Uveitis

Uveitis

1. OPHTHAL MOLOGY SG D PRESEN TATION

2. Presented By Bismita Patgiri (09) Arko Probho Chattopadhyay (03) Nitika Sharma (04) Pratiksha Baruah (06)

3. EYE- ANATOMY

4. - It refers to the inflammation of the uveal tissue. The inflammatory process may involve predominantly anterior ,intermediate or posterior uvea although there is always some associated inflammation of the adjacent structure such as retina, vitreous, sclera and cornea. Intraocular Inflammation/ Uveitis

5. Anatomy - Uvea

6. ANTERIOR UVEITIS/IRIDOCYCLITIS CLINICAL FEATURES- SYMPTOMS- PAIN - It is dominant symptom of acute anterior uveitis . Dull, aching and throbbing Usually referred along the distribution of CN V REDNESS- Occurs due to circumcorneal congestion , which is a result of active hyperemia of anterior ciliary vessels due to toxin , histamine and histamine like substances. PHOTOPHOBIA AND BLEPHAROSPASM- Occurs due to a reflex between sensory fibres of irritated CN V and motor fibres of CN VII supplying the orbicularis oculi .

7. LACRIMATION Occurs as a result of lacrimatory reflex mediated by CN V( afferent) and CN VII (efferent) DEFECTIVE VISION Defect may vary from a slight blur in early phase to marked deterioration in late phase Factors responsible: Induced myopia due to ciliary spasm Corneal haze due to edema and KPs Aqueous turbidity Pupillary block due to exudates Complicated cataract Vitreous haze Cyclitic membrane Associated macular edema Paplillitis Secondary glaucoma

8. B. SIGNS- Lid edema Circumcorneal congestion Corneal sign Corneal edema Keratic precipitates ( pathognomic ) Posterior corneal opacity (chronic cases) Anterior chamber signs Aqueous flare (earliest sign) Aqueous cells Hypopyon Changes in the depth and shape of anterior chamber due to synechiae formation Changes in the angle of anterior chamber Iris signs Loss of normal pattern Changes in iris color Iris nodule : Koeppe’s nodule and Busacca’s nodule

9. Posterior synechiae : These are adhesions between posterior surface of iris and anterior surface of lens. Rubiosis iridis Pupillary signs : Narrow pupil Festooned pupil Ectropion pupillae Sluggish pupillary reaction Occlusio pupillae Lens : Pigment dispersal on anterior capsule Exudate deposition Complicated cataract Vitreous & Retina : Presence of exudate and inflammatory cells. Cystoid macular edema. IOP : Normal Increased Decreased

10. INTERMEDIATE UVEITIS/ PARS PLANITIS SYMPTOMS : Asymptomatic in many cases Floaters : most common presentation Blurring and decreased vision Absence of : pain, redness, photophobia and posterior synechiae . B. SIGNS : Anterior segment : Low grade flare and cells Few KPs Posterior segment : Vitreous cells Snowball/ cottonball opacities Snowbanking ( hallmark) Severe vitreous opacification Chronic macular edema

11. POSTERIOR UVEITIS SYMPTOMS : a. Defective vision : due to - vitreous haze (mild) central choroiditis (severe) b. Photopsia : due to irritation of rods and cones c. Floaters : d. Metamorphopsia : due to alteration in the retinal contour caused by rays patch of choroiditis e. Micropsia & Macropsia f. Positive scotoma

12. B. SIGNS : 1. Anterior segment : Usually no external signs but fine KPs may be found. 2. Vitreous opacities : Usually present in the medial or posterior part Fine/coarse/stringy/snowball 3. Patch of choroiditis : Active patch – Pale yellow / dirty white raised area Ill defined edges Due to exudation and cellular infiltration Typically deeper to retinal vessels.

13. Healed patch – Sharply defined Delineated from the rest of normal area The involved area shows white sclera below the atrophic choroid and black pigmented clumps at the periphery

14. Clinical Signs Of Granulomatous and Non Granulomatous Inflammation Of Uvea

15. Features Granulomatous Non Granulomatous Onset Insidious Acute Pain Minimal Marked Photophobia Slight Marked Ciliary Congestion Minimal Marked Keratic Precipitates ( KPs ) Mutton Fat Small Aqueous Flare Mild Marked Iris nodules Usually Present Absent Posterior Synaechiae Thick & Broad based Thin & tenous Fundus Nodular Lesions Diffuse involvement

16. A. Lid Edema – usually mild. B. Circumcorneal Congestion – Marked in Acute iridocyclitis . Minimal in Chronic Iridocyclitis C. Corneal Signs : 1. Corneal Oedema : Due to toxic endothilitis & raised IOP When present. 2. Keratic Precipitates : ‘ Pathognomic Sign ’ of Anterior Uveitis . Proteinaceous cellular deposits at Corneal endothelium. Arlt’s Triangle Keratic Precipitates

17. Types Of KPs Mutton Fat KPs Granular KPs Stellate KPs Old KPs 3. Posterior Corneal opacities - Long standing cases of iridocyclitis D. Anterior Chamber Signs : 1. Aqueous Flare – Earliest sign of acute anterior uveitis . Due to leakage of protein particles in aqueous humor.

