Uveitis and Metabolic Diseases Flashcards
Types of Uveitis
- Anterior
- Intermediate
- Posterior Uveitis
- Panuveitis
- Endophthalmitis
- Panophthalmitis
Uveitis Definition
Inflammation of Uveal tract ( May involves retina and vessels)
Acute Uveitis
Sudden onset Limited duration
Recurrent Uveitis
Repeated seperated by inactivity w/o tx 3 or >3/12
Chronic Uveitis
Persistent Prompt Relapse ( if tx stopped)
Remission Uveitis
Inactive for at least 3/12 after tx stops
Patient history factors
- Age 2. Race 3. Geo location 4. Past ocular history ( POH) 5. Past medical history 6. Hygiene & Diet 7. Sexual practice 8. Recreation drug use 9. Pets
- Age
Certain age groups prone to certain types of uveitis
- Race
Genetics
- Geographic location
Endemic spread over the world
- Past ocular history
Uveitis as a result of ocular trauma/ surgery ( Infection/ Inflammation)
- Past medical history
Infectious agents: TB, Syphilis Systemic Diseases Rx ( Prescriptions) eg. Corticosteroids
- Hygiene & Diet
Infection: Toxocariasis Taxoplasmosis
- Sexual practice
Sexual transmitted diseases Syphilis HIV
- Recreational drug use
Eg. Needles HIV infection Fungal Endophthalmitis
- Pets
Cats: toxoplasmosis & Cat-scratch diseases Dogs: Taxocariasis
ACUTE ANTERIOR UVEITIS ( AAU) Characteristics
Most common Sudden onset Duration of 3/12 or less Easy to recognise ( Severe symptoms)
AAU Symptoms:
Unilateral pain Photophobia Redness Lacrimation
AAU Signs:
- Good at presentation
- Ciliary Injection: Vessels from EOMs may present through ophthalmic arteries 
- Miosis ( Sphincter spasm) = Involuntary sudden contraction of sphincter papillae ==> Pupil constric
- Endothelial dusting
- Aqueous flare ( Protein in AC)
- Hypopyon ( Pus- WBCs accumulated)
- Posterior Synechiae ( Adhesion of Iris into lens)
Sign?
Ciliary Injection
Sign?
AAU
Miosis
( Sphincter Spasm)
Sign?
AAU
Endothelial Dusting
Sign?
AAU
Aqueous cells in AC
Show disease severity ( No. of cells)
AAU
Grading of cells ?
No. of cells within slit beam
( 2mm long & 1mm wide )
Signs?
AAU
Aqueous flare
( Protein leaking in AC)
Grading
Sign?
AAU Hypopyon
( Pus - WBCs in AC inferiorly forming horizontal level)
Signs
AAU
Posterior Synechiae
( adhesion of Iris to Lens)
AAU
Course and Prognosis ?
- If treated, inflammation ⇒ completely resolve (5-6 weeks)
► Excellent visual prognosis
- Complications and poor visual prognosis are related to delayed or inadequate management
- Steroid-induced in IOP may occur but glaucomatous damage is uncommon
CHRONIC ANTERIOR UVEITIS
CAU
- Less common than AAU
- Persistent inflammation- promptly relapses < 3/12, after discontinuation of tx
- Gradual presentation:
many patients are asymptomatic until the development of complications (e.g., cataract, band keratopathy)
CAU
Signs
- Aqueous cells & aqueous flare
- Iris nodules
- Keratic precipitates (KP) ⇔ Clusters of cellular deposits on the cornea
Sign?
CAU
Keratic Precipitate on Cornea
CAU
Causes and Prognosis ?
