Anterior Uveitis
Anterior Uveitis <ul><li>Prevalence </li></ul><ul><li>Symptoms </li></ul><ul><li>Diagnostic techniques and signs </li></ul...
Anterior Uveitis - Introduction <ul><li>Unilateral </li></ul><ul><li>Asymmetrical </li></ul><ul><li>Inflammation of the uv...
Anterior Uveitis - Prevalence <ul><li>The most common form of intraocular inflammatory disease </li></ul><ul><li>We must c...
Anterior Uveitis –  History & Symptoms <ul><li>History of blunt trauma </li></ul><ul><li>History of associated systemic co...
Anterior Uveitis –  Diagnostic Techniques & Signs <ul><li>Monocular Visual Acuity measurement </li></ul><ul><li>Slit lamp ...
Anterior Uveitis –  Diagnostic Techniques & Signs <ul><li>Monocular Visual Acuity measurement </li></ul><ul><ul><li>Reduce...
Anterior Uveitis –  Diagnostic Techniques & Signs <ul><li>Slit lamp biomicroscopy </li></ul><ul><ul><li>Circumlimbal injec...
Anterior Uveitis –  Diagnostic Techniques & Signs <ul><li>Slit lamp biomicroscopy </li></ul><ul><ul><li>Fibrin in the AC <...
Anterior Uveitis –  Diagnostic Techniques & Signs <ul><li>Tonometry </li></ul><ul><ul><li>IOP reduced </li></ul></ul><ul><...
Anterior Uveitis –  Diagnostic Techniques & Signs Circumlimbal injection
Anterior Uveitis –  Diagnostic Techniques & Signs Circumlimbal injection
Anterior Uveitis –  Diagnostic Techniques & Signs Aqueous Flare
Anterior Uveitis –  Diagnostic Techniques & Signs Cells in aqueous
Anterior Uveitis –  Diagnostic Techniques & Signs 50+ cells in view Intense flare (coagulated aqueous, no circulation, fib...
Anterior Uveitis –  Diagnostic Techniques & Signs Keratic Precipitates
Anterior Uveitis –  Diagnostic Techniques & Signs Hypopyon vs Hyphaema
Anterior Uveitis –  Diagnostic Techniques & Signs Hypopyon vs Hyphaema
Anterior Uveitis –  Diagnostic Techniques & Signs Band Keratopathy
Anterior Uveitis –  Diagnostic Techniques & Signs Fibrin in aqueous
Anterior Uveitis –  Diagnostic Techniques & Signs Fibrin in aqueous
Anterior Uveitis –  Diagnostic Techniques & Signs Posterior Synechiae
 
 
 
 
Anterior Uveitis –  Diagnostic Techniques & Signs Rubeosis Iridis
Anterior Uveitis –  Diagnostic Techniques & Signs Mutton Fat Keratic Precipitates
Anterior Uveitis –  Diagnostic Techniques & Signs Iris Nodules
Anterior Uveitis –  Diagnostic Techniques & Signs Severe Acute Anterior Uveitis
Anterior Uveitis –  Diagnostic Techniques & Signs Gonioscope view of Peripheral Anterior Synechiae (PAS)
Anterior Uveitis –  Classification <ul><li>Uveitis by location: </li></ul><ul><ul><li>Anterior Uveitis </li></ul></ul><ul>...
Anterior Uveitis –  Classification <ul><li>Uveitis by time course: </li></ul><ul><ul><li>Acute </li></ul></ul><ul><ul><ul>...
Anterior Uveitis –  Classification <ul><li>Chronic Anterior Uveitis associated with: </li></ul><ul><ul><li>Juvenile chroni...
Anterior Uveitis –  Classification <ul><li>Source: </li></ul><ul><ul><li>Endogenous </li></ul></ul><ul><ul><li>Exogenous <...
Anterior Uveitis –  Classification of Severity Moderate to severe symptoms VA <6/30 Deep circumcorneal flush KPs 3-4+ cell...
Anterior Uveitis –  Classification of Severity Sluggish or fixed pupil Fibrous posterior synechiae Boggy iris (crypts) IOP...
Anterior Uveitis –  Pathophysiology <ul><li>Non-granulomatous </li></ul><ul><ul><li>No pathogen </li></ul></ul><ul><ul><li...
Anterior Uveitis –  Pathophysiology <ul><li>Inflammatory response causes breakdown of the blood-aqueous barrier </li></ul>...
Anterior Uveitis –  Pathophysiology <ul><li>Deposition of calcium salts in cornea </li></ul><ul><ul><li>Band keratopathy <...
