This document provides an overview of anterior uveitis, including: 1. It describes the anatomy of the uvea, which includes the iris, ciliary body, and choroid. 2. Anterior uveitis is defined as inflammation of the iris and anterior ciliary body. It is the most common form of uveitis. 3. Treatment for anterior uveitis involves local cycloplegic drops, steroids, antibiotics, and systemic steroids or immunosuppressants depending on the cause of inflammation.

1. ANTERIOR
UVEITIS
By Dr Snehal sonewane
Junior Resident in Ophthalmology

2. ANATOMY OF UVEA
 Middle VASCULAR coat
of eyeball
 Divided into 3 parts
 Iris
 Ciliary body
 Choroid
 Diameter- 12 mm
 Pupil -opening in centre
, comparable to the
diaphragm of camera

3. IRIS
Iris - attached peripherally to
the middle of the anterior
surface of ciliary body
Thickness of iris
Least at IRIS ROOT- 0.5 mm
 Maximum at collaterate 1.5
mm
Clinical importance-
IRIDODIALYSIS
During blunt trauma, damage
to the iris occurs most
commonly at the iris root,
where the iris rips away from
the ciliary body

4. ANTERIOR SURFACE OF IRIS
Ciliary zone- 1.6 mm wide
Crypts-where superficial
layer of iris is missing ,
central and peripheral
Contraction furrow
Pupillary Zone between
collarette and Pupillary
frill.(highly pigmented d/t
extension of posterior
pigment epithelium ,
represents anterior end of
optic cup)

5. MICROSCOPIC STRUCTURE
Iris consist of 4 layers from anterior to posterior
1.Anterior limiting layer
2.Iris Stroma
3.Anterior Pigmented Epithelium-give rise to dilator pupillae muscle
4.Posterior Pigmented Epithelium

7. CILIARY BODY
Continuation of choroid at Ora
Serrata
Anterior side-part of angle and
posterior chamber, attachment to iris
Outer side lies against sclera with
suprachoroidal space in between
Inner side divided into two parts.The
anterior part (2 mm) with finger-like
processes is known as pars plicata
(corona ciliaris) and the posterior
smooth (4 mm) is known as pars
plana (orbicularis ciliaris).

8. LAYERS OF CILIARY BODY
1.SUPRACILIARY LAMINA-
pigmented collagen fibres,
continuation of suprachoroidal
lamina and anteriorly continues as
Anterior limiting membrane of
IRIS
2.STROMA OF CILIARY BODY
3.PIGMENTED EPITHELIUM- cont
of RPE, anteriorly cont asAnterior
pigmented epithelium of iris
4.NON PIGMENTED EPITHELIUM
cont of Sensory retina , anteriorly
cont as Posterior pigmented
epithelium of iris
5.INTERNAL LIMITING
MEMBRANE

9. CHOROID
Choroid Extends from Optic Disc to Ora Serrrata
1. SUPRACHOROIDAL LAMINA
2. STROMA OF CHOROID
3. CHORIOCAPILLARIES
4. BASAL LAMINA(BRUCH’S MEMBRANE/ LAMINAVITRA)

10. BLOOD SUPPLY
Short Posterior Ciliary arteries- 2 trunks from ophthalmic artery.
Each divides into 10 to 20 branches.
These branches pierce the sclera near optic nerve to supply the choroid in a segmental
manner.
Long posterior ciliary arteries- Nasal andTemporal, pierce the sclera on medial and
lateral side of optic nerve.They run forward in the suprachoroidal space, reach the
ciliary muscle.
At the anterior end they anastomose with each other and anterior ciliary arteries to
form the MAJOR ARTERIAL CIRCLE. Branches from this supply the ciliary
muscle.(each branch for each process)
Many branches from MAJOR arterial circle run through the iris towards the pupillary
margin and anastomose with each other- MINOR ARTERIAL CIRCLE
Anterior Ciliary arteries- Derived from the muscular branches of ophthalmic
arteries.7 in number, 2 from MR, SR, IR and 1 from LR.
Pass anteriorly in the episclera, give branches to Conjunctiva, limbus and sclera.
Pierce the sclera to anastomose with posterior cilary arteries Near the ROOT OF IRIS.

