Diseases and DISORDERSOF UVEAL TRACT 1.ppt

Diseases of uvueal tract

1. DISORDERS OF UVEAL TRACT

2. Middle coat of eye: Iris,Ciliary Body, Choroid

3. •Anterior Uvea
Iris and Ciliary body
•Posterior Uvea
Choroid
•Intermediate uvea
Reffers to part of ciliary body called PARS PLANA

4. IRIS
•diaphragm that controls light entering eye by constricting or enlarging
•constriction governed by circumferential sphincter muscle controlled
by parasympathetic nervous system
•dilation governed by radial dilator muscle controlled by sympathetic
nervous system
•lined posteriorly by pigment epithelium
•anterior stroma made of collagen, muscle and pigment cells
•Color of iris governed by amount of pigment in stroma

5. •Color of iris varies from brown to blue
•Determined by the pigment the iris and RAYLEIGH scattering
•Just like the sky blue .
There is no blue or green pigment in the eye
Where pigment is completely absent iris appears red because of the
colour of haemoglobin as in albinos.

8. Lisch Nodules occur in more than 95%
casesof NF1 after age of 12

9. IRIS PEARLS OF LEPROSY

10. Iris Pearls of Leprosy

11. Brushfield spots of Downs syndrome

12. Koeppe and Bussaca nodules in
Granulomatous uveitis

13. CILIARY BODY
Ciliary body:has two components: secretory epithelium and muscle
• secretory epithelium manufactures aqueous fluid
•muscle controls accommodation, change in refracting power of lens
•when ciliary muscle contracts, zonules loosen, lens assumes more
rounded shape, which gives it more refracting power and allows eye
to focus on objects viewed at reading distance
•accommodation is gradually lost with aging ("presbyopia"); lens
stiffens and cannot react to loosening of zonules

14. Ciliary Body
•Gives attachment to lens through zonules
•Produces aqueous humour
•Drains aqueous humour
•Epithelium responsible for the Blood/Aqueous barrier
•Responsible for accommodation
•Pars plana safe route to the vitreous
•Located 3mm from limbus and is 4 mm wide
Vitreous surgery or Intravitreal injections Through the Pars Plana

17. UVEITIS:Inflammation of uveal tract
•Common disorder of uveal tract
•Causes painful red eye
•Causes red eye with reduced vision
Classification
• According to part involved
Iritis : iris involved
Cycitis : ciliary body inflammed
Iridocyclitis : iris and ciliary body inflammed
These forms also called anterior uveitis

18. •Choroiditis
Inflammation of choroid
•Retinochoroidis
Inflammation involves retina and then choroid
•Choroidoretinitis
Inflammation involves choroid and then retina
These are forms of Posterior uveitis
•Intermediate uveitis
Inflammation of ciliary body
•Panuveitis
Anterior and posterior uveitis
•According to whether Acute or Chronic
•According to: Granulomatous And None Granulomatous
Granulomatous inflammation there are Epitheliod cells

19. Other types of inflammation
•Panophthalmitis ; Suppurative inflammation of all coats of the eye
including intraocular contents
•Endophthalmitis suppurative Inflammation of intraocular structures

20. •Pathology of Acute Anterior Uveitis
• Vascular phase of inflammation
Increased blood supply leads to Ciliary Injection
Irritation of iris leads Vasodilatation and increased Vascular Permeability to formation
Protein Rich Exudate
•Normally aqueous humour has no protein.
•Presence of Protein causes AQUEAUS FLARE
•PLASMOID AQUEAUS: When protein is much aqueous becomes viscous may lead to
interference with drainage of Aqueous humor leading to SECONDARY GLAUCOMA

21. •Exudate causes distortion of PATTERN and color OF IRIS leading to a MUDDY IRIS
•Exudate irritates muscles of iris. The sphincter pupillea muscle is stronger Therefore the PUPIL IS
SMALL
• Oedema makes: Pupil Reactions Sluggish or Absent
•Oedema of iris makes it stick to neighbouring structures.
•Posterioly to the lens leading to POSTERIOR SYNECHIAE
•Whole iris margin stuck to lens causes TOTAL POSTERIOR SYNECHIA or RING SYNECHIAE
•Ring synechia causes SECLUSIO PUPILLAE
•In seclusio pupillae aqueous cannot flow from posterior chamber to anterior chamber leading to PUPIL
BLOCK . This may lead to raise of INTRAOCULAR PRESSURE and thus SECONDARY GLAUCOMA

