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• Infectious, traumatic,
neoplastic, autoimmune,
idiopathic
• Inflammatory response:
chemical mediators result
in vasodilation, increased
vascular permeability, and
chemotaxis of
inflammatory cells in eye.
Inflammatory Cascade
Posterior Uveitis
Panuveitis
Symptoms
• Redness
• Pain
• Photophobia
• Epiphora
• Blur
• Scotoma
• Floaters
Photo Credit: www.sunglasswarehouse.com
Clinical Signs
Anterior to Posterior
Eyelid
• Vitiligo
• Nodules
• Lesions
• Diffuse injection
• Keratic Precipitates
• Granulomatous
• Non-granulomatous
• Fibrin
• Pigment
• Corneal Edema
• Band Keratopathy*
Photo Credit:
http://www.optometricmanagement.com/articleviewer.aspx?artic
leid=71765
Anterior Chamber
• Cells
• Flare (serous)
• Pigment
• Hypopyon (purulent)
• Plasmoid (Fibrinous)
• Hyphema + hypopyon
(sanguinoid)
Grading
Iris
• Nodules
• Busacca
• Koeppe
• Posterior synechiae
• Heterochromia
• Granulomas
• Atrophy (stromal)*
• Cyclitic membrane
formation*
Angle
• Nodule (Berlin)
• Vascularization
• Peripheral anterior
synechiae
• Secondary Glaucoma*
• Cells
• Flare
• Snowball Opacities
• Snowbanking
• Active
• Inactive Photo credit: Mohawk Valley Retina
• Vitreal Strands
Retina
• Retinal/choroidal
inflammatory infiltrates
• Sheathing of arteries/veins
• Retinal detachment
• Schwartz syndrome
• RPE hypertrophy/atrophy
• Atrophy/swelling of retina,
choroid, optic nerve head Photo Credit: Oculist.net
• Macular edema
Major Complications
• Cataracts
• Glaucoma
• Band Keratopathy
• Non-infectious
• Masquerade syndromes
• Juvenile Xanthogranuloma
• Retinal Detachment
• Retinitis pigmentosa
PANUVEITIS
INTRMEDIATE UVEITIS:
• Sarcoidosis
• Pars Planitis
• Sympathetic Ophthalmia
• Multiple Sclerosis
• Vogt-Koyanagi-Harada Syndrome
• Behcet Disease
Acute Anterior Uveitis
HLA-B27 diseases
Glaucomatocyclitic crisis
Lens associated uveitiis
Postoperative inflammation: IOL associated
HLA-B27 DISEASES
• Class 1 surface antigen
Include:
• Ankylosing spondylitis
• Psoriatic arthritis
Ankylosing
Spondylitis
• lower back pain and
stiffness
• men, 20-40‟s
• HLA-B27: 90%
• dx: sacroiliac imaging
studies - “bamboo spine”
Ocular findings:
Keratoderma blennorrhagicum
Psoriatic Arthritis
1. Rifabutin 1. Metipranolol
2. Miotics
2. Bisphosphonates
3. Prostaglandins
3. Sulphonamides
• Intracameral Drugs
4. Diethylcarbamazine
1. Cidofovir
5. Cidofovir (intravenous)
2. Antibiotics
3. Urokinase
• Vaccines
Chronic Anterior
Uveitis
Juvenile idiopathic arthritis
Fuchs heterochromic iridocyclitis
Idiopathic iridocyclitis
• most common systemic disorder
Juvenile Idiopathic associated with iridocyclitis in
children
Arthritis
• iritis develops within 5-7 yrs of
onset of joint disease
• negative RF
• Unilateral uveitis,
heterochromia, iris stromal
atrophy, small white stellate
KPs scattered diffusely over
endothelium
• synechiae almost never
forms but glaucoma and
cataracts often occur
• Associations with
toxoplamosis, HSV, and
CMV infections
Idiopathic Iridocyclitis
Clinical Characteristics:
• 80% bilateral
Wegener‟s Granulomatosis
• Multisystem autoimmune
Systemic Lupus connective tissue disorder
Erythematosus
• Type 3 hypersensitivity reaction:
Antibody-immune complexes
precipitate and cause further
immune response
• Labs: ANA
• Systemic vasculitis –
