Uveitis •Presented by :

•The Boys Batch 28

Learning
Objectives:
• What is Uveitis
• What is its Etiology
• To understand its Pathology
• To differentiate between its Types
• How it clinically manifests
• What are the treatment options
It is the inflammation in one or more of the tissues that comprise uvea.

Uveitis
Anatomy

Uveal tract:
• Middle vascular Layer
• Consists of three parts
1. Chroid
2. Ciliary body
3. Iris
Anatomy
CHROID
• Extends from optic disc to ora serata
• Three layers
1. Suprachroidal lamina
2. Vascular layer
3. Bruch’s membrane

• Nourishes outer retina up to outer

plexiform layer
Anatomy
CILIARY BODY
• Forward continuation of choroid
• Two parts
1. Pars plicata
• Anterior 1/3
• Ciliary muscle >> Accommodation
• Ciliary process >> Aqueous
production
2. Pars plana
• Posterior 2/3
• Relatively avascular
Anatomy
IRIS
• Circular diaphragm
• Central aperture
• Three layers
1. Anterior limiting layer
• melanocytes
2. Stroma
• Muscles
• Vessels and nerves
3. Posterior epithelium
Anatomy
 • Infective
i. Exogenous
ii. Endogenous
• Non infective
i. Secondary
• Trauma

Aetiology ii.
• Toxins
Autoimmune
• hypersensitivity reaction
• Systemic inflammatory conditions
• Idiopathic
Pathogenesis

Dilatation of Congestion
Slow blood Edema
Inflamation blood
flow
of blood
(Exudate)
vessels vessels
Pathogenesis

Inflammation can be of two types:

1. Non granulomatous/ Exudative
• Usually allergy
• Acute onset and short course
• Polymorphs and lymphocytic infiltrate
2. Granulomatous
• Usually infections or autoimmune
• Usually chronic
• Infiltrate includes lymphocytes, epithelioid and giant cells
Classification

It is classified in various ways:

• Anatomical
• Clinical
• Histological
Classification

Anatomical classification is used commonly:

• Anterior Uveitis
• Intermediate Uveitis
• Posterior Uveitis
• Pan uveitis
Anterior Uveitis

•Inflammation of Iris to the anterior part of ciliary body (pars plicata).

•Further divided into
1. Acute anterior uveitis
2.Chronic anterior uveitis
Acute Anterior Uveitis

• Acute non granulomatous inflammation

• Also called acute iridocyclitis
• Idiopathic
• Most common (90% cases)
Acute Anterior Uveitis
PATHOGENESIS
Inflammation leads to
• Edema
• Ciliary congestion
• Ciliary spasm
• Miotic pupil
• Posterior synechiae
• Exudate
• Keratic precipitates (KP)
• Hypopyon
• Secondary glaucoma
Acute Anterior Uveitis

CLINICAL FEATURES:
• All the cardinal signs and symptoms of
inflammation
i. Rubor
ii. Calor
iii. Dolor
iv. Tumor
• Circumcorneal congestion
v. Functio laesa
• Lacrimation
• Photophobia
Acute Anterior Uveitis

Rest of the signs can be explained by exudate:

• Aqueous flare and cells
• Reduced visual Acuity
• Muddy iris
• Posterior synechiae
• Keratic Precipitates
• Hypopyon
Acute Anterior Uveitis

INVESTIGATIONS:
• Often are negative because of idiopathic nature
• Blood work to exclude infections and systemic diseases
• CBC
• ESR, CRP
• Blood sugar
• HLA tissue typing (HLA B27) associates with reiter’s disease
• Optical Coherence Tomography (OCT)
Acute Anterior Uveitis

TREATMENT
1. Symptomatic
• Mydriatic and cycloplegia agent
2. Treat the under lying condition
• Antibiotics for infective type
• steroids, NSAIDs and antimetabolites for non infective
3. Prevent Complications
 • Less common
Chronic • Persistent inflammation > 3 Months
Anterior • Usually Asymptomatic
• Presents when complication develops
Uveitis • Granulomatous inflammation
Chronic Anterior Uveitis

CLINICAL PRESENTATION
Similar to acute type but less marked
But specific signs also appear
• White eye due to iris atrophy
• Mutton fat KPs
• Iris Nodules
• Koppe (small and at pupillary margin)
• Busacca (large and on iris surface)
Chronic Anterior Uveitis

