uveitis Flashcards
what is uveitis ?
. inflammation of uveal tract
what is the anatomical classification of uveitis?
- anterior ( 75%)- classified into
. iritis
. iridocyclitis - intermediate
. posterior ciliary body ( pars plana), extreme periphery or retina and choroid are affected - posterior
. where retina and choroid are affected - panuveitis
. where all parts of the eye anterior, intermediate and posterior are affected
what is iritis ?
inflammation predominantly affects iris
what is iridocyclitis ( more common) ?
inflammation predominantly affects iris and anterior part of the ciliary body ( pars plicata )
what are the standards of classifying uveitis?
- onset: sudden or insidious
- duration : limited, if it is < 3months or persistent , i.e.> 3 months in duration
- recurrent: describes repeated episodes of uveitis separated by periods of inactivity without treatment of > 3 months in duration
- chronic : describes persistent uveitis characterised by prompt relapse in < 3 months after discontinuation of therapy
what is endogenous aetiology of uveitis ?
associated with internal diseases
1. majority of cases assumed to be autoimmune and may be associated with systemic disease ( e.g. inflammatory bowel disease )
- prior infection ( e.g. herpes simplex, herpes zoster )
- idiopathic ( not associated with an underlying systemic disease )
- specific uveitis entities with distinct characteristics
. fuchs heterochromic iridocyclitis
. posner-schlossman syndrome
. anterior segment ischaemia
what is exogenous aetiology ?
. external injury or infection that results in uveitis
how is anterior uveitis classified ?
. anterior uveitis is traditionally classified as ‘ non-granulomatous’ or ‘granulomatous ‘ based on the nature of the keratic precipitates ( KPs)
-most common duvets
what is non-granulomatous uveitis ?
. typically has an acute onset
. fine KP on slit lamp
. more likely to be idiopathic - not have a known cause
-can see spikes on endothelium in slit lamp
what is granulomatous uveitis ?
. typically presents as a chronic condition
. with large ‘mutton fat’ KP and iris nodules
. more likely to be associated with systemic conditions
what are the predisposing factors for Uveitis ?
. age over 20 years in 90% of cases ( mean age at onset = 40 years )
. major histocompatibility complex antigen HLA-B27 is positive in 8% of the general population, but in approximately 50% of all patients with this condition
. systemic disease as above: it is important to take a comprehensive medical history
what are the symptoms of anterior uveitis ?
- red eye
- unilateral ( usually in acute)
- may be bilateral or change eye if chronic - rapid onset if acute
- but more gradual at recurrent episodes - moderate-severe dull pain
- usually reported as ‘behind the eye’
- more severe if chronic - vision reduced
- px complains hazy vision
- more sever if chronic - photophobia
- milder if chronic - epiphora
what are the signs of anterior uveitis ?
What is the investigation to detect this?
- hyperaemia: ciliary flush
- keratic precipitates
- cells and aqueous flare
- iris nodules
sometimes
. miosis
. raised IOP- check pressure
. must check fundus in both eye to check if it actually just anterior uveitis or intermediate or posterior uveitis
-check IOP as they may be raised
what are the signs of keratic precipitates ( KPs) ?
. endothelial dusting
- acute anterior uveitis
. medium
- acute and chronic anterior uveitis
. large
‘mutton fat’
chronic anterior uveitis - big blobs on endothelium
. old KPs
. pigmented
. chronic anterior uveitis
. kruckenberg’s spindle
. melanin pigment forming a vertical line on the posterior central cornea- can be diff patterns depending on aqueous but usually aqueous
explain cells as a sign of anterior uveitis ?
cells represent
. active inflammation
. WBC
. number of cells can be graded-
e.g hypopyon- classed as grade 5- pooling effect on the bottom of eye- check pic
explain flare as a sign of anterior uveitis?
. proteins leaked from damaged iris bv’s
. tyndall effect- light scattering by particles in a colloid very fine suspension
. with cells= active inflammation
. without cells = no active inflammation
explain iris nodules as a sign of anterior uveitis?
- bussaca -
. whitish-yellow lumps away from pupil border
. internal iris stroma
. always associated with granulomatous uveitis - koeppe
. cellular aggregates at pupil border
. may accumulate pigment over time
what are the complications of anterior uveitis?
. anterior synechiae-
between iris and posterior cornea - iris stuck to cornea
. posterior synechiae - between iris and lens capsule- iris and lens capsule stuck together
what is the management of first episode of anterior uveitis ?
. refer to ophthalmologist ‘urgent’ ( within 1 week )
. if reduced VA, severe pain or raised IOP= same day referral to ophthalmologist
. sunglasses for photophobia
. topical cycloplegic
- first check for possibility of angle closure
. analgesics
what is the management of subsequent episodes of anterior uveitis ?
. refer back to HES
. monitor for ocular complications
. IOP check
. consider near add for cycloplegia
what is the management by ophthalmologist for anterior uveitis?
. cycloplegia
. topical steroid
- treat secondary glaucoma
. sub-tenon’s steroid injection may be required
. possible systemic immunosuppression
. referral for investigation of associations
what are the differential diagnosis for uveitis , scleritis and episcleritis?
- uveitis
. moderate pain
. circumcorneal flush
. corneal involvement
Other causes of red eye e.g. endophthalmitis
Other forms of uveitis e.g intermediate, posterior, panuveitis - scleritis
. severe pain
. deep injection - episcleritis
. no pain
. superficial injection
. other causes or red eye
- closed angle gluacoma
what is intermediate uveitis ?
. least common type of uveitis
- 1.5 per 100,000 population per year
. mostly idiopathic
- recently recognised association with human T-cell lymphotropic virus type 1 ( HTLV-1) - type of virus
. high prevalence in japan and brazil - strong association between pars planitis ( snowball) and MS
- most common in children and young adults
. onset after age 40 is rare
what is intermediate uveitis classified as?
. chronic cyclitis: peripheral uveitis: pars planitis; vitritis
. chronic inflammation of peripheral retina
- vitreous involvement
. unknown aetiology
- autoimmune/MS linked
what are the symptoms of intermediate uveitis?
. bilateral ( 60-80%)
. eye may be quiet
. hazy vision
- corneal involvement
- band keratopathy
. floaters
. reduced VA
what are the signs of intermediate uveitis?
. yellow exudates in peripheral retina
- scleral indentation
. exudates may break off to form snowbanks
-99% inferior retina
. exudates may break off and float about in the vitreous
what is the management of intermediate uveitis ?
. refer to HES for soon appointment
. steroid drops
. steroid injections
. immunosuppressives
. vitrectomy
what are the complications associated with intermediate uveitis?
. secondary glaucoma . posterior subcapsular cataract . vitreous detachment/ haemorrhage . retinal breaks/ tears/ detachment . optic disc oedema . macular oedema- snowabank
what is the epidemiology of posterior uveitis?
. 1 to 3% of uveitis cases
. most common cause is toxoplasmosis
. idiopathic
. most common in developing world
what are the signs of posterior uveitis ?
. retinitis
. choroiditis
. vasculitis ( inflammation of blood vessels)
what is the management of posterior uveitis ?
. refer to HES
. to be seen soon
what is panuveitis ?
affects all layers of the uvea ( iris, ciliary body and choroid) and can include retina and vitreous humour
what is the epidemiology of panuveitis?
. most common type of uveitis in south america. africa and asia
. mostly idiopathic
