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BCSCSAP Review > Intraocular Inflammation and Uveitis > Flashcards

Intraocular Inflammation and Uveitis Flashcards

1
Q

Test that is indicator of active infection in syphilis

A

serum rapid plasma reagin (RPR)

does not confirm that patient has syphilis

Confirmatory: fluorescent treponemal antibody absorption (FTA-ABS) assay and microhemagglutination assay for T pallidum antibodies (MHA-TP) (treponemal antigent tests that do not correlate with disease activity, may be positive for a lifetime)

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2
Q

What topical corticosteroid medication is most likely to cause a corticosteroid-response elevation in IOP?

A

prednisolone acetate 1%

greatest at reducing intraocular inflammation with greatest effect on IOP

(Fluorometholone is very potent but penetrates poorly into eye)

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3
Q

Equivalent of difluprednate 0.05% to PF1%

A

dosing 4 times daily is equivalent of 8 or more toal drops of PF1% but higher rise in IOP than PF1%

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4
Q

MOA of methotrexate (in reducing inflammation)

A

extracellular release of adenosine

folic acid analogue and inhibitor of dihydrofolate reductase inhibits DNA replication but its anti-inflammatory effects result from extracellular release of adenosine

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5
Q

Tx Lyme dz

A

doxycycline

alt: ceftriaxone, amoxicillin, cefuroxime

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6
Q

unilateral stellate KP, cataracts, increased risk for glaucoma

A

Fuchs heterochromic uveitis

(AKA: fuchs heterchromic iridocyclitis or Fuchs uveitis syndrome)

other s/s: elevated IOP, diffuse iris atrophy, TID, 5% bilateral, rubella

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7
Q

Another name for chronic anterior uveitis

A

iridocyclitis

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8
Q

2-3% of patients referred to uveitis clinics have this dz

A

Fuchs heterochromic uveitis

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9
Q

Signs of Fuchs heterochromic uveitis

A

diffuse iris stromal atrophy with variable pigment epithelial layer atrophy

small, white, stellate KPs scattered diffusely over entire endothelium

cells in AC and anterior vitreous

glaucoma + cataracts (PSC)

RARE/ABSENT: macular edema, synechiae, fundus scars, retinal periphlebitis

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10
Q

chronic indolent intraocular inflammatin s/p cataract, think..

A

propionibacterium acnes

Candida parapsilosis

others implicated: aspergillus flavus, torulopsis candida, paecilomyces lilacinus, verticillum

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11
Q

Uveitis associated CME that fails topical corticosteroids. Next steps?

A

20-40 mg triamcinolone sub-Tenon (superotemporal posterior) q monthly

delivers juxtascleral corticosteroid closest to macula

if still fails…

2-4 mg of intravitreal preservative-free triamcinolone

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12
Q

uveitis tx CI in uveitis a/w MS

A

tumor necrosis factor-alpha inhibitors

etanercept and infliximab - aw exacerbations of CNS demyelination

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13
Q

% of patients with MS that have uveitis and pars planitis

A

30% uveitis in patients with MS

15% pars planitis in patients with MS

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14
Q

Preferred tx for MS-associated

A

IV and intravitreal corticosteroids

topical cycloplegics

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15
Q

ocular inflammatory disorder aw activation of mast cells via IgE antibodies

A

vernal conjunctivitis

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16
Q

how long does 0.59-mg fluocinolone acetonide implant release therapeutic levels of corticosteroids to the vitreous cavity?

A

30 months

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17
Q

Positive RPR, next step?

A

serum FTA-ABS (since RPR may be falsely positive) if positive

Lumbar puncture with

CSF VDRL (diagnostic) and

CSF FTA-ABS

Antibiotic therapy - series of PCN IV or IM dosing

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18
Q

Percentage of blindness in the US attributed to inadequately treated uveitis

A

10%

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19
Q

Clinical triad to diagnose ocular histoplasmosis syndrome

A

peripapillary atrophy (pigment changes)

multiple white, atrophic punched-out chorioretinal scars (histo spots)

choroidal neovascular membrane causing maculopathy

NO vitreous cells

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20
Q

If histo spots are seen in the macula, what is % chance of macular CNV developing in 3 years

if no spots are observed

A

25%

2% (no spots)

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21
Q

What would active CNV look like in ocular histoplasmosis syndrome (OHS)

A

yellow-green subretinal membrane typically surrounded by a pigment ring

overlying neurosensory detachment

subretinal hemorrhage

frequently border of histo scar in disc-macula area

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22
Q

Useful clinical feature suggests Vogt-Koyanagi-Harada syndrome?