necrotizing inflammation of
medium and small sized
arteries
• 40-60 yrs, men, hepatitis B
• Ocular involvement in 20%
• Mortality rate of untreated
PAN is 90% by 5 yrs
• Labs: p-ANCA, ESR, CRP,
tissue biopsy
Wegener‟s
Granulomatosis
• Triad: necrotizing granulomatous vasculitis of upper and lower respiratory
tract, glomerulonephritis, necrotizing vasculitis of small arteries and veins
• Young females
• Acute posterior multifocal placoid
pigment epitheliopathy (APMPPE)
• Birdshot choroidopathy
• Serpiginous choroiditis
Panuveitis
Sarcoidosis
Sympathetic Ophthalmia
Vogt Koyanagi-Harada Syndrome
Behcet Disease
Sarcoidoses
• Multisystem non-caseating
granulomatous disorder of
unknown etiology
• 2% of uveitis cases
• 4% of uveitis referrals in US
• chronic, relapsing,
occlusive systemic
nongranulomatous
vasculitis of unknown
etiology
• recurrent oral ulcers,
skin lesions, genital
ulcers, ocular
inflammatory disease
(70%)
• can affect all portions
of uveal tract
Ocular Findings
80% bilateral
• Anterior uveitis:
hypopyon in 25% of
cases
• Posterior segment:
necrotizing retinal
vasculitis affects both
veins and arteries
• Optic nerve affected in
25% of pts
• Visual prognosis is
guarded -25% VA <
20/200
Infectious Uveitis
• Herpes Simplex:
• Herpes Zoster
• 72 hours PHN
• ¼ ocular involvement
• Infiltrative pseudodendrites (negative stain)
• Typically elderly and immunocompromised
Image:Yanoff, Myron, and Jay Duker. Ophthalmology. 3rdrd ed. N.p.: Mosby Elsevier, 2009. 223. Print.
•
Viral
ARN
• VZV>HSV>CMV
• Immunocompetent
• Starts unilateral but 36%Fellow eye
• Within 6 weeks of onset
• Painful, Floaters, LOV
• Peripheral „creamy‟ necrosis that spread,
occlusive vascular involvement, Panuveitis
• Poor Prognosis, RD in 75%
• PORN
• VZV mainly
• Immunocompromised
• Posterior pole involved early
• Patchy confluent necrosis, weak or
absent uveitis, no vascular involvement
• Poor Prognosis, RD in 70%
Images: Baumal, Caroline et al. Duane‟s Ophthalmology ,2006.‟Acute Retinal
Necrosis and Progresive Outer Retinal Necrosis Syndromes Accessed online:
http://www.oculist.net/downaton502/prof/ebook/duanes/pages/v3/v3c028.html#ref
Viral
• CMV
• CD4 <50-100
• Most common opportunistic infection in AIDS
• In congenital cases + birth defects
• Before HAART ~30% of CD4<50
• After HAART incidence decreased 75-80%
• May start by looking like CWS (small infiltrates)
• Perivascular hemorrhages, white necrotic retina, frosted
branches /vasculitis
Image: Yanoff, Myron, and Jay Duker. Ophthalmology. 3rdrd ed. N.p.: Mosby Elsevier, 2009. 796. Print.
Protozoal
• Toxoplasmosis
• Toxoplasma gondii
• Undercooked meat /cat feces
• Most common posterior uveitis in immunocompetent
individuals
• Often acquired in utero (0.2-1% of pregnancies)
• Further Trimester = increased chance of exposure, worst if
acquired early (spontaneous abortion)
• Majority do not develop ocular manifestations
Image: Tabbara. Khalid. „Toxoplasmosis‟. Duane‟s Ophthalmology 2006. Accessed online:
http://www.oculist.net/downaton502/prof/ebook/duanes/pages/v4/v4c046.html
Protozoal
• Toxoplasmosis
• Toxocaraisis
• Ingesting eggs of Toxocara
• Dogs >cats
• Acquired through soil, or uncooked food
• Particularly affects kids with pica
• Yellow white mass with tractional component, may have
vitritis.
