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5.opththalmology Uveitis.over view pptx
- 1. 1 Uveitis By Bekuma Jima(MD) Ophthalmology Resident- (R4)
- 2. 2 Introduction – “Uvea”= “Grape” (Latin). – Uveal Tract = Three parts --- Iris + Ciliary body + Choroid.
- 3. 3 – Ciliary body--- two parts: – Pars plicata --- anterior part. – Pars plana --- posterior part.
- 4. 4 Uveitis – Itis an inflammation of the uvea --- and, it can affect: – Any part of the uveal tract: • Iris ---> iritis. • Choroid ---> choroiditis. • Ciliary body --- cyclitis. • Pars plicata ---> anterior cyclitis. • Pars plana ---> pars planitis (intermediate uveitis). – More than one part of the uveal tract: • Iris and ciliary body ---> iridocyclitis. • Whole uveal tract ---> panuveitis.
- 5. 5 Classification ofUveitis – Anatomical (the most widely accepted) – Anterior uveitis – Intermediate uveitis – Posterior uveitis – Panuveitis – Mode of onset & course – Acute uveitis (<3 months) – chronic uveitis (>3 months) – Recurrent uveitis – Etiologic – Infectious – Traumatic – Neoplastic – Autoimmune – Idiopathic – Type of inflammation – Granulomatous – Non-granulomatous
- 6. 6 Anatomical classification ofuveitis • Anterior Uveitis – The inflammation involves the iris and anterior part of the ciliary body. » Iritis » Iridocyclitis » Keratouveitis – Anterior uveitis is further divided into acute and chronic.
- 7. 7 – Causes ofanterior uveitis: – Arthritis --- JRA, ankylosing spondylitis, Reiter’s syndrome, psoriasis – Sarcoidosis – Behcet’s disease – Infections ---bacterial, viral, fungal, parasitic, others. » HSV, HZV, Syphilis, TB, Lyme disease – Trauma – Surgery --- esp. associated with lens – Idiopathic (unknown cause)
- 8. 8 – Acute AnteriorUveitis --- AAU – Has classic presentation • Rapid onset of unilateral pain, visual loss, photophobia, redness and watery discharge • sometimes preceding mild ocular discomfort for a few days. – Signs • Conjunctival injection • Perilimbal (ciliary flush) --- in early cases • Diffuse --- in severe cases
- 9. 9 • Miosis dueto pupillary sphincter spasm • Endothelial dusting or Keratic precipitates (KP’s) • Inflamm. cells and flare (protein influx) in A/C • Sometimes inflamm. membrane covering pupil • Posterior synechiae
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- 12. 12 – Chronic AnteriorUveitis --- CAU – Gradual onset, persistent inflammation, lasts > 3months. – Symptoms: • Variable --- redness, discomfort, photophobia. • Sometimes --- asymptomatic until complications develop --- E.g., cataract.
- 13. 13 – Signs: • Aqueouscells and flare • Old KP’s (endothelial aggregates of inflammatory cells) • Posterior synechiae • Iris atrophy or nodules
- 14. 14 • Intermediate Uveitis –Inflammation of the middle portion of the uvea. – Presentation: – Insidious onset of blurred vision and floaters. – Externally, the eye looks quiet and normal. – Anterior vitreous cells. – Snow ball --- aggregation of inflammatory cells in the anterior part of vitreous. – Snow banking --- grey-white fibrovascular plaque in the inferior peripheral retina
- 15. 15 • Posterior Uveitis –Inflammation affecting the choroid, retina, and/or retinal vessels. – Clinical Presentations: – The eye may look quiet or may have AC inflammation. – Symptoms --- blurry / loss of vision, scotoma, floaters. – Signs --- infiltrates within the vitreous, retina or choroid; signs of RD.
- 16. 16 • Panuveitis ---Diffuse Uveitis – Inflammation of the entire inner eye. – Presentation --- findings of the anterior and posterior uveitis. – Endophthalmitis – A type of panuveitis which is of infectious cause --- usually unilateral.
- 17. 17 Investigation forUveitis – Diagnosis often made on clinical grounds --- as in: – Mild unilateral acute anterior uveitis. – Systemic diagnosis already made --- E.g., sarcoidosis. – Distinct features --- E.g., toxoplasmosis, CMV retinitis, sympathetic ophthalmia. – When investigations is needed, it should be done based on the most likely cause clinically.
- 18. 18 – General investigations: –CBC, ESR, CRP – Serology for syphilis --- VDRL, rapid plasma reagin (RPR), – Chest x-ray – Specific workups: – Infectious workup --- HIV test, toxoplasma IgG/IgM, Sputum AFB – ANA --- for children with arthritis – Serum ACE, lysozyme – Biopsy --- from conj., aqueous, vitreous, retina, choroid – Imaging tests --- Ultrasound, Fluorescein angiography, OCT, CT scan, MRI
- 19. 19 Treatment ofUveitis – Steps of management: – Proper workup and diagnosis. • Especially, differentiate infectious from the non infectious causes. – Treatment of the underlying cause, if any. – Supportive management.
- 20. 20 – Treatment ofunderlying causes: – TB --- initiate proper anti-TB – CMV retinitis --- Gancyclovir, Foscarnet – HSV --- Acyclovir – Toxoplasmosis: • 1st line --- pyrimethamine, sulfadiazine, folinic acid, and prednisolone. • 2nd Line --- Clindamycin. • 3rd Line --- trimethoprim and sulfamethoxazole. – Systemic inflammatory d’ses: • Systemic corticosteroids • Immunomodulatory agents
- 21. 21 – Supportive treatment: –Important for both infectious & non infectious causes. – Include: • Cycloplegics • Uses --- relieve pain, prevent synechiae. • Tropicamide, cyclopentolate, atropine. • Corticosteroids --- to control inflammation. • Immunosuppressive drugs --- indications being: • Sight threatening uveitis despite steroid use. • Steroid resistant or steroid dependent cases. • Intolerable side effects of steroids. • If corticosteroid use is contraindicated.
- 22. 22 – Possible routesfor corticosteroids: – Topical --- for treatment of anterior uveitis. – Sub-Tenon injection --- for intermediate or posterior uveitis. – Intravitreal --- as injection or implant --- for posterior uveitis. – Systemic --- for: • Vision threatening uveitis --- posterior uveitis, panuveitis. • Simultaneous treatment of underlying systemic inflammatory d’ses.
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