Uveitis

Uveitis

Uveitis Inflammation of the uveal tract

Uveitis is a sight threatening disorder, and may be associated with life threatening diseases. Uveitis can be caused by various ocular or systemic infectious, immunological, and malignant diseases.

Classification: Anatomical: Anterior uveitis 75% : inflammation of the iris (iritis), and anterior part of the ciliary body (iridocyclitis). Intermediate uveitis: inflammation of the ciliary body (cyclitis, pars planatis). Posterior uveitis : inflammation behind ora serrata; inflammation of the choroid and retina (choroiditis, retinitis, chorio-retinitis, retinal vasculitis). - Pan uveitis: inflammation of the entire uveal tract.

Clinical: - Acute: sudden, short duration Chronic: insidious, long duration, sometimes with exacerbation and remission Recurrent: repeated episodes of uveitis separated by periods of inactivity without treatment.

Pathological classification: -Non granulomatous Small keratic precipitate (KP) Endothelium dusting -Granulomatous uveitis: Large KP (muttan fat) or median size KP Iris nodules Iris granuloma

Etiology: - Infections: Viral; CMV, Herpes virus Bacteria; T.B., T. pallidum, M. leprae Fungal; candidia Parasite; toxoplasmosis. toxocara -Non-infectious: Systemic: Arthrits; Ankylosing spondylitis, Skin diseases: VKH, Behjet disease, Psoriasis C.N.S. disorders: Multiple sclerosis Respiratory diseases; Sarcodosis: G.I.T. diseases: Ulcerative colitis Genitourinary diseases : Reiter’s disease Ocular: Specific ocular; Fuch’s hetrochromic iridiocyclitis Non-specific idiopathic

A- Infectious origin 92(28.9%) Toxoplasmosis 52 (16.4%) Presumed Ocular Tuberculosis 28 (8.8%) Herpes simplex anterior uveitis 4 (1.3%) Herpes zoster anterior uveitis 2 (0.6%) Syphilis 2 (0.6%) Acute retinal necrosis 2 (0.6%) Presumed toxocarasis 1 (0.3%) CMV retinitis 1 (0.3%) B-Non-infectious 118 (37.1%) Systemic diseases 74 (23.3%) VKH 39 (12.3%) Behçet's disease 26 (8.2%) Ankylosing sponylitis 3 (0.9%) Juvenile idiopathic arthritis 2 (0.6%) Multiple sclerosis 2 (0.6%) Antiphospholipid Syndrome 1 (0.3%) Sarcodosis 1 (0.3%) Primary specific ocular disorders 44 (13.8%) Pars planitis 18 (5.7%) Punctate inner choroidopathy 5 (1.6%) Fuchs heterochromic iridocyclitis 5 (1.6%) Eales disease 4 (1.3%) Bird shot retinochoroidopathy 3 (0.9 %) Primary retinal vasculitis 3 (0.9%) Serpiginous choroidopathy 2 (0.6%) APMPPE* 2 (0.6%) Antiphospholipid syndrome 1 (0.3%) Sympathetic ophthalmitis 1 (0.3%) Non-specific idiopathic 108 (34%) Total 318

Anterior uveitis Symptoms: - Pain Photophobia Redness Lacrimation Blurring of vision

Anterior uveitis Signs Reduced visual acuity (V.A.) Circum-corneal congestion Cornea: Keratic precipitate. KP: (aggregation of inflammatory cells on the posterior surface of the endothelium) small , endothelium dusting (non-granulomatous uveitis) Large (muttan fat) (chronic, granulomatous uveitis) Ant. Chamber: cells and flare ( increase protein in the aqueous) hypopyon (aggregation of inflammatory cells at the bottom of anterior chamber with fluid level) Pupil: Miosed (constricted) Irregular, posterior synechiae (adhesion between the iris and the lens), Iris: Rubeosis ( iris neo-vascularization). Iris atrophy (chronic) Iris nodules and granuloma (chronic, granulomatous uveitis) Intra-ocular pressure (IOP): may be normal, elevated or depressed

Anterior uveitis Signs Reduced visual acuity (V.A.)

Circum-corneal congestion Signs Circum-corneal congestion

Keratic precipitate. KP: Signs Cornea: Keratic precipitate. KP: aggregation of inflammatory cells on the posterior surface of the endothelium) Small , endothelium dusting (non-granulomatous uveitis) Large (muttan fat) (chronic, granulomatous uveitis) Band keratopathy: deposition of calcium at Bowmann’s layer

-flare ( increase protein in the aqueous) Signs Ant. Chamber: - cells -flare ( increase protein in the aqueous) -hypopyon (aggregation ofinflammatory cells at the bottom of anterior chamber with fluid level)

Pupil: Miosed (constricted) Irregular, posterior synechiae Signs Pupil: Miosed (constricted) Irregular, posterior synechiae (adhesion between the iris and the lens),

Iris: Rubeosis ( iris neovascularization). Iris atrophy (chronic) Signs Iris: Rubeosis ( iris neovascularization). Iris atrophy (chronic) Iris nodules and granuloma (granulomatous uveitis)

Intra-ocular pressure (IOP): may be normal, elevated or depressed Signs Intra-ocular pressure (IOP): may be normal, elevated or depressed

Ankylosing Spondylitits Young adults Male are affected more Arthritis; axial skeleton -sacroiliac joint and intervertebral joints 90% positive HLA-B27 Acute, Recurrent, non-granulomatous Anterior Uveitis

Juvenile idiopathic arthritis Chronic arthritis Age under16 years. Females are affected more commonly Pauciarticular type (less than 5 joints are involved) seronegative (for R.F.), 80% positive for ANA Bilateral, Chronic, non-granulomatous Ant. Uveitis painless, Complications: 1- Cataract 2- Band keratopathy .

