1) The document discusses the anatomy, classifications, clinical features, and treatment of uveitis. 2) Uveitis refers to inflammation of the uveal tract which includes the iris, ciliary body, and choroid. It can be classified anatomically by which structure is involved - anterior, intermediate, or posterior uveitis. 3) Clinical signs of anterior uveitis/iridocyclitis include pain, redness, photophobia, blurred vision, and keratic precipitates on the cornea. Treatment involves cycloplegic eye drops to relieve inflammation and prevent complications.

1. OPHTHALMOLOGY
SGD
PRESENTATION

2. Presented By
Bismita Patgiri (09)
Arko Probho Chattopadhyay (03)
Nitika Sharma (04)
Pratiksha Baruah (06)

3. EYE- ANATOMY

4. -It refers to the inflammation of the uveal tissue. The
inflammatory process may involve predominantly
anterior ,intermediate or posterior uvea although
there is always some associated inflammation of the
adjacent structure such as retina, vitreous, sclera and
cornea.
Intraocular Inflammation/ Uveitis

5. Anatomy - Uvea

6. ANTERIOR UVEITIS/IRIDOCYCLITIS
• CLINICAL FEATURES-
A. SYMPTOMS-
PAIN-
It is dominant symptom of acute anterior uveitis.
• Dull, aching and throbbing
• Usually referred along the distribution of CN V
REDNESS-
• Occurs due to circumcorneal congestion , which is a result of active hyperemia
of anterior ciliary vessels due to toxin , histamine and histamine like
substances.
PHOTOPHOBIA AND BLEPHAROSPASM-
• Occurs due to a reflex between sensory fibres of irritated CN V and motor
fibres of CN VII supplying the orbicularis oculi.

7. LACRIMATION
• Occurs as a result of lacrimatory reflex mediated by CN V( afferent) and CN VII
(efferent)
DEFECTIVE VISION
• Defect may vary from a slight blur in early phase to marked deterioration in
late phase
• Factors responsible:
a. Induced myopia due to ciliary spasm
b. Corneal haze due to edema and KPs
c. Aqueous turbidity
d. Pupillary block due to exudates
e. Complicated cataract
f. Vitreous haze
g. Cyclitic membrane
h. Associated macular edema
i. Paplillitis
j. Secondary glaucoma

8. B. SIGNS-
 Lid edema
 Circumcorneal congestion
 Corneal sign
Corneal edema
Keratic precipitates (pathognomic)
Posterior corneal opacity (chronic cases)
 Anterior chamber signs
Aqueous flare (earliest sign)
Aqueous cells
Hypopyon
Changes in the depth and shape of anterior chamber due to synechiae formation
Changes in the angle of anterior chamber
 Iris signs
Loss of normal pattern
Changes in iris color
Iris nodule : Koeppe’s nodule and Busacca’s nodule

9. Posterior synechiae : These are adhesions between posterior surface of iris and anterior surface of lens.
Rubiosis iridis
 Pupillary signs :
Narrow pupil
Festooned pupil
Ectropion pupillae
Sluggish pupillary reaction
Occlusio pupillae
 Lens :
Pigment dispersal on anterior capsule
Exudate deposition
Complicated cataract
 Vitreous & Retina :
Presence of exudate and inflammatory cells.
Cystoid macular edema.
 IOP :
Normal
Increased
Decreased

10. INTERMEDIATE UVEITIS/ PARS PLANITIS
A. SYMPTOMS :
 Asymptomatic in many cases
 Floaters : most common presentation
 Blurring and decreased vision
 Absence of : pain, redness, photophobia and posterior synechiae.
B. SIGNS :
1. Anterior segment : Low grade flare and cells
Few KPs
2. Posterior segment : Vitreous cells
Snowball/cottonball opacities
Snowbanking ( hallmark)
Severe vitreous opacification
Chronic macular edema

