Uveitis Flashcards
What is uveitis?
Inflammation of the Uveal tract
What are the four different types of anatomical uveitis?
Anterior Uveitis (accounts for 75% of cases) - of anterior section of the eye.
Intermediate Uveitus - uveitis of the Posterior ciliary body (pars plana), extreme periphery of retina and choroid
Posterior Uveitis - uveitis of the retina and choroid
Panuveitis - of the whole eye
What are the two examples of anterior uveitis?
Iritis & Iridocyclitis.
What is iritis?
Inflammation predominantly affecting iris
What is iridocyclitis?
Inflammation predominantly affecting iris AND anterior part of ciliary body (pars plicata).
It is the more common form of Anterior uveitis.
What is the international standard for classifying Uveitis?
Onset: sudden or insidious?
- Duration: limited- if it is ≤3 months, or persistent - if >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 characterized by prompt relapse (in <3 months) after discontinuation of therapy
Define Endogenous.
having an internal cause or origin
What is the aetiology of Uveitis?
Endogenous- in which case:
- From systemic diseases
- Asscoaited with prior infections (e.g. herpes simplex)
- Idiopathic
Exogenous - so from the following:
External injury
Infection
How do we classify (i.e. sort) anterior uveitis?
Anterior uveitis is traditionally classified as ‘non-granulomatous’ or ‘granulomatous’, based on the nature of the keratic precipitates (KPs)
What are characteristics of Non-granulomatous Uveitis?
Typically has an acute onset
- Fine KP (keratic precipitates) (would be seen on corneal endothelium in slit lamp)
- More likely to be idiopathic
What are characteristics of Granulomatous Uveitis?
- Typically presents as a chronic condition
- With large, ‘mutton fat’ Keratic Precipitates (can be seen on corneal endothelium in the picture) and iris nodules
- More likely to be associated with systemic conditions
What are predisposing factors to 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 c/o hazy vision - More severe if chronic
- Photophobia -Milder if chronic
- Epiphora
What are signs of anterior Uveitis?
- Hyperaemia: ciliary flush
- Keratic precipitates
- Cells and aqueous flare
- Iris nodules Sometimes: • Miosis • Raised IOP
• NB MUST CHECK FUNDUS IN BOTH EYES!!
Keratic Precipitates (KPs) are a sign of Uveitis. Differences in KP indicate which type of Uveitis a px has. What are these?
- Endothelial dusting –> Indicates Acute anterior uveitis
- Medium sized KP —> Present in Acute and chronic anterior uveitis
- Large “mutton fat” KP—> Indicates Chronic anterior uveitis
- Old - old KP tend to become Pigmented thus they are a sign of Chronic anterior uveitis
[Might also see something called Kruckenberg’s spindle this is a collection of KP that forms a sort of line]
Define Miosis
excessive constriction of the pupil
Cells in the anterior chamber are a sign of Uveitis. What does this mean and how do they appear?
They are a sign of active inflammation.
They are White blood cells.
Due to gravity they will actually fall to the bottom and collect there- this is known as a hypopyon ( as can be seen in the picture).
[Number of cells present can be graded to assess condition]
Flare is a sign of Uveitis. Describe what it is, what effect it causes and how we can identify active inflammation.
Flare is proteins leaked from damaged iris bv’s (blood vessels)
• It causes a Tyndall effect - light scattering by particles in a colloid very fine suspension ( this can be seen in second beaker in picture)
If flare is present…
- With cells = active inflammation
- Without cells = no active inflammation
Iris Nodules are a sign of Uveitis.
What types of iris nodules may we see?
Where may they be located?
And what type of uveitis are they associated with?
Bussaca (picture b at the top) :
These are Whitish-yellow lumps away from pupil border
- Located in Internal iris stroma
- Always associated with granulomatous uveitis
Koeppe (picture a at the bottom):
- Cellular aggregates at Pupil border
- May accumulate pigment over time
What are complications of anterior uveitis?
Iris Synechiae. (Basically a condition where the iris sticks to posterior cornea- in the image its the bottom left one. ).
Posterior Synechiae (where iris and lens capsule stick together)
What is the optometric managment of a 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 - NB first check for possibility of angle closure - e.g. cyclopentolate 1% tds
Topical cycloplegic is prescribed to prevent synechiae formation + symptomatic relief
• Analgesics (this basically means a pain releaving drug)
What is the optometric managment of subsequent episodes of anterior Uveitis?
- Refer back to HES (Hospital eye service) to Monitor for ocular complications
- IOP check
- Consider near add for cycloplegia
How would managment of anterior uveitis occur?
Topical Cycloplegic would be prescribed e.g. gutt. cyclopentolate 1%
- Topical steroid might be prescribed for inflammation e.g. gutt. dexamethasone 0.1% or gutt. prednisolone acetate 1%
- Any secondary glaucoma would be treated as follows:
- Sub-Tenon’s steroid injection may be required
- Possible systemic immunosuppression
- Referral for investigation of associations
What are the diffrential diagnosis of Episcleritis, Scleritis and Uveitis?
What is the epidemiology of intermediate uvieitis?
What are the different types of intermediate uveitis?
-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 (in 60-80% of cases)
- Eye may be quiet
- Hazy vision
- corneal involvment
- Band keratopathy
- Floaters
- Reduced VA Secondary macular oedema
What are the signs of Intermediate Uveitis?
- Yellow exudates in peripheral retina - Which may only be seen with Scleral Indentation
- Exudates may break off to form snowbanks -99% of these are found in the inferior retina
- Exudates may break off and float about in the vitreous
[Snowballs collect together forming a snowbank]
What is the managment of Intermediate Uveitis?
• Refer to HES for soon appointment
There they could be given:
• 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
What is the Epidemiology of Posterior Uveitis?
- 1 to 3% of uveitis cases
- Most common cause is Toxoplasmosis
- Can have Idiopathic cause
- More common in developing world
What are the Signs of Posterior Uveitis?
Retinitis - inflammation of the retina (seen as a hazy retina)
Choroiditis - inflammation of the choroid - (the yellow areas on the retina in the picture b)
Vasculitis - inflammation of the blood vessels (look at vessels in picture c)
What is the management for Posterior Uveitis?
Referral to HES to be seen spoon
What does Panuveitis affect?
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
What does it mean to have a quiet eye?
For it to not be red
