Anterior uveitis

1. Anterior Uveitis Dr.Gayatree Mohanty KIMS, BBSR,Orissa

2. Definition Inflammation of the uveal tract from the iris upto the plars plicata of ciliary body

3. Classification Iritis Iridocyclitis Cyclitis

4. Clinical Features Acute: Symptoms more severe Chronic: Signs more severe than signs

5. 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

6. Signs Lid Edema

7. Ciliary Congestion

8. 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

9. Keratitic Precipitate

10. AC Signs: Aqueous Cells and Flare

11. Anterior Chamber Signs: Aqueous cells Early sign On oblique illum.:3mm long 1mm wide slit with max light and magnifications Grading: 0 :0 cell +_ : 1-5 cell 1+ : 6-10 cells 2+: 11-20 cells 3+ : 21-50 cells 4+ : >50

12. Anterior Chamber Signs: Aqueous Flare D/t leakage of protein into the AC from the leaky vessels On oblique illum .: a point of beam projected on the iris plane Protein particles seen floating the beam of light: Tyndall phenomenon Marked in NGU Grading: 0 : No flare 1+ : Just detectable 2+: Moderate flare with clear detail view of iris 3+ : Marked flare with iris details not clear 4+ : Intense flare with no view of iris details

13. Hypopyon : Sterile Pus in AC

14. AC signs Hyphema : Blood in AC Irregular AC depth d/t synechia Deposits of debris in AC angle Anterior synechia

15. Exudates in AC Angle

16. Iris Signs Loss of normal pattern Muddy in color in active stage & hyper/ hypopigmented Iris nodules: Aggregations of lymphyocytes and epitheloid cells.

17. Koeppe’s nodule; Bussacca’s nodule

18. Posterior Synechiae : Adhesion of post. Surf. Of iris to Ant. Surf of Lens

19. Posterior Synechiae : Segmental Annular Total

20. Sluggish Pupillary Reaction & Miosis

21. Irregular Pupil: Festooned Pupil

22. Fibrinous Exudate : Occulsio pupil

23. Ectropion Pupillae

24. Lens Signs Pigment dispersion on lens surface Fibrin exudates on lens surface Complicated cataract: Polychromatic lusture Bread crumb appearance

25. Complicated Cataract

26. Spill over anterior vitreous inflammation

27. Complications and Sequelae

28. Complicated Cataract

29. Secondary Glaucoma Early glaucoma: In active phase of disease Due to exudates & inflammatory cells in AC angle blocking the TM Decreased aqueous flow leading to increased IOP (Hypertensive Glaucoma)

30. Exudates in AC Angle

31. Late Glaucoma (Post Inflammatory Glaucoma): D/t pupillary block ( Seclusio Pupil/ Occlusio pupil) Causes Iris Bombe then occlusion TM Decreased aqueous outflow

32. Cyclitic Membrane: retrolental , fibrovascular membrane which stretches across the back of the lens

33. Choroiditis

34. Retinal Signs: Cystoid Macular Degeneration Macular Degeneration Serous Retinal Detachment Secondary Peripapilitis Retinae

35. Retinal Signs: Cystoid Macular Edema

36. Serous Retinal Detachment

37. Periphlebitis :

38. Papillitis

39. Band Keratopathy

40. Phthisis Bulbi Shunken Disorganized eyeball D/t chronic uveitis caused ciliary shock & reduced aqueous production….then hypotony ….shrunken disorganized globe

41. Differential Diagnosis Causes painful red eye Granulomatous & Non granulomatous Uveitis Etiological D/d

42. Causes of Red Eye Acute Conjunct ivitis Acute Iridocyclitis Acute Congestive Glaucoma Onset Gradual Usually gradual Sudden Pain Mild discomfort Moderate V 1 n. distribn . Severe Whole V n. distrib . Discharge Mucopurulent Watery Watery Colored haloes +/- -- +++ Vision Unaltered Impaired Severely impaired Congestion Conjunctival Ciliary Ciliary

43. Causes of Red Eye ( contd ) Acute Conjunct ivitis Acute Iridocyclitis Acute Congestive Glaucoma Tenderness Absent Marked Marked Pupil Normal Reacting Small,irregular Sluggish 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

44. 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

45. 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

46. 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

47. 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

48. 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.

49. Treatment: Non- specific treatment Local therapy Systemic therapy Specific Treatment T/t of Complications

50. Non-Specific Treatment: Local Therapy Cycloplegics Corticosteroids Broad spectrum antibiotics

51. 1.Cycloplegics Short acting cycloplegics : Tropicamide 1% e/d (3hrs) Cyclopentolate 1% e/d(24hrs) Long acting cycloplegics Homatropine 2% e/d(4days) Atropine sulphate 1% e/d (7-14days)

52. 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

53. 2.Corticosteroid: To reduce inflammation Commonly used steroids: Long acting: Dexamethasone Betamethasone Hydrocortisone Prednisolone Triamcinolone Short acting: Fluoromethalone Loteprednol Fluocinolone

54. Route of administration: Topical: Eye drops or eye ointments 6times a day Anterior subtenon injection For severe cases

55. Broad spectrum antibiotic Doesn’t have much role in anterior uveitis

56. Systemic Therapy Corticosteroids Non-Steroidal Anti-inflammatory Drugs(NSAIDS) Immunosupressives

57. Corticosteroids Indication: Intractable anterior uveitis Prednisolone : 1mg/ kgbdwt & taper gradually according to response Side effects: Glaucoma & Cataract

58. Non- Steroidal Anti-inflammatory Drugs: Used when steroid are contraindicated or not tolerated. Phenylbutazone & oxyphenylbutazone

59. Immunosuppressives In corticosteroid resistant or intolerant cases In specific inflammations: Behcet’s syndrome Sympathetic ophthalmitis VKH Pars planitis

60. Specific Treatment Tuberculosis: ATT Parenteral Penicillin:Syphilis HSV: Acyclovir

61. Treatment of Complication : Inflammatory Glaucoma: Timolol 0.5% BD & T.Acetazolamide 250mg BD Contraindicated 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 bulbi Enucleation