SLIDE UVEITIS ANTERIOR TO POSTERIOR .pptx

• The uvea consists of the middle, pigmented,
vascular layer of the eye and includes
 the iris,
 ciliary body, and
 choroid.
Uveitis is broadly defined as inflammation (ie, -itis) of the
uvea (from the Latin uva, meaning “grape”).
Inflammation of the uvea can involve other ocular
structures such as the retina, sclera, cornea, vitreous, and
optic nerve.
The etiology of uveitis is infectious or inflammatory and is
variably associated with systemic disease.
OVERVIEW

OVERVIEW
Uveitis  associated with systemic disease or infection a careful history and review of systems is an
essential first step in diagnosis.
• A comprehensive physical examination of the eye and pertinent organ systems  characterize the
type of inflammation present and to identify any associated systemic findings.
• The anatomical location of inflammation combined with results from the history and physical
examination  to guide further investigations.
• Multimodal ophthalmic imaging  to characterizing certain types of intraocular inflammation.
• Laboratory studies can help determine the etiology of the intraocular inflammation but are never
a substitute for a thorough history and physical examination.
Determining the specific type of uveitis guides the selection of treatment

EPIDEMIOLOGY
Uveitis  approximately 10% of all blindness in the US and Europe and up to 25% of
blindness worldwide.
In the US --> the prevalence of uveitis is 58–131 per 100,00
Developing world  up to 1070 per 100,000
Anterior uveitis is the most common type of uveitis, representing 70%–80% of
cases, followed by panuveitis, posterior uveitis, and intermediate uveitis.
have slightly higher rates of uveitis overall.
Most surveys show that uveitis incidence peaks between 20 and 60 years of age, recent data
suggests that it may also increase over the age of 65.

EPIDEMIOLOGY
Prevalence is about five- to tenfold lower in
children than in adults.
Developing countries have higher rates of
infectious uveitis and posterior and
panuveitis compared to industrialized nations.
Certain uveitides have greater distribution by
geographic region, such as :
• Birdshot chorioretinopathy in western Europe,
• Behçet disease in Turkey and China, and
• Tuberculous uveitis in India.

CLASSIFICATION OF UVEITIS
SUN system of classification  universal method of describing uveitis entities based on :
• Anatomic location of inflammation, and
• Specific descriptors of onset, duration, and course.
This text uses an etiologic division of uveitic entities into :
• noninfectious (autoimmune) and
• infectious conditions
and further describes them using the SUN system’s basic anatomical classification of uveitis into 4
subcategories:
(1) anterior uveitis,
(2) intermediate uveitis,
(3) Posterior uveitis, and
(4) Panuveitis.
When both anterior chamber and vitreous inflammatory cells are present, but the vitritis is more than
expected in an isolated anterior uveitis, the classification should be “anterior and intermediate uveitis”
and not “panuveitis.”

ANATOMICAL CLASSIFICATION – ANTERIOR UVEITIS
Anterior uveitis produces inflammatory signs predominantly in the anterior
chamber, as a result of inflammation of the iris and ciliary body.
Iritis : Inflammation confined to the anterior chamber
iridocyclitis : Cells in the retrolental (anterior vitreous) space
keratouveitis : Inflammatory processes that originate in the cornea with
secondary involvement of the anterior chamber
sclerouveitis : An inflammatory reaction that involves the sclera and uveal
tract (iris, ciliary body, and choroid)
When more than one ocular structure is involved, the convention is that the
primary site of inflammation is named first.
Severe or chronic anterior uveitis may produce secondary structural
complications such as uveitic macular edema, optic disc swelling, cataract,
corneal edema, band keratopathy, or iris abnormalities.
These complications are not part of the formal classification system but may
contribute to disease recognition and therapy.
38-old woman with spondyloarthropathy HLA B27 positive, showing severe
anterior uveitis associated with UME. (a): posterior synechiae and fibrinous
deposit in the anterior chamber; (b): horizontal central OCT scan showing UME.
Band
Keratopat
hy

ANATOMICAL CLASSIFICATION – INTERMEDIATE UVEITIS
Intermediate Uveitis  inflammation is most
prominent in the vitreous cavity
Inflammation occurs in the ciliary body, pars plana
(Pars planitis) and/or peripheral retina.
Clinical signs include :
• Vitreous haze and cellular debris  often
associated with peripheral retinal vasculitis.
• Macular edema is the most common structural
complication;
• severe or chronic disease may cause peripheral
exudative or tractional detachments, retinal
neovascularization, cataract, or retrolental membrane
formation.