22. •Total posterior synechia leads to bending forward of the iris like a funnel. Bending forward of
IRIS is called IRIS BOMBE
•Iris bombe may lead to PERIPHERAL IRIS to contact the cornea leading to Formation of
PERIPHERAL ANTERIOR SYNECHIAE . this causes the CLOSURE OF ANNGLE OF ANTRIOR
CHAMBER and therefore raise of INTRAOCULAR PRESSURE : SECONDARY GLAUCOMA
•Changes occurring in the anterior chamber can lead to disturbance in the nutrition of the lens
leading to a COMPLICATED CATARACT
•FIBRIN DEPOSITION IN THE PUPILLARY AREA MAY LEAD TO OCCLUSIO PUPILLAE

23. Seclusio pupillae,Iris bombe,
PeripheralAnterior Synechia

24. Posterior Synechiae

25. Posterior Synechiae

26. Clover Leaf iris

27. Clover Leaf

28. Posterior Synechiae

29. Kps in ARLT
̕ s Triangle

30. •CELLULAR PHASE OF INFLAMMATIOM
• Margination of neutrophils and EMIGRATIN of cells by DIAPEDESIS
• CELLS CAN BE SEEN IN THE ANTERIOR CHAMBER. PRESENCE OF CELLS
INDICATES THAT THE UVEITIS
• IS ACTIVE.
• Some of the cells are deposited on the back of the cornea.These are called
KERATIC PRECIPITATES KPs . Some may be large MUTTON FAT KPS. Some may
be small or medium size. Mutton fat Kps occur in Granulomatous iridocyclitis.
Small kps occur in None granulomatous iridocyclitis

31. Kps in ARLT
̕ s Triangle

32. Keratic Precipitates( Kps)

33. Hypopyon:Pus cell level in Anterior Chamber

34. Hypotony and Phthisis bulbi
•In cases of severe Cyclitis the ciliary body may stop producing
aqueous humour. This can lead to hypotony or low pressure in the
eye. Persistent Hypotony leads to shrinking of eyeball or PHTHISIS
BULBI

35. •SYMPTOMS OF ACUTE ANTERIOR UVEITIS
•PAIN In the Eye ball may be severe
•Photophobia
•Redness of the eye
•Reduced or loss of vision . May be mild or profound
•Tearing

36. Signs of acute Iridocyclitis
•Reduced vision
due to exudation in the anterior chamber and in vitereous chamber
lens involvement in form of opacities
Corneal haze due to Kps
Macular oedema
•Ciliary Tenderness
•Ciliary Injection
Maximum at limbus and fades towards fornix
Brick red
vessels are radial

37. •Anterior chamber may have hypopyon
•Iris pattern and colour distorted MUDDY IRIS
• Pupil small
•Koeppe nodules on pupillary margin
•Bussaca nodules in periphery
•Pupil may be irregular because of synechiae
•Pupil reactions to light sluggish or absent
•Exudate in pupillary area
•Lens may show pigment deposition
•Lens may show opacities
•Vitreous may show Haze

38. Slit lamp Examination
Small slit beam may show
•Aqueous flare
normally aqueous humour optically empty
•Cells in the anterior chamber
Sign that uveitis is Active
•Keratic Precipitates
small, medium or Mutton fat
Fresh kps greyish
Old kps pigmented

39. Signs of anterior uveitis

41. Panophthalmitis

42. Endophthalmitis

43. •COMPLICATIONS OF ANTERIOR UVEITIS
1.SECONDARY GLAUCOMA
• Caused by Posterior synechiae leading to pupil block
• Iris bombe causing anterior synechia and closing
• of the anterior chamber angle
• Plasmoid aqueous
• Trabeculitis

44. 2.COMPLICATED CATARACT
3.Band shaped keratopathy
4.Formation of Cyclitic membrane
5.Persistent Hypotony
•6. Phthisis Bulbi

45. •TREATMENT
Treat cause if known
• 1. ATROPINE EYE DROPS
• Dilates pupil : Breaks synechia which are
• formed
• Prevents formation of
• new synechiae