• Often leads to TRD
• Treat uveitis, consider anti-helminthics (albendazole)
Image: Yanoff, Myron, and Jay Duker. Ophthalmology. 3rdrd ed. N.p.: Mosby Elsevier, 2009. 834. Print.
Bacterial
• Syphilis
• Treponema pallidum
• „Great Mimicker/Masquerader/Imitator‟
• Enters through intact mucosa
• Ocular Syphilis in 2‟ and 3‟ stages (2-6 mo after)
• Uveitis most common ocular manifestation (up to 10%)
• Affects immunocompetent or immunocompromised
• Borrelia burgdorferi
• 1: rash (e. migrans)
• 2: dermatologic, neurologic, cardiac
• 3: Late arthritis, cranial and peripheral nerves
• 50% reported no hx of tick bite
Image: Sources for Rashes: Poster: "Looking for a Bull's-Eye Rash? Look again - erythema migrans can take many
forms. A collaborative effort between the Maryland Department of Health and Mental Hygeine and the Lyme
Disease Research Foundation of Maryland Maryland.http://www.bayarealyme.org/get-help/lymes-many-symptoms
Bacterial
• Lyme
1. Conjunctivitis early
2.Motility / CN palsies, optic neuropathy, PTC,
chorioretinitis, uveitis
3. Stromal keratitis, symblepharon
ELISA, Western Immuoblot
Tx: Doxycycline, amoxicillin, if needed ceftriaxone
Image: Pediatric Associates of Connecticut. „Tick Bites and Lyme Disease, Accessed Online:
http://www.pediatricdoc.com/newsletter.cfm?nid=625
Bacterial
• Tuberculosis
• Mycobacterium tuberculosis
• Incidence: Annually ~9.3 million patients worldwide
• Communicable: inhaled aerosolized droplets
• Primarily involves the lungs
• Uveitis is common
• Cough, fever, night sweats
• Caseating necrotic granulomas
• CXR
• PPD / Mantoux testing
• TB blood tests: interferon-gamma release assays (IGRAs)
Images taken from wikipedia . Accessed online: http://en.wikipedia.org/wiki/Tuberculosis_diagnosis
Bacterial
• Tuberculosis
• Exogenous
• Trauma, Surgery, Infection
• Acutely is usually gram + (normal flora)
• Decrease in occurrence over the last 30 years.
• Bleb-associated may occur at any time.
• Acute 0.061-0.3%
• Delayed 0.2-18% (variable reports)
Image taken from „Endophthalmitis‟ by the American Academy of Ophthalmology 2013. Accessed Online:
http://www.aao.org/theeyeshaveit/red-eye/endophthalmitis.cfm
Infectious
Endophthalmitis
• EVS
• used <6 weeks, for cataract PO (Acute Onset)
• Blur (94%), red eye (82%), pain (74%), hypopyon
(86%)
• No view of retinal vessels in 79%
• Red reflex present in only 32%
• Immediate vitrectomy if LP or worse.
• B scan
• Tx: culture, Vancomycin/Amikacin/Ceftazidime +/-
Dexamethasone
Masquerade
Syndromes
Accounts for nearly 5% of all patients with uveitis at tertiary referral.
