Transcript Uveitis

Uveitis
Uveitis
Uveitis
Inflammation of the uveal tract
Uveitis is a sight threatening disorder, and may be
associated with life threatening diseases.
Uveitis can be caused by various ocular or systemic
infectious, immunological, and malignant diseases.
•
Classification:
Anatomical:
-
Anterior uveitis 75% : inflammation of
the iris (iritis), and anterior part of the
ciliary body (iridocyclitis).
-
Intermediate uveitis: inflammation of
the ciliary body (cyclitis, pars
planatis).
-
Posterior uveitis : inflammation
behind ora serrata; inflammation of
the choroid and retina (choroiditis,
retinitis, chorio-retinitis, retinal
vasculitis).
- Pan uveitis: inflammation of the entire
uveal tract.
• Clinical:
- Acute: sudden, short duration
- Chronic: insidious, long duration,
sometimes with exacerbation and remission
- Recurrent: repeated episodes of uveitis
separated by periods of inactivity without
treatment.
• Pathological classification:
-Non granulomatous
Small keratic precipitate (KP) Endothelium dusting
-Granulomatous uveitis:
Large KP (muttan fat)
or median size KP
Iris nodules
Iris granuloma
Etiology:
- Infections:
Viral; CMV, Herpes virus
Bacteria; T.B., T. pallidum, M. leprae
Fungal; candidia
Parasite; toxoplasmosis. toxocara
-Non-infectious:
Systemic:
Arthrits; Ankylosing spondylitis,
Skin diseases: VKH, Behjet disease, Psoriasis
C.N.S. disorders: Multiple sclerosis
Respiratory diseases; Sarcodosis:
G.I.T. diseases: Ulcerative colitis
Genitourinary diseases : Reiter’s disease
Ocular:
Specific ocular; Fuch’s hetrochromic iridiocyclitis
Non-specific idiopathic
A- Infectious origin
Toxoplasmosis
Presumed Ocular Tuberculosis
Herpes simplex anterior uveitis
Herpes zoster anterior uveitis
Syphilis
Acute retinal necrosis
Presumed toxocarasis
CMV retinitis
B-Non-infectious
Systemic diseases
VKH
Behçet's disease
Ankylosing sponylitis
Juvenile idiopathic arthritis
Multiple sclerosis
Antiphospholipid Syndrome
Sarcodosis
Primary specific ocular disorders
Pars planitis
Punctate inner choroidopathy
Fuchs heterochromic iridocyclitis
Eales disease
Bird shot retinochoroidopathy
Primary retinal vasculitis
Serpiginous choroidopathy
APMPPE*
Antiphospholipid syndrome
Sympathetic ophthalmitis
Non-specific idiopathic
Total
92(28.9%)
52 (16.4%)
28 (8.8%)
4 (1.3%)
2 (0.6%)
2 (0.6%)
2 (0.6%)
1 (0.3%)
1 (0.3%)
118 (37.1%)
74 (23.3%)
39 (12.3%)
26 (8.2%)
3 (0.9%)
2 (0.6%)
2 (0.6%)
1 (0.3%)
1 (0.3%)
44 (13.8%)
18 (5.7%)
5 (1.6%)
5 (1.6%)
4 (1.3%)
3 (0.9 %)
3 (0.9%)
2 (0.6%)
2 (0.6%)
1 (0.3%)
1 (0.3%)
108 (34%)
318
Anterior uveitis
Symptoms:
- Pain
- Photophobia
- Redness
- Lacrimation
- Blurring of vision
Anterior uveitis
Signs
- Reduced visual acuity (V.A.)
- Circum-corneal congestion
- Cornea: Keratic precipitate. KP: (aggregation of inflammatory cells
on the posterior surface of the endothelium)
small , endothelium dusting (non-granulomatous uveitis)
Large (muttan fat) (chronic, granulomatous uveitis)
- Ant. Chamber: cells and flare ( increase protein in the aqueous)
hypopyon (aggregation of inflammatory cells at the
bottom of anterior chamber with fluid level)
- Pupil: Miosed (constricted)
Irregular, posterior synechiae (adhesion between the iris and the lens),
- Iris: Rubeosis ( iris neo-vascularization).
