Uveitis (Classification, Panuveitis, Endophthalmitis, Panophthalmitis, Synechiae, Congenital anomalies of uvea)

Uveitis
• Inflammation of uveal tissue.
• Associated inflammation of adjacent structures, such as Retina, Vitreous, Sclera and Cornea.




Figure 1 uveitis

Anatomical classification
Clinical classification

Pathological classification

Etiological classification
(Duke Elder’s)
1. Anterior uveitis
Can be divided as follow;
1) Iritis_ inflammation mainly the iris

2) Iridocyclitis _iris and pars plicata involved

3) Cyclitis_ pars plicata is affected
Acute uveitis
Onset is sudden,
Last for less than 3 weeks Granulomatous uveitis
Infective nature
Inflammation is insidious in onset
Chronic in nature with minimum clinical features Infective uveitis
2. Intermediate uveitis
Inflammation of pars plana, peripheral retina and choroid.
Also called as “pars planitis”. Chronic uveitis
Onset is insidious
Duration is more than 3 weeks
Non-granulomatous uveitis
due to allergic or immune related reaction
acute onset
short duration
Allergic uveitis or immune related uveitis
3. Posterior uveitis
Inflammation of choroid(choroiditis)
Associated inflammation of retina (chorioretinitis) Recurrent uveitis
uveitis keeps reoccurring periodically
Toxic uveitis
4. Panuveitis
Inflammation of whole uveal tract Traumatic uveitis
5. Uveitis associated with non-infective systemic diseases
6. Idiopathic uveitis
7. Neoplastic

Figure 2 anatomical classification of uveitis


















Panuveitis
Endophthalmitis
Panophthalmitis
Inflammation of all layers of uvea of eye
Can also affect lens, retina, optic nerve and vitreous causing reduced vision or blindness. Inflammation of internal structures of the eye, I;e choroid, retina and vitreous Purulent inflammation of all structures of eye
Including all the three coats and Tenon’s capsule as well.
Etiology

1. Idiopathic
After ruling out other causes
2. Infectious
Tuberculosis
Syphilis
Lyme disease
Leptospirosis
Infectious endophthalmitis
3. Immune related
Sarcoidosis
Vogt-koyanagi-Harada syndrome
Sympathetic ophthalmitis
Behcet syndrome
Etiology

Acute process 1-7 days following intraocular surgery such as Cataract surgery and filtering operation
Commonly caused by Bacteria-staphylococcus, pseudomonas, pneumococcus, streptococcus, E. coli,

Fungus -aspergillus fumigatus, candida albicans, fusarium,


Etiology

1.Exogenous
Due to infected wounds
Common pathogens are pneumococcus, staphylococcus, pseudomonas, pneumococcus, streptococcus, E. coli.

2.Endogenous
Due to metastasis of infected embolus in retinal artery and choroidal vessels.
Clinical Features

• Sudden onset of unilateral pain, redness, photophobia
• Maybe associated with lacrimation
• Visual acuity is usually good at presentation except in eyes with severe hypopyon.
• Low IOP
• Fibrinous exudate
• Posterior synechiae
• Miosis
• Aqueous flare and cells
• Endothelial dusting


Clinical Features

Bacterial endophthalmitis
• Sudden onset with severe pain
• Redness
• Visual loss
• Lid oedema, chemosis, corneal haze
• Low

1. Uveitis
1.Classification of uveitis, 2. Panuveitis Endophthalmitis
Panophthalmitis, 3. Synechiae, 4. Congenital anomalies of
uvea
Maryam Fida
Optometry and Orthoptics

2. Uveitis
 Inflammation of uveal tissue.
 Associated inflammation of adjacent structures, such as Retina, Vitreous, Sclera
and Cornea.




