5.opththalmology Uveitis.over view pptx
- 1. 1 Uveitis By Bekuma Jima (MD) Ophthalmology Resident- (R4)
- 2. 2 Introduction Uvea = Grape (Latin). Uveal Tract = Three parts --- Iris + Ciliary body + Choroid.
- 3. 3 Ciliary body --- two parts: Pars plicata --- anterior part. Pars plana --- posterior part.
- 4. 4 Uveitis It is an inflammation of the uvea --- and, it can affect: Any part of the uveal tract: Iris ---> iritis. Choroid ---> choroiditis. Ciliary body --- cyclitis. Pars plicata ---> anterior cyclitis. Pars plana ---> pars planitis (intermediate uveitis). More than one part of the uveal tract: Iris and ciliary body ---> iridocyclitis. Whole uveal tract ---> panuveitis.
- 5. 5 Classification of Uveitis Anatomical (the most widely accepted) Anterior uveitis Intermediate uveitis Posterior uveitis Panuveitis Mode of onset & course Acute uveitis (<3 months) chronic uveitis (>3 months) Recurrent uveitis Etiologic Infectious Traumatic Neoplastic Autoimmune Idiopathic Type of inflammation Granulomatous Non-granulomatous
- 6. 6 Anatomical classification of uveitis Anterior Uveitis The inflammation involves the iris and anterior part of the ciliary body. 損 Iritis 損 Iridocyclitis 損 Keratouveitis Anterior uveitis is further divided into acute and chronic.
- 7. 7 Causes of anterior uveitis: Arthritis --- JRA, ankylosing spondylitis, Reiters syndrome, psoriasis Sarcoidosis Behcets disease Infections ---bacterial, viral, fungal, parasitic, others. 損 HSV, HZV, Syphilis, TB, Lyme disease Trauma Surgery --- esp. associated with lens Idiopathic (unknown cause)
- 8. 8 Acute Anterior Uveitis --- AAU Has classic presentation Rapid onset of unilateral pain, visual loss, photophobia, redness and watery discharge sometimes preceding mild ocular discomfort for a few days. Signs Conjunctival injection Perilimbal (ciliary flush) --- in early cases Diffuse --- in severe cases
- 9. 9 Miosis due to pupillary sphincter spasm Endothelial dusting or Keratic precipitates (KPs) Inflamm. cells and flare (protein influx) in A/C Sometimes inflamm. membrane covering pupil Posterior synechiae
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- 12. 12 Chronic Anterior Uveitis --- CAU Gradual onset, persistent inflammation, lasts > 3months. Symptoms: Variable --- redness, discomfort, photophobia. Sometimes --- asymptomatic until complications develop --- E.g., cataract.
- 13. 13 Signs: Aqueous cells and flare Old KPs (endothelial aggregates of inflammatory cells) Posterior synechiae Iris atrophy or nodules
- 14. 14 Intermediate Uveitis Inflammation of the middle portion of the uvea. Presentation: Insidious onset of blurred vision and floaters. Externally, the eye looks quiet and normal. Anterior vitreous cells. Snow ball --- aggregation of inflammatory cells in the anterior part of vitreous. Snow banking --- grey-white fibrovascular plaque in the inferior peripheral retina
- 15. 15 Posterior Uveitis Inflammation affecting the choroid, retina, and/or retinal vessels. Clinical Presentations: The eye may look quiet or may have AC inflammation. Symptoms --- blurry / loss of vision, scotoma, floaters. Signs --- infiltrates within the vitreous, retina or choroid; signs of RD.
- 16. 16 Panuveitis --- Diffuse Uveitis Inflammation of the entire inner eye. Presentation --- findings of the anterior and posterior uveitis. Endophthalmitis A type of panuveitis which is of infectious cause --- usually unilateral.
- 17. 17 Investigation for Uveitis Diagnosis often made on clinical grounds --- as in: Mild unilateral acute anterior uveitis. Systemic diagnosis already made --- E.g., sarcoidosis. Distinct features --- E.g., toxoplasmosis, CMV retinitis, sympathetic ophthalmia. When investigations is needed, it should be done based on the most likely cause clinically.
- 18. 18 General investigations: CBC, ESR, CRP Serology for syphilis --- VDRL, rapid plasma reagin (RPR), Chest x-ray Specific workups: Infectious workup --- HIV test, toxoplasma IgG/IgM, Sputum AFB ANA --- for children with arthritis Serum ACE, lysozyme Biopsy --- from conj., aqueous, vitreous, retina, choroid Imaging tests --- Ultrasound, Fluorescein angiography, OCT, CT scan, MRI
- 19. 19 Treatment of Uveitis Steps of management: Proper workup and diagnosis. Especially, differentiate infectious from the non infectious causes. Treatment of the underlying cause, if any. Supportive management.
- 20. 20 Treatment of underlying causes: TB --- initiate proper anti-TB CMV retinitis --- Gancyclovir, Foscarnet HSV --- Acyclovir Toxoplasmosis: 1st line --- pyrimethamine, sulfadiazine, folinic acid, and prednisolone. 2nd Line --- Clindamycin. 3rd Line --- trimethoprim and sulfamethoxazole. Systemic inflammatory dses: Systemic corticosteroids Immunomodulatory agents
- 21. 21 Supportive treatment: Important for both infectious & non infectious causes. Include: Cycloplegics Uses --- relieve pain, prevent synechiae. Tropicamide, cyclopentolate, atropine. Corticosteroids --- to control inflammation. Immunosuppressive drugs --- indications being: Sight threatening uveitis despite steroid use. Steroid resistant or steroid dependent cases. Intolerable side effects of steroids. If corticosteroid use is contraindicated.
- 22. 22 Possible routes for corticosteroids: Topical --- for treatment of anterior uveitis. Sub-Tenon injection --- for intermediate or posterior uveitis. Intravitreal --- as injection or implant --- for posterior uveitis. Systemic --- for: Vision threatening uveitis --- posterior uveitis, panuveitis. Simultaneous treatment of underlying systemic inflammatory dses.
- 23. 23 Thank you!