Uveitis

By

Husain J. Patanwala

3rd year, B.Optom

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

Anatomical

Anterior Uveitis: a) Iritis

b) Cyclitis

c) 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

Clinical – 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

a) 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

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

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

Anterior uveitis• Clinical picture:

Symptoms:-

i. Pain

ii. Redness

iii. Photophobia

iv. Lacrimation

v. Dimness of vison

• Ocular signs :

i. Circumcorneal congestion

ii. 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 KP’s; shrunken, pigmented, haloes surrounding them

• Anterior chamber signs Aqueous cells: cells should be counted in oblique slit lamp beam

Aqueous flare: due to leakage of protein into the aqueous through the damaged capillaries causing tyndall effect

Hypopyon: Sterile pus In the anterior chamber . Classically seen in Behcets 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

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

• 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.• Muddy 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

• 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 3rd 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.

• 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

Complications

• Complicated cataract

• Secondary glaucoma

• Posterior synechiae

• Occlusio pupillae

• Cystoid macular oedema

• Band shaped keratopathy

• Phthisis bulbi

• Retinal complications

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

Treatment

The Aims of treating uveitis are :

1) To prevent vision-threatening complications

2) To relieve the patients discomfort and pain

3) To treat the underlying cause of uveitis

• Non-specific treatment :

1. Short Acting :

i. Tropicamide (0.5 and 1 %)

ii. Cyclopentolate ( 0.5 and 1%)

iii. Phenylephrine (2.5 to 10%)

2. Long Acting :

i. Atropine (lasts for 2 weeks)

3. Sub conjunctival injection(0.25 ml) (mydriacaine,atropine, adrenaline, procaine)

4. Steroids/ Corticosteroids

i. Topically as drops or ointments(dexamethasone, betamethasone, prednisolone)

ii. Periocular injection( tissue plasminogen activater) (triamcinoloneacetonide(kenalog), methylprednisolone acetate(depomedrone))

iii. Intravitral injection

iv. Systemic Therapy

5. NSAIDS (aspirin) (phenylbutazone , oxyphenylbutazone) in uvietis of rheumatoid type

Treatment for complications• Inflammatory glaucoma :

i. Drugs to lower intraocular pressure e.g. Tab.Diamox, timolol maleate eyedrops. etc.

ii. Pilocarpine and latanaprost are contra-indicated in such cases

• Complicated cataract :i. Requires lens extraction ii. Presence of fresh KP’s is considered a contraindication for intraocular surgery

• Retinal Detachment :i. If an exudative type the RD will settle down on itself if uveitis is treated properlyii. If an tractional type vitrectomy should be done

• Pthisis bulbi : especially painful , requires removal by enucleation operation

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

Clinical types• Suppurative chorioditis (purulent inflammation of the choroid):

It usually does not occur alone mainly seen with 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:

i. Diffuse

ii. Desseminated

iii. Localized/focal - central, papillary, periphery and equator

Clinical picture• Symptoms :

i. Defective vision

ii. Photopsia

iii. Black floaters

iv. Metamorphopsia

v. Micropsia

vi. Macropsia

vii. Scotoma

• Signs i. Vitreous opacities

Fine opacities

Coarse opacities

Stringy opacities

Snowball opacities

ii. 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

Early focal and late multifocal choroiditis with panuveitis

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

Complications

i. Extension of inflammation towards the anterior section

ii. Complicated cataract

iii. Vitreous degeneration

iv. Macular oedema

v. Retinal Detachment

Investigation

• Investigation for tuberculosis

• Investigation for sarcoidosis

• VDRL and FTA-ABS for syphilis

• ELISA for toxocariasis

Treatment

• Non- specific treatment:

i. Topical and Systemic corticosteroids

ii. Posterior sub-tenon injections

iii. Rarely immunosuppressive agents may be needed

• Specific treatment:

is required for causative diseases such as toxoplasmosis ,toxocariasis, tuberculosis, syphilis, etc.

Reference

• Clinical ophthalmology : J. kanski

• Ophthalmology : Khurana

• Ophthalmology : Basak

Thank You