A

Alopecia

Poliosis

(is the decrease or absence of melanin (or colour) in head hair, eyebrows, eyelashes or any other hairy area)

Vitiligo (loss of pigment in skin)

3 seen in 30%

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23
Q

Usefulness (positive predictive value) of ANA screen in uveitis

A

prevelance of lupus is less than 0.47% in patients with uveitis so the PPV of ANA for diagnosis is less than 3%

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24
Q

weight loss, cough and findings in image. Test for granulomatosis with polyangiitis

A

c-ANCA antibody (anti-proteinase 3 antibody)

most specific

(picture: anterior scleritis)

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25
How to differentiate progressive outer retinal necrosis from acute retinal necrosis
**Host immunosuppression** ## Footnote ARN - intact immune function PORN - immunocompromised
26
HLA Aw33
increased RR of ARN in Japanese patients
27
virus aw conjunctival papillomas
human papillomavirus (HPV) 6 and 11
28
65 yo M with unilateral vision loss (photophbia, floaters, pain), **occlusive retinal arteriolitis**, **vitritis**, **multifocal yellow-white peripheral retinitis**. Best Tx?
**systemic ACYCLOVIR (IV 10mg/kg q8 hrs x 10-14 days)** after 24-48 hours antiviral **add prednisone** 1mg/kg/day then taper Dx: ARN Note: presentation above is classic triad seen within 2 weeks for ARN
29
Feared complication of ARN
75% of patients will develop a combined **tractional-rhegmatogenous retinal detachment**
30
immune response to mycobacterial infection
conversion of macrophages to giant cells that form caseating granulomas
31
Causative organisms in healthy 40 year old man
**herpes simplex and varicella-zoster virus** ARN AKA necrotizing herpetic retinitis
32
Diagnosis
ARN
33
Diagnosis
ARN
34
Diagnostic criteria for this disease
One or more **foci of retinal necrosis with discrete borders**, located in the peripheral retina Rapid **progression** in absence of antiviral therapy **Circumferential** spread **Occlusive vasculopathy**, affecting **arterioles** **Prominent vitritis** and/or anterior chamber inflammation
35
Diagnostic characteristic of this syndrome
**Usually unilateral** MEWDS
36
Goldmann-Witmer (GW) test needs these 2 tissues
**Aqueous and serum** GW = (xIgG in aqueous/total IgG in aqueous)/(xIgG in serum/total IgG in serum)
37
systemic complication of prolonged NSAID use in patient with non-necrotizing anterior scleritis
**myocardial infarction** others: HTN, stroke (COX-2), GI ulceration, GI bleeding, nephrotoxicity, hepatotoxicity
38
most likely cause of uveitis in HIV patient with CD4+ \<50/uL who responded to HAART
immune recovery uveitis
39
Condition can lead to elevated IOP due to blockage of angle by inflammatory cells and debris
***TOXOPLASMA* retinochoroiditis** others: ARN, CMV, sarcoid, Fuchs heterochromic iridocyclitis
40
Should always be ruled out as common causes of uveitis
TB, syphilis, sarcoid (CXR)
41
27 year old bilateral anterior and intermediate uveitis, vitreous cell, KP, vitreous cellular aggregates near vitreous base. Test provides most definitive evidence of this disease?
**histopathology of conjunctival nodule, lung secimen or other tissue involved demonstrating noncaseating granuloma** Other tests: spiral CT (higher sensitivity) CXR (plain PA and lateral) ACE (least specific, moderate sensitivty)
42
Frequency of ocular invovement in sarcoidosis? MC ocular involvement
50% uveitis
43
Posterior uveitis + marked visual symtoms + minimal findings on clinical exam
**Acute zonal occult outer retinopathy** | (AZOOR)
44
acute loss of one or more zones of outer retinal function (not apparent on exam) VA 20/40 Photopsia abnormal ERG Unilateral Young myopic women 50% vitritis