ANATOMICAL CLASSIFICATION – POSTERIOR UVEITIS
Posterior Uveitis  is defined as intraocular inflammation primarily involving the retina and/ or choroid.
• Inflammatory cells may be observed diffusely throughout the vitreous cavity,overlying foci of active
inflammation,or on the posterior vitreous face.
• Fundoscopy reveals focal, multifocal, or diffuse areas of retinitis and/or choroiditis, often with retinal vasculitis.
Entities may have a similar clinical appearance, though some clinical patterns of disease are nearly pathognomonic for
diagnosis.
Structural complications such as macular edema, epiretinal membrane,and retinal or choroidal
neovascularization are not sufficient for the anatomical classification of posterior uveitis
In panuveitis, inflammation is present diffusely throughout the eye without a
predominantly affected site.
Inflammation may be associated with an infectious or noninfectious systemic disease.

ANATOMICAL CLASSIFICATION – RETINAL VASCULITIS
Retinal vasculitis is defined by the presence of retinal
vascular changes in association with ocular inflammation.
Retinal vasculitis is used in distinction to vasculopathy, in which
there are vessel changes but no visible evidence of
inflammation.
Retinal vasculitis encompasses :
• perivascular sheathing,
• vascular leakage, or
• occlusion shown on fluorescein angiography studies.
Peripheral vascular sheathing can be observed in
intermediate uveitis but is not sufficient for the anatomical
classification of posterior/panuveitis.
Retinal vasculitis is not considered to be a defining feature for the
anatomical classification of uveitis.
Fundus photographs of two patients with extensive vascular sheathing
secondary to intraocular tuberculosis.
Panel A demonstrates vascular sheathing accompanied by intraretinal
hemorrhages.
In Panel B, there are extensive perivascular hemorrhages in all four quadrants.
Fluorescein angiography of
a patient with occlusive
vasculitis. The vessels of
the lower arcade show
inflammation denoted by
leakage of the vessel wall.
There is an extensive area
of capillary non-perfusion
downstream (demarcated
by dotted square)
suggestive of obliteration
of blood flow.

ANATOMICAL CLASSIFICATION – RETINAL VASCULITIS
Frosted branch angiitis

CLASSIFICATION BY CLINICAL FEATURES
The severity of the inflammation can influence categorization and
prognosis.
The inflammatory process may occur in one or both eyes, or it may
alternate between them.
The distribution of ocular involvement—focal, multifocal, or diffuse—is
also helpful to note when classifying uveitis.
The classification of uveitis as either granulomatous or nongranulomatous is
still in use.
However, the clinical appearance of uveitis as granulomatous or
nongranulomatous may not necessarily correlate with the histologic description
and can instead be related to the disease stage, the amount of antigen at

CLASSIFICATION BY CLINICAL FEATURES
• Nongranulomatous inflammation typically has a lymphocytic
and plasma cell infiltrate; clinically, cellular deposits (keratic
precipitates) tend to be finer and distributed diffusely.
• Granulomatous inflammation also includes epithelioid and
giant cells; clinically, cellular deposits with large, clumped, or
greasy appearance are predominantly located in a gravity-
dependent position on the inferior cornea.
 Discrete granulomas are characteristic of sarcoidosis and
tuberculosis;
 Diffuse granulomatous inflammation appears in Vogt-
Koyanagi-Harada syndrome and sympathetic ophthalmia.
 Zonal granulomatous disease can be observed in lens-
induced uveitis.

SYMPTOMS OF UVEITIS
Symptoms produced by uveitis depend on :
• which part of the uveal tract is inflamed,
• the rapidity of onset (sudden or insidious),
• the duration of the disease (limited or persistent),
• the course of the disease (acute, chronic, or recurrent), and
• sometimes the underlying etiology.
Anterior uveitis 
• from a quiet asymptomatic white eye to an extremely painful red eye depending on the type of uveitis
and/or severity of inflammation.
• Sudden-onset anterior uveitis usually causes acute pain, photophobia, redness, and blurred vision.
• Pain results from ciliary spasm associated with inflammation in the region of the iris and may
radiate over the larger area served by cranial nerve V (the trigeminal nerve)/ due to ↑ IOP due to
angle closure or trabeculitis

SYMPTOMS OF UVEITIS
Chronic anterior uveitis in patients with juvenile idiopathic arthritis (JIA) may not be associated with
any symptoms at all.
However, even if initially asymptomatic, chronic or severe anterior uveitis can cause blurred vision because
of structural complications such as calcific band keratopathy, cataract, or macular edema.
Isolated intermediate uveitis
• a white, quiet eye; and
• produces symptoms of floaters (the shadows cast by vitreous cells and debris on the retina) and
• blurred vision (result from macular edema or vitreous opacities in the visual axis).
Patients with posterior uveitis
• painless blurred vision (primarily by retinitis and/or choroiditis directly affecting macular function, or
secondarily by complications of inflammation),
• floaters,
• photopsias,
• scotomata,
• metamorphopsia,
• nyctalopia, or a combination of these symptoms.

