This PPT is beneficial for undergraduate Medical students

1. Dr. Atul Kumar Anand
Senior Resident
AIIMS Patna

2. DEFINITION
Uveitis is a complex
intraocular
inflammatory process
that primarily involves
the uveal tract or
adjacent structures.

3. Inflammation of the uveal tract from the
iris upto the plars plicata
of ciliary body

4.  Numerous classification schemes have been
used to categorize the various types of uveitis.
 These are based on such factors as follows:
 Location (e.g., anterior, intermediate posterior),
 Course (acute, chronic, recurrent),
 Pathology (granulomatous, non-granulomatous)
 Causative factors (e.g., infectious, autoimmune,
systemic, neoplastic diseases).

5. 5
Anterior Uveitis
 Iritis
 Anterior cyclitis
 Iridocyclitis
Intermediate Uveitis
 Posterior cyclitis
 Hyalitis
 Basal retinochoroiditis
Posterior uveitis
 Focal, multifocal or diffuse choroiditis, chorioretinitis,
retinochoroiditis or neurouveitis
Panuveitis

6.  COURSE:
ACUTE: Characterized by sudden onset and limited duration.
RECURRENT: Repeated episodes separated by periods of
inactivity without treatment > 3 months
duration.
CHRONIC: Persistent uveitis with relapse in <3 months after
discontinuing treatment.
 ONSET: SUDDEN / INSIDIOUS

7.  Infective uveitis
 Allergic uveitis
 Toxic uveitis
 Traumatic uveitis
 Uveitis associated with non-infective systemic
diseases
 Idiopathic uveitis

8. Infective uveitis – Inflammation is induced
by invasion of organisms
 Exogenous infection
• Secondary infection
• Endogenous infection

9.  Bacterial infections
 Viral infections
 Fungal uveitis
 Parasitic uveitis
 Rickettsial uveitis

10.  Microbial allergy
 Anaphylactic uveitis
 Atopic uveitis
 Autoimmune uveitis
 HLA – associated uveitis

12.  Endotoxins
 Endocular toxins
 Exogenous toxins

13. • Seen in accidental or operative injuries to uveal tissue
▫ Direct mechanical effects of trauma
▫ Irritative effects of blood products after intraocular
hemorrhage
▫ Chemical effects of retained intraocular foreign bodies
▫ Sympathetic ophthalmia in other eye

14. • Sarcoidosis
• Collagen realated diseases
▫ Polyarteritis nodosa
(PAN)
▫ Disseminated lupus
erythematosus (DLE)
▫ Rheumatic and
rheumatoid arthritis
• Metabolic diseases
▫ Gout
• Diseases of skin
▫ Psoriasis
▫ Lichen planus
▫ Erythema nodosum

15. Iritis
Iridocyclitis
Cyclitis

16.  Pain: Acute
Severe
Radiates along V1 nerve distribution
Worst at night
 Redness:
 Photophobia
 Lacrimation
 Diminution of vision

17.  Corneal haze (due to oedema and KP’s)
 Aqueous turbidity
 Pupillary block due to exudates
 Complicated cataract
 Vitreous haze
 Cyclitic membrane
 Associated macular oedema
 Papillitis
 Secondary glaucoma

18. Lid Edema
Ciliary Congestion

19.  Corneal edema d/t toxic endothelitis & increased
IOP
 Keratitis precipitates{KP}:
Cellular deposits on the corneal endothelium.
Distributed in a base down triangular area
inferiorly (Arlt’s triangle)
Small, medium, large (mutton fat)

21. Large KPs
Mutton fat KPs

23. Early sign
Grading:
 0 = 0 cells
 ± = 1 – 5 cells
 +1 = 6 – 10 cells
 +2 = 11 – 20 cells
 +3 = 21 – 50 cells
 +4 = over 50 cells

24. D/t leakage of protein into the AC from the leaky vessels
On oblique view.: a point of beam projected on the iris plane
Protein particles seen floating the beam of light: Tyndall
phenomenon
Marked in Non-granulomatous Uveitis
Grading:
0 : No flare
1+ : Just detectable
2+: Moderate flare with clear detail view of iris
3+ : Marked flare with iris details not clear
4+ : Intense flare with no view of iris details

