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Optometry > Uveitis > Flashcards

Uveitis Flashcards

1
Q

Signs of anterior Uveitis

A

Conjunctival injection

Keratic precipitates

anterior chamber flare

anterior chamber cells

Hypopyon

Iris nodules

Koeppe nodules

synechiae

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2
Q

What causes keratic percipitates and what layer of the cornea will you see them on?

A

o Leukocytes adhering to the endothelium. May deposit in Arlt’s triangle (due to aqueous dynamics).
o Can be non-granulomatous (fine)
o Comprised of lymphocytes and macrophages
o In chronic uveitis, there is a granulomatous KP deposition- (MUTTONFAT). Comprised of giant cells

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3
Q

What causes anterior chamber flare?

A

o Protein in aqueous

o Cause by breakdown of the blood ocular barrier (BOB).

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4
Q

What causes anterior chamber cells?

A

o Leukocytes migrate through the leaky BOB and are attracted by cytokines, chemokines, etc.
o The location of these cells is a very good indicator of the source of the inflammation

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5
Q

What are the symptoms of uveitis?

A

• Photophobia
o Trigeminal irritation underlies photophobia.
o In fact an intact visual system is not required.
o The more anterior the lesion the greater the photophobic symptoms
o Epiphora occurs as a result of the trigeminal reflex
• Pain
o Originates from Iris/ Ciliary body spasm. – This explains the “dull ache” with uveitis.
o Evidence for this location is the fact that cycloplegics reduce the pain.

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6
Q

According to the sun grading scale what is the primary site of inflammation of anterior uveitis?

A

Anterior chamber.

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7
Q

According to the sun grading scale what is the primary site of inflammation of intermediate uveitis?

A

Vitreous

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8
Q

According to the sun grading scale what is the primary site of inflammation of posterior uveitis?

A

retina or choroid

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9
Q

According to the sun grading scale what is the primary site of inflammation of panuveitis?

A

Anterior chamber, vitreous and retina or choroid

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10
Q

According to the ‘Sun working descriptors of uveitis’ what is the difference between a persistent and limited onset of uveitis?

A

limited is less than or equal to 3 months of duration, where as persistent is over 3 months.

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11
Q

According to the ‘Sun working descriptors of uveitis’ what is the difference between a persistent and limited duration of uveitis?

A

limited is less than or equal to 3 months of duration, where as persistent is over 3 months.

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12
Q

According to the ‘Sun working descriptors of uveitis’ what is the difference between a acute, chronic and recurrent course of uveitis?

A

acute: sudden onset, limited duration

Recurrent: repeated episodes seperated by periods of inactivity without treatment greater or equal to 3 months of duration

Chronic: Persistent uveitis with relapse in <3 months after discontinuing treatment

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13
Q

What is the sun grading scale for anterior chamber cells?

A

0: none
0.5: 1-5
1+: 6-15
2+: 16-25
3+:26-50
4+: >50

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14
Q

Sun grading for anterior chmaber flare?

A

0: none
1: faint
2: moderate (iris and lens detials cear)
3: Marked (Iris and lens details hazy)
4: Intense (fibrin or plastic aqueos)

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15
Q

Specific signs to acute uveitis

A
  • Ciliary flush
  • Anterior chamber cells and flare
  • Keratic precipitates
  • Pupillary miosis
  • Posterior synechiae
  • Peripheral anterior synechiae
  • OP may be down (due to CB shutdown) or up
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16
Q

specific signs to chronic uveitis

A
  • Usually a white eye
  • Various numbers of cells (even large numbers of cells might still be asymptomatic)
  • Flare may be more marked in eyes with longstanding activity
  • Large ‘mutton-fat’ KP
  • Iris nodules, typically in granulomatous cases
  • Iris atrophy
17
Q

What are some systemic associations to uveitis?

A 
ankylosing spondylitis 
Behcet's disease
Crohn's disease
Juvenile idiopathic artheritis 
Multiple sclerosis 
sarcoidosis 
Sjogrens sydrome 
Lupus
18
Q

What differentials could you consider?