Iris atrophy (chronic)
Iris nodules and granuloma (chronic, granulomatous uveitis)
- Intra-ocular pressure (IOP): may be normal, elevated or
depressed
Anterior uveitis
Signs
- Reduced visual acuity (V.A.)
Signs
-Circum-corneal congestion
Signs
-Cornea:
Keratic precipitate. KP:
aggregation of inflammatory cells on the posterior
surface of the endothelium)
Small , endothelium dusting
(non-granulomatous uveitis)
Large (muttan fat) (chronic,
granulomatous uveitis)
Band keratopathy: deposition of calcium at
Bowmann’s layer
Signs
-Ant. Chamber:
- cells
-flare ( increase protein in the aqueous)
-hypopyon (aggregation ofinflammatory
cells at the bottom of anterior
chamber with fluid level)
Signs
-Pupil: Miosed (constricted)
Irregular, posterior
synechiae
(adhesion between the
iris and the lens),
Signs
-Iris: Rubeosis ( iris neovascularization).
Iris atrophy (chronic)
Iris nodules and granuloma
(granulomatous uveitis)
Signs
-Intra-ocular pressure (IOP): may be
normal, elevated or depressed
Ankylosing Spondylitits
Young adults
Male are affected more
Arthritis; axial skeleton
-sacroiliac joint and
intervertebral joints
90% positive HLA-B27
Acute, Recurrent,
non-granulomatous Anterior Uveitis
Juvenile idiopathic arthritis
Idiopathic,
Chronic arthritis
Age under16 years. Females are affected more commonly
Pauciarticular type (less than 5 joints are involved)
seronegative (for R.F.),
80% positive for ANA
Bilateral, Chronic, non-granulomatous Ant. Uveitis
painless,
Complications:
1- Cataract
2- Band keratopathy
.
• Intermediate uveitis: inflammation of the
ciliary body (cyclitis, pars planatis).
Intermediate uveitis
• Symptoms
- Floaters (moving shadows in
the field of vision caused by
vitreous opacities)
- Blurring of vision
Intermediate Uveitis
Signs:
• Vitreous: cells,
snow-balls
• No fundus lesions
Intermediate Uveitis
• Causes of intermidiate
uveitis
1- Pars planatis:
Most common
Idiopathic
2- TB
3- Multiple sclerosis
-
.
Posterior uveitis: inflammation behind
ora serrata, inflammation of the
choroid and retina (choroiditis,
retinitis, chorio-retinitis, retinal
vasculitis).
Posterior Uveitis
• Symptoms
- Floaters (moving shadows in the field of
vision caused by vitreous opacities)
- Blurring of vision
Posterior uveitis
Signs:
• Vitreous: cells, flare and opacities
• fundus lesions may be focal, multi-focal, or geographical lesions
-Choroiditis; yellow, well demarcated patches
-Retinitis; white cloudy patches with indistinct margins
-Old inactive lesion appears as white well defined area of
chorio- retinal atrophy with pigmented borders
-Vasculitis; fluffy haziness surrounding blood columns
vascular sheathening
Toxoplasmosis
•
-
Toxoplasma gondii is an obligatory,
intracellular protozoan parasite
Acquired, congenital
Vitritis.
Retinitis;
Active lesion: creamy-white lesion with
indistinct margins
Inactive lesion: white well defined area of
chorio- retinal atrophy with pigmented
borders
Toxoplasmosis
Treatment:
Antiprotozoal drugs; Clindamycin,
sulphonamides
Steroids
-
Pan uveitis:
inflammation of the entire uveal tract.
Pan uveitis
• Idiopathic, multisystem disease
characterized by recurrent episodes of
orogenital ulceration and vasculitis
Behçet syndrome
•
•
Diagnosis:
1 Recurrent oral ulceration characterized by painful minor or major aphthous
lesions that have recurred at least three times in a 12-month period.
2 Plus at least two of the following:
• Recurrent genital ulceration
• Ocular inflammation.