25. Hypopyon: Sterile Pus in AC
Hyphema: Blood in AC
Irregular AC depth d/t synechia
Deposits of debris in AC angle
Anterior synechia

26. Hypopyon:
When exudates heavy and thick they settle down in
lower part of ant chamber

27. Hyphaema (blood in AC):

28.  Loss of normal pattern
 Changes in iris colour : Muddy in color in active stage &
hyper/ hypopigmented
 Iris nodules : Aggregations of lymphyocytes and epitheloid
cells.
 Two types :-
• Koeppe’s nodules
• Busacca’s nodules
 Neovascularization of iris (rubeosis iridis)

29. Busacca nodules
Koeppe’s nodules
Neovascularization of iris

31. ▫ Posterior synechiae
▫ Adhesions between posterior
surface of iris and anterior capsule
of lens
▫ Due to organizations with fibrin rich
exudates
 Segmental posterior synechiae
 Annular posterior synechiae
 Total posterior synechiae

35. Seclusio pupillae -
Iris Bombe With A
360 Degree Posterior
Synechiae

36. Pupillary
signs
Posterior
synechiae
Irregular
pupil
shape
Miosis &
Sluggish
Pupillary
reaction
Seclusio
pupillae -
Iris
Bombe
Occlusio
pupillae

37. Pigment dispersion on anterior
lens surface
Fibrin exudates on lens surface
Complicated cataract:
Polychromatic lusture
Bread crumb appearance

39. Spill over anterior vitreous inflammation :-
May show exudates and inflammatory cells in
vitreous

40.  Complicated cataract
 Secondary glaucoma
 Cyclitic membrane due to fibrosis of exudates present behind the
lens
 Choroiditis
 Retinal complications
• Cystoid macular edema ,Macular degeneration
• Exudative retinal detachment ,etc.
 Band shaped keratopathy
 Papillitis
 Phthisis bulbi

42. Early glaucoma:
In active phase of disease
Due to exudates & inflammatory cells
in AC angle blocking the TM
Decreased aqueous flow leading to
increased IOP (Hypertensive
Glaucoma)

43. Late Glaucoma (Post
Inflammatory Glaucoma):
D/t pupillary block (Seclusio
Pupil/Occlusio pupil)
Causes Iris Bombe then occlusion
TM
Decreased aqueous outflow

44. retrolental,
fibrovascular
membrane
which stretches
across the back
of the lens

46. Cystoid Macular Edema
Macular Degeneration
Serous Retinal Detachment
Secondary Peripapilitis
Retinae

52. Shunken Disorganized eyeball
D/t chronic uveitis causes
ciliary shock & reduced
aqueous production….then
hypotony….shrunken
disorganized globe

53. All Red eyes are NOT
conjunctivitis

54. Features Acute
conjunctivitis
Acute
iridocyclitis
Acute
congestive
glaucoma
Onset Gradual Usually gradual Sudden
Pain Mild discomfort
Mod. In eye & along 1st
div. of trigeminal nerve
Severe in eye & entire
trigeminal area
Discharge Mucopurulent Watery Watery
Colored halos May be present Absent Present
Vision Good Slightly impaired Markedly impaired
Congestion
Superficial
conjunctival
Deep cilliary Deep cilliary
Tenderness Absent Marked Marked

55. AC Normal May be deep
Very shallow
Iris Normal Muddy
Edematous
IOP Normal Usually normal
Raised
Constitutional
symptoms
Absent Little
Prostration &
vomitting
Features Acute
conjunctivitis
Acute
iridocyclitis
Acute
congestive
glaucoma
Pupil Normal Small, irregular
Large, vertically oval
Media Clear
Hazy - KPs, aq. Flare
,pupillary exudates
Hazy –edematous
cornea

