INTRODUCTION TO UVEITIS

1. INTRODUCTION TO UVEITIS
DR SHRUTI LADDHA

2. • Inflammation of the uveal tract comprised by the iris, ciliary body, and
choroid.
• Infections of the eye, autoimmune disorders, trauma to the eye,
certain medications which can incite ocular inflammation, and rarely
malignancies

3. EPIDEMIOLOGY
• 10 % blindness worldwide
• Prevalence-115-204 /lac
• Incidence-17-52/lac
• Mean age-40 yrs
• M=F

4. SYMPTOMS
• dependent upon the anatomic location of the inflammation in the eye, rapidity of
onset of the inflammation, and duration and course of disease.
• Anterior segment (ocular injection, light sensitivity, pain, blurry vision, epiphora)
• Intermediate and posterior segment (floaters, flashing lights, blurry vision)

5. SIGNS
ANTERIOR SEGMENT
• Cells
• Flare
• Fibrin
• Hypopyon
• Synechiae (both anterior and posterior)
• Iris nodules
• Iris atrophy
• Keratic precipitates
• Band keratopathy

6. INTERMEDIATE SEGMENT
• vitreal cells
• “snowball” opacities in the vitreous
• exudates over the pars plana (snowbanking)
• neovascularization of the pars plana

7. POSTERIOR SEGMENT
• Vascular sheathing (arteries, veins, or both)
• Retinal pigment epithelial hypertrophy or atrophy
• Cystoid macular edema
• Atrophy or swelling of the retina, choroid, or optic nerve head
• Exudative, tractional, or rhegmatogenous retinal detachment
• Retinal or choroidal neovascularization

8. CLASSIFICATION
The classification of uveitis is important for multiple reasons that are as follows:
• The location of ocular inflammation may assist in diagnosis or at least narrow the
potential etiologies (e.g., Fuch’s heterochromic iridocyclitis involves the anterior chamber;
ocular toxoplasmosis primarily effects the retina with significant inflammatory spillover
into the choroid and vitreous)
• Uveitis may be a manifestation of an underlying serious or potentially lethal systemic
disease. The correct diagnosis can be sight and on occasion life-preserving.
• Uveitis may be caused by a vast number of conditions including infections, autoimmune
disorders, medication induced, traumatic, and neoplastic. The correct characterization of
the ocular manifestations may assist in identifying an underlying etiology.

9. The Standardization of Uveitis Nomenclature (SUN) Working Group guidance on uveitis
terminology, endorsed by the International Uveitis Study Group (IUSG), categorizes uveitis
anatomically
Anterior • Iritis
• Iridocyclitis
• Anterior cyclitis
Intermediate • Pars planitis
• Posterior cyclitis
• Hyalitis
Posterior • Choroiditis (focal, multifocal, diffuse)
• Chorioretinitis
• Retinochoroiditis
• Retinitis
• Neuroretinitis
Panuveitis

10. THE SUN WORKING GROUP
GRADING SCHEME FOR ANTERIOR CHAMBER CELLS
Grade Cells per field
0 <1
0.5+ 1-5
1+ 6-15
2+ 16-25
3+ 26-50
4+ >50
To grade cells and flare,
the slit lamp is set to
maximum intensity and
both the width and length
of the beam at 1mm.

11. THE SUN WORKING GROUP
GRADING SYSTEM FOR ANTERIOR CHAMBER FLARE
Grade Description
0 Complete absence
+ Faint, barely detectable
++ Moderate - iris and lens details clear
+++ Marked—iris and lens details hazy
++++ Intense--fixed coagulated aqueous with fibrin

12. Category Descriptor Comment
Onset
Sudden
Insidious
Duration
Limited
Persistent
≤3 months’ duration
>3 months’ duration
Course Acute
Recurrent
Chronic
Episode characterized by sudden onset and limited duration
Repeated episodes separated by periods of inactivity without
treatment ≥3 months duration
Persistent uveitis with relapse in <3 months after discontinuing
treatment
THE SUN WORKING GROUP DESCRIPTORS IN UVEITIS

15. Term Definition Comment
Inactive Grade 0 cells (anterior chamber)
Worsening activity
2-step increase in level of inflammation
(eg, anterior chamber cells, vitreous haze) or
increase from grade 3+ to 4+
Improved activity
2-step decrease in level of inflammation
(eg, anterior chamber cells, vitreous haze) or
decrease to grade 0
≤3 months’ duration
Remission
Inactive disease for ≥3 months after
discontinuing all treatments for eye disease >3 months’ duration
THE SUN WORKING GROUP ACTIVITY OF UVEITIS TERMINOLOGY

16. FEATURES OF GRANULOMATOUS AND NON GRANULOMATOUS UVEITIS
Features Granulomatous Non Granulomatous
Onset Insidious Acute
Course Chronic Short (may be recurrent)
Circumcorneal congestion + +++
Pain + +
Iris nodule +++ -
KP’s Large mutton fat Small or medium
Flare + +++
Posterior Segment Commonly involved Rarely involved
Vitreous Heavy exudates Fine opacities
Nodular lesions Diffuse involvement with edema