18. 2. Hypopyon - Heavy & thick exudates settle down in lower part of the anterior chamber. Cold H ypopyon Dense Immobile H ypopyon Haemorrhagic H ypopyon 3. Changes in Depth & shape of anterior chamber may occur due to synechiae formation. 4. Changes in angle of anterior chamber. Marked in Non granulomatous Uveitis . Minimal in Granulomatous Uveitis .

19. E. Iris Signs 1. Loss of normal pattern : Due to edema & waterlogging of Iris in active phase. Due to Atropic changes in chronic phase. 2. Change in Iris Colour : Muddy in active phase. Hyperpigmented / Depigmented in healed stage. 3. Iris Nodules: typically in Granulomatous uveitis Koeppe’s Nodules Busacca’s Nodules

20. F . Pupillary Signs- 1. Narrow Pupil- In Acute attack Of Iridocyclitis . 2. Irregular Pupil Shape- Festooned Pupils 3. Ectropion Pupillae - evertion of pupillary margin 4. Sluggish Pupillary reaction 5. Occulsio Pupillae Segmental Posterior Synechiae Annular Posterior Synechiae Total Posterior Synechiae 5.Neovascularisation Of Iris ( Rubeosis Iridis ) 4. Posterior Synechiae -

21. G. Changes in the Lens 1. Pigment Dispersal- universal occurrence in anterior uveitis . 2. Exudates - Acute Plastic iridocyclitis . 3. Complicated Cataract - Typical feature , Polychromatic Luster & Bread crumb Appearance of early posterior subcapsular opacities. H . Changes In Vitreous & Retina . 1. Exudates and inflammatory cells. 2. C ystoid Macular Edema. I. IOP may be normal , Increased ( Secondary glaucoma) or Decreased.

22. Granulomatous Uveitis Tubercular Uveitis Aquired Syphilitic Uveitis Leprotic Uveitis Sarcoidosis Non- Granulomatous Uveitis Behcet’s Disease Reiter’s syndrome Juvenile Idiopathic Arthritis Ankylosing Spondylitis

23. Classifications and Investigations of Uveitis

24. Classifications of Uveitis Anatomical classification Clinical classification Pathological classification Etiological classification

25. Anatomical classification Anterior uveitis Iritis Iridocyclitis Anterior cyclitis Intermediate uveitis Posterior uveitis Choroiditis Chorioretinitis Retinochoroiditis Neuroretinitis Panuveitis

26. Clinical classification Acute uveitis Sudden symptomatic onset Duration- 6 weeks to 3 months Chronic uveitis Insidious and asymptomatic onset Duration- longer than 3 months to years Recurrent uveitis Repeated episodes separated by inactive periods of more than 3 months

27. Pathological classification Suppurative or Purulent uveitis Nonsuppurative uveitis Nongranulomatous uveitis Granulomatous uveitis

28. Infectious uveitis Bacterial Viral Fungal Parasitic Rickettsial Masquerade syndromes Non- neoplastic Neoplastic Non-infectious uveitis Immune-related Microbial allergic Autoimmune HLA associated Anaphylactic Atopic Uveitis associated with non-infectious systemic diseases Toxic Traumatic Idiopathic Etiological classification

29. Investigations for Uveitis Ocular examinatio n

30. Haematological Investigations TLC and DLC ESR Blood sugar levels Blood uric acid Serological tests Syphilis Toxoplasmosis Histoplasmosis Other Tests: Antinuclear antibodies Rh factor LE Cells C- Reactive proteins HLA Typing for associated diseases like: HLA B-27 : Ankylosing spondylitis HLA B51 : Bechet disease

31. Urine examination for WBCs, pus cells, RBCs and culture Stool examination for cysts and ova Radiological examination X rays of chest, PNS, sacroilliac joints and lumbar spine CT Scan high resolution, of thorax for suspected Sarcoidosis MRI Scan of head for suspected Sarcoidosis , demyelination and lymphomas

32. Skin tests: Tuberculin test Kveim’s test for sarcoidosis Toxoplasmin test Lepromin test Pathergy test for Behcet’s disease Biopsy/ Intraocular fluid samples for examination : Aqueous samples for PCR Vitreous biopsy for culture and PCR Lungs and Lymph node biopsy for Sarcoidosis

