Uveitis Flashcards
Signs of anterior Uveitis
Conjunctival injection
Keratic precipitates
anterior chamber flare
anterior chamber cells
Hypopyon
Iris nodules
Koeppe nodules
synechiae
What causes keratic percipitates and what layer of the cornea will you see them on?
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
What causes anterior chamber flare?
o Protein in aqueous
o Cause by breakdown of the blood ocular barrier (BOB).
What causes anterior chamber cells?
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
What are the symptoms of uveitis?
• 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.
According to the sun grading scale what is the primary site of inflammation of anterior uveitis?
Anterior chamber.
According to the sun grading scale what is the primary site of inflammation of intermediate uveitis?
Vitreous
According to the sun grading scale what is the primary site of inflammation of posterior uveitis?
retina or choroid
According to the sun grading scale what is the primary site of inflammation of panuveitis?
Anterior chamber, vitreous and retina or choroid
According to the ‘Sun working descriptors of uveitis’ what is the difference between a persistent and limited onset of uveitis?
limited is less than or equal to 3 months of duration, where as persistent is over 3 months.
According to the ‘Sun working descriptors of uveitis’ what is the difference between a persistent and limited duration of uveitis?
limited is less than or equal to 3 months of duration, where as persistent is over 3 months.
According to the ‘Sun working descriptors of uveitis’ what is the difference between a acute, chronic and recurrent course of uveitis?
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
What is the sun grading scale for anterior chamber cells?
0: none
0.5: 1-5
1+: 6-15
2+: 16-25
3+:26-50
4+: >50
Sun grading for anterior chmaber flare?
0: none
1: faint
2: moderate (iris and lens detials cear)
3: Marked (Iris and lens details hazy)
4: Intense (fibrin or plastic aqueos)
Specific signs to acute uveitis
- 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
specific signs to chronic uveitis
- 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
What are some systemic associations to uveitis?
ankylosing spondylitis Behcet's disease Crohn's disease Juvenile idiopathic artheritis Multiple sclerosis sarcoidosis Sjogrens sydrome Lupus
What differentials could you consider?
- Intraocular foreign body
- Endophthalmitis
- Posterior segment tumour
- Ocular ischemia syndrome
- Giant cell arthritis
- Retinal detachment
Possible exam plan?
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
Management of AAU?
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)
