopathy? What about the rest (and why this outcome for them)?
20% will recover
The rest have exacerbations or poor VA due to CMO or atrophic scars
What is the treatment for birdshot retinochoroidopathy (2)?
Steroids/cyclosporins
What visual changes occur with acute retinal pigment epitheliitis (2)?
Acute VA drop and/or metamorphopsia
What age does acute retinal pigment epitheliitis tend to occur?
Young
What do you expect to see with acute retinal pigment epitheliitis (2)?
Subtle RPE changes
-deep grey/dark spots with a yellow halo clustered around the posterior pole
Central serous retinopathy
True or false
EOG is normal with acute retinal pigment epitheliitis
What does this indicate?
False, it is abnormal
-indicates widespread RPE upset
What kind of aetiology is acute retinal pigment epitheliitis thought to have?
Viral
What is puncate inner choroidopathy part of (2)? What is the diagnosis for this condition?
Part of multifocal choroiditis and panuveitis
Dx ocular histoplasmosis
In what age, gender, and ametropic status does puncate inner choroidopathy tend to occur?
Young myopic females
What is vision (VA and VF) often like with puncate inner choroidopathy?
Blurred vision
Light flashes
Paracentral scotoma
Is intraocular inflammation present with puncate inner choroidopathy?
No
Describe the lesions of puncate inner choroidopathy, including deepness, elevation, colour, number, and position.
Multiple, deep, yellow punched out appearance
Do lesions of puncate inner choroidopathy resolve?
Yes, after a few weeks
-atrophic/pigmented
What risk do lesions of puncate inner choroidopathy present?
CNV
What is the prognosis of puncate inner choroidopathy like?
Good, if the macula is unaffected
Describe serpiginous choroidopathy, mentioning whether it is uni- or bilateral, acute or progressive.
Idiopathic bilateral progressive inflammation
What is the onset of serpiginous choroidopathy?
4th to 6th decade
What is vision like with serpiginous choroidopathy (2)?
Blurred vision ± metamorphopsia
What are lesions like with serpiginous choroidopathy? Include colour, borders, shape, and where they spread to.
Yellow-white subretinal infiltrates
Spreads outwards to the macula
Is vitritis and anterior uveitis present with serpiginous choroidopathy?
Yes
Do remisison/reactivation cycles occur with serpiginous choroidopathy?
Yes
What is the treatment of serpiginous choroidopathy (3)?
Steroids
Cyclosporin
Azathyoprine
What is ophthalmomyiasis caused by? Is it common or rare?
Intraocular larval infestation
-rodent fly
-rare
Is ophthalmomyiasis anterior or posterior?
Can be either
How does ophthalmomyiasis appear on funduscopy?
Tracks in the sub-retinal space
-can still be moving
What is the treatment option for ophthalmomyasis if the causative agent is alive (1) or dead (1)?
Alive - laser PC
Dead - removal via vitrectomy
List four causes of visual loss with active inflammation in posterior uveitis.
Vitritis
CMO
Disc oedema
Obliterative retinal vasculitis
List five causes of visual loss with non-inflammatory causes in posterior uveitis.
Cataract
Vitreous debris
Chronic macular problem
Glaucoma
Optic atrophy
List 5 examples of chronic macular problems that can lead to visual loss in posterior uveitis with non-inflammatory causes.
Persistent/chronic CMO
RPE disturbance
ERM
SRNVM
Macular hole (full/partial)
What is usually the treatment for posterior uveitis (5)? What about systemic treatment (5)?
Systemic/oral steroids unless
-condition is selflimiting or minimally sight threatening
-steroids aggravating condition/contraindicated
-specific drug used
-causative agent/organism is known
Systemic
-treat autoimmune aspect of uveitis
-antimetabolites
-cyclophosphamides
-cyclosporin
-tacrolimin
What three conditions would you consider if you see multiple white lesions on funduscopy with no inflammation?
POHS
PIC
Dystrophies
What three conditions would you consider if you see multiple white lesions on funduscopy with minimal inflammation?
AMPPPE
MEWS
RPE epitheliitis
What eight conditions would you consider if you see multiple white lesions on funduscopy with lots of inflammation?
Multifocal choroiditis including
-sympathetic ophthalmia
-birdshot
-sarcoid
-behcets
-VKH
-infections
-post-op/trauma