SIGN OF UVEITIS
The chemical mediators
involved in inflammation (see
Chapter 1) result in :
• vascular dilation (ciliary
flush),
• increased vascular
permeability (aqueous flare),
and
• chemotaxis of inflammatory
cells into the eye (aqueous
and vitreous cellular reaction)

SIGN OF UVEITIS- ANTERIOR SEGMENT
Signs of uveitis in the anterior portion of the
eye include
• inflammatory cells (Fig 5-1)
• flare (Fig 5-2)
• hypopyon
• fibrin in the anterior chamber
• keratic precipitates (Figs 5-3, 5-4)
• iris nodules (Fig 5-5)
• iris atrophy or heterochromia
• pupillary miosis
• synechiae, anterior and posterior (Fig 5-6) •
pigment dispersion
• cataract*
• band keratopathy*
*Observed in long-standing uveitis

eye include
• flare (Fig 5-2)
• hypopyon
pigment dispersion
• cataract*
Figure 5-3 Keratic
precipitates (medium and
small).
Figure 5-4 Large “mutton-fat”
keratic precipitates in a patient with
sarcoidosis. Large keratic
precipitates such as these
generally indicate a
granulomatous disease process.

eye include
• flare (Fig 5-2)
• hypopyon
pigment dispersion
• cataract*

The major finding in anterior uveitis is the
presence of inflammatory cells and flare in
the anterior chamber, but there may be many
additional sequalae.
The SUN system grades the intensity of anterior
chamber cells according to the number of
inflammatory cells observed on slit-lamp
examination in a field defined as a 1 × 1 mm
high-power beam at full intensity at a 45°–60°
angle in a dark room.
Flare is defined by the visibility of the slit-
lamp beam in the anterior chamber.
The SUN system adopted the flare grading method
described previously by Hogan and colleagues (Table
5-8)
The anterior chamber reaction can be described as
• serous (aqueous flare caused by protein influx)
• purulent (polymorphonuclear leukocytes and necrotic
debris causing hypopyon)
• fibrinous (plasmoid, or intense fibrinous exudate)
• sanguinoid (inflammatory cells with erythrocytes, as
manifested by hypopyon mixed with hyphema)

• Keratic precipitates (KPs) are collections of inflammatory cells on the corneal endothelium.
Newly formed KPs tend to be white and smoothly rounded, later transitioning to crenated (shrunken),
pigmented, or glassy in nature. Large, yellowish KPs are called mutton- fat KPs and are usually associated
with granulomatous types of inflammation.
• Associated corneal edema may be present.
• Band keratopathy is seen in chronic uveitis (especially JIA associated).
• Iris involvement may manifest as either anterior or posterior synechiae, iris nodules (Koeppe nodules at the
pupillary border, Busacca nodules within the iris stroma and Berlin nodules in the angle, iris granulomas,
heterochromia (eg, Fuchs uveitis syndrome), or stromal atrophy (eg, herpetic uveitis).
• With uveitic involvement of the ciliary body and trabecular meshwork, IOP is often low, secondary to decreased
aqueous production or increased uveoscleral outflow, but IOP may increase precipitously if the meshwork becomes
clogged by inflammatory cells or debris or if the trabecular meshwork itself is the site of inflammation
(trabeculitis). Pupillary block with iris bombé and secondary angle closure may also lead to an acute rise in IOP

SIGN OF UVEITIS- INTERMEDIATE SEGMENT
Signs of uveitis in the intermediate portion of the eye include :
• inflammatory cells in vitreous
• vitreous haze (Fig 5-7)
• snowballs (clumped vitreous cells)
• snowbanks (exudate over pars plana)
• ciliary body detachment
• retrolental membrane
• vitreous strands or traction band
• The hallmark of intermediate uveitis is
vitreous cell and haze.
• Cells may be clumped or individual.
• The cells make up vitreous haze when viewed
in combination with protein-aceous vitreous debris.
Uveitis with snowballs,
voluminous white vitreous
condensation, and finer
white-colored linear
inflammatory condensation
of the vitreous associated
with multifocal pigmented
scars in an Ebola survivor.
Snowball (arrow) and a string
of pearls-like vitreous
opacities (circled).
Snowbanks