• Diagnosis • Treatment
• MRI • Intravenous and
• Cerebrospinal fluid intravitreal methotrexate
analysis • Radiation & IV
• Tissue diagnosis Cytarabine
(definitive method)
• >60 years = chemo only
• <60 years = combination
radiation & chemo
• Prognosis = poor
Uveal Melanoma Retinoblastoma
• Treatment: topical,
periocular, systemic
steroids
Metastic Tumors
• Anterior uveitis
• Rare
Nonneoplastic
Masquerade
• RP
• Waxy disc pallor,
attenuation of arterioles,
bone-spicule mid-periphery
• +FHx
• Nyctolopia
• Vitritis, CME
• ERG depressed early
Source: http://www.rpfightingblindness.org.uk
Ocular Ischemic
Syndrome
• Males >65 • Carotid doppler > 90%
• CC: decreased vision, mild diagnostic
pain
• Corneal edema, A/C
• Treatment
reaction, flare>cells, NVI, • Endarterectomy
NVA, • Topical corticosteroids &
• decreased IOP (ischemia), cycloplegics
high with NVG • PRP for neo
• Mild disc edema, dilated • Anti-VEGF injection
tortous veins
• 5 year mortality rate of
• mid peripheral hemes patients 40%
• NVD/NVE • Transient improvement,
• FA usually worsens
• Delayed arteriole filling
• Diffuse leakage
• Capillary non-perfusion
Retinal Detachment
• Chronic Peripheral
• Photoreceptor outer
Rhegmatogenous
segments may be present
• AC reaction in AC simulating
inflammatory response
• Vitreous inflammatory &
pigment cells • IOP elevated, OAG
• Peripheral demarcation
lines, subretinal fluid,
retinal breaks, subretinal
fibrosis, peripheral cysts
http://gridironforgirls.blogspot.com
Intraocular FB Pigment Dispersion Syndrome
• Gonio, ultrasound, CT of
eye/orbits
• Complications:
proliferative
vitreoretinopathy and
endophthalmitis
Management and
Treatment
Cycloplegics and mydriatics
Corticosteriods
Immunomodulating Agents
Pressure-lowering medications
• These opthalmic
preparations block the
Cycloplegics responses of the iris
sphincter and the
Mydriatics accommodative muscle of
the ciliary body to
cholinergic stimulation,
producing pupillary dilation
(mydriasis) and paralysis of
accommodation
(cycloplegia)
• Tropicamide 1%,
cyclopentolate and atropine
have both properties
• Phenylephrine has only
mydriasis.
www.lookfordiagnosis.com/mesh_info.php?term=
Cycloplegics
Purpose:
•To break or prevent posterior
synechiae and to relieve ciliary
spasm induced photophobia.
•Short acting vs. long acting
cycloplegics
•Dosing depends on the extent
of inflammation
•(1-2xdaily atropine, 3xdaily
tropicamide and
phenylephrine)
www.opsweb.org/?page=Scien
tificExhibit
portalcodgdh.min-
saude.pt/index.php/Dissecção
_
Posterior synechiae
Antigen-dependent lymphocyte activation and STEROID/NSAID
activation sites
http://pubs.niaaa.nih.gov/publications/arcr
344/images/stephens01.png
Common uses of
corticosteroids
-Mainstay of initial therapy
TOPICAL STEROIDS
Topical Steroids
Cunningham, Emmett. Practical approach to the use of corticosteroids in patients with uveitis. Can
J Opthalmol 2010; 45:352-8
Topical Steroids
•Suspension vs.
emulsion
•Concentration vs.
efficacy
www.pharmainfo.net/reviews/microemulsions-
novel
Potency
www.amardeepeyecare.com/ptosis.html
continued
www.lpeyecare.com/eyeconditions/252-2
Intravitreal Injections
• www.uninet.edu/cin2001-old/conf/bala/bala.html
• www.thedrugmonitor.com/coxi.html
Systemic NSAIDS
• Complications of prolonged use:
-myocardial infarction
-hypertension
www.mayoclinic.com/health/medic
www.ohioinjurylaw.com/ohio-
attorney/medical-mal
Immunomodulating
Medications (IMT)
• Antimetabolites
• Alkylating Agents
www.riskindoc.com/new_psoria
Indications for IMT
inadequate response of uveitis to corticosteroid therapy for greater than 3
months with doses exceeding 5-10mg/day.
www.fortiusfitness.com/blog/steroi
d-side-effects
Precautions
No infection present
Teratogenic
mamaprayed.blogspot.com/2012/08/if-you-give-m
Antimetabolites
• Azathioprine, methotrexate, mycophenolate mofetil
-GI side effects (nausea, upset stomach) are cause for D/C.
www.lookfordiagnosis.com/mesh_info.php?term
Methotrexate
• Folic Acid analogue
• Inhibitor of dihydrofolate
reductase and it’s DNA
replication
• Causes extracellular
accumulation of adenosine to
create an anti-inflammatory
effect.