46. • Paralyses ciliary Muscle : CYCLOPLEGIA
• relieves pain and rests the eye
• Stabilises blood/Aqueous barrier
• This reduces exudation into the aqueous
• Frequency o application depends on severity
• of inflammation. Mild once a day. Severe TDS

47. 2.ANTINFLAMMATORY DRUG S : CORTICOSTEROIDS; To suppress the inflammation
• In severe cases use systemic and topical medication
• SYSTEMIC: Prednisolone tablets 1mg /kg body weight
• Once a day early in morning
• TOPICAL; Prednisone1% Eye or Dexamethasone 0.5% Eye
• drops applied 2 hourly depending on severity
•Very severe cases subconjunctival injection or subtenon injection

48. CAUSES OF UVEITIS
•Idiopathic
over 30% of cases cause is not known
•Associated with Diseases of Joints
Ankylosing spondylitis
Juvenile rheumatoid Arthritis( Pauci articular type)
Psoriatic Arthritis
Reactive Arthrits(formerly Reiters syndrome)
•Associated with GIT diseases
Regional Ileitis ( Crohns Disease)
Ulcerative colitis
Whipples Disease

49. Causeas of Uveitis
•Associted with viral infections
Herpes Simplex
Herpes Zoster
Rubella
Cytomegalovirus
•Fungal infections
Histoplasmosis
Coccidioidomycosis
Cryptococcus Neoformans
•Bacterial infections
Leprosy, Tuberculosis
•Parasitic infections
Onhocerciasis
Toxoplasmosis
Toxocariasis
•TRAUMA
Blunt trauma
Surgical Trauma
•Lens Induced
•Masquerade Syndrome
Retinoblatoma
malignant melanoma

50. HLA B27
•Histocampatibility antigen HLA B27
Associated with uveitis
Occurs in: PAIR
•Psoriatic Arthritis
•Ankylosing Spondylitis
•Inflammatory Bowel Disease
•Reactive Arthritis( Reiters Syndrome)
̒

51. POSTERIOR UVEITIS

52. •POSTEROR UVEITIS
•Signs and symptoms
•Usually Painless
•Presents with Loss of vision which is painless
•Flashes of light due to irritation of retina
•Floaters in the visual field
•Micropsia due to separation of Photoreceptors
•Macropsia due to crowding together of the photoreceptors
•Metamorphopsia alterd shape of objects e.g. straight lines may appear curved

53. •A patch of choroiditis
The retina appears hazy
Lesion is ill defined
Vitreous may be hazy
AS time goes the lesion becomes well demarcated
The lesion becomes white and it becomes pigmented
White appearance is sclera choroid having been destroyed
 

54. Old posterior uveitis

55. Choroiditis

56. SPECIAL FORMS OF UVEITIS

57. •Uveal meningeal syndromes
Vogt Koyanagi Harada Disease
Also called the oto- oculo- cutaneous syndrome
• Bilateral exudative retinal detachment;
• Severe anterior uveitis
•Signs of meningeal irritation
•Hearing loss, whitening of the eyelashes and eyebrows

58. Heterochromic iridocycyclitis of Fuchs

59. SYMPATHETIC OPHTHALMITIS
 
Severe uveitis which occurs in the second eye
after one eye is badly ruptured or injured
especially in the region of ciliary body.
It is a panuveitis. IF the injured Eye removed
within two weeks of injury it does not occur. It
is a rare disease.
 

60. •Behcets Syndrome
There is a generalised vasculitis
Characterised by
•Recurrent Painful mouth ulcers
•Recurrent Painful genital ulcers
•Skin lesins: papulopustular lesions
Erythema nodosum
•Positive Pathergy test:pustule develops after subcutaneous injection
•SEVERE UVEITIS with a hypopyon

61. Mouth ulcers

62. Juvenile Rheumatoid Arthritis
•Three modes of presentation of Rheumatoid arthritis in children
•Polyarticular type:
Five or more joints affected
•Pauciarticular type
Less than five joints affected
•Systemic disease with Fever ,hepoatosplenomegaly and arthritis ….. Also called STILL´S disease
Uveitis most likely in the Pauciarticular type
Cataract, Uveitis , Band Keratopathy in a young girl suggestive of Rheumatoid Arthritis
In adults Rhuatoid arthritis causes
Keratoconjunctivitis sicca, Episcleritis, scleritis , or Scleromalacia Perforans