UveitisUveitis

UveitisUveitis

• Inflammation of one or all parts of Inflammation of one or all parts of the uveal tract. the uveal tract.

• Components of the uveal tract Components of the uveal tract include the iris, the ciliary body, and include the iris, the ciliary body, and the choroid.the choroid.

Classification of UveitisClassification of Uveitis

• AnatomicalAnatomical

• ClinicalClinical

• EtiologicalEtiological

• Pathological Pathological

Anatomical ClassificationAnatomical Classification

• Anterior uveitisAnterior uveitis– IritisIritis– IridocyclitisIridocyclitis

• Intermediate Intermediate uveitisuveitis

• Posterior uveitisPosterior uveitis

• PanuveitisPanuveitis

Clinical ClassificationClinical Classification

• Acute uveitisAcute uveitis

• Chronic uveitisChronic uveitis

Etiological ClassificationEtiological Classification

• Exogenous uveitisExogenous uveitis

• Endogenous uveitisEndogenous uveitis– Associated with systemic diseaseAssociated with systemic disease– Infections with bacteria, fungi, viruses, Infections with bacteria, fungi, viruses,

protozoans, or roundwormsprotozoans, or roundworms– Idiopathic specific uveitis entitiesIdiopathic specific uveitis entities– Idiopathic non specific uveitis entitiesIdiopathic non specific uveitis entities

Pathological ClassificationPathological Classification

• GranulomatousGranulomatous

• Non- granulomatousNon- granulomatous

When to investigate?When to investigate?

• One of the most pressing questions that arises in One of the most pressing questions that arises in the mind of every ophthalmologist who sees a the mind of every ophthalmologist who sees a new case of uveitis is "what is the cause of this new case of uveitis is "what is the cause of this disease?" In evaluating patients with uveitis, the disease?" In evaluating patients with uveitis, the ophthalmologist must consider that a lengthy list ophthalmologist must consider that a lengthy list of infections, autoimmune systemic diseases, of infections, autoimmune systemic diseases, distinctive inflammatory conditions and distinctive inflammatory conditions and masquerade syndromes may all cause uveal masquerade syndromes may all cause uveal inflammation. Despite this array of potential inflammation. Despite this array of potential diagnoses, the vast majority of patients have diagnoses, the vast majority of patients have disease that defies categorisation.disease that defies categorisation.

Clinical Features of UveitisClinical Features of Uveitis

• Anterior uveitisAnterior uveitis– Signs: Photophobia, pain, redness, Signs: Photophobia, pain, redness,

decreased vision, and lacrimationdecreased vision, and lacrimation– InjectionsInjections– Keratic precipitatesKeratic precipitates

•Endothelial dustingEndothelial dusting

•Medium KPMedium KP

•Large KPLarge KP

•Old KPOld KP

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• Iris nodulesIris nodules– KoeppeKoeppe– BusaccaBusacca

• Aqueous cellsAqueous cells– 5-10 cells= +15-10 cells= +1– 11-20 cells= +211-20 cells= +2– 21-50 cells= +321-50 cells= +3– >50 cells= +4>50 cells= +4

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• Aqueous flareAqueous flare– Faint- just detectable= +1Faint- just detectable= +1– Moderate- iris details clears= +2Moderate- iris details clears= +2– Marked- iris details hazy= +3Marked- iris details hazy= +3– Intense- with severe fibrinous Intense- with severe fibrinous

exudates= +4exudates= +4

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ComplicationsComplications

• Posterior synechiaePosterior synechiae– Seclusio pupillaeSeclusio pupillae– Iris bombeIris bombe

• Anterior vitreous cellsAnterior vitreous cells

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Intermediate UveitisIntermediate Uveitis

• Symptoms: intially floaters and later Symptoms: intially floaters and later impairment of visual acuityimpairment of visual acuity

• Signs: Cellular infiltration of vitreousSigns: Cellular infiltration of vitreous

• Complications: cystoid macular Complications: cystoid macular edema, cyclitic membrane formation, edema, cyclitic membrane formation, cataract and tractional retinal cataract and tractional retinal detachmentdetachment

Posterior UveitisPosterior Uveitis

• Symptoms:Symptoms:– FloatersFloaters– Impaired visionImpaired vision

• Signs:Signs:– Vitreous opacitiesVitreous opacities– ChoroiditisChoroiditis– Inactive lesionsInactive lesions– RetinitisRetinitis– Vasculitis Vasculitis

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• Three main types of posterior uveitis:Three main types of posterior uveitis:– UnifocalUnifocal– Multifocal Multifocal – GeographicalGeographical