Anterior Uveitis –  Pathophysiology <ul><li>Circumlimbal injection </li></ul><ul><ul><li>Due to common blood supply with u...
Anterior Uveitis –  Management <ul><li>Chronic - Early referral to GP if not being managed currently </li></ul><ul><li>Rec...
Anterior Uveitis –  Management <ul><li>Goals of management </li></ul><ul><ul><li>Preserve visual acuity </li></ul></ul><ul...
Anterior Uveitis –  Management <ul><li>Treatment regimen </li></ul><ul><ul><li>Topical Corticosteroid therapy </li></ul></...
Anterior Uveitis –  Associated Conditions <ul><li>Blunt Trauma </li></ul><ul><li>Ocular Surgery </li></ul><ul><li>Juvenile...
Anterior Uveitis –  Clinical Pearls <ul><li>Four major complications exist </li></ul><ul><ul><li>Cataract </li></ul></ul><...
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Anterior Uveitis

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Anterior Uveitis

  1. 1. Anterior Uveitis
  2. 2. Anterior Uveitis <ul><li>Prevalence </li></ul><ul><li>Symptoms </li></ul><ul><li>Diagnostic techniques and signs </li></ul><ul><li>Pathophysiology </li></ul><ul><li>Associated conditions </li></ul><ul><li>Management </li></ul>
  3. 3. Anterior Uveitis - Introduction <ul><li>Unilateral </li></ul><ul><li>Asymmetrical </li></ul><ul><li>Inflammation of the uvea anterior to the middle of the vitreous cavity </li></ul><ul><li>One of the serious “red eye” conditions </li></ul><ul><li>Associated with trauma </li></ul><ul><li>Associated with systemic disease </li></ul><ul><li>Has vision threatening complications </li></ul>
  4. 4. Anterior Uveitis - Prevalence <ul><li>The most common form of intraocular inflammatory disease </li></ul><ul><li>We must consider incidence, not prevalence </li></ul><ul><li>8-12 per 100,000 population per year </li></ul><ul><li>Highest in age range 20-50 (20-30 is peak) </li></ul><ul><li>Risk factors </li></ul><ul><ul><li>Associated systemic conditions </li></ul></ul><ul><ul><li>Blunt trauma </li></ul></ul><ul><ul><li>Previous history </li></ul></ul>
  5. 5. Anterior Uveitis – History & Symptoms <ul><li>History of blunt trauma </li></ul><ul><li>History of associated systemic condition </li></ul><ul><li>If acute: </li></ul><ul><ul><li>Painful eye </li></ul></ul><ul><ul><li>Watery eye </li></ul></ul><ul><ul><li>Photophobia </li></ul></ul><ul><ul><li>Mild to moderate reduction in vision </li></ul></ul><ul><li>If chronic: </li></ul><ul><ul><li>No symptoms </li></ul></ul>
  6. 6. Anterior Uveitis – Diagnostic Techniques & Signs <ul><li>Monocular Visual Acuity measurement </li></ul><ul><li>Slit lamp biomicroscopy </li></ul><ul><li>Tonometry </li></ul><ul><li>Gonioscopy? </li></ul>
  7. 7. Anterior Uveitis – Diagnostic Techniques & Signs <ul><li>Monocular Visual Acuity measurement </li></ul><ul><ul><li>Reduced to 6/6-6/9 in mild disease </li></ul></ul><ul><ul><li>Reduced to 6/9-6/30 in moderate disease </li></ul></ul><ul><ul><li>Reduced to <6/30 in severe disease </li></ul></ul><ul><li>Visual Acuity reduced due to: </li></ul><ul><ul><li>Corneal oedema </li></ul></ul><ul><ul><li>Aqueous flare </li></ul></ul><ul><ul><li>Aqueous cells </li></ul></ul><ul><ul><li>Cystoid macular oedema (CME) </li></ul></ul>
  8. 8. Anterior Uveitis – Diagnostic Techniques & Signs <ul><li>Slit lamp biomicroscopy </li></ul><ul><ul><li>Circumlimbal injection </li></ul></ul><ul><ul><li>AC flare and cells </li></ul></ul><ul><ul><li>Keratic precipitates (KP) </li></ul></ul><ul><ul><li>Pupil miosis </li></ul></ul><ul><ul><li>Hypopyon </li></ul></ul><ul><ul><li>Band Keratopathy </li></ul></ul>