AZOOR
45
regional immunity
many organs and tissue sites possess modifications to the classic immune response
46
Many organs and tissue sits possess modifications to the classic immune response arc (afferent, processing, effector)
regional immunity
47
Patients with what ocular inflammatory disorder might benefit from pars plana vitrectomy
intermediate uveitis
48
resident macrophage of retina
microglial cells
49
Factor AW vision loss in patients with ocular sarcoidosis
delay of more than 1 year in presentation to a uveitis specialist (may need IMT!)
50
MC ocular manifestation a/w inflammatory bowel disease?
**anterior uveitis** (Scleritis LESS COMMON!) frequently carry HLA B27
51
26 to 50 cells/hpf
Grade 3+
52
Diagnosis. Active or recurrent?
**Serpiginous choroiditis** lesions involve the outer retina, RPE, choriocapillaris, and large choroidal vessels. Patients present with acute geographic or serpentine lesions that are gray or gray–yellow (due to disruption of the RPE or outer retina). Fundus photo showing recurrence of serpiginous choroiditis near the edge of a scar.
53
Only presenting feature. Diagnosis?
**Granular pigment changes in the fovea** Multiple Evancescent White Dot Syndrome (MEWDS) pathognomonic
54
Diagnosis Expected finding on FA?
**MEWDS** Fundus photo: * subtle numerous white spots at the level of the RPE/deep retina.* * There are also blurred disc margins.* * There is foveal granularity.* FA: subtle early and late hyperfluorescence of the white dots in a **wreath-like pattern**
55
Tx for uveitic CME
sub-Tenon triamcinolone
56
autoimmune regulator (AIRE) deficient mice develop spontaneous uveitis
auotoreactive T cells escape deletion
57
HLA-A29 with fundus and FA Diagnosis?
Birdshot chorioretinopathy multiple creamy, subretinal lesions radiating fom ON FA: CME
58
Diagnosis
left posterior pole showing a hazy view and the distribution of deep creamy oval lesions **Birdshot chorioretinopathy**
59
27 yo AA M with unilateral photophobia and reduced VA. Grade 3+ vitritis with peripheral retinal whitening. Possible PMHx?
**Previous viral meningitis** Younger patients with HSV-1 and HSV-2 retinitis have a higher RR of previous viral encephalitis or meningitis (Image: ARN)
60
MC cause of ARN
VZV \> HSV1, HSV-2 \>\>\> CMV
61
Histological finding in Vogt-Koyanagi-Harada (VKH) syndrome
**Dalen-Fuchs nodules** epithelioid hisiocytes and lymphocytes between Bruch membrane and RPE
62
Risk factor for ocular involvment of Candida?
**Hospitalization** ## Footnote candidemia in 10%-37% of patients (Note: Immunodeficiency is NOT a risk factor)
63
Risk factors for this disease
**Candida chorioretinitis or endophthalmitis** **Hospitalization** with h/o recent GI surgery bacterial sepsis systemic abx indwelling catheter hyperalimentation debilitating Dz eg, DM immunomodulatory therapy prolonged neutropenia organ transplantation NOT Immunodeficiency
64
RF a/w increased risk for corneal transplant rejection
stromal vascularization of the recipient cornea
65
Mechanism of type IV hypersensitivity
recognition of antigen by memory T cell results in activation and amplification of clones that react to specific antigent in skin produces clinical signs of inflammation in 24-36 hours
66
Mechanism of low IOP in inflamed eye
**ciliary body hyposecretion**
67
TNF alpha inhibitor used for nonocular inflammation that doesn't work for uveitis
**Etanercept** used in JIA and RA (less effective than inliximab and adalimumab for uveitis)
68
White dot syndrome that lesions on FA are LEAST aparent
**birdshot uveitis**
69
Diagnosis
Block early, stain late **APMPPE** Acute posterior multifocal placoid pigment epitheliopathy
70