- Inflammation persists for >3/12 (sometimes years)
- Remissions and exacerbations are common
- Prognosis is guarded
- Complications can ensue (e.g., cataract, glaucoma)
- Further towards back → Harder to treat
Posterior Uveitis
- Includes retinitis, choroiditis and retinal vasculitis
- Often both retina & choroid involved
- Symptoms: vary according to inflammation location
Floaters
Impaired central vision
RETINITIS
( Posterior Uveitis)
- Focal (solitary) or multifocal
- Active lesions - whitish retinal opacities with indistinct borders due to surrounding oedema
CHOROIDITIS
( Posterior Uveitis)
- Focal, multifocal or geographic
- Active choroiditis is characterised by a round, yellow nodule
VASCULITIS
( Posterior Uveitis)
- Can occur as a 1˚ condition or 2˚ to retinitis
- Affects Veins > Arteries
- Active: Yellowish or grey-white, patchy, perivascular cuffing
- Quiet: Perivascular scarring
SPONDELOARTHRIPATHIES
( Ankylosing Spondylitis)
- Strong rlts with Uveitis
- Inflammatory joint diseases of the vertebral column, associated with human leukocyte antigen HLA-B27
- Patients with spondyloarthropathies often test +ve for HLA-B27
- Prevalence of HLA-B27 varies markedly in the general population
6-8%: Caucasian
4%: North African
2-9%: Chinese
0.1- 0.5%: Japanese
24%: North Scandinavia
Ankylosing Spondylitis
(AS)
- Inflammation, calcification and finally ossification of ligaments and capsules of joints
- Causes bony ankylosis of the axial skeleton
- Typically affects males, about 95% of whom are HLA-B27 +ve
- Early adulthood
AS Prevalence
- 25% of patients with AS develop acute anterior uveitis (AAU)
- 25% of males with AAU have AS
- Either eye can be affected at different times
Uveitis in Juvenile Arthritis
[Juvanile Idiopathic Arthritis]
- Inflammatory arthritis of at least 6/52 duration occurring before age 16
- Affects girls more commonly than boys (3:2)
- Causes childhood anterior uveitis
Juvanile Idiopathic Arthritis + Anterior Uveitis
Symptoms ?
- Usually asymptomatic ( uveitis is detected on routine slit-lamp exam)
- Even present with 4+ aqueous cells, rarely patients complain
Occasionally c/o vitreous floaters
SARCOIDOSIS ?
- Idiopathic granulomatous inflammatory disorder
- Can affect one organ or many
- Mostly affects:
Lymph nodes
Lungs
Liver
Spleen
Skin
Eyes
SARCOIDOSIS
Ocular signs ?
- AAU
- Granulomatous CAU
- Intermediate uveitis (uncommon)
- Periphlebitis
- Choroidal infiltrates
SARCOIDOSIS
Ocular signs
Choroid?
Retina?
Optic nerve?
- Multifocal choroiditis
- Retinal granulomas
- Choroidal granulomas
- Retinal neovascularisation in the periphery
- Optic nerve granulomas or papilloedema
Sign?
Sarcoidosis
Sign?
Sarcoidosis
Multifocal Choroiditis
Sign?
Saccoidosis
Choroidal Granulomas
Sign?
Sarcoidosis
Optic nerve granulomas or papilloedema
Behcet syndrome ?
- Idiopathic, multi-system disease
- Recurrent episodes of orogenital ulceration & vasculitis
- Ocular complications in 95% of men & 70% of womenEye complications occur within 2 years of oral ulcers appearing
- Onset is usually in the 30s
- Mostly affects people of Eastern Mediterranean & Japanese descent
Behcet Syndrome
Ocular signs
- Recurrent AAU with hypopyon
- Retinal infiltrates
- Retinal vasculitis
- Vascular leakage
- Vitritis
- OtherConjunctivitis, episcleritis, scleritis
Parasitic Uvetis
TOXOPLASMOSIS
Cause?
- Caused by Toxoplasma gondiiAn intracellular protozoan
- T. gondii = common cause of infectious retinitis in otherwise healthy individuals
- Cats = definitive host of the parasite
TOXOPLASMOSIS
Transmission?
Humans become infected with T. gondii:
- By ingesting soil or infected animal faeces containing T. gondii cysts
- Accidental contamination of hands when disposing of cat litter
- By consuming raw or undercooked meat containing T. gondii cysts
- mother to foetus when T. gondii is contracted during pregnancy
⇒ CNS causing inflammatory response ( treated with corticosteroid)
TOXOPLASMOSIS
Prognosis?