  9. 9. Anterior Uveitis – Diagnostic Techniques & Signs <ul><li>Slit lamp biomicroscopy </li></ul><ul><ul><li>Fibrin in the AC </li></ul></ul><ul><ul><li>Cells in the anterior vitreous </li></ul></ul><ul><ul><li>Peripheral Anterior Synechiae (PAS) </li></ul></ul><ul><ul><li>Posterior synechiae </li></ul></ul><ul><ul><li>Rubeosis iridis </li></ul></ul><ul><ul><li>Mutton fat KP (granulomatous disease) </li></ul></ul><ul><ul><li>Iris nodules (granulomatous disease) </li></ul></ul>
  10. 10. Anterior Uveitis – Diagnostic Techniques & Signs <ul><li>Tonometry </li></ul><ul><ul><li>IOP reduced </li></ul></ul><ul><ul><li>IOP unaffected </li></ul></ul><ul><ul><li>IOP elevated (corneal oedema) </li></ul></ul><ul><li>Gonioscopy </li></ul><ul><ul><li>PAS </li></ul></ul>
  11. 11. Anterior Uveitis – Diagnostic Techniques & Signs Circumlimbal injection
  12. 12. Anterior Uveitis – Diagnostic Techniques & Signs Circumlimbal injection
  13. 13. Anterior Uveitis – Diagnostic Techniques & Signs Aqueous Flare
  14. 14. Anterior Uveitis – Diagnostic Techniques & Signs Cells in aqueous
  15. 15. Anterior Uveitis – Diagnostic Techniques & Signs 50+ cells in view Intense flare (coagulated aqueous, no circulation, fibrin visible) 4+ 20 to 50 cells in view Marked flare (iris and lens hazy) 3+ 10 to 20 cells in view Moderate flare (iris and lens still clear) 2+ 5 to 10 cells in view Faint flare (barely detectable) 1+ No cells Complete absence 0 Cells Flare Grade Grading of cells and flare
  16. 16. Anterior Uveitis – Diagnostic Techniques & Signs Keratic Precipitates
  17. 17. Anterior Uveitis – Diagnostic Techniques & Signs Hypopyon vs Hyphaema
  18. 18. Anterior Uveitis – Diagnostic Techniques & Signs Hypopyon vs Hyphaema
  19. 19. Anterior Uveitis – Diagnostic Techniques & Signs Band Keratopathy
  20. 20. Anterior Uveitis – Diagnostic Techniques & Signs Fibrin in aqueous
  21. 21. Anterior Uveitis – Diagnostic Techniques & Signs Fibrin in aqueous
  22. 22. Anterior Uveitis – Diagnostic Techniques & Signs Posterior Synechiae
  23. 27. Anterior Uveitis – Diagnostic Techniques & Signs Rubeosis Iridis
  24. 28. Anterior Uveitis – Diagnostic Techniques & Signs Mutton Fat Keratic Precipitates
  25. 29. Anterior Uveitis – Diagnostic Techniques & Signs Iris Nodules
  26. 30. Anterior Uveitis – Diagnostic Techniques & Signs Severe Acute Anterior Uveitis
  27. 31. Anterior Uveitis – Diagnostic Techniques & Signs Gonioscope view of Peripheral Anterior Synechiae (PAS)
  28. 32. Anterior Uveitis – Classification <ul><li>Uveitis by location: </li></ul><ul><ul><li>Anterior Uveitis </li></ul></ul><ul><ul><ul><li>Iritis </li></ul></ul></ul><ul><ul><ul><li>Iridocyclitis </li></ul></ul></ul><ul><ul><ul><li>Cyclitis </li></ul></ul></ul><ul><ul><li>Intermediate Uveitis </li></ul></ul><ul><ul><ul><li>Pars planitis </li></ul></ul></ul><ul><ul><li>Posterior Uveitis </li></ul></ul><ul><ul><ul><li>Choroiditis </li></ul></ul></ul><ul><ul><ul><li>Chorioretinities </li></ul></ul></ul><ul><ul><ul><li>Retinochoroiditis </li></ul></ul></ul><ul><ul><ul><li>Retinitis </li></ul></ul></ul><ul><ul><li>Panuveitis </li></ul></ul>
  29. 33. Anterior Uveitis – Classification <ul><li>Uveitis by time course: </li></ul><ul><ul><li>Acute </li></ul></ul><ul><ul><ul><li>< 6 weeks duration </li></ul></ul></ul><ul><ul><ul><li>May be recurrent </li></ul></ul></ul><ul><ul><li>Chronic </li></ul></ul><ul><ul><ul><li>> 6 weeks duration </li></ul></ul></ul><ul><ul><ul><li>White eye </li></ul></ul></ul><ul><ul><ul><li>Mild signs of inflammation </li></ul></ul></ul><ul><ul><ul><li>Mild or no symptoms </li></ul></ul></ul>
