Uveitits classifications and Approach

classifications
History
Examination

1. Uveitis Aseel Al Rashdi OMSB ( Oman Medical Specialty board ) Uveitis course/ 2019

2. Outline Anatomy of the Uveal tract Uveitis and its classifications Epidemiology Clinical History Clinical Examination C ase

3. Anatomy

4. Ciliary Body

5. Definitions Uveitis : inflammation of the uveal tract ( ie , iris, ciliary body, choroid) may be accompanied by adjacent ocular structures ( eg , retina, optic nerve, vitreous, sclera ). Keratouveitis : inflammation originate in the cornea with secondary involvement of the anterior chamber. Sclerouveitis : inflammation the involve the sclera and uveal tract.

6. Classification Of Uveitis Based on : Anatomy Clinical course Etiology Histology THE STANDARDIZATION OF UVEITIS NOMENCLATURE (SUN) WORKING GROUP

7. Anatomical classification Type Primary site of inflammation Includes Anterior uveitis Anterior chamber Anterior vitreous (behind the lens) Iritis Iridocyclitis Anterior cyclitis Intermediate uveitis Vitreous Pars planitis Posterior cyclitis Hyalitis Posterior uveitis Retina or choroid Focal , multifocal or diffuse Choroiditis , Chorioretinitis Retinochoroiditis Retinitis Neuroretinitis Panuveitis Anterior chamber , vitreous , Retina or choroid

8. Epidemiology American Academy of Ophthalmology . Intraocular inflammation and uveitits . 9 th Edition.

9. Epidemiology The prevalence of uveitis among all eye patients was 1.5% and the annual incidence was 129 cases.

10. Classification by Clinical Course Onset Duration Course Sudden Insidious 3 months Limited Persistent 3 months 6months 9months Chronic Recurrent Acute

11. Classification by Etiology Infectious ( Bacteria , Viral , Fungal, protozoal ) Non- infectious ( Autoimmune systemic association ) Masquerade ( neoplastic , non- neoplastic )

12. Histological classification Granulomatous ( Epithelioid and giant cells infiltrate ) Non – granulomatous (Plasma cell and lymphocyte infiltrate ) Mutton fat KP I ris nodules

13. ANTERIOR UVEITIS clinical symptoms Symptoms (Acute onset) : Pain ( cilliary spasm , secondary glaucoma ) Photophobia Redness Epiphora Blurred vision Symptoms (chronic ) : No symptoms Blurred vision (cataract , calcific band keratopathy , CME)

14. ANTERIOR UVEITIS clinical signs Anterior segment : Conjunctiva : Ciliary Congestion Cornea : Keratic Precipitates , Band keratopathy ( chronic complication ) AC : Cells , Flare , Hypopyon Pupils : Miosis Iris : Nodules , Anterior / Posterior synechia

15. Mutton Fat KPs

16. Busacca’s nodule Koeppe nodule Berlin’s nodule

17. Iris Heterochromia ( eg . Fuches heterochromic uveitits ) Iris Stromal Atrophy

18. Anterior Uveitis Often low due to decease ciliary body production of aqueos when it is inflamed or increase uveoscleral outflow. High IOP only when : Trabiculitits . Debris and inflammtory cells clog the TM. Pupillary block , secondary angle closure. IOP ?

19. Anterior Uveitis causes

20. Intermediate uveitis clinical symptoms Floaters Vitreous cells Snowballs in retina Blurred vision Vitreous opacity in visual axis CME ( cystoid macular edema )

21. Intermediate uveitis clinical signs Vitreous cells and protiens arise from ciliary body Snowballs Cells aggregate

22. Snowbanking ’ in Pars Planitis is the appearance of a white plaque, typically overlying the inferior pars plana and retina but it can encompass the entire peripheral fundus 

23. Peripheral retinal vasculitis

24. Vitreous strands and membranes Best seen with indirect ophthalmoscope Risk of PVD and CME

25. Intermediate uveitis causes

26. Posterior uveitis clinical symptoms Decrease VA Floaters I mage disturbance   photopsia ( flashes of light , M etamophopsia ) Visual defects ( Scotoma)   Nyctalopia ( night blindness )

27. Posterior uveitis clinical signs Unifocal , multifocal or diffuse : Retinal and choroidal inflammatory infiltrate. (choroiditis , retinitis) Vasculopathy : inflammatory sheathing of arteries and veins , narrowing of vessels , obliterations. + Vitreous haze and cells . Structural Complications : Periretinal or Subretinal fibrosis Retinal holes , atrophy, edema. Retinal detachment ( RD) CME RPE hypertrophy or atrophy Retinal or choroidal neovascularization Optic nerve swelling , atrophy or neovacularization Cataract

28. 23 yrs old female , serology + ve for syphillis White retinal lesions and a few retinal hemorrhages Thinning and occlusion of retinal vessels

29. 20-D field view Post retinal laser photocoagulation due to retinal vein occlusion associated with Behçet’s disease. There is optic nerve pallor intraretinal hemorrhages laser spots.

30. prominent vascular sheathing and scattered retinal pigmented epithelium (RPE) changes

31. Recurrent ocular toxoplasmosis. Note the active retinal lesion associated with an old inactive scar.

32. Uveitis + Retinal Vasculitis

33. Panuveitis causes There is no predominant site of inflammation, but inflammation is observed in the anterior chamber, vitreous, and retina and/or choroid.

34. Unilateral uveitis

35. Disease Activity

36. History taking and clinical Examination

37. History Patient Demographics : Age Gender Ethnicity

38. History

39. History Ocular symptoms

40. History Associated Systemic symptoms Al- Dhibi , H. A., Al-Mahmood, A. M., & Arevalo, J. F. (2014). A systematic approach to emergencies in uveitis.  Middle East African journal of ophthalmology ,  21 (3), 251.

41. History Occupational , social & family Hx Travel Tobacco use Sexual practices IV drug use Medications? Allergy?

42. Examination VA Pupils , RAPD , color vision , color saturation EOM IOP Thorough eye exam Thorough Systemic examination

43. Case A 42 -year-old white woman presented with a 10-year history of bilateral uveitis treated intermittently with topical and systemic corticosteroids and a chief complaint of blurred vision that was worse in the left eye since 5 days .last episode was 4 weeks ago. A detailed medical history was significant for sinusitis and depression . VA : OD 20/50 OS 20/100 Slit-lamp biomicroscopy showed mutton-fat KPs in the left eye . There were trace vitreous cells and haze in the right eye and vitreous cells and haze in the left eye. There were peripheral retinal vasculitis and cystoid macular edema in both eyes Physical examination revealed no rash, joint findings, or other abnormalities. Neurologic examination was normal.

44. References American Academy of Ophthalmology . Intraocular inflammation and uveitits . 9 th Edition. N. Robbert . Uveitis Fundamental and clinical practice. 4 th Edition. Al- Dhibi , H. A., Al-Mahmood, A. M., & Arevalo, J. F. (2014). A systematic approach to emergencies in uveitis.  Middle East African journal of ophthalmology ,  21 (3), 251 . Al- Mezaine , H. S., Kangave , D., & Abu El- Asrar , A. M. (2010). Patterns of uveitis in patients admitted to a University Hospital in Riyadh, Saudi Arabia.  Ocular immunology and inflammation ,  18 (6), 424-431. EyeWiki website : Intermediate uveitits .