TreatmentTreatment

• MydriaticsMydriatics

• SteroidsSteroids

• Immunosuppresants Immunosuppresants

MydriaticsMydriatics

MydriaticsMydriatics

• IndicationsIndications– To provide comfortTo provide comfort– To prevent formation of posterior To prevent formation of posterior

synechiaesynechiae– To break down recently formed To break down recently formed

synechiae synechiae

SteroidsSteroids

• Mainstay of treatmentMainstay of treatment

• Dexamethasone, Bethamethasone, Dexamethasone, Bethamethasone, PrednisolonePrednisolone

SteroidsSteroids

ComplicationsComplications

• GlaucomaGlaucoma

• CataractCataract

• Corneal complicationsCorneal complications

• Systemic side effectsSystemic side effects

Immunosuppressive AgentsImmunosuppressive Agents

Uveitis associated with Uveitis associated with ArthritisArthritis

• Ankylosing spondylitisAnkylosing spondylitis– 22ndnd and 3 and 3rdrd decade of life decade of life– Gradual onset of chronic backache and Gradual onset of chronic backache and

stiffnessstiffness– HLA-B27HLA-B27– Ocular features: acute, recurrent, non Ocular features: acute, recurrent, non

granulomatous iritisgranulomatous iritis

Ankylosing SpondylitisAnkylosing Spondylitis

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Uveitis associated with Uveitis associated with ArthritisArthritis

• Reiter’s syndromeReiter’s syndrome– Episode of arthritis of more than 1 Episode of arthritis of more than 1

month durationmonth duration– (+) HLA-B27(+) HLA-B27– Triad: Urethritis, conjunctivitis & Triad: Urethritis, conjunctivitis &

seronegative arthritisseronegative arthritis– 33rdrd decade of life decade of life

• Ocular featuresOcular features– Bilateral mucopurulent conjunctivitisBilateral mucopurulent conjunctivitis– Acute anterior iritisAcute anterior iritis– Punctate epithelial keratitisPunctate epithelial keratitis

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Psoriatic arthritisPsoriatic arthritis

• Idiopathic, seronegative, chronic, Idiopathic, seronegative, chronic, anodular, erosive arthritisanodular, erosive arthritis

• HLA-B27, HLA-B17HLA-B27, HLA-B17

• Ocular features:Ocular features:– ConjunctivitisConjunctivitis– Acute iritisAcute iritis– KeratitisKeratitis– Secondary Sjorgen’s syndrome Secondary Sjorgen’s syndrome

Psoriatic ArthritisPsoriatic Arthritis

Juvenile Idiopathic ArthritisJuvenile Idiopathic Arthritis

• Idiopathic, inflammatory arthritis of at Idiopathic, inflammatory arthritis of at least 6 wks durationleast 6 wks duration

• Seronegative for IgM rheumatoid factorSeronegative for IgM rheumatoid factor

• Systemic onset: transient Systemic onset: transient maculopapular rash, generalized maculopapular rash, generalized lymphadenopathy, lymphadenopathy, hepatosplenomegaly and serositishepatosplenomegaly and serositis

• Pauciarticular onsetPauciarticular onset

• Ocular findings:Ocular findings:– AsymptomaticAsymptomatic– Uninjected white eye even in the Uninjected white eye even in the

presence of severe uveitispresence of severe uveitis– KPs are usually small to mediumKPs are usually small to medium– Posterior synechiaePosterior synechiae

• Treatment: topical steroidsTreatment: topical steroids

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Uveitis in Non- Infectoius Uveitis in Non- Infectoius systemic diseasesystemic disease

SarcoidosisSarcoidosis

– Common, idiopathic multisystem Common, idiopathic multisystem disorderdisorder

– Non caseating granulomataNon caseating granulomata– Presentation:Presentation:

•Acute onsetAcute onset

• Insidious onsetInsidious onset

SarcoidosisSarcoidosis

• Diagnostic tests:Diagnostic tests:– Chest x-rayChest x-ray– BiopsyBiopsy

• Ocular features: Ocular features: – Eyelid lesions- violaceous sarcoid Eyelid lesions- violaceous sarcoid

plaquesplaques– Anterior segment lesions- Anterior segment lesions-

keratoconjunctivitis siccakeratoconjunctivitis sicca

SarcoidosisSarcoidosis

• Anterior uveitisAnterior uveitis– Acute anterior uveitis- acute onset Acute anterior uveitis- acute onset

sarcoidsarcoid– Chronic granulomatous anterior uveitis- Chronic granulomatous anterior uveitis-

older patients with pulmonary sarcoidolder patients with pulmonary sarcoid

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SarcoidosisSarcoidosis

• Intermediate uveitisIntermediate uveitis– Vitreous cells and opacitiesVitreous cells and opacities

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SarcoidosisSarcoidosis

• Posterior uveitisPosterior uveitis– Retinal phlebitisRetinal phlebitis– Choroidal granulomasChoroidal granulomas– Retinal granulomasRetinal granulomas– Preretinal granulomasPreretinal granulomas– Optic disc granulomasOptic disc granulomas– Peripheral retinal granulomasPeripheral retinal granulomas

