3Introduction Uveitis : inflammation of uveal tract (iris, ciliay body & choroid)It is classified anatomically toAnt.uveitis (iritis)inflammation of iris accompanied by increased vascular permeability which allow both protein & WBCs to extravasate into the aqueous.2 types : granulomatous (Sarcoidosis,Syphilis, Vogt-Koyanagi-Harada disease Sympathetic ophthalmi Multiple sclerosis Lyme disease Tuberculosis.) nongranulomatous.circulating White cells could be seen in the aqueous humor of Ant. Chamber using a slit lamp.Protein which leaked from BV is picked out by itslight scattering properties appear as “flare” in the beam of slit lamp.
4Anterior Uveitis with hypopyon in a patient with IBD
52. Intermediate uveitisInflammation of ciliary body (cyclitis),of the pars plana (pars planitis) and of the vitreous (vitritis)3. Posterior uveitisInflammation of posterior uvea May also involve the choroid(choroiditis) or retina(retinitis)Panuveitis :its when inflammatory changes involve the anterior chamber,vitreous,retina and/or choroid.
6Incidence 15/100000 (75% ant.uveitis) 8/100000 in US EpidemiologyIncidence 15/ (75% ant.uveitis)8/ in US50% of pts have ass. Systemic dis.
7pt come to clinic complaining of: Hx.pt come to clinic complaining of:ocular pain (less frequent with post.U)Abrupt onset dull aching eye pain worsen when touch the eye through eye lid, may refered to temple or periorbital regionPhotophobiaBlurring of vision Redness of the eyeMostly unilateral
9visual acuity may reduced ciliary injection:mostly around limbus Signsvisual acuity may reducedciliary injection:mostly around limbusAnterior uveitis:Keratitic precipitatesinflam. Cells maybe visible as clumps on endothelial of cornea (mostly Inferior)On slit lamp exam.flare & hypopyon in severe inflam.Hypopyon highly suggestive for HLAB27 related & less commonly with infectious iritis.ciliary injection peripheral hyperemia of the anterior ciliary vessels which produces a deep red or rose color of the corneal stroma, and must be distinguished from hyperemia of the conjunctival vessels. May spread to the perilimbic corneal tissue. Called also ciliary flush
10Dilated vessels on iris Posterior synechia……….iris adhere to lensElevated IOP(inc aqeous protein or due to occlusion of drainage angle by PAS)
11Intermediate and posterior uveitis Cells in the vitreousRetinal or choroidal foci of inflammationMacular edema
12Gading of aqueous cells Grading of flare(flare refers to liberated protein from the inflamed iris or ciliary body which gives the aqueous a particulate, or smoky, appearance.)Gading of aqueous cellstrace……………… cells+1 …………………+2 …………………+3 ……………………+4 …………………….. >50Completely absentBarely present+1moderate+2marked+3Intense (fibrin)+4
14SignsKP: fibrous deposits on the posterior surface of the cornea, usually associated with uveitis.Both the size and distribution of keratic precipitates are helpful in the differential diagnosis.White, yellowish greasy precipitates of inflammatory cellsTypically distributed in a wedge-shaped region on the inferior corneal endothelium, known as Arlt's triangle
15Signs annular s. — adhesion of the whole rim of the iris to the lens. anterior s. — adhesion of the iris to the cornea.peripheral anterior s. — adhesion of the peripheral iris to the cornea.posterior s. — adhesion of the iris to the capsule of the lens or to the surface of the vitreous body.total s. — adhesion of the whole surface of the iris to the lens.
18Aim : determine systemic association InvetigationsAim : determine systemic associationInvestigation guided by past medical Hx & review of system:Pt with first episode of nongranulomatus iritis with unremarkable past medical Hx & review of system…so investigations not indicatedRecurrent persistant iritis with unusual severity, unresponsive to medical therapy or bilateral……….so here investigation is needed* At minmum CXR , RPR (rapid plasma reagin) test & fluorescent treponemal antibody absorption (FTA-ABS FTA-ABS) should be ordered
19ACE test , lysozyme level & ESR for evaluating sarcoidosis HLA B27 typingRF & ANA if we suspect juvenile idiopathic arthritis
20Imaging studies1. CXR to rule out sarcoidosis & TB2. chest CT done if we have –ve CXR butsarcoidosis still highly suspected3. Sacroiliac radiograph , if AS is suspectedProceduresif patient have secluded pupil from extensive post. Synechia , iris bombe with closed angle glucoma ……..here iridotomy maybe needed
21Etiology Individual forms of uveitis may be distinguished on the basis of location within the eye, onset, symmetry and continuity of inflammation, associated complications, and distribution of cells along the corneal endothelium.
22Etiology Infections Systemic immune-mediated disease (40%) Syndromes confined primarily to the eyeMasquerade syndromes30% of patients don’t fit an well-defined disease category .