18. Clinical classification
a. Infectious:
i. Bacterial-TB, Syphilis, leprosy
ii. Viral-HSV, HZV, CMV
iii. Fungal-POHS, pneumocystis, Candida, Aspergillus
iv. Parasitic-Toxoplasma ,Toxocara, Cystecercosis
b. Non-infectious:
i. Known systemic association
ii. No known systemic association
iii. Masquerade:
Pathological Classification
i. Granulomatous and non-granulomatous
ii. Suppurative and exudative

19. Etiological Classification
• Infectious
i. Exogenous: Staphyloccous, Pseudomonas, Propionibacterium acnes.
• Secondary—Iridocyclitis associated with herpetic keratitis, iridocyclitis associated with
anterior and posterior scleritis
ii. Endogenous:
• Bacterial - TB, Syphilis
• Viral - Herpes simplex, CMV, Measles, Influenza
• Fungal- Histoplasmosis, Candidiasis
• Parasitic – Toxoplasmosis, Toxocariasis, Onchocerciasis, Pneumocystis carinii

20. Hypersensitivity/autoimmune
• Lens induced—autoimmune reaction to lens protein
• Sympathetic ophthalmia—autoimmunity to uveal pigment.
• VKH
• Behcet’s suspected autoimmune origin
Associated with Systemic Conditions
• Ankylosing spondylitis (AS)
• Rheumatoid arthritis (RA)
• Juvenile rheumatoid arthritis (JRA)
• Psoriatic arthritis
• Associated with GIT disorders: Ulcerative colitis
• Associated with respiratory system : Sarcoidosis, leprosy, TB.

21. Idiopathic
• i. Specific—Fuch’s
• ii. Nonspecific—Account for 25% of all uveitis.
Associated with Neoplasms
• Retinoblastoma, choroidal melanoma.
Non-infective systemic diseases
• Sarocoidosis
• Polyarteritis nodosa (PAN)
• Disseminated lupus erythematosus (DLE)
• Diseases of skin (psoriasis, lichen planus, erythema nodosum, pemphigus).
Traumatic uveitis
accidental or operative injuries to the uveal tissue

22. HISTORY TAKING
Questionnaire by Dr
Stephen Foster

27. IOP-
• high in 42 % cases
• Diseases thought to have a higher rate of ocular hypertension include Fuch’s heterochromic
iridocyclitis (FHIC), glaucomatocyclitic crisis or Posner-Schlossman syndrome, sarcoidosis,
juvenile rheumatoid arthritis, VKH, toxoplasmosis, and herpetic keratouveitis.

28. KERATIC PRECIPITATES-
• helpful in defining between acute versus chronic inflammation, and based on the appearance,
may also give clues into the pathogenesis
• Fine precipitates - more common in spondyloarthropathies and juvenile arthropathies.
• Stellate precipitates seen involving the superior cornea (as opposed to the typical inferior
corneal base down triangular appearance of most precipitates) are often seen with Fuch’s
heterochromic iridocyclitis.
• Mutton fat” precipitates are larger and are formed from macrophages and epithelioid cells.
These may be indicative of a granulomatous disease

29. Granulomatous kps non granulomatous kps

30. HYPOPYON-
• enough cells(leucocytes) as well as fibrin to clump it
• The most common etiologies include infectious (both bacterial and viral), HLA-B27
associated uveitis, and Behcet’s disease.
• With infectious endophthalmitis the patient will typically have a history of recent surgery,
trauma, or have risk factors for endogenous infection (e.g.,intravenous drug use)
• Behcets disease- shifting hypopyon
• Pseudohypopyon, composed of tumor cells and debris can occur in some of the
masquerade syndromes.

31. Iris Changes-
• Sectoral atrophy- HSV, HZV, CMV (if associated with raised IOP ,should arise the suspicion
of Herpes)
• Nodules on iris-accumulation of inflammatory cells on or within the iris –more common
in granulomatous disease
• Heterchromia- Fuchs disease

32. Retinal/Choroidal findings
• VKH- Serous retinal detachments ,Dalen-Fuchs nodules (small, discrete, deep, yellow-
white chorioretinal lesions) may be associated with VKH and sympathetic ophthalmia.
• Acute retinal necrosis (ARN) is a type of necrotizing retinitis most commonly caused by
herpetic viruses (HSV, VZV). The classic posterior appearance includes vitritis, retinal
vascular arteriolitis, and peripheral retinitis. Typically, the retinitis begins as peripheral
areas of multifocal retinal yellowing, often flat with scalloped edges. This can eventually
progress into confluent whitening extending into the posterior pole.
• Classic toxoplasmosis lesions present as focal and white with overlying vitritis with a
“headlight in the fog” appearance, often with adjacent pigmented retinochoroidal
scarring.

33. • Cytomegalovirus (CMV) retinitis may also be identified clinically and should be
suspected in patients who are immunosuppressed.
The classic exam findings - peripheral or posterior yellow-white lesions that
follow the retinal vasculature centripetally, vasculitis with a “frosted branch”
appearance, and retinal hemorrhages. This constellation of findings has been
described as a “scrambled eggs or cottage cheese with ketchup” appearance.
There may be little to no vitritis, given the immunocompromised state of
these patients.

34. • Optic Nerve—Disc hyperemia, papillitis or papilledema can occur in many uveitic
disorders,
However, classically prominent disc hyperemia is noted in VKH.