Uvea: Uveitis Flashcards
1
Q
What is uveitis?
A
- Broad range of disorders
- Any inflammation of any part of uveal tract
- Wide range of causes and associations
2
Q
What is the classification of location of uveitis?
A
o Anterior – iris
o Intermediate – ciliary body
o Posterior – choroid
o Panuveitis – all layers
3
Q
What is the classification of cause of uveitis?
A
o Infectious – bacterial, viral, parasitic, fungal
o Non-infectious – inflammatory (most cases)
o Masquerade – neoplastic or non-neoplastic (uveitis is not predominant problem it could be a lymphoma for e.g.)
4
Q
What is the classification of onset of uveitis?
A
o Acute
o Recurrent – quiet periods in between episodes
o Chronic – quiet period lasts <3 months
o Persistent – episode lasts >3 months
5
Q
What is the anterior chamber grading for flare?
A
- Standardisation of Uveitis Nomenclature group (SUN)
- Not looking at cells but looking at general look of anterior chamber
GRADE DESCRIPTION
0 None
1+ Faint
2+ Moderate – iris & lens detail clear
3+ Marked – iris & lens details hazy
4+ Intense – fibrin or plastic aqueous
6
Q
What is the vitreous grading of haze in uveitis?
A
HAZE SEVERITY GRADING
Good view of nerve fibre layer (NFL) 0
Clear disc & vessels but hazy NFL +1
Disc & vessels hazy +2
Only disc visible +3
Disc not visible +4
Things like cataract can affect this, AC changes can also impact this
7
Q
What are the symptoms of uveitis?
A
- Red eye
- Pain
- Photophobia
- Watering
- Blurred vision
- Onset is usually rapid – within days but can be insidious
- None – particularly in children with Juvenile Idiopathic Uveitis
- Systemic symptoms – enquire about these
8
Q
What are the signs of uveitis?
A
- Ciliary/ limbal injection – red eye – injection at the limbus
- Keratic precipitates – inflammatory aggregates that sit on the corneal endothelium
- AC Cells
- AC Flare
- Posterior synechiae – pupil margin gets stuck to lens
- Iris atrophy – so much inflammation that some pigmented tissue of iris is lost – can see red reflex through iris
- Cataract – can be due to inflammation itself or to prolonged steroid use
- High or low IOP
9
Q
Describe anterior uveitis & its management?
A
- Commonest form of uveitis is acute anterior uveitis (AAU)
- 50% idiopathic
- Infectious – viral (commonest), TB, syphilis, Lyme disease
- Non-infectious – usually idiopathic – associated with systemic conditions
- Masquerade – neoplastic or non-neoplastic – things like lymphomas
- Management:
o Single episode AAU does not require investigation
o Recurrent AAU, bilateral severe AAU or chronic anterior uveitis (CAU) need investigation – investigation is to exclude infectious causes or any systemic causes & to look for any other things that may be causing the uveitis
o Uveitis screen:
Blood tests – looking for inflammatory markers & indicators of other conditions
Urine sample – a form of uveitis can be associated with kidney disease
Chest x-ray
o May consider “AC tap” – if uveitis v severe and concerned it is not settling down
Fine needle is inserted into limbus & small sample of aqueous taken and investigated – tested for viral/bacterial causes & cancerous causes
10
Q
What are the systemic associations of acute anterior uveitis?
A
- Spondyloarthropathies – e.g. ankylosing spondylitis – associated with HLA-B27 – HLA is Human Leukocyte Antigen (cell surface proteins on human cells that are responsible for regulation of immune system) – variations/abnormalities of HLA types can affect regulation of immune system & can cause autoimmune conditions
- Sero-negative arthropathies – don’t have HLA +ve disease but can still have inflammatory autoimmune conditions
- Inflammatory bowel disease
- Sarcoidosis – largely respiratory condition but can also affect eyes and skin
- Behcet’s disease – affects skin, causes mouth ulcers, autoimmune condition
- Tubulointerstitial nephritis and uveitis (TINU) – uveitis w/ kidney disease
- Multiple sclerosis – typically causes optic neuritis but can also cause anterior uveitis or intermediate uveitis
- Systemic lupus erythematosus (SLE) – autoimmune condition that can be associated with uveitis
- Juvenile idiopathic arthritis
11
Q
What is the treatment for acute anterior uveitis?