23InfectionsCytomegalovirus (CMV) in adults is found almost exclusively in the immunocompromised host, especially patients with HIV infection who have extremely low CD4 countsToxoplasmosis is a surprisingly common cause of uveitis in the normal host. In many instances, it is presumed to be a reactivation of a congenitally acquired infection. It is suspected on the basis of a typical chorioretinal lesion; the diagnosis is supported by serology. Most chorioretinal scarring from toxoplasmosis is due to infection during gestation, but scarring is increasingly recognized as a result of recent infection . Patients may complain of hazy vision and floaters.retina is the target choroiditis is secondary.Syphilis accounts for less than 1 percent of patients with uveitis in most large series. It may present in a variety of forms, including posterior uveitis, such as a chorioretinitis or retinal vasculitis
26InfectionsTuberculosis is an uncommon cause of uveitis in North American referral centers. It should be considered in the differential diagnosis when the uveitis worsens despite glucocorticoid therapy. Additional factors that raise suspicion for this diagnosis are active tuberculosis elsewhere in the body, cachexia, homelessness, a granulomatous appearance for the ocular inflammation, or immunosuppression. In some geographic areas such as Saudi Arabia, tuberculosis is considered a common cause of uveitis.Both herpes simplex and herpes zoster can cause a keratouveitis, an inflammation of the cornea along with uveitis that is primarily anterior. The presence of cutaneous vesicles, characteristic corneal changes, reduced corneal sensation, elevated intraocular pressure, and iris atrophy may be clues to the diagnosis. Both herpes simplex and zoster can also cause a retinitis known as acute retinal necrosis. This is a rare but treatable cause of visual loss.
27Iris atrophy in a patient with herpes simplex virus–associated anterior uveitis.
28Immune-mediated systemic disorders Spondyloarthritides (SpA), such as ankylosing spondylitis and reactive arthritis, are the most common systemic immune disorders associated with uveitis in North America and Europe20-40 %Male >femaletypically unilateral, and tends to resolve within three months of its onset. Recurrences are common, and can occur in the contralateral eye.The prognosis for this form of uveitis is generally excellent provided that acute attacks are treated early and vigorousely
29ASFibrin clot and posterior synechiae in a patient with acute, anterior uveitis and ankylosing spondylitis.
30Immune-mediated systemic disorders 7% psoriatic arthritis and 2 to 9 % of patients with IBD may develop uveitis.uveitis associated with IBD or psoriatic arthritis is frequently bilateral, posterior to the lens, insidious in onset, chronic in duration, and more common in females than males .In 10 of 17 patients in one series, the uveitis preceded signs of IBDSarcoidosis accounts for a significant percentage of patients with uveitis in most series from referral centers .Approximately 20 % develop eye disease as their initial presentation of sarcoid.The eye disease can take on many forms, including uveitis, dry eyes, optic neuritis, lid inflammation, or orbital disease .Uveitis in patients with sarcoid is frequently associated with retinal vasculitis, which may be either perivascular or involve retinal vascular changes The eye disease may persist despite the resolution of adenopathy [ (
31Immune-mediated systemic disorders as many as 80 percent of patients with Behcet's disease develop uveitis .Uveitis is often the dominant manifestation of this disease, and is typically bilateral. Similar to HLA-B27-associated iritis, it is frequently episodic, but unlike HLA-B27-associated disease, the uveitis generally does not resolve completely between episodes. Retinal vasculitis is a frequent manifestation of Behcet's disease .The uveitis typically leads to blindness if the eye inflammation is not treatedJuvenile idiopathic arthritis (JIA) may be associated with uveitis, particularly in the subset of patients with pauciarticular disease and a positive antinuclear antibody. The onset of uveitis is more common in younger children and, in the majority of patients, can be asymptomatic. (white eye but wuth signs of uveitis present ) The uveitis associated with JIA is usually bilateral, insidious in onset, chronic in duration, and anterior. The eye disease is commonly associated with complications such as band keratopathy, posterior synechiae , cataract formation, and glaucoma. The uveitis sometimes lasts for decades, long after the joint disease has disappeared.
33Immune-mediated systemic disorders (SLE) can involve the eye in a variety of forms .Dryness is the most common ocular manifestation; cotton wool spots) occur in about 7 percent of patients and indicate local retinal ischemia .Anterior uveitis is a rare manifestation.'.)Uveitis is infrequently associated with other systemic vasculitides, including polyarteritis and granulomatosis with polyangiitis (Wegener’s). More typical vision-threatening manifestations of granulomatosis with polyangiitis (Wegener’s) are scleritis and orbital disease
34Vogt-Koyanagi-Harada is the second leading cause of uveitis in Japan after Behçet’s syndromeMultisystem disorderBilateral panuveitis with exudative retinal detachment followed by neurological and cutananeous manifestations (baldness and loss of lash and skin pigment)F>M20-50sProdromal stage(fever,headache,tinnitus and CSF pleocytosis),weeks later bilateral posterior uveitis and subsequebt datachment.few weeks later the daetachment subsides with pigmentary choriodal changes and depigmentation of the retina.