11. ANTERIOR UVEITIS
 Definition: It is inflammation of anterior uveal
tract i.e, iris &anterior part of cilliary body
(pars plicata)
 It is the mc form of uveitis

12. Classification-
 I. ANATOMICALCLASSIFICATION
 II. CLINICAL CLASSIFICATION
 III. ETIOLOGICAL CLASSIFICATION
 IV. PATHOLOGICALCLASSIFICATION

13. A. Anatomical Classification – (IUSG)
International Uveitis Study Group
 1) Anterior Uveitis – Inflammation of iris and
anterior part of ciliary body.
 2) Intermediate Uveitis – Involvement of
posterior part of ciliary body and extreme
periphery of retina. (Pars planitis)
 3) Posterior uveitis – Retinochoroiditis,
choroiditis, retinitis, chorioretinitis
 4) Diffuse or pan uveitis – Involvement of
entire uveal tract

14. B. Clinical Classification -
 1) Acute – sudden symptomatic onset.
Persists for 3 weeks or less.
 2) Chronic – Frequently insidious and
asymptomatic. Persists for months or years.
 3) Recurrent

15. C. Etiological Classification
In most of the cases, probably, allergy is the cause.
 1) Exogenous-
Introduction of organism into the eye through a perforating wound or ulcer.
 2) Secondary infection-
Due to direct spread from adjoining structures-
 Cornea
 Sclera
 Retina
 3) Endogenous
 4) Allergic inflammation: Result of an antigen-antibody reaction occurring in the eye
due to previous sensitization of uveal tissue to some allergen.The allergen is a foreign
protein.
 Most of the cases of iridocyclitis do not have any specific cause and are probably
allergic in nature.
 5) Auto-immune -
Immune disorders
e.g. rheumatoid arthritis, SLE, ankylosing spondylitis, Reiter’s syndrome, Behcet’s
Syndrome.

16. Granulomatous Non-
granulomatous
1. Aetiology Organismal
invasion
Antigen-antibody
reaction
2. Course
a) Onset Insidious Acute
b) Duration Chronic Short
c) Inflammation Moderate Severe
D. Pathological Classification

17. Granulomatous Non-
granulomatous
3. Pathology
a) Lesion Circumscribed Diffuse
b) Iris Focal reaction Diffuse reaction
c) Keratic
precipitates
Mutton fat Fine plenty
d) Iris
adhesions
Coarse, few, thick Fine, plenty, thin
4.
Investigations
May be positive Negative

18. SYMPTOMS
 PAIN-
Dull aching
Worse at night
Referred along branches of trigeminal nerve
towards forehead &scalp
 Redness –Hyperemia of anterior cilliary arteries
 Decreased vision –Mild reduction
Factors responsible are: -corneal edema
- Aqueous flare&cells
- cilliary spasm (myopia)
- pupillary membrane
- complicated cataract
-cyclitic membrane
- vitreous exudates
- macular edema
 Photophobia
 Lacrimation

19. SIGNS
 Lid oedema
 Circumcorneal
congestion with
purplish hue due
to involvement of
deeper vessels

20. Corneal signs
1.Corneal oedema: Raised IOP /Toxins
2.Keratic precipitates (KPs)
-Nutrition of corneal endothelium is affected due to toxins
-Corneal endothelium becomes sticky and edematous
-Cells desquamated at places
-Inflammatory cells stick to endothelial layer as cellular deposits .
3. Posterior corneal opacity

21. Anterior chamber signs
 1. Aqueous cells. It is an early feature of iridocyclitis.
 – = 0 cells,
 +0.5 = 1–5 cells,
 +1 = 6–10 cells,
 +2 = 11-20 cells,
 +3 = 21–50 cells, and
 +4 = over 50 cells
 2. Aqueous flare. It is due to leakage of protein particles into the aqueous humour
from damaged blood vessels. It is demonstrated on the slit lamp examination by a
point beam of light passed obliquely to the plane of iris.
 Grade :
 0 = no aqueous flare,
 +1 = just detectable;
 +2 = moderate flare with clear iris details;
 +3 = marked flare (iris details not clear);
 +4 = intense flare (fixed coagulated aqueous
with considerable fibrin).
3. Hypopyon. When exudates are heavy and thick, they settle down in lower part of the
anterior chamber as hypopyon (sterile pus in the anterior chamber)
4. Hyphaema (blood in the anterior chamber): It may
be seen in haemorrhagic type of uveitis.

