The document provides an overview of various forms of uveitis, including panuveitis, and outlines their classifications, causes, and management strategies. It elaborates on sympathetic ophthalmia as a severe form of panuveitis that can arise after ocular trauma, alongside details of other conditions like Vogt-Koyanagi-Harada disease and sarcoidosis. Treatment options primarily include corticosteroids and immunosuppressives, with specific considerations given to the etiology, such as infections or autoimmune diseases.

1. Dr. Anupama Karanthwww.ophthalclass.blogspot.comPanuveitis

2. Classification of uveitisAnatomic Classification of UveitisAnteriorIntermediatePosteriorPanuveitisClinical Classification of Uveitis

3. Anatomic classificationPanuveitisPrimary site of inflammation: anterior chamber, vitreous, retina or choroid

4. Clinical Classification of UveitisInfectious Bacterial / Viral / Fungal / Parasitic / Others Non-infectiousKnown/No known systemic association MasqueradeNeoplastic / Non-neoplastic

5. Panuveitis

6. DefinitionIt 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.Sensitization to some intraocular antigen/s occurs and results in bilateral ocular inflammationSympathetic ophthalmia

7. Penetrating injury is the precursorCommoner after non-surgical trauma than surgical traumaIncarceration of uveal tissue in the wound is a risk factorIn 80% of cases, presentation is between 2 weeks to 3 months after injuryMay even occur after 50 yearsSympathetic ophthalmia

8. Prodromal symptoms in the sympathizing eye (due to iridocyclitis)PhotophobiaBlurring to near objects (accommodation affected)Redness Early signsKeratic precipitates Retrolental cells and flareSympathetic ophthalmia

9. Granulomatous iridocyclitisMutton-fat KPsPlastic iridocyclitisVitritis Multiple yellow white nodules in the choroid – Dalen-Fuchs nodulesThickening of uveal tractPapillitisCan result in blindness in both eyesEstablished disease in both eyes

10. ProphylaxisEnucleation of the injured eye before onset of sympathetic ophthalmia is the only way of prevention, usually within 2 weeks of injury? Enucleation within 2 weeks of onsetTherapyCorticosteroids – topical, periocular, systemicAntimetabolites and cyclosporineTherapy

11. A few other common causes of panuveitis….

12. 10 year history of recurrent bilateral granulomatous uveitis with waxing and waning exudative retinal detachments, on steroids and immunosuppressives…www.ophthalclass.blogspot.comhttp://www.aao.org/publications/eyenet/200804/am_rounds.cfm

13. Koeppe and Busacca nodules in the iris Koeppe and Busacca nodules in the iris

14. Extensive pigment alterations in the fundus Koeppe and Busacca nodules in the iris

15. Extensive pigment alterations in the fundus

16. Dalen-Fuchs like peripheral nodules Koeppe and Busacca nodules in the iris

17. Extensive pigment alterations in the fundus

18. Dalen-Fuchs like peripheral nodules

19. Subretinal fibrosisBilateral granulomatous iridocyclitisVariable vitritis, exudative retinal detachmentsCommoner in pigmented racesAssociated extraocular features important in diagnosisCSF pleocytosis, neck stiffness, seizures, paralysis (CNS)Vitiligo, alopecia, poliosis (skin)Hearing loss and tinnitus (ear)Vogt-Koyanagi-Harada disease

20. DiagnosisClassical clinical picture but rule out SOCSF lymphocytosisManagementVigorous use of steroids- local, periocular and systemicImmunosuppressivesVogt-Koyanagi-Harada disease

21. A 50 year old diabetic with blurry vision…http://www.aao.org/publications/eyenet/200710/am_rounds.cfm

22. Peripapillary atrophy

23. Peripapillary atrophyAreas of RPE atrophy with underlying large choroidal vessels visible

24. Peripapillary atrophyAreas of RPE atrophy with underlying large choroidal vessels visible Pigments in a bony spicule pattern adjacent to vessels

25. Hereditary Retinitis pigmentosaSequelae of auto-immune diseaseToxic etiologiesChloroquine, thioridazineSequelae of infectious diseaseTuberculosis Syphilis Lyme diseaseD/D Pigmentary retinopathies

26. RPR reactive and positive FTA-ABS…… syphilis

27. Secondary syphilisGranulomatous iridocyclitisIris roseola, iris papulosa, iris nodosaFocal/multifocal choroiditisRetinitis, perivasculitisPapillitis, neuroretinitisSyphilis – the great masquerader

28. ManagementOcular involvement to be treated as neurosyphilisCSF evaluation should be done in any syphilitic uveitisPenicillin G 2-5 million units IV 4th hourly – 2 weeksSteroids only after effective antibiotic therapySyphilis – the great masquerader

29. A 35 year old male patient with blurry vision…

30. Hypopyon uveitis, nongranulomatous, vitritis

31. Core lab tests…Mantoux highly positive, Chest x-ray suggestive….Tuberculosis

32. Chronic iridocyclitisGranulomatous / nongranulomatousChoroiditisFocal / multifocal / choroidal tuberclesRetinal vasculitis, vitritis, papillitisDifficulty - in establishing the diagnosis and ensuring treatment complianceTuberculosis

33. A 46 year old lady with floaters…http://www.aao.org/publications/eyenet/200801/am_rounds.cfm

34. Granulomatous KPs, aqueous flare and cells

35. InfectionsTuberculosisSyphilisLyme diseaseNon-infectiousSarcoidosis VKH syndromeD/D granulomatous iridocyclitis

36. Chest x-ray, serum ACE…… elevated ACE, hilar lymphadenopathySarcoidosis

37. Granulomatous KPsBilateral hilar lymphadenopathyConjunctival folliclesNoncaseatinggranuloma

38. Multisystem granulomatous diseaseOcular findingsAcute / chronic granulomatous iridocyclitisVitreous snowballsRetinal periphlebitis, candle wax drippingsChoroidal small or large granulomasSarcoidosis

39. Suspect in any uveitisChest x-ray or CT, serum ACE and lysozymeBiopsy from skin / conjunctiva / lacrimal glandManagementCorticosteroids – topical, periocular and systemicImmunosuppressives may be requiredSarcoidosis

40. Behçet’s diseaseGeneralized occlusive vasculitisFour major criteria Oral aphthous ulcersGenital ulcersSkin – e.g. erythemanodosumOcular inflammation Acute iritis with transient hypopyonRetinal arteritis, periphlebitis, vitritisOcular disease recurrent and explosiveInitial immunosuppressives indicated

41. Aphthous ulcersHypopyoniritisOcclusive vasculitisSheathing and optic atrophy