Uveitis

Uveitis is an interesting disease of the with such a varied and diverse pathogenesis, various systemic causes and Dangerous complications in relation to the eye which makes it difficult and challenging to treat in a proper way. I hope this share will help.

1. Uveitis By Husain J. Patanwala 3 rd year, B.Optom

2. Introduction Inflammation of the uveal tract with associated inflammation of the adjacent structures such as cornea, sclera, vitreous and retina Classification Anatomical Clinical Pathological Aetiological

3. Anatomical Anterior Uveitis: Iritis Cyclitis Iridocyclitis Intermediate Uveitis : inflammation of posterior part of ciliary body and extreme periphery of retina (pars planitis ) Posterior uveitis : inflammation of choroid ( chorioiditis ) and or associated inflammation of retina ( chorioretinitis ) Panuveitis : inflammation of whole uvea

4. C linical Acute uveitis : sudden symptomatic onset , last for six weeks or more Chronic uveitis : insidious and asymptomatic onset ,last for more than three months or even years Pathological Granulomatous Non Granulomatous Etiological Infective uveitis Allergic uveitis Toxic Uveitis Idiopathic Uveitis Uveitis associated with systemic diseases

5. Non granulomatous Uveitis due to tissue invasion by leptospirae represents the manifestation of non granulomatous uveitis It is acute ,occurring due to physical and toxic insult to the tissue The alterations consists of dilatation and increase permeability of vessels, breakdown of blood aqueous barrier and infiltration of lymphocytes, plasma cells and large macrophages of the uveal tissue As a consequence mobility is reduced, pupil becomes small due to sphincter irritation and engorgement of iris vessels Etiopathogenesis

6. b) Granulomatous : Chronical inflammation of proliferative nature due to irritant foreign body, a haemorrhage or a necrotic tissue in the eye Characterized by infiltration with lymphocytes and proliferation of large mononuclear cells which aggregate into nodules Necrosis of adjacent structures leads to reparative process resulting in fibrosis and gliosis of the involved area

7. Feature Granulomatous Non granulomatous Onset Insidious and Chronic course Acute and symptomatic Pain Mild Marked Photophobia Slight Marked Ciliary congestion Minimal Marked Keratic precipitates Mutton fat type of KP’s Fine KP’s Aqueous flare Mild Intense flare, often with heavy fibrinous exudates Iris nodules Usually present Absent Posterior synechia Thick and broad based Thin Fundus Nodular lesions Diffused Area Anterior uvea and choroid retina are equally involved Mainly limited to anterior uvea

8. Anterior uveitis Clinical picture: Symptoms:- Pain Redness Photophobia Lacrimation Dimness of vison

9. Ocular signs : Circumcorneal congestion Corneal signs: The KP’s (cellular deposits on the endothelium) are small, medium, large mutton fat KP’s arranged base down at the lower part of the cornea due to gravitation Fresh KP’s; round white and hydrated Old K P ’s; shrunken, pigmented, haloes surrounding them

10. Anterior chamber signs Aqueous cells: cells should be counted in oblique slit lamp beam Aqueous flare: d ue to leakage of protein into the aqueous through the damaged capillaries causing tyndall effect Hypopyon: Sterile pus In the anterior chamber . Classically seen in B ehcets syndrome or infectious changes Hyphaema: Blood seen in herpetic and traumatic uveitis Aqueous Flare Grade Faint – just detectable +1 Moderate – iris details clear +2 Marked- iris details hazy +3 Intense with fibrinous exudates +4 Aqueous cells Grade <5 +/- 5-10 +1 11-20 +2 21-50 +3 50 +4

11. Depth and shape: deep and regular in posterior synachiae . Funnel shape in iris bombe While gonioscopy we see cellular deposits in active stage and peripheral anterior synachiae in chronic stage

12. Iris sign: Change in iris colour \ pattern : due to oedema and waterlogging of iris in active phase and due to atrophic changes in chronic phase. Fuchs heterochromic iridocyclitis . M uddy colour in active phase, hyperpigmented and depigmented areas in healed stage Iris Nodules: seen in granulomatous type. Koeppe nodules : at pupillary border, smaller in size. Busacca nodules : near the colarette , large and few in number. Rubeosis iridis : neovascularization in chronic anterior uveitis and in fuchs heterochromic cyclitis

13. Synechiae Posterior synechiae : adhesion of pupillary margin to the anterior surface of lens due to organisation of fibrinous exudates. Ring annular synechiae Total posterior synechiae Anterior synechiae : Adhesion of iris to corneal endothelium Pupil: Sluggish or non reacting : due to edema of the iris , irritation of 3 rd nerve endings and also due to posterior synechiae . Miotic Pupil: due to waterlogging of the iris ,toxins act on the sphincter pupillae , ring synechiae . Irregular or festooned pupil: irregular diladation due to mydriatic , due to segmental posterior synechiae . Occlusio pupillae : occluded due to organization of the exudates across the entire pupillary area.