Figure 1 uveitis


Anatomical
classification

Clinical
classification


Pathological
classification


Etiological
classification
(Duke Elder’s)
Classification of uveitis

3. 1. Anterior uveitis
Can be divided as
follow;
1) Iritis_
inflammation
mainly the iris

2) Iridocyclitis _iris
and pars plicata
involved

3) Cyclitis_ pars
plicata is affected

Acute uveitis
Onset is
sudden,
Last for less
than 3 weeks
Granulomatous
uveitis
Infective nature
Inflammation is
insidious in onset
Chronic in nature
with minimum
clinical features
Infective uveitis
2. Intermediate uveitis
Inflammation of pars
plana, peripheral retina
and choroid.
Also called as “pars
planitis”.
Chronic uveitis
Onset is
insidious
Duration is
more than 3
weeks

Non-
granulomatous
uveitis
due to allergic or
immune related
reaction
acute onset
short duration

Allergic uveitis or
immune related
uveitis
3. Posterior uveitis
Inflammation of
choroid(choroiditis)
Associated inflammation
of retina (chorioretinitis)
Recurrent
uveitis
uveitis keeps
reoccurring
periodically

Toxic uveitis
4. Panuveitis
Inflammation of whole
uveal tract
Traumatic uveitis
5. Uveitis
associated with
non-infective
systemic
diseases
6. Idiopathic uveitis
7. Neoplastic

4. Figure 2 anatomical classification of uveitis

5. Panuveitis

Endophthalmitis

Panophthalmitis
Inflammation of all layers
of uvea of eye
Can also affect lens,
retina, optic nerve and
vitreous causing reduced
vision or blindness.
Inflammation of internal
structures of the eye, I;e
choroid, retina and vitreous
Purulent inflammation of all
structures of eye
Including all the three
coats and Tenon’s capsule
as well.
Etiology

1. Idiopathic
After ruling out other
causes
2. Infectious
Tuberculosis
Syphilis
Lyme disease
Leptospirosis
Infectious
endophthalmitis
3. Immune related
Sarcoidosis
Vogt-koyanagi-
Harada syndrome
Sympathetic
ophthalmitis
Behcet syndrome

Etiology

Acute process 1-7 days
following intraocular
surgery such as Cataract
surgery and filtering
operation
Commonly caused by
Bacteria-staphylococcus,
pseudomonas,
pneumococcus,
streptococcus, E. coli,

Fungus -aspergillus
fumigatus, candida
albicans, fusarium,



Etiology

1.Exogenous
Due to infected wounds
Common pathogens are
pneumococcus,
staphylococcus,
pseudomonas,
pneumococcus,
streptococcus, E. coli.

2.Endogenous
Due to metastasis of
infected embolus in retinal
artery and choroidal
vessels.
Clinical Features

 Sudden onset of
unilateral pain,
redness,
photophobia
 Maybe associated
with lacrimation
 Visual acuity is
usually good at
presentation except
in eyes with severe
hypopyon.
 Low IOP
 Fibrinous exudate
Clinical Features

Bacterial
endophthalmitis
 Sudden onset with
severe pain
 Redness
 Visual loss
 Lid oedema,
chemosis, corneal
haze
 Low intraocular
tension(hypotony)
 Fibrinous exudate
or hypopyon seen in
Clinical Features

 Severe pain
 Limitation of eye
movements
 Rise in temp,
headache, vomiting
and rapid failure of
vision
 Red and swollen
lids with marked
conjunctival and
ciliary congestion
 Purulent
conjunctival

6.  Posterior synechiae
 Miosis
 Aqueous flare and
cells
 Endothelial dusting



anterior chamber
 Associated vitritis
and haze in
vitreous.
 Yellowish reflex
behind lens,
absence of red
reflex, inability to
fundus visualization
with indirect
ophthalmoscope



Fungal endophthalmitis
 Incubation period of
several week
 Mild pain, redness,
transient hypopyon
 Affect anterior
vitreous and
anterior uvea
 Vitreous turns into
granulomatous
mass


discharge,
conjunctival and
ciliary congestion
 Corneal wound
appears necrotic
and hypopyon
present
 Yellow reflex is
seen through pupil
(vitreous abscess)
 Fundus
examination- media
is hazy,
oedematous retina
faintly visible or
invisible.

7. Synechiae
abnormal adhesions of the iris to other ocular structures.
1. Anterior synechiae is an adhesion of the iris to the posterior cornea due to
abnormal fibro vascular tissue formation.
2. Posterior synechiae is an adhesion of the iris to the anterior lens capsule and/or
vitreous due to abnormal fibrovascular tissue formation or due to organization of
the fibrin rich exudates.
There can also be concurrent anterior and posterior synechiae.
Associated lesions include staphyloma (partial protrusion of the iris into the corneal
stroma), entropion uveae (posterior inversion of the pupillary margin of the iris), and
occlusion of the pupil by an abnormal fibrovascular membrane, and inflammation,
among others.



