Panuveitis Flashcards
Vogt–Koyanagi disease
skin changes and anterior uveitis
Harada disease
neurological features and exudative retinal detachments
VOGT–KOYANAGI–HARADA - phases
Prodromal (CNS, auditory), Acute uveitic (Bilateral granulomatous anterior and multifocal posterior uveitis), Convalescent (skin, depigmented fundus)
sunset glow
depigmented fundus in Convalescent phase VKH. Also residual chorioretinal scarring in Sympathetic ophthalmitis
Diagnostic criteria for VKH
- Absence of a history of penetrating ocular trauma 2. Absence of other ocular disease entities 3. Bilateral uveitis 4. Neurological and auditory manifestations 5. Integumentary findings, not preceding
CSF in VKH
transient lymphocytic pleocytosis and melanin-containing macrophages
secondary Frosted branch angiitis
cytomegalovirus retinitis, lymphoma, leukaemia
primary Frosted branch angiitis
idiopathic, children and young adults. bilateral
Multifocal choroiditis and panuveitis
bi, asymmetrical, chronic/recurrent, young and middle females, anterior 50%, vitritis, Multiple discrete, ovoid, yellowish-grey. CNV 25-35%, CMO. VF large defects
Punctate inner choroidopathy
myopic women, bi sequentially, small yellow–white macular spots, CNV 40%, serous RD
Lyme disease
- Uveitis is relatively uncommon but can be anterior (granulomatous or non-granulomatous), intermediate (the most common), or posterior including multifocal choroiditis, vasculitis and neuroretinitis.
- Other manifestations include early (stage 1) transient conjunctivitis, bilateral stromal keratitis, episcleritis, scleritis, orbital myositis, optic neuritis, papilloedema and ocular motor and facial nerve palsy (up to 25% of facial nerve palsy in endemic areas).
Acquired syphilis
• Anterior may be granulomatous or non-granulomatous and is bilateral in 50%. Roseolae are dilated iris capillaries • Chorioretinitis is often multifocal, bilateral and associated with vitritis • Acute syphilitic posterior placoid chorioretinopathy • Retinitis • Optic neuritis and neuroretinitis
Tuberculosis
• Anterior uveitis granulomatous; iris nodules may be present. • Vitritis • Choroidal granuloma • Choroiditis typically multifocal and in a centrifugally spreading serpiginous • Retinal vasculitis is preferentially venous
fluffy ‘cotton ball’ or ‘string of pearls’ colonies
Endogenous Candida endophthalmitis
Sympathetic ophthalmitis - what time
between 2 weeks and 3 months after initial injury in 65%.
Dalen–Fuchs nodules
granulomas located between Bruch membrane and the RPE
Sympathetic ophthalmitis - how often relapse
50%
Sympathetic ophthalmitis - FA
multiple foci of leakage at the level of the RPE, with subretinal pooling in the presence of exudative retinal detachment
Sympathetic ophthalmitis - ICGA
hypofluorescent spots in active disease, which resolve with treatment
LENS-INDUCED UVEITIS - other names
phacogenic (previously phacoanaphylactic)
LENS-INDUCED UVEITIS - features
• Anterior uveitis is granulomatous • Corneal oedema is common adjacent to an anterior chamber lens fragment • IOP is frequently elevated. • Vitritis of variable severity is usually present if lens fragments lie within the vitreous cavity
Sarcoidosis - most common presentation
granulomatous anterior uveitis
Sarcoidosis - ocular inflammation features
- ‘Mutton fat’ KPs and/or small granulomatous KPs and/or iris nodules 2. Trabecular meshwork (TM) nodules and/or tent-shaped PAS 3. Vitreous opacities: snowballs and/or ‘strings (sznury) of pearls’. 4. Multiple chorioretinal peripheral lesions - uncommon 5. Nodular and/or segmental periphlebitis (± ‘candle wax drippings’ - Perivenous exudates) and/or retinal macroaneurysm 6. Optic disc nodule(s)/granuloma(s) and/or solitary choroidal nodule. 7. Bilaterality. 8. conjunctival nodules, lacrimal gland infiltration, dry eye, eyelid skin nodules, orbital and scleral lesions
Sarcoidosis - 5 significant investigations
- Negative tuberculin skin test in a BCG-vaccinated patient or in a patient having had a positive tuberculin skin test previously. 2. Elevated serum ACE levels and/or elevated serum lysozyme 3. Chest X-ray showing bilateral hilar lymphadenopathy (chest abnormal in 90%), 4. Abnormal liver enzyme tests. 5. Chest CT scan in patients with a negative chest X-ray result
Definite ocular sarcoidosis