• CBC monthly
Sirolimus:
• Non-calcineurin inhibitor-
disrupts T cell signaling that
inhibits Ab production and B-
lymphocytes.
www.bdbiosciences.com/research/tcell/reg
Cyclosporine
• AE: nephrotoxicity
• GI side effects
Chlorambucil
• AE:myelosuppression, sterility
• +PPD, contraindication
super-trainer.com/fitness-business-becoming-a-bu
Anterior Uveitis
• Cycloplegic
• Steroid
medlibes.com/entry/anterior-uveitis
Intermediate/Posterior Uveitis
• Determine extent of
inflammation, if anterior
involvement, start on
cycloplegic and steroid.
www.retinaeye.com/uveitis.html
Uveitic Treatment
Adverse Effects
• Steroid responders:
• OIS
• PDR
OIS!
• CC:
redness, pain, photophobia, bl
urry vision
• Neck - Lymphadenopathy
• ?????
• Ran pertinent lab tests for her age (CBC c diff.,ANA, ACE,
Lyme titer,ESR,RF, HLA B27)
• CBC with diff., lyme titre, RF, ANA, ACE, serum lysozyme
• 46 year old WM
• Redness OS x 5 days, gradually getting worse
that is constant throughout the day
• (+) photophobia, epiphora
• ( - ) eye pain, flashes, floaters, cold sores
• He was seen at Patient First 3 days ago where
they diagnosed him with shingles over the left
eyelid, noting ocular involvement
• Treated with 20 mg Pred, mild pred taper and 1
gm of Valtrex tid x 10 days
History
• Medical History
• Hypertension, GERD
• Treated with Omeprazole and Diovan
• OD unremarkable findings
• OS
• Lid: vesicles along upper
forehead & nose, lid
erythema, small hordeolum
• Conj: nasal injection
Examination
• Cornea
• Punctate Epithelial Keratitis
• Inferior stromal haze
• Anterior Chamber
• Cells – WBC 2+
• ( - ) Flare
• IOP 16, 19 mm Hg
• Fundus
• Unremarkable OU
Examination
• Fundus Unremarkable, OU
Assessment
• Thinks it is getting
worse
• OD unremarkable
• Cornea
• Prominent pseudodendrites
• Anterior Chamber
• 2+ WBC
• IOP 16, 27
• Fundus: Unremarkable OU
Assessment: 2 days
• Finished Valtrex
• Feels improvement
Examination: 1 week
• VA sc 20/25 OD, 20/40-2
PH 20/25-, OS
• OD unremarkable
• OS
• Lids: healed vesicles, mild
ptosis
• Conjunctiva: Trace injection
• Cornea: Pseudodendrites
with endothelialitis inferiorly
• Anterior Chamber: 2+ WBC
• IOP 17, 20
Assessment: 1 week
4. Pseudodendrites stable
Follow up 2 weeks later
• Patient reports improvement
• VA sc 20/30 PH 20/25 OD, OS
• OD unremarkable
• OS
• Lid: no vesicles
• Conjunctiva: trace injection
• Cornea: punctate staining
• Anterior chamber: KP‟s less
evident
• IOP 16, 18 mm Hg
Assessment: 2 weeks
--RTO 5 weeks
Follow up 5 weeks later
• Patient currently on • Assessment
Combigan BID OS only • H. Zoster Iridicyclitis
• No signs of recurrent
• VA sc 20/25 OD; 20/30 inflammation; IOP well
• OD unremarkable • D/C combigan
• Follow up 1 month for IOP
• OS check
• Conjunctiva: tr injection
• Cornea: punctate staining
• Anterior chamber: NO cells
• IOP 16, 18 mm Hg
References
• Cunningham, Emmett. Practical approach to the use of corticosteroids
in patients with uveitis. Can J Opthalmol 2010; 45:352-8
• http://www.uveitis.org/uveitis-questionnaire
• http://emedicine.medscape.com/article/1209891-clinical