Intermediate uveitis: inflammation of the ciliary body (cyclitis, pars planatis).

Intermediate uveitis Symptoms Floaters (moving shadows in the field of vision caused by vitreous opacities) Blurring of vision

Intermediate Uveitis Signs: Vitreous: cells, snow-balls No fundus lesions

Intermediate Uveitis Causes of intermidiate uveitis 1- Pars planatis: Most common Idiopathic 2- TB 3- Multiple sclerosis

Posterior uveitis: inflammation behind ora serrata, inflammation of the choroid and retina (choroiditis, retinitis, chorio-retinitis, retinal vasculitis). .

Posterior Uveitis Symptoms Floaters (moving shadows in the field of vision caused by vitreous opacities) Blurring of vision

Posterior uveitis Signs: Vitreous: cells, flare and opacities fundus lesions may be focal, multi-focal, or geographical lesions -Choroiditis; yellow, well demarcated patches -Retinitis; white cloudy patches with indistinct margins -Old inactive lesion appears as white well defined area of chorio- retinal atrophy with pigmented borders -Vasculitis; fluffy haziness surrounding blood columns vascular sheathening

Toxoplasmosis Toxoplasma gondii is an obligatory, intracellular protozoan parasite Acquired, congenital - Vitritis. Retinitis; Active lesion: creamy-white lesion with indistinct margins Inactive lesion: white well defined area of chorio- retinal atrophy with pigmented borders

Toxoplasmosis Treatment: Antiprotozoal drugs; Clindamycin, sulphonamides Steroids

Pan uveitis: inflammation of the entire uveal tract.

Pan uveitis Idiopathic, multisystem disease characterized by recurrent episodes of orogenital ulceration and vasculitis

Behçet syndrome Diagnosis:    1    Recurrent oral ulceration characterized by painful minor or major aphthous lesions that have recurred at least three times in a 12-month period.    2    Plus at least two of the following:     •    Recurrent genital ulceration    •    Ocular inflammation.    •    Skin lesions include erythema nodosum, folliculitis, acneiform nodules    •    Positive pathergy test, cutaneous hypersensitivity, which is characterized by the formation of a pustule after 24–48 hours at the site of a sterile needle prick

Behjet’s disease Ocular features; Bilateral, chronic with exacerbation and remission, non- granulomatous pan-uveitis iridocyclitis Vitritis Retinitis Vasculitis; venous occlusion, neovascularization,

Behjet’s disease

Pan uveitis Vogt Koyanagi Harada (VKH) Multi-systemic auto-immune disorder affect pigmented cells in the body. Involves CNS, eyes, and skin

Vogt Koyanagi Harada (VKH)    - Neurological and auditory manifestations Headache, Tinnitus    -  Integumentary findings, not preceding onset of central nervous system or ocular disease, such as alopecia, poliosis and vitiligo

Vogt Koyanagi Harada (VKH) - Bilateral uveitis Acute stage: Multifocal serous detachment of sensory retina Bilateral exudative retinal detachment Chronic stage: Depigmentation of the fundus; Vitilligo of the fundus Dalen Fuchs atrophic spots

Presumed Tuberculous Uveitis According to WHO: About one third of the world's population, are infected by tuberculosis 10% of infected people are symptomatic 90% have latent TB TB is endemic in Iraq TB uveitis develops following hematogenous spread from a primary latent focus and usually occurs without evidence of systemic TB.

Presumed TB uveitis -Granulomatous anterior uveitis Clinical signs include ; -Granulomatous anterior uveitis - Focal, multifocal choroiditis, choroidal granuloma, - Retinal vasculitis.

Management of Uveitis: 1- Investigations: Aimed for determining the etiology. Indications: chronic, recurrent, and granulomatous anterior uveitis Intermidiate, posterior and pan-uveitis 2-Steriods: Topical, Side effects of corticosteroids eye-drops: Flare up of pre-existing eye infection Predispose for microbial keratitis, e.g. viral keratitis. Inhibit collagen synthesis of the cornea, and predispose for corneal thinning Cataract (chronic use) Open angle glaucoma (chronic use) Periocular injections of steroids; used in severe ant. , Intermidiate, posterior uveitis Systemic steroids; used in; severe anterior, Intermidiate uveitis, posterior uveitis 3- Mydriatics: -decrease pain by relieve ciliary muscles spasm - prevent synechiae, break down synechiae 4- Anti-microbial drugs: in infectious types; Toxoplasmosis, Presumed TB uveitis. 5- Immunomodulator and/or Immunoppressive agents: In bilateral, severe , vision threatening , steroid sparing, non-infectious -Cyclosporin; T-cell immunosuppressive agent -Methotrexate - Azathioprine

Red Eye Symptoms Conjunctivitis Keratitis or corneal foreign body Acute iritis Acute Glaucoma Vision Not affected depressed Redness + Pain Foreign body sensation, itching Pain localized to the eye Severe pain radiating Secretion Watery, mucoid or purulent watery Photophobia absent mild marked Systemic Sometimes, e.g. adenovirus none- 50% associated with systemic disorders Headache, nausea and vomiting

Signs Conjunctivitis Keratitis or corneal foreign body Acute iritis Acute Glaucoma Congestion Conjunctival Cicumcorneal Cornea normal Ulceration or Suppuration Keratitic precipitates Oedema Anterior chamber Cells, Hypopyon Shallow Pupil Constricted Constricted, irregular Fixed, mid-dilated Tension Normal High, Normal, or Low High