  30. 34. Anterior Uveitis – Classification <ul><li>Chronic Anterior Uveitis associated with: </li></ul><ul><ul><li>Juvenile chronic arthritis </li></ul></ul><ul><ul><li>Posterior Uveitis due to: </li></ul></ul><ul><ul><ul><li>Sarcoidosis </li></ul></ul></ul><ul><ul><ul><li>Toxoplasmosis </li></ul></ul></ul><ul><ul><ul><li>Syphilis </li></ul></ul></ul><ul><ul><ul><li>Tuberculosis </li></ul></ul></ul><ul><ul><ul><li>Herpes Zoster </li></ul></ul></ul><ul><ul><ul><li>Cytomegalovirus </li></ul></ul></ul><ul><ul><ul><li>AIDS </li></ul></ul></ul><ul><ul><li>Fuch’s Heterochromic Iridocyclitis </li></ul></ul><ul><ul><ul><li>Asymptomatic </li></ul></ul></ul><ul><ul><ul><li>2% of uveitis patients </li></ul></ul></ul><ul><ul><ul><li>Progressive loss of iris stromal pigment -> heterochromia </li></ul></ul></ul><ul><ul><ul><li>Mild inflammation resistant to treatment </li></ul></ul></ul>
  31. 35. Anterior Uveitis – Classification <ul><li>Source: </li></ul><ul><ul><li>Endogenous </li></ul></ul><ul><ul><li>Exogenous </li></ul></ul><ul><ul><ul><li>trauma </li></ul></ul></ul><ul><ul><ul><li>surgery </li></ul></ul></ul><ul><li>Inflammatory process: </li></ul><ul><ul><li>Granulomatous </li></ul></ul><ul><ul><li>Non-granulomatous </li></ul></ul><ul><li>Unable to find cause? </li></ul><ul><ul><li>“ idiopathic anterior uveitis” – 30% of all cases </li></ul></ul>
  32. 36. Anterior Uveitis – Classification of Severity Moderate to severe symptoms VA <6/30 Deep circumcorneal flush KPs 3-4+ cells and flare Moderate to severe symptoms AV 6/9 to 6/30 Deep circumcorneal flush KPs 1-3+ cells and flare Mild to moderate Symptoms VA 6/6 to 6/9 Superficial circumcorneal flush No KPs 0-1+ cells and flare Severe Moderate Mild Clinical Degree of Anterior Uveitis
  33. 37. Anterior Uveitis – Classification of Severity Sluggish or fixed pupil Fibrous posterior synechiae Boggy iris (crypts) IOP increased Moderate to severe anterior vitreous cells Miotic, sluggish pupil Mild posterior synechiae Mild iris swelling IOP reduced 3-6 mmHg Anterior vitreous cells Normal pupil . No posterior synechiae No iris swelling IOP reduced <4mmHg Severe Moderate Mild Clinical Degree of Anterior Uveitis
  34. 38. Anterior Uveitis – Pathophysiology <ul><li>Non-granulomatous </li></ul><ul><ul><li>No pathogen </li></ul></ul><ul><ul><li>Responsive to topical treatment </li></ul></ul><ul><li>Granulomatous </li></ul><ul><ul><li>Pathogen induced </li></ul></ul><ul><ul><li>Less responsive to topical treatment </li></ul></ul>
  35. 39. Anterior Uveitis – Pathophysiology <ul><li>Inflammatory response causes breakdown of the blood-aqueous barrier </li></ul><ul><li>Plasma protein -> Flare </li></ul><ul><li>Cells are WBC </li></ul><ul><li>Fibrin derives from clotting factors </li></ul><ul><li>Deposition of cells and proteins </li></ul><ul><ul><li>KP </li></ul></ul><ul><ul><li>Hypopyon </li></ul></ul>
  36. 40. Anterior Uveitis – Pathophysiology <ul><li>Deposition of calcium salts in cornea </li></ul><ul><ul><li>Band keratopathy </li></ul></ul><ul><ul><li>Only after recurrent attacks </li></ul></ul><ul><li>Inflammation causes iris tissue to become sticky </li></ul><ul><ul><li>PAS -> reduced aqueous outflow -> IOP+ </li></ul></ul><ul><ul><li>Posterior synechiae -> pupil block -> IOP+++ </li></ul></ul><ul><li>Deposition of Macrophages </li></ul><ul><ul><li>Mutton Fat KP </li></ul></ul><ul><ul><li>Iris nodules </li></ul></ul>
