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Uveitits classifications and Approach
- 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 Case
- 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
- 8. EPIDEMIOLOGY American Academy of Ophthalmology . Intraocular inflammation and uveitits. 9th 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 Sudde n Insidious 3 months Limite d Persisten t 3 6month9month Chronic Recurre nt Acute
- 12. Classification by Etiology 1. Infectious ( Bacteria , Viral , Fungal, protozoal ) 2. Non- infectious ( Autoimmune systemic association ) 3. Masquerade ( neoplastic , non- neoplastic )
- 13. HISTOLOGICAL CLASSIFICATION Granulomatous ( Epithelioid and giant cells infiltrate ) Non – granulomatous (Plasma cell and lymphocyte infiltrate ) Mutton fat KP Iris nodules
- 14. 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)
- 15. 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
- 16. Mutton Fat KPs
- 19. Iris Heterochromia ( eg. Fuches heterochromic uveitits ) Iris Stromal Atrophy
- 20. 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 ?
- 22. INTERMEDIATE UVEITIS clinical symptoms • Floaters •Vitreous cells •Snowballs in retina •Blurred vision •Vitreous opacity in visual axis •CME ( cystoid macular edema )
- 23. INTERMEDIATE UVEITIS clinical signs Vitreous cells and protiens arise from Snowballs Cells aggregate
- 24. 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
- 26. Vitreous strands and membranes Best seen with indirect ophthalmoscope Risk of PVD and CME
- 28. POSTERIOR UVEITIS clinical symptoms •Decrease VA • Floaters • Image disturbance photopsia ( flashes of light , Metamophopsia) • Visual defects ( Scotoma) • Nyctalopia ( night blindness )
- 29. 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
- 30. 23 yrs old female , serology +ve for syphillis White retinal lesions and a few retinal hemorrhages Thinning and occlusion of retinal vessels
- 31. 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.
- 32. prominent vascular sheathing and scattered retinal pigmented epithelium (RPE) changes
- 33. Recurrent ocular toxoplasmosis. Note the active retinal lesion associated with an old inactive scar.
- 35. PANUVEITIS CAUSES There is no predominant site of inflammation, but inflammation is observed in the anterior chamber, vitreous, and retina and/or choroid.
- 37. DISEASE ACTIVITY
- 38. HISTORY TAKING AND CLINICAL EXAMINATION
- 40. HISTORY
- 42. 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.
- 43. HISTORY Occupational , social & family Hx •Travel • Tobacco use •Sexual practices •IV drug use Medications? Allergy?
- 44. EXAMINATION • VA • Pupils , RAPD , color vision , color saturation • EOM • IOP • Thorough eye exam • Thorough Systemic examination
- 46. 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.
- 47. REFERENCES •American Academy of Ophthalmology . Intraocular inflammation and uveitits. 9th Edition. •N. Robbert . Uveitis Fundamental and clinical practice. 4th 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 .
Editor's Notes
- https://www.slideshare.net/drkaushikp/anatomy-of-uvea-56488116
- Methods: In this retrospective study, clinical records of randomly selected cases of uveitis attending the King Khaled Eye Specialist Hospital, Saudi Arabia, from 2001 to 2010, were reviewed. series included 888
- Viral Uveitis Herpesviridae Family Rubella Lymphocytic Choriomeningitis Virus Measles (Rubeola) West Nile Virus Rift Valley Fever Human T-Lymphotropic Virus Type 1 Dengue Fever Chikungunya Fever Other Viral Diseases Fungal Uveitis Ocular Histoplasmosis Syndrome Protozoal Uveitis Toxoplasmosis Helminthic Uveitis Toxocariasis Cysticercosis Diffuse Unilateral Subacute Neuroretinitis Onchocerciasis Bacterial Uveitis Syphilis Lyme Disease Leptospirosis Ocular Nocardiosis Tuberculosis Ocular Bartonellosis Whipple Disease
- Risk Factors HLA-B27 allele, anklyosing spondylitis, psoriatic arthritis Pathophysiology Unknown. A leading theory is that exposure of an individual with a genetic predisposition to an infectious agent results in cross reactivity with ocular specific antigens (molecular mimicry) with resultant iritis.
- Ciliary flush : cilliary body inflammation , dilation of blood vessels Hypopyon : WBC settles in AC . Kps : accumalaition of inflammatory cells in endothelium of cornea / usually base down triangle shape / seen by slit and retroillumination / granula and non granulamtuos / follow the course of disease ( after resolving they become transulcent , pigmented or disapper ) . In persistent disease they become granulomatous.
- Dim light Slit 1x1 mm field Full intesity Angle 45-60 Magnify Flare : break blood ocular barrier , proteins out , scattering of light , image not clear.
- Nodules : Accumaltion of inflammatory cells on the iriis Posterior S : cause pupillary block Anterior Sy : cause secondary glaucoma , block the outflow. release of mediators that promote fibrin deposition, clotting, and fibroblast proliferation, which are the probable causes of synechiae.
- Examination of the retinal periphery and pars plana is an important part of the ocular examination of patients with uveitis. Pars plana snowbanking is the accumulation of a white broglial mass over the pars plana and adjacent retina. It is usually restricted to the inferior pars plana but may extend superiorly.
- photopsia is a visual distortion caused by something inside the eye or brain. The distortions could be floaters, flashes of light, or other sudden small changes in the visual field N
- Acute vascular occlusion >> retinal edema Old vascular loss >> retinal atrophy If accompanying retinal vasculitis > inflammtion cause vessel ischemia > cotton-wool spots and retinal hemorrhage. isolated to the choroid, they often appear as grayish-yellow elevated masses ,vary in size from 50 μm to 500 μm in diameter. Chorioretinal specific to disease : Dalen–Fuchs nodules are associated with sarcoidosis and sympathetic ophthalmia.