biopsy-supported diagnosis in the presence of a compatible uveitis
Presumed ocular sarcoidosis
biopsy not done but chest X-ray shows BHL (bilateral hilar lymphadenopathy) with a compatible uveitis
Probable ocular sarcoidosis
biopsy not done, no BHL on chest X-ray but >3/7 of the intraocular signs above and >2/5 positive laboratory tests
Possible ocular sarcoidosis
lung biopsy negative but >4/7 signs and >2/5 positive laboratory tests
BEHÇET DISEASE - age
third decade
BEHÇET DISEASE - which vessels
Vasculitis (small, medium and large veins and arteries)
BEHÇET DISEASE - criteria
recurrent oral ulceration (at least three times in a 12-month period plus at least two of genital ulceration), ocular inflammation, characteristic skin lesions (erythema nodosum, pseudofolliculitis, acneiform nodules, papulopustular lesions) and a pathergy reaction: pustule 24–48 hours after a sterile needle prick (>95% specific). Other: aneurysms, arthritis
BEHÇET DISEASE - uveitis features
AAU, often bilateral, is typical. It is not granulomatous. A transient mobile hypopyon in a relatively white eye • Vitritis • Retinitis. Transient superficial white infiltrates that heal without scarring may be seen
Toxoplasmosis - definitive host
cat
Toxoplasmosis - intermediate hosts
mice, livestock, birds and humans
Toxoplasmosis - the average age of presentation
29 years
Toxoplasmosis - pregnancy
may provoke the recurrence
Toxoplasmosis - uveitis features
• ‘Spill-over’ (rozprzestrzeniający się) anterior uveitis (granulomatous or resemble Fuchs) • A single inflammatory focus - Lesions tend to involve the posterior pole • Vitritis - ‘Headlight in the fog’ • Vasculitis may be arterial, but is more commonly venous • Optic disc oedema is common • Neuroretinitis - acutely acquired rather than reactivated infection
average number of recurrent attacks of Toxoplasmosis
2.7
Toxoplasmosis - Serology
Toxoplasma IgG antibodies are detectable in the serum within 1–2 weeks of initial infection. Positivity to IgM antibodies usually means that infection has been acquired within the last year
Goldmann–Witmer coefficient
Ocular fluid antibody assessment. Calculating the ratio (Goldmann–Witmer coefficient) of specific IgG in aqueous humour to that in serum
Toxoplasmosis - treatment
Prednisolone (1 mg/kg) is given initially and tapered according to clinical response, but should always be used in conjunction with a specific anti-Toxoplasma agent, most frequently pyrimethamine combined with sulfadiazine (‘classic’ or ‘triple’ therapy, sometimes supplemented with clindamycin). Some authorities start steroids only after 24–48 hours of antimicrobial therapy.
Toxocariasis - how infestation
ingestion of soil or food contaminated with ova shed in canine faeces
Toxocariasis - forms
○ Chronic endophthalmitis (include anterior uveitis, vitritis, chorioretinitis, papillitis and a fundus granuloma) ○ Posterior pole or peripheral granuloma without inflammation - older child or adult
Onchocerciasis - forms
• Anterior uveitis • Keratitis • Chorioretinitis • Optic neuritis
VKH - what ethnic groups
Asian-Indians, Hispanics, Native Americans, Middle Easterners
Chronic recurrent stage of VKH
granulomatous anterior uveitis, KPs, iris nodules, posterior synechiae, iris atrophy
Owl’s eye
inclusion bodies in CMV
Langerhans giant cell
mostly tuberculosis, may also sarcoidosis
IBD
sclerouveuitis HLA B-B27 (-). B27(+) sacroilitis. intermediate uveitis B27(-)
Measles (rubeola) - basic
3 C’s: cough, coryza, conjunctivitis
Measles (rubeola) - ophthalmic
conjunctivitis, retinopathy (edema, macular star, optic disc swelling, narrowed arterioles, intraretinal hemor). When subsides: bone spicules, salt-and-pepper
Which organisms are associated with the best prognosis in endophthalmitis
coagulase-negative staphylococci
Which organisms are associated with the worst prognosis in endophthalmitis
Enterococci
Primary intraocular lymphoma - diagnosis
IL10:IL6 >1,0 . Myeloid Differentiation Primary Gene 88 (MYD88) mutation. kappa:lambda light-chain ratio of >3 or <0.6 - marker of monoclonality
Can present with hypopyon
Behcet, HLA-B27, Rifabutin, lymphoma, TASS
candle-wax drippings
peri-venous exudates in sarcoidosis
best screening test for sarcoidosis
Chest X-Ray
IBD
sclerouveuitis HLA B-B27 (-). B27(+) sacroilitis. intermediate uveitis B27(-)