11. POSTERIOR UVEITIS
A. SYMPTOMS :
a. Defective vision :
due to - vitreous haze (mild)
central choroiditis (severe)
b. Photopsia :
due to irritation of rods and cones
c. Floaters :
d. Metamorphopsia :
due to alteration in the retinal contour caused by rays patch of choroiditis
e. Micropsia & Macropsia
f. Positive scotoma

12. B. SIGNS :
1. Anterior segment :
Usually no external signs but fine KPs may be found.
2. Vitreous opacities :
 Usually present in the medial or posterior part
 Fine/coarse/stringy/snowball
3. Patch of choroiditis :
 Active patch – Pale yellow / dirty white raised area
Ill defined edges
Due to exudation and cellular infiltration
Typically deeper to retinal vessels.

13.  Healed patch – Sharply defined
Delineated from the rest of normal area
The involved area shows white sclera below the
atrophic choroid and black pigmented clumps at the periphery

14. Clinical Signs
Of
Granulomatous and Non Granulomatous
Inflammation Of Uvea

15. Features Granulomatous Non Granulomatous
Onset Insidious Acute
Pain Minimal Marked
Photophobia Slight Marked
Ciliary Congestion Minimal Marked
Keratic Precipitates ( KPs ) Mutton Fat Small
Aqueous Flare Mild Marked
Iris nodules Usually Present Absent
Posterior Synaechiae Thick & Broad based Thin & tenous
Fundus Nodular Lesions Diffuse involvement

16. A. Lid Edema – usually mild.
B. Circumcorneal Congestion – Marked in Acute iridocyclitis.
Minimal in Chronic Iridocyclitis
C. Corneal Signs:
1. Corneal Oedema : Due to toxic endothilitis & raised IOP When present.
2. Keratic Precipitates : ‘Pathognomic Sign’ of Anterior Uveitis.
Proteinaceous cellular deposits at Corneal endothelium.
Arlt’s Triangle
Keratic Precipitates

17. Types Of KPs
Mutton Fat KPs Granular KPs Stellate KPs Old KPs
3. Posterior Corneal opacities- Long standing cases of
iridocyclitis
D. Anterior Chamber Signs:
1. Aqueous Flare – Earliest sign of acute anterior
uveitis.
Due to leakage of protein particles
in aqueous humor.

18. 2. Hypopyon- Heavy & thick exudates settle down in lower part of the anterior
chamber.
Cold Hypopyon
Dense Immobile
Hypopyon
Haemorrhagic
Hypopyon
3. Changes in Depth & shape of anterior chamber may occur due to synechiae
formation.
4. Changes in angle of anterior chamber.
Marked in Non granulomatous Uveitis. Minimal in Granulomatous Uveitis.

19. E. Iris Signs
1. Loss of normal pattern:
Due to edema & waterlogging of Iris in active phase.
Due to Atropic changes in chronic phase.
2. Change in Iris Colour:
Muddy in active phase.
Hyperpigmented/Depigmented in healed stage.
3. Iris Nodules: typically in Granulomatous uveitis
Koeppe’s Nodules Busacca’s Nodules

20. F. Pupillary Signs-
1. Narrow Pupil- In Acute attack Of Iridocyclitis.
2. Irregular Pupil Shape- Festooned Pupils
3. Ectropion Pupillae- evertion of pupillary margin
4. Sluggish Pupillary reaction
5. Occulsio Pupillae
Segmental Posterior
Synechiae
Annular Posterior
Synechiae
Total Posterior
Synechiae
5.Neovascularisation Of Iris (Rubeosis Iridis)
4. Posterior Synechiae-

21. G. Changes in the Lens
1. Pigment Dispersal- universal occurrence in anterior uveitis.
2. Exudates - Acute Plastic iridocyclitis.
3. Complicated Cataract- Typical feature ,
Polychromatic Luster & Bread crumb Appearance of
early posterior subcapsular opacities.
H. Changes In Vitreous & Retina.
1. Exudates and inflammatory cells.
2. Cystoid Macular Edema.
I. IOP may be normal, Increased ( Secondary glaucoma) or Decreased.

