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Published on has the complete class and MCQs on uveitis for undergraduate medical students. Class 5 in the series of classes on uveitis deals with the common causes of panuveitis and briefly discusses their management. The clinical feature of each of the disease entities is explained with the help of case studies.

Published in: Health & Medicine, Business


  1. 1. Dr. Anupama Karanth<br /><br />Panuveitis <br />
  2. 2. Classification of uveitis<br />Anatomic Classification of Uveitis<br />Anterior<br />Intermediate<br />Posterior<br />Panuveitis<br />Clinical Classification of Uveitis<br />
  3. 3. Anatomic classification<br />Panuveitis<br />Primary site of inflammation: anterior chamber, vitreous, retina or choroid<br />
  4. 4. Clinical Classification of Uveitis<br />Infectious <br />Bacterial / Viral / Fungal / Parasitic / Others <br />Non-infectious<br />Known/No known systemic association <br />Masquerade<br />Neoplastic / Non-neoplastic<br />
  5. 5. Panuveitis<br />
  6. 6. Definition<br />It is a rare, bilateral, granulomatous panuveitis which occurs after penetrating ocular trauma to one eye, the injured eye is referred to as the exciting eye while the uninjured eye is the sympathizing eye.<br />Sensitization to some intraocular antigen/s occurs and results in bilateral ocular inflammation<br />Sympathetic ophthalmia<br />
  7. 7. Penetrating injury is the precursor<br />Commoner after non-surgical trauma than surgical trauma<br />Incarceration of uveal tissue in the wound is a risk factor<br />In 80% of cases, presentation is between 2 weeks to 3 months after injury<br />May even occur after 50 years<br />Sympathetic ophthalmia<br />
  8. 8. Prodromal symptoms in the sympathizing eye (due to iridocyclitis)<br />Photophobia<br />Blurring to near objects (accommodation affected)<br />Redness <br />Early signs<br />Keratic precipitates <br />Retrolental cells and flare<br />Sympathetic ophthalmia<br />
  9. 9. Granulomatous iridocyclitis<br />Mutton-fat KPs<br />Plastic iridocyclitis<br />Vitritis <br />Multiple yellow white nodules in the choroid – Dalen-Fuchs nodules<br />Thickening of uveal tract<br />Papillitis<br />Can result in blindness in both eyes<br />Established disease in both eyes<br />
  10. 10. Prophylaxis<br />Enucleation of the injured eye before onset of sympathetic ophthalmia is the only way of prevention, usually within 2 weeks of injury<br />? Enucleation within 2 weeks of onset<br />Therapy<br />Corticosteroids – topical, periocular, systemic<br />Antimetabolites and cyclosporine<br />Therapy <br />
  11. 11. A few other common causes of panuveitis….<br />
  12. 12. 10 year history of recurrent bilateral granulomatous uveitis with waxing and waning exudative retinal detachments, on steroids and immunosuppressives…<br /><br /><br />
  13. 13. <ul><li> Koeppe and Busacca nodules in the iris</li></li></ul><li><ul><li> Koeppe and Busacca nodules in the iris
  14. 14. Extensive pigment alterations in the fundus</li></li></ul><li><ul><li> Koeppe and Busacca nodules in the iris
  15. 15. Extensive pigment alterations in the fundus
  16. 16. Dalen-Fuchs like peripheral nodules</li></li></ul><li><ul><li> Koeppe and Busacca nodules in the iris
  17. 17. Extensive pigment alterations in the fundus
  18. 18. Dalen-Fuchs like peripheral nodules
  19. 19. Subretinal fibrosis</li></li></ul><li>Bilateral granulomatous iridocyclitis<br />Variable vitritis, exudative retinal detachments<br />Commoner in pigmented races<br />Associated extraocular features important in diagnosis<br />CSF pleocytosis, neck stiffness, seizures, paralysis (CNS)<br />Vitiligo, alopecia, poliosis (skin)<br />Hearing loss and tinnitus (ear)<br />Vogt-Koyanagi-Harada disease <br />