INVESTIGATIONS:
• Blood work
• ANA, Rh factor
• ANCA
• Serum ACE >> indicates granulomatous disease
• Skin tests
• Radiological investigations
• OCT
• Biopsy if not responding to treatmeny
Chronic Anterior Uveitis

TREATMENT
• Treat the underlying cause
• Control the symptoms
• Correct the complications
Complications
• Complicated cataract
• Secondary glaucoma
• Obstruction
• Edema
• Posterior synechiae
• Hypotony
• Cyclitic membrane
• Choroiditis
Complications

• Retinal
• Cystoid macular edema
• Exudative detachment
• Optic disc edema
• Vitreous opacities
• Band keratopathy
 • Inflammation of posterior part of ciliary
body and vitrous base
Intermediate • Bilateral usually
• Often Asymptomatic
Uveitis • Retinal periphlebitis is a common
Intermediate Uveitis

CLINICAL PRESENTATION
• Insidious onset
• Floaters is main presentation
• Vitritis with
• Snowballs (aggregation of inflammatory cells)
• Snowbanking (accumulation of exudate)
• Optic disc swelling
Diagnosis is based on clinical findings
Lab work to exclude other causes
Intermediate Uveitis

COMPLICATIONS
• Cystoid macular edema
• Retinal neovascularization
• Virous hemorrhage
• Tractional detachment
• Complicated cataract
• Secondary Glaucoma
• Band Keratopathy
Intermediate Uveitis

TREATMENT
• Steroids
• Periocular injection
• Intravitreal injection
• Systemic
• Systemic immunosuppressants
• Intravitreal anti-VEGF
• Cryotherapy
• Laser photocoagulation
• Pars plana vitrectomy lastly, may reduce macular edema
Posterior Uveitis

• Inflammation of choroid
• Almost always involve adjoining retina
• Infective cause such as bacteria, virus or fungi
• Non infective causes include collagen vascular disease or sarcoidosis
Posterior Uveitis
PATHOGENISIS
Vitreous haze
Inflammatory
exudate
Reduced vision

Exudative clumps Floaters

Edema
Metamorphopsia

Micropsia
Raised choroidal
patches
Macropsia

Photopsia
Posterior Uveitis

CLINICAL MANIFESTATIONS:
• Painless loss of vision
• Floaters
• Metamorphopsia
• Micro/Macropsia
• Photopsia
• Positive scotoma
Posterior Uveitis

TREATMENT
According to underlying cause
Usually unsatisfactory because a lot of damage is done to the retina
 • Bilateral granulomatous panuveitis
Sympathetic • Caused by penetrating ocular injury
Ophthalmitis • Traumatized eye >> Exciting Eye
• Fellow eye develops uveitis>> sympathizing
eye

AETIOLOGY
Allergic theory is most accepted
Sympathetic Ophthalmitis
PATHOGENESIS

Penetrating injury to eye

Uveal pigment stimulates immune system

Infiltration of lymphocytes, macrophages, plasma cells

GRANULOMATEOUS inflammation b/w Bruch’s membrane and RPE due

to proliferation of pigment epithelium
Sympathetic Ophthalmitis

CLINICAL PRESENTATION
• 65% present 2-3 weeks after injury
• 90% present within one year
• Exciting eye becomes red and irritable
• Sympathizing eye becomes photophobic and irritable
• Multifocal choroid infiltrate
• Tractional retinal detachment in severe cases
Sympathetic Ophthalmitis

DIAGNOSIS
• OCT to assess changes in choroid and retina
• Ultrasonography may show choroidal thickening and retinal detachment
• FFA shows foci of leakage
TREATMENT
Enucleation of injured eye
Rest symtomatic
 • Low grade cyclitis
Fuchs Uveitis • Unilateral
Syndrome • Depigmentation of iris
• No posterior synechiae
• Fine KPs
• Complicated Cataract develops
• Vitrectomy may be required if vitreous
opacification develops
 • Iritis is most common presentation in AIDS
AIDS patients
• Caused by
• Pneumocystis carinii
• Candida
• Cryptococcus
• TB
• syphilis