  37. 41. Anterior Uveitis – Pathophysiology <ul><li>Circumlimbal injection </li></ul><ul><ul><li>Due to common blood supply with uveal vessels </li></ul></ul><ul><li>Lack of normal oxygen supply to iris </li></ul><ul><ul><li>Vessel growth factors released </li></ul></ul><ul><ul><li>Leaky new vessel growth on iris </li></ul></ul><ul><ul><li>Rubeosis Iridis </li></ul></ul><ul><ul><li>Extension of vessels into AC angle </li></ul></ul><ul><ul><li>ACG </li></ul></ul>
  38. 42. Anterior Uveitis – Management <ul><li>Chronic - Early referral to GP if not being managed currently </li></ul><ul><li>Recurrent acute episode – Urgent referral to GP for prescription of treatment regimen and monitoring </li></ul><ul><li>Acute episode, previously undiagnosed – Urgent referral to hospital eye casualty department </li></ul><ul><li>All patients – check IOP. If raised refer to GP or casualty depending on level </li></ul><ul><li>Counsel patients on importance of condition </li></ul>
  39. 43. Anterior Uveitis – Management <ul><li>Goals of management </li></ul><ul><ul><li>Preserve visual acuity </li></ul></ul><ul><ul><li>Relieve ocular pain </li></ul></ul><ul><ul><li>Eliminate ocular inflammation </li></ul></ul><ul><ul><li>Identify the source of inflammation </li></ul></ul><ul><ul><li>Prevent formation of synechiae </li></ul></ul><ul><ul><li>Control the IOP </li></ul></ul>
  40. 44. Anterior Uveitis – Management <ul><li>Treatment regimen </li></ul><ul><ul><li>Topical Corticosteroid therapy </li></ul></ul><ul><ul><ul><li>Reduce inflammation </li></ul></ul></ul><ul><ul><ul><li>Reduce exudate leakage </li></ul></ul></ul><ul><ul><ul><li>Increase cell wall stability </li></ul></ul></ul><ul><ul><ul><li>Inhibit lysozyme release by granulocytes </li></ul></ul></ul><ul><ul><ul><li>Inhibit circulation of lymphocytes </li></ul></ul></ul><ul><ul><li>Cycloplegia </li></ul></ul><ul><ul><ul><li>Relieve pain </li></ul></ul></ul><ul><ul><ul><li>Prevent posterior synechiae </li></ul></ul></ul><ul><ul><ul><li>Stabilize the blood-aqueous barrier </li></ul></ul></ul><ul><ul><li>Systemic steroid therapy </li></ul></ul><ul><ul><li>Systemic NSAID therapy (aspirin, ibuprofen) </li></ul></ul>
  41. 45. Anterior Uveitis – Associated Conditions <ul><li>Blunt Trauma </li></ul><ul><li>Ocular Surgery </li></ul><ul><li>Juvenile Chronic Arthritis </li></ul><ul><li>Ankylosing Spondylitis </li></ul><ul><li>Reiter’s syndrome </li></ul><ul><li>Sarcoidosis </li></ul><ul><li>Tuberculosis </li></ul><ul><li>Herpes Zoster </li></ul><ul><li>Herpes Simplex </li></ul><ul><li>Syphilis </li></ul><ul><li>Hypermature Cataract </li></ul><ul><li>Lens Rupture </li></ul><ul><li>Sympathetic ophthalmitis </li></ul><ul><li>Fuch’s heterochromic iridocyclitis </li></ul>
  42. 46. Anterior Uveitis – Clinical Pearls <ul><li>Four major complications exist </li></ul><ul><ul><li>Cataract </li></ul></ul><ul><ul><li>Secondary glaucoma </li></ul></ul><ul><ul><li>Band keratopathy </li></ul></ul><ul><ul><li>Cystoid macular oedema </li></ul></ul><ul><li>Easy to spot acute by signs & symptoms </li></ul><ul><li>Check patients with associated systemic conditions for chronic condition, which may be asymptomatic </li></ul><ul><li>Acute condition is most commonly caused by blunt trauma. Recurrence in such cases is rare </li></ul><ul><li>Any three recurrent acute episodes, with no other explanations, indicates a systemic cause </li></ul>
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