MBBS ppt

2. Anterior
Uveitis
Jino JB

4. Anterior Uveitis
• Exogenous Infection
• Secondary Infection
• Endogenous
Infection
Immune Related
Uveitis
• Microbial Allergy
• Anaphylactic
• Atopic
• Autoimmune
• HLA associated
Toxic Uveitis
• Endotoxins
• Endo ocular toxins
• Exogenous toxins

5. Anterior Uveitis
• Exogenous Infection
• Secondary Infection
• Endogenous
Infection
Immune Related
Uveitis
• Microbial Allergy
• Anaphylactic
• Atopic
• Autoimmune
• HLA associated
Toxic Uveitis
• Endotoxins
• Endo ocular toxins
• Exogenous toxins
Traumatic Uveitis
Associated with Non
infective systemic
Disease
Idiopathic Uveitis

7. It is the inflammation of the uveal tissue from iris up to
pars plicata of the ciliary body.
It may be subdivided into
a) Iritis: Inflammation predominantly affects the iris.
b) Iridocyclitis: Iris and pars plicata equally involved.
c) Anterior Cyclitis: Pars plicata involved

8. SYMPTOMS
1. Pain: It is dominant symptom of acute anterior
uveitis. Patients usually complain of a dull aching
throbbing sensation which is typically worse at
night. The ocular pain is usually referred along the
distribution of branches of fifth nerve, especially
towards forehead and scalp.
2. Redness: It is a feature of acute anterior uveitis and
occurs due to circumcorneal congestion, which is
result of active hyperaemia of anterior ciliary
vessels due to the effect of toxins, histamine and
histamine like substances and axon reflex.

9. SYMPTOMS
3. Photophobia and blepharospasm observed in
patients with acute anterior uveitis is due to a reflex
between sensory fibers of fifth nerve ( which are
irritated) and motor fibers of the seventh nerve,
supplying the orbicularis oculi muscle.
4. Lacrimation occurs as a result of lacrimatory reflex
mediated by fifth nerve (afferent) and secretomotor
fibers of the seventh nerve (efferent).
5. Defective vision in a patient with iridocyclitis may
vary from a slight blur in early phase to marked
deterioration in late phase

10. SIGNS

11. Lid oedema
Lid oedema usually mild, may accompany a severe attack of acute
anterior uveitis.

12. Circumcorneal congestion
Circumcorneal congestion is marked in acute iridocyditis and
minimal in chronic iridocyclitis. It must be differentiated from
superficial congestion occurring in acute conjunctivitis

13. CORNEAL
SIGNS

14. Corneal oedema
Corneal oedema is due to toxic endotheliitis and raised intraocular
pressure when present.

15. Keratic precipitates (KPs)
Keratic precipitates (KPs) are the pathognomonic sign of anterior
uveitis. These are proteinaceous cellular deposits occurring at the
back of cornea. Mostly, these are arranged in a triangular fashion
occupying the centre and inferior part of cornea due to convection
currents in the aqueous humour. The composition and morphology of
KPs varies with the severity, duration and type of uveitis. Following
types of KPs may be seen:

16. Keratic precipitates (KPs)
1) Mutton fat KPs. These typically occur in granulomatous
iridocyclitis and are composed of epithelioid cells and
macrophages. They are large, thick, fluffy, lardaceous KPs,
having a greasy or waxy appearance. Mutton fat KPs are usually
a few (10 to 15) in number (Fig. 8.98).
2) Small and medium KPs (gran1Ular KPs). These are pathognornic
of nongranulom:atous uveitis and are composed of lymphocytes.
These small, discrete, dirty white KPs are arranged irregularly at
the back of cornea. Small KPs may be numerous.

17. Keratic precipitates (KPs)
3) Fine KPs, also called as 'stellate' KPs, typically cover entire
corneal endothelium and form the so called endothelial
dusting. These are seen in Fuchs heterochromic iridocyclitis,
herpetic iritis and CMV retinitis.
4) Old KPs. These are sign of healed uveitis. Either of the above
described KPs with healing process shrink, fade, become
pigmented and irregular in shape (crenated margins). Old
mutton fat KPs usually have a ground glass appearance due to
hyalinization.

18. Posterior corneal opacity
Posterior corneal opacity may be formed in long standing cases of
iridocyclitis.

19. ANTERIOR
CHAMBER SIGNS

20. Aqueous cells.
It is an early feature of iridocyclitis. The cells should be counted in
an oblique slit-lamp beam, 1 mm long and 1 mm wide, with maximal
light intensity and magnification, and graded as per
'Standardization of Uveitis Nomenclattue (SUN)' working group as
below:

21. Aqueous flare.
It is the earliest sign of acute anterior uveitis and occurs 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
oflight passed obliquely to the plane of iris. In the beam of light,
protein particles are seen as suspended and moving dust particles.
This is based on the 'Brownian movements' or 'Tyndall
phenomenon’.