35VKH skin changes (vitiligo of the lashes and eyebrows)
36Fuchs heterochromic uveitis Rare , chronic ,young adultsUnknown cause , no systemic associationMild ant uveitis,no signs of conjunctival inflamation, no ant synechiaKPs diffusely distributed over the corneaHeterochromic iris due to loss of pigment epithelial cells.Inflamed vitreous70% catarctSteroids arent effective and not prescribed,catarct surgery is done when indicated,and patients usually respond well
37Sympathetic ophthalmitis rare, bilateral granulomatous uveitisafter either surgical or accidental trauma to one eye.The ocular inflammation in the fellow eye becomes apparent usually within 3 months after injury.Clinical presentation is an insidious or acute anterior uveitis with mutton-fat keratic precipitates.The posterior segment manifests moderate to severe vitritis, usually accompanied by multiple yellowish-white choroidal lesions. Evidence suggests that it represents an autoimmune inflammatory response against choroidal melanocytes mediated by T cells.Diagnosis is based on clinical findings and a history of previous ocular trauma or surgery. Other causes of granulomatous uveitis, such as Vogt-Koyanagi-Harada disease, sarcoidosis, tuberculosis, and syphilis should be considered.Treatment of sympathetic ophthalmia consists of systemic anti-inflammatory agents with high dose oral corticosteroid as the drug of choice.However, if the inflammation cannot be controlled, cyclosporine is then used. Other immunosuppressive agents, such as chlorambucil, cyclophosphamide or azathioprine, may be necessary for the control of inflammation.The role of enucleation after the diagnosis of sympathetic ophthalmia remains controversial. Visual prognosis is reasonably good with prompt wound repair and appropriate immunomodulatory therapy.
38TreatmentAims:1. relief pain & inflammation2. prevent ocular structural damage3. prevent visual loss & retinal or opticdamageMedication:cycloplegiaLong acting cycloplegic agents (cyclopentolate , hematropine )used to relief pain& photophobia by medriasis .
39Corticosteroids1. Topical , is the mainstays of therapy used aggressively esp. in initial phases of therapy ,if no response in 7-10 days we use :2. subconjunctival injection (celestone) , used if pt poorly complies to topical type or iritis not respond to topical ttt alone3. oral corticosteroid maybe necessary in severe cases of iritis and post uveitis
40Topical aqueous suppressant in case of elevated IOPLittle or No benefit of using NSAIDS in iritis
41Ant.uveitis:dilating pupil to prevent synechia (homatropine , cyclopentolate or atropine drops)To break synechia1. initially …….intensive cyclopentolate ,phenylphrene or tropicamide drops2. if resistant synechia …. Subconjuctivalmydriatics
42post.Uveitis:visual loss occur due to destructive process by retinitis or macular edema due to fluid acumulation…………. So here we use antiviral, antibiotics or systemic steroidssome rare severe uveitis may need other immunesuppresive agents (Azathioprine, cyclophosporin)
43Follow up:* reexamine pt 2-3 wks later to ensure no residual inflammation presentComplication* recurrent episodes of iritis & the subsequent therapy may lead to cataract or glucomaPrognosis* Most pt expect to have recurrent iritis.* Visual prognosis is good in absence of either cataract or glucoma.
44Specific conditions ass. with uveitis PrognosisTreatmentInvestigati-onsSignsHxDiseaseRecuurent attacksBut good for visionOcular tttAnti-inflammatorphysiotherapyHLAB27Sacroili-acX-rayTypical signs ofAnt.uveitisStifness at restBackacheAS40% withAcute ant uveitisMale , HLAB27Urethritis , arthritis, conjunctivitisRieter’sdiseaseSystemic ttt of arthritisANAWhite eye70% shows bilateralChronicasymptomatic ant. UveitisProfound visual defectJuvenile chronic arthritisNot respond to steroidRespond to cataract surgeryMild ant. uveitisHeterochromic irisCatract 70%Glucoma,KPs,No post. SynechiaBlurred vision & floaters(not present with typical iritis Hx.)Fuch’sHeterochromic uveitis
45Treatment investigations Signs Hx Dis. Systemic steroid&clindamycin+ve toxoplasmosisAntibody test is suggestiveCreamy foci ofInflammatoryCells at the marginAt the margin of chorioretinal scarMostly Congenital(50-75%)Hazy vision , floaters , red & painful eyeToxoplasmosis