ANTERIOR UVEITIS

Dr.Gayatree Mohanty

KIMS, BBSR,Orissa

DEFINITION

Inflammation of the uveal tract from the iris upto the plars plicata

of ciliary body

CLASSIFICATION

IritisIridocyclitisCyclitis

CLINICAL FEATURESAcute: Symptoms more severe

Chronic: Signs more severe than signs

SYMPTOMS Pain: Acute Severe Radiates along V1 nerve distribution Worst at night Redness: Photophobia Lacrimation Diminution of vision a.Turbid aqueous e. Sec. glaucoma b.Vitreous exudates f.Ciliary spasm c.Exudates in pupillary area g.Complic. Cat d.CME

SIGNS

Lid Edema

CILIARY CONGESTION

3. CORNEAL SIGNS:

Corneal edema d/t toxic endothelitis & increased IOP

Keratitis precipitates: Cellular deposits on the corneal

endothelium. Distributed in a base down

triangular area inferiorly (Arlt’s triangle)

Small, medium, large (mutton fat)

Posterior corneal opacities

KERATITIC PRECIPITATE

AC SIGNS: AQUEOUS CELLS AND FLARE

ANTERIOR CHAMBER SIGNS: AQUEOUS CELLSEarly signOn oblique illum.:3mm long 1mm wide

slit with max light and magnificationsGrading:0 :0 cell+_ : 1-5 cell1+ : 6-10 cells2+: 11-20 cells3+ : 21-50 cells4+ : >50

ANTERIOR CHAMBER SIGNS: AQUEOUS FLARED/t leakage of protein into the AC from the

leaky vessels On oblique illum.: a point of beam projected on

the iris planeProtein particles seen floating the beam of

light: Tyndall phenomenonMarked in NGUGrading:0 : No flare1+ : Just detectable2+: Moderate flare with clear detail view of iris3+ : Marked flare with iris details not clear4+ : Intense flare with no view of iris details

HYPOPYON: STERILE PUS IN AC

AC SIGNS

Hyphema: Blood in ACIrregular AC depth d/t synechia

Deposits of debris in AC angle

Anterior synechia

EXUDATES IN AC ANGLE

IRIS SIGNS

Loss of normal patternMuddy in color in active stage & hyper/ hypopigmented

Iris nodules: Aggregations of lymphyocytes and epitheloid cells.

KOEPPE’S NODULE; BUSSACCA’S NODULE

POSTERIOR SYNECHIAE: ADHESION OF POST. SURF. OF IRIS TO ANT. SURF OF LENS

POSTERIOR SYNECHIAE:

SegmentalAnnularTotal

SLUGGISH PUPILLARY REACTION & MIOSIS

IRREGULAR PUPIL: FESTOONED PUPIL

FIBRINOUS EXUDATE : OCCULSIO PUPIL

ECTROPION PUPILLAE

LENS SIGNS

Pigment dispersion on lens surface

Fibrin exudates on lens surface

Complicated cataract: Polychromatic lusture

Bread crumb appearance

COMPLICATED CATARACT

Spill over anterior vitreous inflammation

Complications and Sequelae

COMPLICATED CATARACT

SECONDARY GLAUCOMA

Early glaucoma:In active phase of diseaseDue to exudates & inflammatory cells in AC angle blocking the TM

Decreased aqueous flow leading to increased IOP (Hypertensive Glaucoma)

EXUDATES IN AC ANGLE

Late Glaucoma (Post Inflammatory Glaucoma):

D/t pupillary block (Seclusio Pupil/Occlusio pupil)

Causes Iris Bombe then occlusion TM

Decreased aqueous outflow

CYCLITIC MEMBRANE:retrolental, fibrovascular membrane which stretches across the back of the lens

CHOROIDITIS

RETINAL SIGNS:Cystoid Macular Degeneration

Macular DegenerationSerous Retinal Detachment

Secondary Peripapilitis Retinae

RETINAL SIGNS: CYSTOID MACULAR EDEMA

SEROUS RETINAL DETACHMENT

PERIPHLEBITIS:

PAPILLITIS

BAND KERATOPATHY

PHTHISIS BULBI

Shunken Disorganized eyeball

D/t chronic uveitis caused ciliary shock & reduced aqueous production….then hypotony….shrunken disorganized globe

DIFFERENTIAL DIAGNOSIS

1.Causes painful red eye

2.Granulomatous & Non granulomatous Uveitis

3.Etiological D/d

CAUSES OF RED EYEAcute Conjunct ivitis

Acute Iridocyclitis

Acute Congestive Glaucoma

Onset Gradual Usually gradual

Sudden

Pain Mild discomfort

ModerateV 1 n. distribn.

SevereWhole V n. distrib.