• Tx: SteroidsTx: Steroids

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Behcet diseaseBehcet disease

• Idiopathic disease that typically Idiopathic disease that typically affects men from the eastern affects men from the eastern Mediterranian and JapanMediterranian and Japan

• Third to fourth decade of lifeThird to fourth decade of life

Behcet diseaseBehcet disease

• Ocular findings:Ocular findings:– Acute recurrent anterior uveitisAcute recurrent anterior uveitis– RetinitsRetinits– Retinal vasculitisRetinal vasculitis– General vascular leakageGeneral vascular leakage– Vitritis Vitritis

Behcet diseaseBehcet disease

• Ocular features:Ocular features:– Acute recurrent iridocyclitisAcute recurrent iridocyclitis

• Posterior segment Posterior segment – Diffuse vascular leakageDiffuse vascular leakage– PeripheblitisPeripheblitis– RetinitisRetinitis– Vitritis Vitritis

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Behcet diseaseBehcet disease

• Treatment of posterior uveitisTreatment of posterior uveitis– Systemic steroidsSystemic steroids– ChlorambucilChlorambucil– CyclosporinCyclosporin– Plasma exchangePlasma exchange

Vogt-Koyanagi-Harada Vogt-Koyanagi-Harada SyndromeSyndrome• Idiopathic, granular, granulomatous Idiopathic, granular, granulomatous

panuveitispanuveitis• Vogt- koyanagi: Skin & hair changes with Vogt- koyanagi: Skin & hair changes with

anterior uveitisanterior uveitis– Alopecia, vitiligoAlopecia, vitiligo

• Harad disease: Neurological features and Harad disease: Neurological features and retinal detachmentretinal detachment– IrritationIrritation– encephalopathyencephalopathy– Auditory symptomsAuditory symptoms– CSF lymphocytosisCSF lymphocytosis

Vogt-Koyanagi-Harada Vogt-Koyanagi-Harada SyndromeSyndrome

• 3 phases:3 phases:1.1. Uveitic phaseUveitic phase

- Bilateral anterior uveitis- granulomatousBilateral anterior uveitis- granulomatous- Bilateral posterior uveitis- disc edema & Bilateral posterior uveitis- disc edema &

multifocal retinal detachmentsmultifocal retinal detachments

2. Convalascent- numerous residual, small 2. Convalascent- numerous residual, small mottled atrophic scarsmottled atrophic scars

3. Chronic recurrent- chronic 3. Chronic recurrent- chronic granulomatous anterior uveitisgranulomatous anterior uveitis

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Vogt-Koyanagi-Harada Vogt-Koyanagi-Harada SyndromeSyndrome

• Tx: Tx: – SteroidsSteroids– Immunosuppresants Immunosuppresants

Viral UveitisViral Uveitis

Herpes ZosterHerpes Zoster

• VZVVZV

• Remains latent in the primary Remains latent in the primary sensory gangliasensory ganglia

• Herpes zoster ophthalmicusHerpes zoster ophthalmicus

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SignsSigns

ComplicationsComplications

• Iris atrophyIris atrophy

• Secondary glaucomaSecondary glaucoma

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Cytomegalovirus RetinitisCytomegalovirus Retinitis

• Most common ocular infection in AIDS Most common ocular infection in AIDS patientspatients

• Clinical features:Clinical features:1.1. Indolent retinits- mild granular opacificationIndolent retinits- mild granular opacification

2.2. Fulminating retinitis- dense white geogrphical Fulminating retinitis- dense white geogrphical area of opcification associated with vasculitis area of opcification associated with vasculitis & mild vitritis& mild vitritis

3.3. Regression- fewer hemorhrrages, less Regression- fewer hemorhrrages, less opacification, diffuse atrophic and opacification, diffuse atrophic and pigmentary changespigmentary changes

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• Tx:Tx:– Systemic GancylcovirSystemic Gancylcovir– Intravitreal GancyclovirIntravitreal Gancyclovir– FoscarnetFoscarnet– CidofovirCidofovir

Mycobacterial UveitisMycobacterial Uveitis

TuberculosisTuberculosis

• Chronic granulomatous infection Chronic granulomatous infection caused by M. Bovis and caused by M. Bovis and M.tuberculosisM.tuberculosis

• Clinical features:Clinical features:– Chronic iridocyclitisChronic iridocyclitis– ChoroiditisChoroiditis– PeriphlebitisPeriphlebitis– Paneuvieitis Paneuvieitis

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LeprosyLeprosy

• Caused by M. LepraeCaused by M. Leprae

• 2 types:2 types:– LeprematousLeprematous– Tuberculoid Tuberculoid

• Ocular findings:Ocular findings:– Acute iritisAcute iritis– Chronic iritisChronic iritis

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