Figure 3 Synechiae

Types:
Morphologically, posterior synechiae may be segmental, annular or total.
1. Segmental posterior synechiae
adhesions of iris to lens at some points.

2. Annular posterior synechiae
adhesion of the whole rim of the iris to the anterior capsule

3. Total posterior synechiae
adhesion of the total posterior surface of the iris to the anterior
of lens. It is rarely formed in acute plastic type of Uveitis and result in deepening of
anterior chamber.

8. Annular Posterior
synechiae
Total posterior synechiae Festooned Pupil


Etiology:

 Infective uveitis: such as herpes simplex, herpes zoster, tuberculosis and syphilis
 Allergic (hypersensitivity) uveitis
 Toxic uveitis
 Traumatic uveitis
 Uveitis associated with non-infective systemic diseases
 Posterior synechiae are the most common ocular complications in chronic or
recurrent
 anterior uveitis, such as idiopathic anterior uveitis, and
 iridocyclitis in juvenile idiopathic arthritis, sarcoidosis, intermediate uveitis, lens-
induced
 Intraocular inflammation, especially of the iris and ciliary body.
 Synechiae can also be squeal of many ocular diseases, such as cataract,
increased
 intraocular pressure, compressive or invasive intraocular neoplasms, and
inflammation
 resulting from various causes.
 Idiopathic uveitis

Signs:

 Central iridocorneal synechiae are frequently associated with rubeotic iris vessels
 Pupil is irregular/ festooned pupil
 Synechiae associated with uveitis have signs like Keratic precipitates, anterior
chamber
 cells and flares,
 irregular pupils,
 ciliary injections,
 vitreous cells,
 iris abnormalities,
 fundal changes

9. Symptoms:

Acute angle closure with the classic constellation of symptoms, including
 ocular pain,
 headaches,
 blurred vision,
 photophobia,
 watering
 halos.
 Reduced vision due to corneal edema or end-stage glaucomatous optic
neuropathy.
 If associated with systemic diseases may have recurrent attacks

CONGENITAL ANOMALIES OF UVEA

1. Heterochromia iridium
One iris may have different color from the other.


Figure 4 Heterochromia iridium
2. Heterochromia iridis
Parts of one iris may have different color



Figure 5 Heterochromia iridis

3. Polycoria
There is more than one pupil.

10. Figure 6 Polycoria

4. Corectopia
Pupil is not central but displaced to nasal side usually




Figure 7 Corectopia
5. Aniridia
Bilateral condition, iris is absent except for a narrow rim at ciliary border. Often
leads to secondary glaucoma.


Figure 8 Aniridia
6. Persistent pupillary membrane
Incidence: Commonly seen in babies

11. Etiology: Persistence of part of anterior vascular sheath of lens which normally
disappears before birth.
Clinical features:
o Fine thread stretches across pupil
o Maybe attached to lens capsule
o Pigments are seen on lens surface as fine brown dots
o Not affect vision usually


Figure 9 Persistent pupillary membrane
7. Coloboma
a hole in one of the structures of the eye, such as the iris, retina, choroid, or optic
disc.
Etiology: due to deficient closure of embryonic cleft resulting in abnormal shape of iris.
Clinical features:
Iris
i. Typical_ pear shaped coloboma seen in lower part and slightly inward


Figure 10pear shaped coloboma

ii. Atypical_ defect in iris is seen in any other direction

12. Choroid and retina
I. Fundus examination show oval or comet-shaped defect with rounded apex
towards disc. Few vessels are seen over surface and edges.
II. Central vision defect
III. Field of vision_ scotoma is present.


Figure 11 retinal and choroidal coloboma
8. Albinism
Defective development of pigment through body
Types
a) Ocular
b) Oculocutaneous
c) Cutaneous
Symptoms
o Defective vision
o Photophobia and dazzling
o Nystagmus
o Strabismus
Signs
o Pink iris
o Fundus examination: Retinal and choroidal vessels seen with great clarity with
glistening white sclera behind them
o Partial albinism is more common. Iris is blue and pigments are absent from
choroid and retina. Macula may look normal.

13. Figure 12 albinism

9. Cysts
a) Serous cysts_ due to closure of iris crypts.
b) Cyst of posterior epithelium_ must be differentiated from iris bombe.
c) Implantation cyst_ occur after perforating wounds or operations.


Figure 13iris ring cysts