22.  Hypopyon in anterior uveitis

23. IRIS SIGNS
1..Loss of normal pattern
Acute-Edema+waterlogging
Chronic-Atrophy
2.Change in colour –
Acute-muddy
Chronic-hyperpigmented /depigmented
3.Nodules-Koeppes nodules
Bussaca nodules
4.Posterior Synechiae-segmental
-annular-360 adhesions these prevents circulation of
aqueous humor from posterior to anterior chamber causing seclusio pupil
lae,aqueous collects behind iris &pushes it anteriorly leading to IRIS BOMBE
formation
5.Neovascularisation of Iris

28. PUPILLARY SIGNS
 Narrow pupil& sluggishly reactive to light
 Irregular Pupil –Due to segmental synichiae
dilatation of pupil at this stage result in
FESTOONED PUPIL
 Ectropion pupil
 Pupillary Reaction
 Occlusio Pupillae

30. CHANGES IN LENS
 Pigment Dispersion
 Complicated cataract

31. CHANGES IN VITREOUS
 Exudates &CME
 CHANGES IN IOP
Normal
Increased(secondary Glaucoma)
Decreased (cilliary shock)

32. INVESTIGATIONS
 PreliminaryTests
Complete hemogram
ESR
Blood sugar
-Fasting&post prandial
Mantoux test
CXR
 SpecificTests
Anterior Uvetis
Acute:
Spondyloarthropathies-HLA B-
27,sacroilliac joint films
Bechet’s syndrome-HLA B 5,B51
Herpetic (HSV,VZV)-clinical,PCR,ELISA
Glaucomatocyclitis crisis-clinical
Postsurgical/posttraumatic-
clinical,vitreous culturevitrectomy
Chronic :
JIA-ANA,ESR
Fuch’s Heterochromic iridocyclitis –
clinical
Tuberculosis-CXR
Sarcoidosis-ACE,CXR
Syphillis-VDRL,RPR,FTA-ABS
Herpetic-PCR, ELISA

34. TREATMENT
 LOCAL
A. CYCLOPEGIC
B. STEROIDS
C. ANTIBIOTICS
D. SUPPORTIVE
 SYSTEMIC
A. STEROIDS
B. ANTIIFLAMMATORY AGENTS
C. IMMUNOSUPPRESION
D. RX OF CAUSE

35. LOCAL
A. Cycloplegics-
- Atropine 1% BD
-Homide 2%TDS
- Cyclopentolate 1%TDS
-Mydricaine s/c – atropine+adrenaline+procaine
- Continue for 2-3weeks after resolution of
uveitis

36. MECHANISM OF CYCLOPLEGICS
Breaks synechiae and
prevents further formation
Relieves ciliary spasm
Decreases exudation Increases blood supply to
anterior uvea

37. B. STEROIDS:
Topical,Subconjuctival
Regional(SubTenon’s),Intraocular for CME
Predmet 1% -1 hourly then taper over 6weeks
Dexamethasone
Loteprednol –less flactuation in IOP
Mechanism:
Anti-inflammatory,Antifibrotic&Antiallergic
S/E-Glaucoma
Secondary infection
C. Antibiotics-As a cover to steroids
D.Supportive-
Hot fermentation( Increase circulation)
Dark glasses(Decrease photophobia)
Tissue PlasminogenActivator
Severe Fibrinous reaction in AC
12-25 mcg intracameral

38.  SYSTEMIC:
A.Steroids-
-Non-granulamatous
T.Prednisolone 1mg/kg/day *2weeks
Taper over 8 weeks
S/E-Cataract
B.Anti-inflammatory agents-NSAIDSs
Rheumatoid Arthtritis-Phenylbutazone,Oxyphenbutazone
Ankkylosing Spondylitis-Naproxen
C.Immunosuppresion
Rare
MTX/Azathioprine
D .RX the cause
Tuberculosis-AKT
Broad SpectrumAntibiotics

39. Complications and sequelae
 Complicated cataract
 Secondary glaucoma
-Early glaucoma
-Late glaucoma in iridocyclitis
 Cyclitic membrane
 Choroiditis
 Retinal complications
 Papillitis
 Band shaped keratopathy
 Phthisi bulbi
- stage of atrophic bulbi without shrinkage
- stage of atropic bulbi with shrinkage
- stage of atrophic bulbi with disorganisation

40. Differential Diagnosis
Character Conjunctivit
is
Iridocycliti
s
Glaucoma
Infection Superficial Deep ----
Secretion Mucopurule
nt
Watery Watery
Pupil Normal Small,
irregular
Large, Oval

41. Character Conjunctivitis Iridocyclitis Glaucoma
Media Clear Sometimes
pupil
opaque
Corneal
oedema
Tension Normal Usually
normal
High
Pain Mild Moderate
with first
division of
trigeminal
Severe and
entire
trigeminal

42. Character Conjunctivitis Iridocyclitis Glaucoma
Tenderness Absent Marked Marked
Vision Good Fair Poor
Onset Gradual Usually
gradual
Sudden
Systemic
complications
Absent Little Prostration
and
vomiting

43. THANKYOU!