UVEITIS

Definition
An inflammation of the uveal tract
Uveal tract: iris, ciliary body, choroid
Intraocular inflammation, not only theuvea,
but also adjacent structures

Classification
Aetiological: exogenous, endogenous
Pathological: granulomatous, non-
granulomatous
Medical history
Systemic Evaluation
Skin
Joints
Lung
Neurologic
GI
GU
etc
Symptoms
and Signs

Symptoms
Redness
Pain
Photophobia
Lacrimation
Floaters
Decreased vision

Signs
Injection
Keratic precipitate (KP)
Iris nodule
Koeppe, Busacca
Cells (AC or Vitreous)
Flares
Posterior synechiae (PS)
Choroiditis
Retinitis
Vasculitis
Fig. 11.2 Signs of acute
anterior uveitis. (A) Ciliary
injection; (B) miosis; (C)
endothelial dusting by cells;
(D) aqueous flare and cells;
(E) fibrinous exudate; (F)
hypopyon

Posterior
synechia
Keratic precipitates. (A)
Aggregate of inflammatory
cells on the corneal
endothelium; (B) large
mutton-fat keratic
precipitates; (C) ghost
keratic precipitates; (D) old
pigmented keratic
precipitates

Iris nodules in granulomatous anterior
uveitis. (A) Koeppe nodules; (B) Busacca
nodules
Signs of
posterior uveitis.
(A) Retinitis; (B)
Choroiditis; (C)
vasculitis
Cells & Flare
Cells: active inflammation
Flare: leakage of protein

Special investigations
Indications
Granulomatous inflammation.
Recurrent uveitis.
Bilateral disease.
Systemic manifestations without a specific
diagnosis.
Confirmation of a suspected ocular picture
which depends on the test result as part of the
criteria for diagnosis such as HLA-A29 testing
for birdshot chorioretinopathy.
Skin test

(A) Positive tuberculin skin reaction; (B)
strongly positive tuberculin skin reaction;
(C) positive pathergy test in Behet
syndrome

Other tests
Imaging:
Fluorescein angiography (FA), Indocyanine green
angiography (ICGA), Optical coherence
tomography (OCT)
Radiology
Chest X-ray, Sacroiliac joint X-ray, CT and MR
Biopsy
HLA type
Treatment
Mydriatics
Steroids
topical, periocular injection, systemic
Calcineurin inhibitors:
Cyclosporin, Tacrolimus
Antimetabolites:
Azathioprine, MTX,
Anterior uveitis
Acute
HLA-B27 related diseases
Behcet syndrome
Glaucomatocyclitic crisis
Lens-associated uveitis
HLA-B27 Related
Diseases
Seronegative spondyloarthropathies
Ankylosing spondylitis
Reiter syndrome
Inflammatory bowel disease
(enteropathic arthritis)
Psoriatic arthritis
Ankylosing Spondylitis
Acute iritis, Sacroiliitis and spondylitis
HLA-B27
General population: 5%
Acute iritis: 45%
AS: 90%
Both AS & acute iritis: 95%
c. Circinate balanitis
d. Keratoderma blennorrhagicum
Reiter Syndrome
Young adult male
Classic triad
Urethritis
Polyarthritis
Conjunctivitis (the most common) or acute iritis
Behcet Syndrome (1)
Generalized occlusive vasculitis




Posterior involvement > Anterior
retinal vasculitis, hemorrhage, necrosis,
macular edema, ischemic optic neuropathy

(A) Major aphthous
ulceration; (B)
genital ulceration; (C)
superficial
thrombophlebitis; (D)
dermatographia


Behcet Syndrome (2)
Skin lesion: erythema nodosum
HLA-B51
Young adults
Recurrence
Poor prognosis
Glaucomatocyclitic Crisis
(Posner- Schlossman Syndrome)
Unilateral mild iritis: (low grade cells, flare)
Markedly elevated IOP
Recurrence are common
A diagnosis of exclusion
Lens-Associated Uveitis
Phacoantigenic glaucoma
Lens capsule injury (immune response to lens
protein)
Mutton-fat KP, dense cells & flare, PS
Phacolytic glaucoma
Intact capsule, hypermature cataract
Acute increase of IOP (clogging of TM by lens
protein & engorged macrophages)
Lack of KP, PS
Chronic Iridocyclitis
Juvenile rheumatoid arthritis
Most common systemic disorder associated with
iridocyclitis in the pediatric
Female/Male: 3/2
Risk factors for iridocyclitis:
female, pauciarticular onset, ANA (+)
Often white & uninflamed in appearance
Complications:
cataract (84%), band keratopathy (70%), macular
edema, vitreous debris, glaucoma, phthisis
Intermediate Uveitis
Anterior vitreous cells:
snowballs, snowbanking
Retinal phlebitis
Associated with sarcoidosis, multiple
sclerosis, Lyme disease, toxocariasis,
syphilis, tuberculosis, connective tissue
disease
Pars Planitis
Most common form of intermediate uveitis
< 40 y/o
Bilateral (80%)
Vitreous condensation, cellular
infiltration in vitreous base
Fluorescein angiography: diffuse peripheral
venular leaking
Major cause of visual loss: cystoid macular
edema

Posterior segment
signs in intermediate
uveitis. (A)
Peripheral
periphlebitis and a
few snowballs
inferiorly; (B) inferior
snowbanking and
snowballs; (C)
severe snowbanking,
neovascularization
and inferior retinal
detachment

Posterior Uveitis
Infectious
Viral: Herpes, CMV, Rubella, Measles, HIV..
Fungal: Histoplasmosis, Candidiasis
Protozoal: Toxoplasmosis
Helminthic: Toxocariasis, Cysticercosis
Immunologic
Collagen vascular dz: SLE, PAN, Wegener
granulomatosis
Retinochoroidopathies
Masquerade conditions
Endophthalmitis: Nocadia asteroids

Cytomegalovirus retinitis
Active toxoplasma retinitis.
Toxocara granuloma
Acute retinal necrosis (ARN)

Classic triad
Vitritis
Occlusive retinal arteriolitis & periphlebitis
Multifocal yellow-white peripheral retinitis
Pts: typically healthy & not debilitated
Varicella-zoster, herpes simplex, CMV
Posterior pole tends to be spared
Multiple posterior retinal breaks &
traction/RRD
Ischemic optic neuropathy
Poor prognosis
Ocular Complications in
AIDS
Up to 70% of individuals with AIDS
May be the first sign of disseminated systemic inf.
Microangiopathy of retina
Various opportunistic infections
Kaposi sarcoma
Lymphoma
Squamous cell carcinoma of conjunctiva
HIV retinopathy: most common
Retinal hemorrhage, microaneurysm, cotton-wool spots
CMV retinitis: most common opportunistic ocular
inf.
Panuveitis
Infectious
Bacterial: Syphilis, Tuberculosis, Lyme dz,
Helminthic: Onchocerciasis
Immunologic & granulomatous
Sarcoidosis
Sympathetic opthalmia
Vogt-Koyanagi-Harada (VKH) syndrome
Masquerade syndrome
Neoplasms
Sympathetic Ophthalmia
Bilateral granulomatous panuveitis occurring after
penetrating trauma
The traumatized :exciting eye and the fellow eye:
sympathizing eye
Diffuse and massive lymphocytic infiltration of the
choroid
65% of cases is between 2 weeks and 3 months after
initial injury and 90% of all cases occur within the first
year.
Treatment:
Enucleation
Topical treatment of the anterior uveitis with steroids and
cycloplegics resistant to this form of therapy (diagnostic
clue)
Systemic steroids, immunomodulatory therapy


Sympathetic Ophthalmia