Uveitis Flashcards
1
Q
Common findings of anterior uveitits
A
Presence of WBCs in the AC and no WBC in the posterior chamber
2
Q
Acute uveitis
A
Never had uveitis before, self limiting, <3m in duration
3
Q
Chronic uveitis
A
> 3m duration, may have periods of exacerbation, but never fully resolves
4
Q
Laterality of uveitis
A
My be bialteral, unilateral, or alternating
5
Q
Uveitis classifications
A
Acute vs chronic Unilateral/bilateral/ chronic Recurrent or isolated Granulomatous vs nongran Anterior (75%), intermediate (8%), or panuveitis (17%)
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)
7
Q
Common symptoms of acute uveitis
A
Pain
Redness
Photophobia
And decreased vision
Patients with chronic uveitis may be asymptomatic
8
Q
What is pain in uveitis from
A
Congestion and irritation of the anterior ciliary nerves
9
Q
What is the only signs necessary to make the diagnosis of active uveitis
A
WBCs within the AC
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
11
Q
What are the three main threats to vision in uveitis
A
Posterior or PAS
Cataracts
CME
12
Q
What is the most common corneal finding in uveitis
A
KPS
13
Q
Stellate KPs
A
Fuchs heterochromic iridocyclitis
Herpetic uveitis
14
Q
Most common causes of severe ocular pain
A
Uveitis
Acute glaucoma
Scleritis
Corneal pathology (ulcer, abrasion)
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
16
Q
Small KPs
A
Nongran
17
Q
Large, “mutton-fat” KPs
A
WBCs+macrophages+epitheliod cells) are noted in Granulomatous uveitis
18
Q
KPs color
A
Typically white in color When fresh, and brown in color when old
19
Q
Common findings in granulomatous uveitis
A
Mutton fat KPs
Iris granulomas
Koeppe nodules (pup margin)
Busacca nodules (mid iris stroma)
20
Q
What causes hyperemia in uveitis
A
Congested ACAs
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)
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
23
Q
Most common causes of granulomatous KPs
A
Herpes Sarcoidosis TB Syphilis Toxo
24
Q
Most common cause of nongran KPs
A
Idiopathic
UCRAP
25
Uveitis in kids
JIA most common association
- bialteral
- nongran
- asymptomatic
- chronic
- (+) ANA
- (-) RF
26
If someone comes in with IOPs of 40 and 15 with unilateral uveitis with mild cells
1. Fuchs (mild uveitis)
2. PSS (mild uveitis)
3. Herpes (not so mild)
27
Ankylosing spondylitis
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
28
What is the most common systemic disease associated with acute anterior uveitis
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
29
Reactive arthritis
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+
30
IBD
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+
31
Psoriatic arthritis
Asymmetric, peripheral, small joint pain, and psoriaticlesions on the knees, elbows, and scalp. 7% of patients will develop anterior uveitis
32
Behçet’s disease
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
PSS
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
Fuchs heterochromic iridocyclitis
```
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
Causes of chronic, anterior, non gran uveitis
Fuchs heterochromic
| JIA
36
Most common cause of uveitis in kids
JIA
37
JIA
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
Causes of chronic, anterior, granulomatous uveitits
```
Sarcoidosis
TB
herpes
Syphilis
Lyme
```
39
Sarcoidosis
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
TB
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
Herpes simplex/zoster
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
Syphilis
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
Syphilis and uveitis
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
Congential syphilis triad
Hutchinson teeth, IKs, and deafness
45
Lyme disease and uveitis
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
Pars planitis
Chronic intermediate uveitis characterized by inflammation over the pars plana (snowbanking) and the peripheral retina; it is not associated with any systemic condition
47
Systemic medications and uveitis
Rifabutin
Systemic sulfa drugs
Cidofovir
48
Posterior uveitis
WBCs in the vitreous; pts may complain of floaters and/or decreased vision.
49
Posterior uveitis most commonly associated with
Toxo
Sarcoidosis
Syphilis
CMV
50
Toxoplasmosis
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
Posterior uveitis and sarcoidosis
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
Syphilis and posterior uveitis
Acute multifocal choroiretintitis with vitritis or panuveitis
53
CMV and posterior uveitis
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
What is the leading cause of scleritis I
RA
55
What testing should be done if IBD is suspected
Colonscopy
56
PPD test results abnormal
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
Active TB
+ chest X ray
Treated with combo drugs (RIPE)
58
Latent TB
- chest X ray
Treated with isoniazid or rifampin
59
Tests for TB
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
What is an ocular manifestation of ethambutol
Retrobulbar optic neuritis
61
EIA for syphilis
Screens for syphilis IgG Abs
- if (+), do RPR
- if (-), done
62
RPR for syphilis
If EIA is positive, do this next
- if (+), active syphilis
- if (-) do FTA-ABS
63
FTA-ABS for syphilis
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
Syphilis screeners
EIA
RPR
VDRL
65
FTA-ABS
F=FOREVER
| -will be (+) forever if ever had syphilis
66
Why is the IOP decreased in the initial stages of uveitis
1. Decreased aqueous humor production due to inflamed ciliary body
2. Increased US outflow due to release of pro-inflammatory PGs
67
Why may IOP be elevated in late stages of uveitis
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
Difference between PSS and Fuchs
Fuchs
- chronic breakdown of TM
- IOP decreasing med needed, NOT steroid
PSS
- increased IOP bc inflamed TM
- TX is steroid
69
What steroids are most commonly used in treating uveitis
PF
| Durezol
70
PS and PAS in uveitis
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
Treatment goals for acute anterior uveitis
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
Treatment of anterior uveitis
PF 1% q1h
Homatropine 5% BID (or cyclo 1% QID or atropine 1% QD)
Taper the PF
73
Tapering of the PF for uveitis
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
Durezol vs PF
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
Treatment of herpes simplex uveitis
PF is alternated with prophylactic viroptic every hour (PF q2h, viroptic q2h)
76
Treatment of traumatic uveitis
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
PF and very mild anteiror uveitis
Too strong