33. DIFFERENTIAL DIAGNOSIS OF RED EYE AND TREATMENT OF ACUTE IRIDOCYCLITIS

34. RED EYE It is the final common response to any anterior segment disease

35. Distinguishing features between, acute conjunctivitis, acute iridocyclitis and acute congestive glaucoma:

36. FIG: IRITIS FIG: ACUTE ANGLE CLOSURE GLAUCOMA FIG: CONJUNCTIVITIS

37. TREATMENT OF IRIDOCYCLITIS Nonspecific treatment A. Local therapy (A) Cycloplegic drugs Very useful and effective during acute phase of iridocyclitis DRUGS – i . 1% atropine sufate eye ointment or drops Sig: 2-3 time/day-(2-3 weeks) Atropin allergy ii.2% homoatropin or 1% cyclopentolate eye drops sig: 2-4 times /day(2-3 weeks) iii. 0.25 mydricain (management of atropine,adrenalin procaine sub conjuctival injection)

38. Mode of action a. comfort and rest to the eye by relieving spasm of iris sphincter and ciliary muscle, b. prevents the forma tion of synechiae and may break the already formed synechiae , c. reduces exudation by decreasing hyperaemia and vascular permeability d. increases the blood supply to anterior uvea by relieving pressure on the anterior ciliary arteries. As a result, more antibodies reach the target tissues and more toxins are absorbed

39. (B) Corticosteroids administered locally, are very effective in cases of iridocyclitis . Drugs; dexamethasone , betamethasone,hydrocortisone or prednisolone Mode of action: Reduce inflammation by theiranti -inflammatory effect; anti-allergic (allergic type of uveitis ) antifibrotic activity, ( reduce fibrosis and thus prevent disorganisation and destruction of the tissues)

40. Route of administration: i ) eye drops 4-6 times a day, (ii) eye ointment at (bed time) (iii) Anterior sub- Tenon injection ( severe cases)

41. B. Systemic therapy i . Corticosteroids: In non- granulomatous . Iridocyclitis Indication - indicated in intractable anterior uveitis resistant to topical therapy. DRUGS - i ) high doses of prednisolone (60- 100 mg) or equivalent quantities of other steroids ( dexamethasone or betamethasone ) Regimes  Daily therapy regime- 2 weeks ( marked inflammatory activity)  Alt day therapy Regime,(absence of acute inflammation)  Tapering of dose of steroids is done by a week interval and tapered completely in 6-8 weeks in both the regime.

42. Complication of steroids - ocular(steroid induced glaucoma and cataract) - st (dyspepsia ,peptic ulcer, mental changes,worsening of diabetes, osteoporosis,cushingoid,electrolyte imbalance)

43. ii. NSAIDS  Aspirin, phenylbutazone , oxyphenbutazone (useful in uveitis associated with RA) M.O.A  Anti inflammatory action Naproxen  Patients with ankylosing spondylitis iii. Immuno -suppressive drugs  Extremely serious cases of uveitisIndications  Severe cases of Behcet's syndrome, VKH syndrome, Sympathetic ophthalmia , Pars planitis Drugs  cyclophosphamide , chlorambucil , azathioprine , methotrexate - cyclosporin powerful T anti-T cell immuno -suppressive drugs. iv) Azithromycin or tetracyclin or erythromycin  To treat chlamydial infections in patients.

44. c) Physical Measures (1) Hot fomentation  either by dry heat it wet heat  very soothing, pain decreases, circulation increases, venous stasis decreases (2) Dark Goggles These give a feeling of comfort, especially when used in sunlight, by reducing photophobia, lacrimation and blepharospasm . Specific treatment of the cause Non specific treatment described above is very effective and usually controls the uveal inflammation, in most of the cases, but It does not cure the disease, resulting in relapses. (a) Anti-tubercular drugs  Koch's disease (b) Treatment for syphilis, toxoplasmosis When no cause is ascertained  broad spectrum antibiotic

45. Treatment of complications Inflammatory glaucoma  0.5% timolol eye drops (twice a day)  Acetazolamide (250 mg thrice a day) ( ii) Post - inflammatory glaucoma (due to Ring Synechiae )  Laser iridotomy  Surgical iridotomy under high doses of corticosteroids (iii) Complicated Cataract  Requires lens extraction (iv) Cystoid Macular Oedema  Intravitreal injection of triamclnolone acetate (v) Retinal detachment Exudative type  self limiting if uveitis is treated aggressively Tractional  vitrectomy (vi) Phthisis Bulbi Painful and requires removal by enucleation operation

46. Thank You