  20. 20. Diagnosis<br />Classical clinical picture but rule out SO<br />CSF lymphocytosis<br />Management<br />Vigorous use of steroids- local, periocular and systemic<br />Immunosuppressives<br />Vogt-Koyanagi-Harada disease <br />
  21. 21. A 50 year old diabetic with blurry vision…<br /><br />
  22. 22. Peripapillary atrophy<br />
  23. 23. Peripapillary atrophy<br />Areas of RPE atrophy with underlying large choroidal vessels visible <br />
  24. 24. Peripapillary atrophy<br />Areas of RPE atrophy with underlying large choroidal vessels visible <br />Pigments in a bony spicule pattern adjacent to vessels <br />
  25. 25. Hereditary <br />Retinitis pigmentosa<br />Sequelae of auto-immune disease<br />Toxic etiologies<br />Chloroquine, thioridazine<br />Sequelae of infectious disease<br />Tuberculosis <br />Syphilis <br />Lyme disease<br />D/D Pigmentary retinopathies<br />
  26. 26. RPR reactive and positive FTA-ABS…… syphilis<br />
  27. 27. Secondary syphilis<br />Granulomatous iridocyclitis<br />Iris roseola, iris papulosa, iris nodosa<br />Focal/multifocal choroiditis<br />Retinitis, perivasculitis<br />Papillitis, neuroretinitis<br />Syphilis – the great masquerader <br />
  28. 28. Management<br />Ocular involvement to be treated as neurosyphilis<br />CSF evaluation should be done in any syphilitic uveitis<br />Penicillin G 2-5 million units IV 4th hourly – 2 weeks<br />Steroids only after effective antibiotic therapy<br />Syphilis – the great masquerader <br />
  29. 29. A 35 year old male patient with blurry vision…<br />
  30. 30. Hypopyon uveitis, nongranulomatous, vitritis <br />
  31. 31. Core lab tests…Mantoux highly positive, Chest x-ray suggestive….Tuberculosis<br />
  32. 32. Chronic iridocyclitis<br />Granulomatous / nongranulomatous<br />Choroiditis<br />Focal / multifocal / choroidal tubercles<br />Retinal vasculitis, vitritis, papillitis<br />Difficulty - in establishing the diagnosis and ensuring treatment compliance<br />Tuberculosis <br />
  33. 33. A 46 year old lady with floaters…<br /><br />
  34. 34. Granulomatous KPs, aqueous flare and cells<br />
  35. 35. Infections<br />Tuberculosis<br />Syphilis<br />Lyme disease<br />Non-infectious<br />Sarcoidosis <br />VKH syndrome<br />D/D granulomatous iridocyclitis<br />
  36. 36. Chest x-ray, serum ACE…… elevated ACE, hilar lymphadenopathySarcoidosis<br />
  37. 37. Granulomatous KPs<br />Bilateral hilar lymphadenopathy<br />Conjunctival follicles<br />Noncaseatinggranuloma<br />
  38. 38. Multisystem granulomatous disease<br />Ocular findings<br />Acute / chronic granulomatous iridocyclitis<br />Vitreous snowballs<br />Retinal periphlebitis, candle wax drippings<br />Choroidal small or large granulomas<br />Sarcoidosis <br />
  39. 39. Suspect in any uveitis<br />Chest x-ray or CT, serum ACE and lysozyme<br />Biopsy from skin / conjunctiva / lacrimal gland<br />Management<br />Corticosteroids – topical, periocular and systemic<br />Immunosuppressives may be required<br />Sarcoidosis <br />
  40. 40. Behçet’s disease<br />Generalized occlusive vasculitis<br />Four major criteria <br />Oral aphthous ulcers<br />Genital ulcers<br />Skin – e.g. erythemanodosum<br />Ocular inflammation <br />Acute iritis with transient hypopyon<br />Retinal arteritis, periphlebitis, vitritis<br />Ocular disease recurrent and explosive<br />Initial immunosuppressives indicated<br />
  41. 41. Aphthous ulcers<br />Hypopyoniritis<br />Occlusive vasculitis<br />Sheathing and optic atrophy<br />