The physician typically grades vitreous cells on a 0–4 numeric scale by
observing the retrolental space in a dilated eye using the slit- lamp
biomicroscope and a 1 × 0.5 mm beam.
• The National Institutes of Health grading system for vitreous haze, which the SUN
system adopted, employs a standardized set of fundus photographs that defines
vitreous haze on a 0–4 scale.
• Vitreous haze has been used in inclusion criteria in clinical trials for
uveitis, and a 2- step improvement has been used as a principal outcome
measure.

Figure 5-7 Grading scale for
vitreous haze: representative
standard images.
Grade 4: Dense opacity
obscuring optic nerve head.
Grade 3: Optic nerve visible,
borders blurred, no retinal
vessels seen.
Grade 2: Significant blurring
of optic nerve and retinal
vessels but still visible.
Grade 1: Few opacities, mild
blurring of optic nerve and
retinal vessels.
Trace (0.5+): Trace.
Grade 0: Clear.

Additional signs of inflammation in the vitreous include :
• snowball opacities (clumps of inflammatory cells in the vitreous) and
• snowbanks (exudates over the pars plana, especially prominent inferiorly).
Active snowbanks have a fluffy or shaggy appearance.
• As pars planitis becomes inactive, the pars plana appears gliotic or fibrotic and smooth; thus,
these changes are not referred to as snowbanks.
• Vitreal strands and snowballs may vary in clinical appearance by disease type.
• Chronic intermediate uveitis may be associated with cyclitic membrane formation, secondary ciliary
body detachment, and hypotony

SIGN OF UVEITIS- POSTERIOR SEGMENT
Signs in the posterior segment of the eye include
• retinal or choroidal inflammatory infiltrates
• inflammatory sheathing of arteries or veins
• exudative, tractional*, or rhegmatogenous* retinal detachment
• retinal pigment epithelial hypertrophy or atrophy*
• atrophy or swelling of the ret ina, choroid, or optic nerve head*
• preretinal or subretinal fibrosis*
• retinal or choroidal neovascularization*
*Indicates structural complications. Retinal and choroidal signs may be unifocal, multifocal, or diffuse.
Posterior segment inflammation is a result of inflammatory or infectious infiltration and resultant
structural damage of the retina and choroid. Retinal and choroidal signs may be unifocal, multifocal, or
diffuse. Lesions are described by size, color, and appearance (eg, well demarcated, geographic), and
anatomical relationship to posterior pole landmarks (see Table 5-7)

• infectious agents (viruses, bacteria, fungi, protozoa, and helminths),
• noninfectious entities of presumed immunologic origin, and unknown/ idiopathic causes
(called undifferentiated uveitis).
• Masquerade syndromes such as intraocular lymphoma, retinoblastoma, leukemia,
choroidal metastases, and malignant melanoma can be mistaken for uveitis.
• Other masquerade syndromes include juvenile xanthogranuloma, pigment dispersion
syndrome, retinal detachment, vitreous hemorrhage, retinitis pigmentosa, and ocular
ischemic syndrome.
• One should consider each of these entities in the differential diagnosis of uveitis.
DIFFERENTIAL DIAGNOSIS OF UVEITIS

Medical history, review of systems, thorough ophthalmologic and general physical examination,
and formulation of a working differential diagnosis are cornerstones of the workup of a patient with
uveitis.
• Laboratory testing is not a substitute for a thorough, hands-on clinical evaluation.
• Most uveitis specialists do recommend syphilis testing for all uveitis patients, as syphilis
can present as any form of uveitis, and systemic infection is often undiagnosed (treating with
steroid in the presence of untreated occult syphilis infection can be disastrous for patient
outcomes).
• where immunomodulatory therapy (IMT) will be used, most uveitis specialists also recommend
testing for tuberculosis with a purified protein derivative (PPD) skin test or interferon-
gamma release assay.
• A chest radiograph can screen for sarcoidosis, which is a common cause of uveitis with protean
manifestations
ANCILLARY TESTING

