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BOARDS2 Episclera/sclera/uvea > Uveitis > Flashcards

Uveitis Flashcards

1
Q

Common findings of anterior uveitits

A

Presence of WBCs in the AC and no WBC in the posterior chamber

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2
Q

Acute uveitis

A

Never had uveitis before, self limiting, <3m in duration

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3
Q

Chronic uveitis

A

> 3m duration, may have periods of exacerbation, but never fully resolves

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4
Q

Laterality of uveitis

A

My be bialteral, unilateral, or alternating

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5
Q

Uveitis classifications

A 
Acute vs chronic 
Unilateral/bilateral/ chronic 
Recurrent or isolated
Granulomatous vs nongran
Anterior (75%), intermediate (8%), or panuveitis (17%)
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6
Q

Who gets anterior uveitis more commonly

A

Young adults (2nd-4th decade), rarely occurs in individuals older than 70 (common causes in this age group are toxo and herpes zoster)

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7
Q

Common symptoms of acute uveitis

A

Pain
Redness
Photophobia
And decreased vision

Patients with chronic uveitis may be asymptomatic

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8
Q

What is pain in uveitis from

A

Congestion and irritation of the anterior ciliary nerves

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9
Q

What is the only signs necessary to make the diagnosis of active uveitis

A

WBCs within the AC

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10
Q

Additional signs of uveitis

A
  • circumlimbal injection of the conjunctival vessels (due to inflammation of the shared vessels in the VB)
  • hypopyon
  • posterior or PAS
  • KPs
  • iris changes (atrophy, heterochromia, Koeppe/Busacca nodules, granulomas)
  • cataract formation (PSC)
  • CME (chronic)
  • decreased or increased IOP in involved eye
  • cyclitic membranes
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11
Q

What are the three main threats to vision in uveitis

A

Posterior or PAS
Cataracts
CME

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12
Q

What is the most common corneal finding in uveitis

A

KPS

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13
Q

Stellate KPs

A

Fuchs heterochromic iridocyclitis

Herpetic uveitis

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14
Q

Most common causes of severe ocular pain

A

Uveitis
Acute glaucoma
Scleritis
Corneal pathology (ulcer, abrasion)

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15
Q

Cause of uveitis

A

Breakdown of the BAB, which is formed by tight junctions in the NPCE, the iris vessels, and schlemms canal. When the BAB is compromised, WBCs and protein enter the AC, resulting in uveitis. WBCs attached to the corneal endo are referred to as KPs

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16
Q

Small KPs

A

Nongran

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17
Q

Large, “mutton-fat” KPs

A

WBCs+macrophages+epitheliod cells) are noted in Granulomatous uveitis

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18
Q

KPs color

A

Typically white in color When fresh, and brown in color when old

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19
Q

Common findings in granulomatous uveitis

A

Mutton fat KPs
Iris granulomas
Koeppe nodules (pup margin)
Busacca nodules (mid iris stroma)

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20
Q

What causes hyperemia in uveitis

A

Congested ACAs

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21
Q

Causes of acute anterior uveitis

A

50% idiopathic
Remaining 50% associated with spondyloarthropathy
50% of patients are HLA-B57 positive (70% if the condition recurs)

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22
Q

Positive HLA-B27

A 
Assocaited with CRAP
-Crohn’s disease 
-ulcerative colitis
—reactive arthritis 
-ankylosing spondylitis 
-and psoriatic arthritis

All problems with peeing, pooping, and lower back pain

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23
Q

Most common causes of granulomatous KPs

A 
Herpes 
Sarcoidosis 
TB
Syphilis 
Toxo
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24
Q

Most common cause of nongran KPs

A

Idiopathic

UCRAP

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25
Q

Uveitis in kids

A

JIA most common association

  • bialteral
  • nongran
  • asymptomatic
  • chronic
  • (+) ANA
  • (-) RF
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26
Q

If someone comes in with IOPs of 40 and 15 with unilateral uveitis with mild cells

A
  1. Fuchs (mild uveitis)
  2. PSS (mild uveitis)
  3. Herpes (not so mild)
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27
Q

Ankylosing spondylitis

A

Males
30s
Chronic inflammation of the spoon and largejoints, leading to a bamboo spine and sacroilliitis; may also present with aortic regurgitation.
Classic symptom is lower back pain that improves with exercise and NSAIDs

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28
Q

What is the most common systemic disease associated with acute anterior uveitis

A

Ankylosing spondylitis
50% of acute anterior uveitis are assocaited with spondyloarthropathies, and 80% of those are Ankylosing spondylitis. 90% of patients with Ankylosing spondylitis are HLA-B27 positive

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29
Q

Reactive arthritis

A

Young males with urethritis, polyarhtritis, and conjunctivitis with iritis
AKA Reiters syndrome
Usually present first with urinary symptoms, followed by low grade fever, conjunctivitis, and arthritis over the next several weeks. 85-90% HAL B27+