Discharge Mucopurulent Watery Watery

Colored haloes

+/- -- +++

Vision Unaltered Impaired Severely impaired

Congestion Conjunctival Ciliary Ciliary

CAUSES OF RED EYE (CONTD)Acute Conjunct ivitis

Acute Iridocyclitis

Acute Congestive Glaucoma

Tenderness Absent Marked Marked

Pupil NormalReacting

Small,irregularSluggish reacting

Dilated, vertically oval & fixed

Media Clear Hazy d/t KP,flare & pupillary exudate

Hazy d/t corneal edema

Anterior chamber

Deep Deep/ may be irregular

Very shallow

Iris Normal Muddy Edematous

CAUSES OF RED EYE (CONTD)

Acute Conjunct ivitis

Acute Iridocyclitis

Acute Congestive Glaucoma

IOP Normal Normal usually

Markedly raised

Constitutional symptom Assoc.

Absent Little Prostration & vomiting

GRANULOMATOUS & NON- GRANULOMATOUS UVIETIS

Granulomatous Non- Granulomatous

Onset Insiduous Acute

Pain Minimal Marked

Photophobia Slight Marked

Ciliary Congestion Minimal Marked

Keratitic Precipitate Large Mutton Fat Fine

GARANULOMATOUS & NON- GRANULOMATOUS UVIETIS

Granulomatous Non- Granulomatous

Iris nodule Koeppe’s & Bussaca’s nodules

Absent

Posterior Synechiae

Thick & broad based

Thin & tenous

Fundus Nodular lesion Diffuse lesions

WORK UP Hematological Examination TLC/DC: Gross idea of inflammatory response of body ESR: r/o Chronic infection Blood sugar: r/o DM Blood Uric Acid: r/o Gout Seological Test: Syphilis, toxoplasmosis &

histoplasmosis Test for: AntiAntinuclear Antibodies CRP Rh factor Anti-streptolysin O LE cells

WORK UP Urine Examination: For WBC, Pus cells, RBS Culture : r/o Urinary tract infection Stool Examination For Cysts & ova to r/o parasitic infestations. Radiological Investigation CXR,Paranasal sinus, Sacroiliac joints,Lumbar

spine. Skin Tests: Tuberculin test, Kveims test & Toxoplasmin

test.

TREATMENT:Non- specific treatment

Local therapySystemic therapy Specific TreatmentT/t of Complications

NON-SPECIFIC TREATMENT: LOCAL THERAPY

CycloplegicsCorticosteroidsBroad spectrum antibiotics

1.CYCLOPLEGICSShort acting cycloplegics:Tropicamide 1% e/d (3hrs)Cyclopentolate 1% e/d(24hrs)

Long acting cycloplegicsHomatropine 2% e/d(4days)Atropine sulphate 1% e/d (7-14days)

MODE OF ACTIONS OF CYCLOPLEGICS

Relieves pain: Relieves spasm of iris sphincter & ciliary m.

Prevents posterior synechiae formation

Breaks posterior synechiae Reduces hyperemia & vascular permeability which reduces exudation

2.CORTICOSTEROID: TO REDUCE INFLAMMATIONCommonly used steroids:Long acting: Dexamethasone Betamethasone Hydrocortisone Prednisolone TriamcinoloneShort acting: Fluoromethalone Loteprednol Fluocinolone

ROUTE OF ADMINISTRATION:

Topical: Eye drops or eye ointments

6times a dayAnterior subtenon injection For severe cases

BROAD SPECTRUM ANTIBIOTIC Doesn’t have much role in anterior uveitis

SYSTEMIC THERAPY

CorticosteroidsNon-Steroidal Anti-inflammatory Drugs(NSAIDS)

Immunosupressives

CORTICOSTEROIDSIndication: Intractable anterior uveitis

Prednisolone: 1mg/kgbdwt & taper gradually according to response

Side effects: Glaucoma & Cataract

NON- STEROIDAL ANTI-INFLAMMATORY DRUGS:

Used when steroid are contraindicated or not tolerated.

Phenylbutazone & oxyphenylbutazone

IMMUNOSUPPRESSIVESIn corticosteroid resistant or intolerant cases

In specific inflammations:

Behcet’s syndromeSympathetic ophthalmitis

VKHPars planitis

SPECIFIC TREATMENT

Tuberculosis: ATTParenteral Penicillin:Syphilis

HSV: Acyclovir

TREATMENT OF COMPLICATION:

Inflammatory Glaucoma:Timolol 0.5% BD & T.Acetazolamide 250mg BDContraindicated are Latanoprost & Pilocarpine. Post-inflammatory Glaucoma(d/t ring

synechiea):Laser iridotomy Complicated Cataract: Cataract sx. After 3mths of quiet period. Retinal Detachment:Anterior vitrectomy Phthisis bulbiEnucleation