A
- Topical:
o Predforte (steroid)
o Maxidex (steroid)
o Cyclopentolate (cycloplegia – given as symptomatic relief)
Paralyses ciliary body and dilates pupil (breaks posterior synechiae – best to do this at the onset of the condition – important as once pupil margin is stuck down to lens it affects the aqueous flow)
o Atropine (cycloplegia – given as symptomatic relief)
Paralyses ciliary body – Limits ciliary spasm helping reduce symptoms of photophobia & pain - Periocular:
o Subconj dexamethasone (steroid)
o Subconj betnosal (steroid)
o Subconj mydricaine (combo of anaesthetic agent and cyclopentolate) - Intraocular:
o Ozurdex implant (dexamethasone) – used if no systemic associations or if condition affecting 1 eye only - Systemic:
o Oral steroids –> Oral second line immunosuppression (after trying the oral steroids 1st)
12
Q
Describe Fuchs Hetereocromic Cyclitis (FHC)?
A
- Chronic non-granulomatous uveitis
- Often asymptomatic – low grade grumbling uveitis
- 90% unilateral
- Usually present with reduced vision – due to cataract – not likely to be symptoms of pain due to the low grade inflammation
- Signs:
o Iris heterochromia – lighter eye is affected eye
o Stellate KPs – only condition where KPs on corneal endothelium are affecting entire cornea
o Mild flare, occasional cells (0.5+)
o Iris atrophy
o Iris nodules
o Cataract
o Raised IOP - Treatment:
o Observation – if low grade inflammation
o Topical steroids for exacerbations – e.g. pain and other uveitis symptoms
o Topical treatment for glaucoma – may need laser/surgery if topical tx not effective
Glaucoma caused due to the inflammation being so insidious that it can affect the trab meshwork causing the glaucoma
o Cataract surgery – higher risk of complications due to anatomy/inflammation in these pxs
13
Q
Describe juvenile idiopathic arthritis (JIA)?
A
- Commonest condition associated with childhood uveitis
- Asymptomatic therefore diagnosed with arthritis are screened
- Uveitis may be presenting feature of the disease
- ALL CHILDREN (<12 YRS OLD) W/ UVEITIS SHOULD BE REFERRED TO EYE CLINIC
- Signs:
o Band keratopathy
o Uveitis
o Posterior Synechiae (PS)
o Cataract
o Glaucoma - Treatment:
o Topical treatments for anterior uveitis – often insufficient
o Joint treatment with paediatricians & rheumatology
o Require immunosuppression – e.g. methotrexate
o Oral steroids not used in children as can slow down growth & cause other problems so often go straight to 2nd line immunosuppression
14
Q
Describe intermediate uveitis (IU)?
A
- Involves ciliary body
- Primary site of inflammation is vitreous
- 50% are idiopathic
- Systemic associations:
o Sarcoidosis
o Multiple Sclerosis
o Behcet’s
o Infectious causes - ALL PATIENTS WITH SIGNS OF INTERMEDIATE UVEITIS MUST BE REFERRED URGENTLY TO EYE CASUALTY CLINIC – need treated to reduce risk of sight loss
- Symptoms:
o Blurred vision
o Floaters
o Pain/redness – can be variable
o Photophobia – can be variable - Signs:
o May have AC cells
o High or low IOP
o Vitreous Cells and vitreous haze
o Cataract
o Snowballs – cells in vitreous clump together and get yellowish deposits that form in inferior vitreous
o Snowbanking – large collections of inflammation – usually associated with pars planitis
o Cystoid Macular Oedema - Investigation:
o Uveitis screen (as for AAU)
o Fluorescein angiography
o AC or vitreous tap – if px has poor response to tx or if have worrying signs of infection then can perform this – use tiny needle, inject into AC or vitreous and sent away for testing
15
Q
Describe the treatment & viral causes of intermediate uveitis?
A
- Treatment:
o Topical:
Predforte
Maxidex
Cyclopentolate
Atropine
o Antibiotic/antiviral/antifungal
o Intra-ocular steroid:
Ozurdex implant
o Systemic Steroid – tend to be used almost all time in intermediate uveitis
o 2nd line immunosuppression
o 3rd line immunosuppression - Viral Causes:
o Herpes Simplex Virus (HSV) – causes dendritic ulcers
o Varicella Zoster Virus (VZV) – causes chicken pox & shingles
o Cytomegalovirus (CMV) – more common in immunosuppressed pxs
o Epstein Barr Virus (EBV) – more common in immunosuppressed pxs
o More common in immunosuppressed patients
o When see these pxs ALWAYS dilate them to make sure no signs of vitritis or any posterial or fundal diseases