Early hyperflourescence with late staining lesions
Punctate Inner Choroiditis (PIC)
71
FA blockage of choroidal flush in early stage and staining at active edge
serpignious choroiditis
72
antibodies to myeloperoxidase
MPO-ANCA or p-ANCA microscopic polyangiitis
73
mature cataract + AC cell + elevated IOP + intact lens capsule
Phacolytic gluaucoma clogging TM by macrophages engoged with lens protein
74
establishes the inner blood-ocular barrier
**tight junctions** between the **endothelial cells** of the retinal circulation
75
establishes outer blood-ocular barrier
**tight junctions** between cells of **RPE**
76
23 yo M with recurrent unilateral anterior uveitis, KP, IOP 32 and 1+ cell and flare with mixed white and pigmented clels in AC. Normal fundus exam. Diagnosis?
Herpes simplex virus keratouveitis stellate KP
77
KP type in sarcoid
mutton-fat bilateral
78
Asian + bilateral uveitis + hearing disturbance + poor vision + yellow-white subretinal scars
VKH
79
Coincide with ocular disease in VKH
auditory problems observed in 75% patients with VKH in prodromal phase central dysacusia 30% (tinnitus or high frequency early in course improves in 2-3 months)
80
What uveitis therapy has highest risk of causing secondary glaucoma severe enough to require pressure-lowering surgery
intravitreal fluocinolone 0.59 mg implant GL Tx required in 75% glaucoma surgery in 37%!
81
Group of JRA or JIA patients with greatest likelihood of developing uveitis
**_Positive ANA_** and Negative RF
82
Group of JRA with lowest likelihood of developing iritis
**(+) RF positive** (-) ANA Still disease
83
AW glaucomatocyclitis crisis (Posner-Schlossman syndrome)
CMV
84
Rhegmatogenous RD in patients with uveitis is characterized by what feature?
a relatively HIGH association with **PROLIFERATIVE VITREORETINOPATHY** **30% have PVR at presentation**
85
Incidence of RRD in patients with uveitis
3% Panuveitis and infectious uveitis MC A/w RRD 30% have PVR at presentation
86
Stage of LD-associated intermediate uveitis occur
Stage 2, disseminated disease less common stage 3
87
MC ocular manifestation of early stage 1 LD
follicular conjunctivitis
88
Medication used to treat severe uveitis that permanently cross-links DNA and highest rate of secondary malignancy
**cyclophosphamide** alkylating agent also hemorrhagic cystitis (hydrate)
89
MC systemic finding AW bechet disease
aphthous ulcers transient hypopyon in 25%
90
Mediator that plays a role in AC-associated immune deviation (ACAID)
**transforming growth factor beta (TGF-beta)**
91
MC infectious cause of unilateral granulomatous conjunctivits with lymphadenopathy
**Bartonella henselae** Parinaud oculoglandular syndrome or granulomatous conjunctivitis and ipsilateral lymphadenopathy Note: Adult chalmydial inclusion conjunctivitis is follicular not granulomatous
92
Largest number of cases of SO result from
PPV
93
JIA occurs MC oligoarticular-onset, girls with +ANA tx strategy?
early consideration of systemic IMT such as MTX
94
Tx Toxoplasma chorioretinitis
pyrimethamine, folinic acid, sulfadiazine
95
Onchocerciasis
"African River Blindness”is a filarial infection caused by the nematode Onchocerca volvulus
96
second leading cause of blindness due to infection in the world
**Onchocerciasis** blindness through corneal sclerosing keratitis, secondary glaucoma, cataracts, chorioretinitis, and optic atrophy.
97
Findings expected Tx
**Sclerosing keratitis from onchocerciasis** intraocular microfilariae (in AC) anterior uveitis SPK sclerosing keratitis scleritis chorioretinitis optic neuritis and atrophy cataract PAS glaucoma Tx: ivermectin, suramin, diethylcarbamazine (DEC)
98
Leading cause of corneal blindness
trachoma

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