• Skin lesions include erythema nodosum, folliculitis, acneiform nodules
• Positive pathergy test, cutaneous hypersensitivity, which is characterized by the
formation of a pustule after 24–48 hours at the site of a sterile needle prick
Behjet’s disease
,
Ocular features;
Bilateral,
chronic with exacerbation and remission,
non- granulomatous
pan-uveitis
iridocyclitis
Vitritis
Retinitis
Vasculitis; venous occlusion,
neovascularization,
Behjet’s disease
Pan uveitis
Vogt Koyanagi Harada (VKH)
Multi-systemic auto-immune disorder affect pigmented
cells in the body.
Involves CNS, eyes, and skin
Vogt Koyanagi Harada (VKH)
- Neurological and auditory manifestations
Headache, Tinnitus
- Integumentary findings, not preceding onset of
central nervous system or ocular disease, such as
alopecia, poliosis and vitiligo
Vogt Koyanagi Harada (VKH)
- Bilateral uveitis
Acute stage:
Multifocal serous detachment of
sensory retina
Bilateral exudative retinal detachment
Chronic stage:
Depigmentation of the fundus; Vitilligo
of the fundus
Dalen Fuchs atrophic spots
Presumed Tuberculous Uveitis
According to WHO:
About one third of the world's population, are infected by tuberculosis
10% of infected people are symptomatic
90% have latent TB
TB is endemic in Iraq
TB uveitis develops following hematogenous spread from a
primary latent focus and usually occurs without evidence of
systemic TB.
Presumed TB uveitis
• Clinical signs include ;
-Granulomatous anterior uveitis
- Focal, multifocal choroiditis, choroidal granuloma,
- Retinal vasculitis.
Management of Uveitis:
1- Investigations: Aimed for determining the etiology.
Indications: chronic, recurrent, and granulomatous anterior uveitis
Intermidiate, posterior and pan-uveitis
2-Steriods:
•
•
•
•
•
Topical, Side effects of corticosteroids eye-drops:
Flare up of pre-existing eye infection
Predispose for microbial keratitis, e.g. viral keratitis.
Inhibit collagen synthesis of the cornea, and predispose for corneal thinning
Cataract (chronic use)
Open angle glaucoma (chronic use)
Periocular injections of steroids; used in severe ant. , Intermidiate, posterior uveitis
Systemic steroids; used in; severe anterior, Intermidiate uveitis, posterior uveitis
3- Mydriatics: -decrease pain by relieve ciliary muscles spasm
- prevent synechiae, break down synechiae
4- Anti-microbial drugs: in infectious types; Toxoplasmosis, Presumed TB uveitis.
5- Immunomodulator and/or Immunoppressive agents:
In bilateral, severe , vision threatening , steroid sparing, non-infectious
-Cyclosporin; T-cell immunosuppressive agent
-Methotrexate
- Azathioprine
Red Eye
Symptoms
Conjunctivitis
Vision
Not affected
Redness
+
+
+
+
Pain
Foreign body
sensation,
itching
Pain localized to
the eye
Pain localized
to the eye
Severe pain
radiating
Secretion
Watery, mucoid
or purulent
watery
watery
watery
mild
marked
mild
none-
50%
Headache,
associated with nausea and
systemic
vomiting
disorders
Photophobia
Systemic
absent
Sometimes, e.g.
adenovirus
Keratitis or
corneal foreign
body
Acute iritis
depressed
Acute
Glaucoma
depressed
depressed
Signs
Conjunctivitis
Keratitis or
corneal foreign
body
Acute iritis
Acute
Glaucoma
Congestion
Conjunctival
Cicumcorneal
Cicumcorneal Cicumcorneal
Cornea
normal
Ulceration or
Suppuration
Keratitic
precipitates
Oedema
Anterior
chamber
normal
Cells,
Hypopyon
Cells,
Hypopyon
Shallow
Pupil
normal
Constricted
Constricted,
irregular
Fixed, middilated
Tension
normal
Normal
High,
Normal, or
Low
High