22. Granulomatous Uveitis
Tubercular Uveitis
Aquired Syphilitic Uveitis
Leprotic Uveitis
Sarcoidosis
Non-Granulomatous Uveitis
Behcet’s Disease
 Reiter’s syndrome
 Juvenile Idiopathic Arthritis
 Ankylosing Spondylitis

23. Classifications and Investigations of
Uveitis

24. Classifications of Uveitis
• Anatomical classification
• Clinical classification
• Pathological classification
• Etiological classification

25. Anatomical classification
• Anterior uveitis
– Iritis
– Iridocyclitis
– Anterior cyclitis
• Intermediate uveitis
• Posterior uveitis
– Choroiditis
– Chorioretinitis
– Retinochoroiditis
– Neuroretinitis
• Panuveitis

26. Clinical classification
• Acute uveitis
– Sudden symptomatic onset
– Duration- 6 weeks to 3 months
• Chronic uveitis
– Insidious and asymptomatic onset
– Duration- longer than 3 months to years
• Recurrent uveitis
– Repeated episodes separated by inactive periods of more than 3
months

27. Pathological classification
• Suppurative or Purulent uveitis
• Nonsuppurative uveitis
– Nongranulomatous uveitis
– Granulomatous uveitis

28. • Infectious uveitis
– Bacterial
– Viral
– Fungal
– Parasitic
– Rickettsial
• Masquerade syndromes
– Non-neoplastic
– Neoplastic
• Non-infectious uveitis
– Immune-related
• Microbial allergic
• Autoimmune
• HLA associated
• Anaphylactic
• Atopic
– Uveitis associated with non-
infectious systemic diseases
– Toxic
– Traumatic
– Idiopathic
Etiological classification

29. Investigations for Uveitis
• Ocular examination

30. Haematological Investigations
– TLC and DLC
– ESR
– Blood sugar levels
– Blood uric acid
– Serological tests
• Syphilis
• Toxoplasmosis
• Histoplasmosis
– Other Tests:
• Antinuclear antibodies
• Rh factor
• LE Cells
• C- Reactive proteins
HLA Typing for associated diseases like:
– HLA B-27 : Ankylosing spondylitis
– HLA B51 : Bechet disease

31. • Urine examination for WBCs, pus cells, RBCs and culture
• Stool examination for cysts and ova
• Radiological examination
– X rays of chest, PNS, sacroilliac joints and lumbar spine
– CT Scan high resolution, of thorax for suspected
Sarcoidosis
– MRI Scan of head for suspected Sarcoidosis, demyelination
and lymphomas

32. • Skin tests:
– Tuberculin test
– Kveim’s test for sarcoidosis
– Toxoplasmin test
– Lepromin test
– Pathergy test for Behcet’s disease
• Biopsy/ Intraocular fluid samples for examination:
– Aqueous samples for PCR
– Vitreous biopsy for culture and PCR
– Lungs and Lymph node biopsy for Sarcoidosis

33. DIFFERENTIAL DIAGNOSIS OF
RED EYE AND TREATMENT OF
ACUTE IRIDOCYCLITIS

34. RED EYE
• It is the final common response to any
anterior segment disease

37. Distinguishing features between, acute conjunctivitis,
acute iridocyclitis and acute congestive glaucoma:

38. FIG: IRITIS FIG: ACUTE ANGLE CLOSURE GLAUCOMA
FIG: CONJUNCTIVITIS

39. TREATMENT OF ACUTE IRIDOCYLITIS
NON SPECIFIC
LOCAL THERAPY
SYSTEMIC
THERAPY
PHYSICAL MEASURE
SPECIFIC TREATMENT
OF THE CAUSE
TREATMENT OF
COMPLICATIONS

40. TREATMENT OF IRIDOCYCLITIS
Nonspecific treatment
A. Local therapy
(A)Cycloplegic drugs
Very useful and effective during acute phase of iridocyclitis
DRUGS –
i. 1% atropine sufate eye ointment or drops
Sig: 2-3 time/day-(2-3 weeks)
Atropin allergy
ii.2% homoatropin or 1% cyclopentolate eye drops
sig: 2-4 times /day(2-3 weeks)
iii. 0.25 mydricain (management of atropine,adrenalin procaine sub conjuctival injection)