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30
Q

IBD

A

Crohn’s and ulcerative colitis.
Chronic intermittent diarrhea with elaternating episodes of constipation. Uveitis is rare in Crohn’s, but is more common in ulcerative colitis. Math be bilateral uvetiis with a posterior uveitis component.
60% of pts with IBD are HLA-B27+

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31
Q

Psoriatic arthritis

A

Asymmetric, peripheral, small joint pain, and psoriaticlesions on the knees, elbows, and scalp. 7% of patients will develop anterior uveitis

32
Q

Behçet’s disease

A

Most common in in young adult males of Asian and middle eastern descent. Acute, recurrent hypopyon iritis, with mouth and genital ulcers. May also be associated with retinal vasculitis, cataracts, and glaucoma

33
Q

PSS

A

Recurrent, self limiting epidsodes of very mild iritis, with trabeculitis, resulting in acute elevations in IOP in the presence of an open angle on gonioscopy; patients may also present with fine KPs.

34
Q

Fuchs heterochromic iridocyclitis

A 
Chronic, unilateral 
Asymptomatic
Mild cells
Increased IOP unilateral
Iris shifted blue

Stellate KPs
Angle neo
Iris atrophy assoacited with glaucoma and cataract
More common in patients with blue eyes

35
Q

Causes of chronic, anterior, non gran uveitis

A

Fuchs heterochromic

JIA

36
Q

Most common cause of uveitis in kids

A

JIA

37
Q

JIA

A

More common in young females and resutls in arthritis of multiple joints and a low grade fever. Patients classically present with an asymptomatic chronic, bialteral, non gran anterior uveitis with minimal injection. Patients will have positive ANA and neg RF

38
Q

Causes of chronic, anterior, granulomatous uveitits

A 
Sarcoidosis
TB
herpes
Syphilis 
Lyme
39
Q

Sarcoidosis

A

Idiopathic condition that classically affects middle aged AA females. The condition is characterized by non caseating granulomas, with 90% of patietns having pulmonary involvement. Serum ACE levels may also be elevated, although 40% of active cases of sarcoidosis are associatd with normal ACE levels. Patients may be asymptomatic or complain of dyspnea, dry cough, and rashes (erythema nodosum)

25% of patietns with sarcoidosis will have ocular manifestation and 75% of those patietns witll have chronic, bilateral, anteiror, granulaomtous uveitis. Additional ocular manifestations include optic nerve disease, chronic dacryoadenoitis, and Bell’s palsy

40
Q

TB

A

Pulmonary infection caused by mycobacterium Tb. The most ccommon systemic symptom include fever, chronic cough, and night sweats. The classic ocular manifestation is chronic, bialteral, anterior granulomatous uveitis

Most patients are from Southeast Asia and Africa; the condition is often spread from co-workers, relatives, spouses, etc through respiratory transmission

41
Q

Herpes simplex/zoster

A

Associated with acutely elevated IOP in the involved eye due to associated trabeculitis; patients may also present with stellate KPs, corneal edema, and/or epithelial defects. Recall that herpes zoster will also present with vessicles along the affected dermatome that do not cross the midline

42
Q

Syphilis

A

STD caused by the spirochete treponema pallidum. Primary syphilis characterized by a chancre; secondary characterized by eye involvement, kidney, mucus membranes, and skin, CNS, and/or liver. Tertiary involves the nervous system

43
Q

Syphilis and uveitis

A

Posterior uveitis occurs in secondary syphilis (less than 1% of cases of uveitis)

Additional ocualr manifestations
-salt and pepper fundus, flame shaped hemes, IK

Known as the great mimicker because it can be confused with several other conditions; the condition may be acquired or congenital

44
Q

Congential syphilis triad

A

Hutchinson teeth, IKs, and deafness

45
Q

Lyme disease and uveitis

A

More common in the northeast US, caused by the bacterial borgdorferi. Patients will have a history of tick bites, bulls eye skin lesions (erythema migrans), chronic arthritis, CNS involvement, and/or cardiac involvement. Most commonly causes intermediate uveitis, but can also cause anterior or posterior uveitis

46
Q

Pars planitis

A

Chronic intermediate uveitis characterized by inflammation over the pars plana (snowbanking) and the peripheral retina; it is not associated with any systemic condition

47
Q

Systemic medications and uveitis

A

Rifabutin
Systemic sulfa drugs
Cidofovir

48
Q

Posterior uveitis

A

WBCs in the vitreous; pts may complain of floaters and/or decreased vision.

49
Q

Posterior uveitis most commonly associated with

A

Toxo
Sarcoidosis
Syphilis
CMV

50
Q

Toxoplasmosis

A

Most common cause of posterior uveitis in the US and most often occurs in a young healthy patient. Result 0of parasitic infection caused by toxoplasma gondii, an obligate intracellular parasite. Toxo classically presents as a unilateral and univocal area of retinitis obscured by an overlying vitritis (headlights in a fog). Patietns may complain of a unilateral red eye and decreased vision.