56. Acute conjunctivitis
Acute congestive glaucoma
Acute iridocyclitis

57. Granulomatous & Non
granulomatous Uveitis

58. Features Granulomatous Non-granulomatous
Onset Insidious
Acute
Pain Minimal
Marked
Photophobia slight
Marked
Ciliary congestion Minimal Marked
Keratic precipitates (KPs) Mutton fat
Small
Aqueous flare Mild marked
Iris nodules Usually present
Absent
Posterior synechiae Thick and broad based
Thin and tenuous
Fundus Nodular lesions
Diffuse involvement

59. Acute non-granulomatous Chronic granulomatous

60.  Hematological Examination
 TLC/DC: Gross idea of inflammatory response of body
 ESR: r/o Chronic infection
 Blood sugar: r/o DM
 Blood Uric Acid: r/o Gout
 Seological Test: Syphilis, toxoplasmosis &
histoplasmosis
 Test for:
 AntiAntinuclear Antibodies CRP
 Rh factor Anti-streptolysin O
 LE cells

61.  Urine Examination:
 For WBC, Pus cells, RBS
 Culture : r/o Urinary tract infection
 Stool Examination
 For Cysts & ova to r/o parasitic infestations.
 Radiological Investigation
 CXR, Paranasal sinus, Sacroiliac joints,
Lumbar spine.
 Skin Tests:
 Tuberculin test, Kveims test & Toxoplasmin
test.

62. Non- specific treatment:
Local therapy
Systemic therapy
Specific Treatment
T/t of Complications

63. Cycloplegics
Corticosteroids

64. Short acting cycloplegics:
Tropicamide 1% e/d (3hrs)
Cyclopentolate 1% e/d(24hrs)
Long acting cycloplegics
Homatropine 2% e/d(4days)
Atropine sulphate 1% e/d (7-14days)

65. Relieves pain & give comfort: By Relieving
spasm of iris sphincter & ciliary muscle
Prevents posterior synechiae formation
Breaks posterior synechiae
Reduces hyperemia & vascular
permeability which reduces exudation

66. Commonly used steroids:
Long acting:
 Dexamethasone
 Betamethasone
 Hydrocortisone
 Prednisolone
 Triamcinolone
Short acting:
 Fluoromethalone
 Loteprednol
 Fluocinolone

67. Topical: Eye drops or eye ointments
6-8 times a day
Anterior subtenon injection
For severe cases

68. Doesn’t have much role in anterior uveitis
unless until etiology infective

69. Corticosteroids
Non-Steroidal Anti-inflammatory
Drugs(NSAIDS)
Immunosupressives & cytotoxic drugs

70. Indication: Intractable anterior uveitis
Prednisolone: 1mg/kg body wt & taper
gradually according to response
Side effects: Glaucoma & Cataract

71. Used when steroid are
contraindicated or not tolerated.
Phenylbutazone &
oxyphenylbutazone

72. In corticosteroid resistant or
intolerant cases
In specific inflammations:
Behcet’s syndrome
Sympathetic ophthalmitis
VKH
Pars planitis

73.  Indication
• Potentially blinding, reversible , uveitis which has failed
to respond to adequate steroid therapy
• Intolerable side effects from systemic steroid
 METHOTREXATE, AZATHIOPRINE ,
CYCLOPHOSPHAMIDE CHLORAMBUCIL etc

74.  Bone marrow depression
 GI ulceration
 Stomatitis
 Liver damage
 Sterility

75.  A powerful anti T cell immunosuppressive agent
therefore does not result in bone marrow supression
 Complication
• HTN
• Nephrotoxicity

76. Tuberculosis: ATT
Parenteral Penicillin:Syphilis
HSV: Acyclovir

77.  Inflammatory Glaucoma:
Timolol 0.5% BD & T.Acetazolamide 250mg BD
Contraindicated are Latanoprost & Pilocarpine.
 Post-inflammatory Glaucoma(d/t ring
synechiea): Laser iridotomy
 Complicated Cataract:
Cataract sx. After 3mths of quiet period.
 Retinal Detachment: RD surgery
 Phthisis bulbi: Enucleation