41. Mode of action
a. comfort and rest to the eye by relieving spasm of
iris sphincter and ciliary muscle,
b. prevents the forma tion of synechiae and may break the already
formed synechiae,
c. reduces exudation by decreasing hyperaemia and vascular permeability
d. increases the blood supply to anterior uvea by relieving pressure on the
anterior ciliary arteries.
As a result, more antibodies reach the target tissues and more toxins are
absorbed

42. (B) Corticosteroids administered locally, are very
effective in cases of iridocyclitis.
Drugs; dexamethasone, betamethasone,hydrocortisone or
prednisolone
• Mode of action:
Reduce inflammation by theiranti-inflammatory effect;
anti-allergic (allergic type of uveitis)
antifibrotic activity, ( reduce fibrosis and thus prevent disorganisation
and destruction of the tissues)

43. Route of administration:
i) eye drops 4-6 times a day,
(ii) eye ointment at (bed time)
(iii) Anterior sub-Tenon injection ( severe cases)

44. B. Systemic therapy
i. Corticosteroids: In non-granulomatous. Iridocyclitis
Indication - indicated in intractable anterior uveitis resistant to topical
therapy.
DRUGS- i) high doses of prednisolone (60- 100 mg) or equivalent
quantities of other steroids (dexamethasone or betamethasone)
Regimes
 Daily therapy regime- 2 weeks ( marked inflammatory activity)
Alt day therapy Regime,(absence of acute inflammation)
Tapering of dose of steroids is done by a week interval and tapered
completely in 6-8 weeks in both the regime.

45. Complication of steroids
- ocular(steroid induced glaucoma and cataract)
- st (dyspepsia ,peptic ulcer, mental changes,worsening
of diabetes, osteoporosis,cushingoid,electrolyte
imbalance)

46. ii. NSAIDS  Aspirin, phenylbutazone, oxyphenbutazone (useful in uveitis associated
with RA)
M.O.A  Anti inflammatory action
Naproxen  Patients with ankylosing spondylitis
iii. Immuno-suppressive drugs Extremely serious cases of uveitisIndications  Severe
cases of Behcet's syndrome, VKH syndrome, Sympathetic ophthalmia, Pars planitis
Drugs  cyclophosphamide, chlorambucil, azathioprine, methotrexate- cyclosporin
powerful T anti-T cell immuno-suppressive drugs.
iv) Azithromycin or tetracyclin or erythromycin  To treat chlamydial infections in
patients.

47. c) Physical Measures
(1) Hot fomentation  either by dry heat it wet heat  very soothing, pain
decreases, circulation increases, venous stasis decreases
(2) Dark Goggles These give a feeling of comfort, especially when used in
sunlight, by reducing photophobia, lacrimation and blepharospasm.
Specific treatment of the cause
Non specific treatment described above is very effective and usually controls
the uveal inflammation, in most of the cases, but It does not cure the
disease, resulting in relapses.
(a) Anti-tubercular drugs  Koch's disease
(b) Treatment for syphilis, toxoplasmosis
When no cause is ascertained  broad spectrum antibiotic

48. Treatment of complications
(i) Inflammatory glaucoma
0.5% timolol eye drops (twice a day)
Acetazolamide (250 mg thrice a day)
(ii) Post - inflammatory glaucoma (due to Ring Synechiae )
Laser iridotomy
Surgical iridotomy under high doses of corticosteroids
(iii) Complicated Cataract
Requires lens extraction
(iv) Cystoid Macular Oedema
Intravitreal injection of triamclnolone acetate
(v) Retinal detachment
Exudative type  self limiting if uveitis is treated aggressively
Tractional vitrectomy
(vi) Phthisis Bulbi
Painful and requires removal by enucleation operation

49. Thank You