22. Aqueous flare.
Aqueous flare is usually marked in non granulomatous and minimal
in granulomatous uveitis. The flare is graded from Oto +4. Grade as
per SUN working group grading scheme:

23. Aqueous flare.
Aqueous flare is usually marked in non granulomatous and minimal
in granulomatous uveitis. The flare is graded from Oto +4. Grade as
per SUN working group grading scheme:

24. 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)
• Dense immobile hypopyon, slow to absorb due to high fibrin
content, is seen in HLA-8 27 acute anterior uveitis.
• Hypopyon in Behcet's syndrome, also known as cold hypopyon,
has minimal fibrin and, therefore, shifts with the head position and
is quick to absorb.
• Haemorrhagic hypopyon is a feature of uveitis associated with
herpetic infection, trauma and rubeosis iridis.

25. Changes in depth and shape of
anterior chamber
Changes in depth and shape of anterior chamber may occur due to
synechiae formation as below:
• Deep and irregular in posterior synechiae.
• Funnel-shap ed in a nnular synechiae with iris bombe.

26. Changes in angle of anterior chamber
Changes in the angle of anterior chamber are observed with
gonioscopic examination. In active stage, cellular deposits and in
chronic stage peripheral anterior synechiae may be seen.

27. IRIS SIGNS

28. IRIS SIGNS
l. Loss of normal pattern. It occurs due to oedema and waterlogging
of iris in active phase and due to atrophic changes in chronic phase.
Iris atrophy is typically observed in Fuchs' heterochromic
iridocyclitis.
2. Changes In iris color. Iris usually becomes muddy in colour during
active phase and may show hyperpigmented and depigmented areas
in healed stage.

29. 3) IRIS NODULES
These occur typically in granulomatous uveitis.
• Koeppe's nodules are situated at the pupillary border and may
initiate posterior synechia.
• Busacca's nodules situated near the collarette are large but less
common than the Koeppe's nodules.

31. 4. Posterior synechiae.
These are adhesions between the posterior surface of iris and
anterior capsule of crystalline lens (or any other structure which
may be artificial lens, after cataract, posterior capsule left after
extracapsular cataract extraction) or anterior hyaloid face.
These are formed due to organisation of the fibrin-rich exudates.
Morphologically, posterior synechiae may be segmental, annular or
total.

32. 4. Posterior synechiae.
i. Segmental posterior synechiae refers to adhesion of iris to the
lens at some points.
ii. Annular posterior synechiae (ring synechiae) are 360°
adhesions of pupillary margin to anterior capsule of lens. These
prevent the circulation of aqueous humour from posterior
chamber to anterior chamber(seclusio pupillae). Thus, aqueous
collects behind the iris and pushes it anteriorly (leading to
'iris-bombe' formation). This is usually followed by a rise in
intraocular pressure.

33. 4. Posterior synechiae.
iii. Total posterior synechiae due to plastering of total posterior
surface of iris with the anterior capsule of lens are rarely formed in
acute plastic type of uveitis. This results in deepening of anterior
chamber

34. 5. Neovascularisation of iris
Neovascularisation of iris (rubeosis iridis) develops in some eyes
with chronic iridocyclitis and in Fuchs heterochromic iridocyclitis.

35. PUPILLARY SIGNS

36. PUPILLARY SIGNS
l. Narrow pupil. It occurs in acute attack of iridocyclitis due to
irritation of sphincter pupillae by toxins. Iris oedema and engorged
radial vessels of iris also contribute in making the pupil narrow.
2. Irregular pupil shape. It results from segmental posterior
synechiae formation. Dilatation of pupil with mydriatics (e.g.
atropine) at this stage results in festooned pupil.
3. Ectropion pupillae ( evertion of pupillary margin). It may develop
due to contraction of fibrinous exudate on the anterior surface of
the iris.

37. PUPILLARY SIGNS
4. Pupillary reaction becomes sluggish or may even be absent due to
oedema and hyperaemia of iris which hamper its movements.
5. Occlusio pupillae results when the pupil is completely occluded
due to organisation of the exudates across the entire pupillary area.

38. CHANGES IN LENS

39. CHANGES IN LENS
I. Pigment dispersal on the anterior capsule of lens is almost of
universal occurrence in case of anterior uveitis.
II. Exudates may be deposited on the lens in cases with acute plastic
iridocyclitis.
III. Complicated cataract may develop as a complication of persistent
iridocyclitis. Typical features of a complicated cataract in early stage
are 'polychromatic luster' and 'bread-crumb' appearance of the
early posterior subcapsular opacities. In the presence of posterior
synechiae, the complicated cataract progresses rapidly to maturity.

40. Changes in the vitreous and retina
1. Exudates and inflammatory cells may be seen in the anterior vitreous
after an attack of acute iridocyclitis.
2. Cystoid macular oedema (CME) may occur, especially in chronic
iridocyclitis.

41. Changes in the intraocular pressure IOP
Changes in the intraocular pressure IOP maybe:
• Normal, or
• Increased (secondary glaucoma) or,
• Decreased (in acute iridocyclitis due to acute ciliary shock and in
chronic, longstanding iridocyclitis due to atrophy of ciliary process
ultimately leading to phthisis bulbi).