OPTICAL COHERENCE
TOMOGRAPHY (OCT)
Figure 5-9 Optical coherence tomography image of uveitic macular
edema in a patient with juvenile idiopathic arthritis–associated uveitis
Figure 5-10 Enhanced-depth imaging
optical coherence tomography in a
patient with Vogt- Koyanagi-Harada
syndrome A, During quiescence with
relatively normal choroidal thickness
(arrows). B, During uveitis activity
with diffuse choroidal thickening
(arrows). (

Fluorescein angiography is an essential imaging modality for evaluating eyes with chorioretinal
disease and structural complications caused by posterior uveitis.
Fluorescein angiography can detect :
• macular edema (Fig 5-11),
• retinal vasculitis, secondary choroidal or retinal neovascularization, and
• areas of optic nerve, retinal, and
• choroidal inflammation.
Several of the retinochoroidopathies, or white dot syndromes, have characteristic appearances on
FA. Wide and ultrawidefield FA can identify retinal vascular pathology not noted on clinical examination
FLUORESCEIN ANGIOGRAPHY
Figure 5-11 Late transit phase fluorescein angiogram of the left eye
of a patient with sarcoid-associated anterior uveitis showing a
petalloid pattern typical of uveitic macular edema.

Anterior segment ultrasound biomicroscopy can be useful in diagnosing pathology of the ciliary
body, iris, and iridocorneal angle in uveitis.
Posterior segment ultrasound, or B-scan ultrasound, can be useful in demonstrating vitreous
opacities, choroidal thickening or elevation, retinal detachment, and cyclitic membrane
formation, as well as in ruling out occult foreign bodies, particularly if media opacities preclude a
view of the posterior segment.
Retained IOL fragments may be visualized in the anterior or posterior segment.
Ultrasonographic imaging may be diagnostic for posterior scleritis.
ULTRASONOGRAPHY

• Paracentesis involves using sterile technique at the slit lamp or with the patient supine on a
treatment gurney or chair.
• Topical anesthetic drops are instilled;
• the eye is prepared with topical povidone- iodine solution; and
• a lid speculum can be placed.
• A tuberculin (1- mL) syringe is attached to a sterile 30- gauge needle.
• The syringe is then advanced under direct or slit-lamp visualization into the anterior chamber
through the temporal limbus or clear cornea parallel to the iris plane.
• As much aqueous is aspirated as is safely possible (usually 0.1–0.2 mL), avoiding contact with
the iris and lens.
• Possible complications include :
• anterior chamber bleeding,
• infection, and
• damage to the iris or lens
ANTERIOR CHAMBER PARACENTESIS TECHNIQUE

Vitreous specimens can be obtained either by needle tap or by using a vitrectomy instrument.
If a small sample is desired, a needle tap of the vitreous is typically performed with the patient partially
reclining in an examination room chair.
Topical and subconjunctival anesthesia are administered;
the eye is prepared with topical povidone- iodine solution, and
a lid speculum is placed.
Typically, a 25- gauge, 1-inch needle on a 3mL syringe (to provide greater vacuum) is introduced through the
pars plana, directed toward the mid-vitreous cavity, and used to aspirate the vitreous sample.
A diagnostic vitrectomy is performed via a standard 3- port pars plana.
The most common indications for vitreous biopsy include:
• suspected infection,
• primary intraocular lymphoma or
• other intraocular malignancy, and
• infectious etiologies of posterior uveitis or
• panuveitis.
VITREOUS BIOPSY TECHNIQUE

chronic uveitis that has an atypical presentation or an inadequate response to
conventional therapy may warrant diagnostic vitrectomy.
Testing typically requires undiluted vitreous specimens.
It is possible to obtain 0.5–1.0 mL of undiluted vitreous for evaluation using standard
vitrectomy techniques.

Complications of diagnostic vitrectomy in uveitic eyes can include :
• retinal tears or detachment,
• suprachoroidal or vitreous hemorrhage,
• worsening of cataract or inflammation, and,
• rarely, sympathetic ophthalmia.
Although vitreous surgery can be therapeutic and diagnostic in cases of uveitis, the
pharmacokinetics of delivered intravitreal drugs are markedly altered in eyes that have
undergone pars plana vitrectomy; the half-life of intravitreal corticosteroids, for example, is
significantly reduced in vitrectomized eyes.

SLIDE UVEITIS ANTERIOR TO POSTERIOR .pptx

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to SLIDE UVEITIS ANTERIOR TO POSTERIOR .pptx

Similar to SLIDE UVEITIS ANTERIOR TO POSTERIOR .pptx (20)

Recently uploaded

Recently uploaded (20)

SLIDE UVEITIS ANTERIOR TO POSTERIOR .pptx