- Recurrent episodes of inflammation are common
Cysts rupture ⇒ release hundreds of tachyzoites → normal retinal cells - Recurrences ( between the ages of 10 and 35 years)
Average age 25 years
Toxoplasmosis
Signs and Symptoms?
- Unilateral sudden onset of floaters, vision loss & photophobia
-
Signs:
Solitary inflammatory focus near old pigmented scar (satellite lesion)
Sometimes multiple foci
Vitritis: Hard to see the fundus and the inflammatory focus, although it may have a “headlight in the fog” appearance
TOXOCARIASIS?
- Infestation with intestinal roundworm of dogs (Toxocara canis)
- Transmission : accidental ingestion of soil or food contaminated with ova shed in dog faeces
TOXOCARIASIS
Complications?
- Chronic endophthalmitisOften patient presents b/w ages of 2 & 9 years with:
Leukocoria
Strabismus
Unilateral VA loss
Anterior uveitis& vitritis
Greyish-white exudateon peripheral ret
- Granulomas
Posterior pole
Peripheral
VA affected if it affects the macula and/or optic nerve
Complication of which disease?
Toxocariasis
( Granulomas)
THYROTOXICOSIS
(Metabolic disease)
- Hyperthyroidism
= excessive secretion of thyroid hormones - Graves disease
Most common subtype of hyperthyroidise
⇒ Autoimmune disorder (over-secretion of thyroid hormones)
More common females
THYROTOXICOSIS
(Metabolic disease)
Symptoms?
- Onset: in 30s or 40s
- Weight loss despite good appetite
- Increased bowel frequency
- Sweating
- Heat intolerance
- Nervousness
- Irritability
- Palpitations
- Weakness and fatigue
THYROTOXICOSIS
(Metabolic disease)
General Signs?
- Goitre
- Finger clubbing
- Raised plaques on the legs
THYROTOXICOSIS
(Metabolic disease)
Symptoms in Eyes ?
- Lid retraction & proptosis (Eye bulging forward)
- Chemosis
= Eye irritation, conjunctiva filled with fluild, swollen
RHEUMATOID ARTHRITIS
( Autoimmune systemic disease)
- Autoimmune systemic disease
- More common in females than males
- Presents in the 40s with joint swelling
RHEUMATOID ARTHRITIS
( Autoimmune systemic disease)
Ocular signs?
- Keratoconjunctivitis sicca
- Scleritis
- Ulcerative keratitis
SYSTEMIC LUPUS ERYTHEMATOSUS ( SLE)
(Metabolic disease)
?
- Autoimmune, non-organ specific connective tissue disease
- Causes widespread vasculitisand tissue damage
- Predominantly affects young females
-
Ocular signs:
madarosis,
keratoconjunctivitissicca,
scleritis,
peripheral ulcerative keratitis,
retinal vasculitisand optic neuropathy
SJOGREN Syndrome
( Metabolic disease)
?
- Autoimmune inflammation
and destruction of lacrimal and salivary glands
( dry tounge) - Classified as primary when it exists in isolation, and secondary when associated with other diseases such as RA, SLE etc
SJOGREN Syndrome
( Metabolic disease)
Signs?
GIANT CELL ARERITIS !!!
Symptoms ?
- Inflammation of medium & large arteries
- Patient usually presents in 70s or 80s with:
Scalp tenderness, first noticed when combing the hair - Headache (frontal, occipital or temporal areas, or more generalized)
- Jaw claudication = pain on speaking and chewing
- Polymyalgia rheumatica
( Muscle pain and stiffness)
GIANT CELL ARERITIS !!!
Signs ?
- Superficial temporal arteritis is characterized by thickened, tender inflamed and nodular arteries which cannot be flattened against the skull
GIANT CELL ARERITIS !!!
Ocular Signs ?
- Arteritic anterior ischaemic optic neuropathy (AION) most common symptom
- Transient ischaemic attacks (amaurosis fugax) may precede AION
- Cilioretinal artery occlusion
- Central retinal artery occlusion
- Diplopiatransient or constant c/b ischaemia of the ocular motor nerves or extraocular muscles
Signs?
Giant Cell Arteritis
[Arteritic Anterior Ischaemic Opic Neuropathy]
AION