14. Lens : Pigmentation :anterior capsule Exudates: deposits in acute cases Complicated cataract: typical features are ‘polychromatic lustre ’ and ‘bread crumb appearance’ in posterior cortex Posterior segment : Vitreous opacities : due to exudates and inflammatory cells Fundus changes: CMO due to liberation of toxins in chronic type

15. Complications Complicated cataract Secondary glaucoma Posterior synechiae Occlusio pupillae Cystoid macular oedema Band shaped keratopathy Phthisis bulbi Retinal complications

16. Investigations Routine haemogram Serological tests: VDRL and FTA-ABS ( for syphilis) Skin tests : Mantaoux test (tuberculosis) kviem test (sarcoidosis) X Ray : chest and joints Urine examination

17. Treatment The Aims of treating uveitis are : To prevent vision-threatening complications To relieve the patients discomfort and pain To treat the underlying cause of uveitis

18. Non-specific treatment : Short Acting : Tropicamide (0.5 and 1 %) Cyclopentolate ( 0.5 and 1%) Phenylephrine (2.5 to 10%) Long Acting : Atropine (lasts for 2 weeks) Sub conjunctival injection(0.25 ml) ( mydriacaine,atropine , adrenaline, procaine)

19. 4. Steroids/ Corticosteroids Topically as drops or ointments( dexamethasone , betamethasone , prednisolone ) Periocular injection( tissue plasminogen activater ) ( triamcinolone acetonide ( kenalog ), methylprednisolone acetate( depomedrone )) Intravitral injection Systemic Therapy 5. NSAIDS (aspirin) ( phenylbutazone , oxyphenylbutazone ) in uvietis of rheumatoid type

20. Treatment for complications Inflammatory glaucoma : Drugs to lower intraocular pressure e.g. Tab.Diamox, timolol maleate eyedrops . etc. Pilocarpine and latanaprost are contra-indicated in such cases Complicated cataract : Requires lens extraction Presence of fresh KP’s is considered a contraindication for intraocular surgery Retinal Detachment : If an exudative type the RD will settle down on itself if uveitis is treated properly If an tractional type vitrectomy should be done Pthisis bulbi : especially painful , requires removal by enucleation operation

21. Posterior uveitis Posterior uveitis refers to the inflammation of the choroid (chorioditis) Since the outer layers of the retina is in contact with the choroid , the inflamed choroid almost always involves the adjoining retina and the resultant lesion is called chorioretinitis

22. Clinical types Suppurative chorioditis (purulent inflammation of the choroid): It usually does not occur alone mainly seen w ith endopthalmitis Non - suppurative chorioditis : It is characterised by exudation and cellular infiltration resulting to greyish white lesion on the red choroidal vessels depending upon the number of lesion it can be classified into: Diffuse Desseminated Localized/focal - central, papillary, periphery and equator

23. Clinical picture Symptoms : Defective vision Photopsia Black floaters Metamorphopsia Micropsia Macropsia Scotoma

24. Signs Vitreous opacities Fine opacities Coarse opacities Stringy opacities Snowball opacities Features of patches on choroid Active stage : pale yellow or dirty white patches with irregular edges Healed stage : black pigmented clumps at periphery of the lesion involved area shows sclera below the healed choroid

25. Early focal and late multifocal choroiditis with panuveitis

26. Acute (A) and healed (B) Pneumocystis carinii choroiditis in a patient with AIDS.

27. Complications Extension of inflammation towards the anterior section Complicated cataract Vitreous degeneration Macular oedema Retinal Detachment

28. I nvestigation Investigation for tuberculosis Investigation for sarcoidosis VDRL and FTA-ABS for syphilis ELISA for toxocariasis

29. Treatment Non- specific treatment: Topical and Systemic corticosteroids Posterior sub- tenon injections Rarely immunosuppressive agents may be needed Specific treatment: i s required for causative diseases such as toxoplasmosis ,toxocariasis, tuberculosis, syphilis, etc.

30. Reference Clinical ophthalmology : J. kanski Ophthalmology : Khurana Ophthalmology : Basak Thank You