A
  • Intraocular foreign body
  • Endophthalmitis
  • Posterior segment tumour
  • Ocular ischemia syndrome
  • Giant cell arthritis
  • Retinal detachment
19
Q

Possible exam plan?

A

Vision
• - Habitual VA should be measured first
• - Check if any improvement with pinhole
o AAU will have little significant impact on VA
o Because we will not be conducting refraction in these patients, a check with PH is especially important to determine if vision is reduced for pathological or refractive reasons

Preliminary Tests 
- As a matter of routine students should get into a habit of efficiently performing the following diagnostic screening techniques: 
•	Motilities – Broad H test 
•	Pupils – DCN and RAPD 
•	Cover Tests

Retinoscopy/Refraction
• Additionally, if you observe the retinoscopy reflex carefully you may be able to get additional clinical information from this test
o For e.g. a dull reflex can indicate a significant amount of flare present in the anterior chamber
Slit lamp evaluation – Anterior eye
• - Signs will be dependent on the level of inflammation, but typically include: circumlimbal flush, constricted pupil, anterior chamber cells and flare and keratic precipitates
• - Evaluate the following structures:

o Cornea
• Small, fine KP may be visible on the posterior surface of the cornea • KP are best visualised using retro-illumination from the iris
• In more severe attacks corneal oedema may be present
• This occurs secondary to inflammation or elevated IOP
• Must rule out other anterior disease presentation which can cause secondary inflammation/uveitis
• E.g. corneal ulceration, microbial keratitis, HSV keratitis

o Conjunctiva/episclera/sclera
• The eye will appear red, with the greatest intensity surrounding the limbus
• Watery or teary discharge is likely to be present

o Anterior chamber
• Look for cells and flare – you must be in a completely dark room with a bright slit lamp beam in order to effectively view cells and flare
• Grade the degree of cells and flare according to the SUN grading scheme – use a 1 x 1 mm beam
• In severe cases hypopyon may be present

o Iris
• Pupil will be miotic and sluggish to react in most cases
• In more severe attacks posterior synechiae (adhesion to lens) and/or posterior anterior synechiae (adhesion to cornea) may be present
• Look for signs of iris heterochromia – this can be indicative of Fuch’s heterochromic iridocyclitis as a cause of the inflammation

o Lens
• Inflammatory debris may be present on the anterior lens surface
• In recurrent cases cataract may develop, secondary to either the disease process or long term topical steroid use

o Vitreous
• In severe cases of AAU, inflammation may spill over into the vitreous

IOP measurement
• IOP measurements also hold primary significance in workup of uveitis – should be measured on initial presentation and at all subsequent visits
• A reduction in IOP can occur due to a combination of ciliary body underproduction of aqueous
• An increase in IOP can occur due to trabeculitis, or due obstruction of outflow by inflammatory debris or anterior or posterior synechiae
• IOP can be raised during the course of treatment as a response to topical steroid medications

Slit Lamp fundus examination and BIO
• Perform biomicroscopic fundus (with 90D lens or similar) and BIO examination under dilated conditions
• Must rule out posterior segment involvement
• Patients are dilated as part of the therapeutic regimen of treatment for AAU – this will break or prevent synechiae from forming and will also relieve the patient’s symptoms of pain and photophobia

o Optic nerve assessment
• Optic nerve damage in AAU is rare, but inflammation and atrophy can occur secondary to elevated IOP

20
Q

Management of AAU?

A 
DAY1: 
•	1% prednisolone acetate load q15min for first hour q30 min for next hour then q1h 
•	 1% atropine tid 
DAY2: 
•	Review 24 hours and if any reduction in symptoms good
•	1%prednisolone acetate q1h 
DAY3: 
•	Review 48 hours
•	There should be some improvement 
•	1%prednisolone acetate q2h 
•	Review until cells are around grade 1
•	Atropine can come off now 
Taper
•	Halve the dose each week for 6 weeks
•	 Can move to a less potent steroid (Flarex,FML)

Optometry (28 decks)

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