51
Q

Posterior uveitis and sarcoidosis

A

Granulaomtous panuveitis associated with retinal vasculitis and vitritis

  • yellow nite exudates caused by periphlebitis (candle wax drippings), as well as sheathing around the retinal veins
  • vitritis may be diffuse or focal with fluffy white opacities within the inferior vitreous (cotton ball opacities)
52
Q

Syphilis and posterior uveitis

A

Acute multifocal choroiretintitis with vitritis or panuveitis

53
Q

CMV and posterior uveitis

A

Most common ocular infection and the leading cause of blindness in AIDS. It is most likely to occur in patients with CD4 counts less than 50. It is characterized by white patches of necrotic retina with a hemorrhagic retinitis and vascular sheathing

54
Q

What is the leading cause of scleritis I

A

RA

55
Q

What testing should be done if IBD is suspected

A

Colonscopy

56
Q

PPD test results abnormal

A

15mm or more of induration in health individuals
10mm of induration or more in health care workers
5mm of induration or more in immunocompromised

57
Q

Active TB

A

+ chest X ray

Treated with combo drugs (RIPE)

58
Q

Latent TB

A
  • chest X ray

Treated with isoniazid or rifampin

59
Q

Tests for TB

A

PPD
IGRA (Quantiferon)

If they are positive, TB is present, you then have to do a chest X-ray to determine if it is active or latent

60
Q

What is an ocular manifestation of ethambutol

A

Retrobulbar optic neuritis

61
Q

EIA for syphilis

A

Screens for syphilis IgG Abs

  • if (+), do RPR
  • if (-), done
62
Q

RPR for syphilis

A

If EIA is positive, do this next

  • if (+), active syphilis
  • if (-) do FTA-ABS
63
Q

FTA-ABS for syphilis

A

Done when EIA is positive, and RPR is negative

  • if (+), syphilis thats been treated, or has been present for less than 6 weeks
  • if (-), no syphilis
64
Q

Syphilis screeners

A

EIA
RPR
VDRL

65
Q

FTA-ABS

A

F=FOREVER

-will be (+) forever if ever had syphilis

66
Q

Why is the IOP decreased in the initial stages of uveitis

A
  1. Decreased aqueous humor production due to inflamed ciliary body
  2. Increased US outflow due to release of pro-inflammatory PGs
67
Q

Why may IOP be elevated in late stages of uveitis

A
  1. Eye getting better
  2. Posterior synechiae
  3. PAS
  4. Inflammatory cells and debris clogging TM
  5. Inflammation of the TM (trabeculitis)
  6. Response to topical steroids
  7. Chronic inflammation of TM
68
Q

Difference between PSS and Fuchs

A

Fuchs

  • chronic breakdown of TM
  • IOP decreasing med needed, NOT steroid

PSS

  • increased IOP bc inflamed TM
  • TX is steroid
69
Q

What steroids are most commonly used in treating uveitis

A

PF

Durezol

70
Q

PS and PAS in uveitis

A

Two of the most important ocular morbidities in uveitis, as they may lead to advanced glaucoma and/or central retinal artery occlusion (in cases of acutely elevated IOP). Additional ocular morbidities include symptoms and CME

71
Q

Treatment goals for acute anterior uveitis

A

Resolve the inflammation
- all cases of uveitis should be treated aggressively in order to prevent PAS and/or break PS, and reduce risk of recurrence

Determine whether an underlying systemic etiology is present and, when indicated, make the appropriate referral for eval and treatment of the condition. Evaluating for a systemic etiology serves 2 purposes

  • helps pt feel better by treating the condition causing the systemic symptoms
  • reduce risk of recurrence of uveitis by treating underlying etiology
72
Q

Treatment of anterior uveitis

A

PF 1% q1h
Homatropine 5% BID (or cyclo 1% QID or atropine 1% QD)

Taper the PF

73
Q

Tapering of the PF for uveitis

A

Q1-2h x 3 days
QID until NO CELLS at all
Then back down from there
Taper over 3-4 weeks

Keep on cyclo until no cells

74
Q

Durezol vs PF

A

Durezol is more potent than PF, and us thus dosed less frequently. Studies have shown that durezol QID has equal efficacy to PF q2h in the treatment of uveitis

There is a higher steroid response in durezol

PF has to be shaken

75
Q

Treatment of herpes simplex uveitis

A

PF is alternated with prophylactic viroptic every hour (PF q2h, viroptic q2h)

76
Q

Treatment of traumatic uveitis

A

Risk of recurrence is very low as the uveitis is due to trauma rather than underlying systemic etiology, doesnt need to be treated as aggressively

77
Q

PF and very mild anteiror uveitis

A

Too strong

BOARDS2 Episclera/sclera/uvea (4 decks)

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