Anterior Uveitis: Signs, Symptoms & the Spondyloarthropathies

1. Anterior Uveitis:Signs, Symptoms & the Spondyloarthropathies Optometry 8370 Jan. 22, 2008 Edward S. Jarka, O.D., M.S.

2. General Background of Anterior Uveitis • The most prevalent form of intraocular inflammatory disease. • Annual incidence of about 8 new cases per 100,000.

3. General Background of Anterior Uveitis • Pathophysiology: • Exact pathophysiology is not known. • Inflammation of the iris or ciliary body causes a breakdown of the blood ocular barrier. • This allows white blood cells and protein to leave the vessels and enter the aqueous (cell & flare). • Often Idiopathic, but sometimes associated with systemic disease.

4. Classification of Anterior Uveitis • 2 Broad categories: 1) Granulomatous • Posterior • Follows active microbial invasion (tuberculosis, toxoplasmosis) 2) Nongranulomatous • Anterior (Iritis, Iridocyclitis) • Much more common (90% of all the uveitis seen).

5. Clinical Classification of Anterior Uveitis • Acute • Sudden onset of symptoms. • More common presentation. • Chronic • Long standing episodes. • Many recurrences. • Complications (Cataract and Glaucoma).

6. Etiological Classification of Uveitis • Exogenous • Caused by trauma or microbes from outside sources. • Endogenous • Associated with systemic disease. • Infections (TB, Candida, H. zoster, …) • Idiopathic specific

7. Anatomical Classification of Uveitis • Anterior • Intermediate • Posterior • Panuveitis *This is also the order of severity and likelihood of occurrence.

8. Anterior Uveitis:Patient Presentation • History • Vital to the diagnosis and treatment of the condition. 1) Pain - Dull aching pain of sudden onset. - May radiate to periorbital region or temple. 2) Redness - Perilimbal (Ciliary flush). - Less commonly there can be severe redness involving the entire bulbar conjunctiva.

9. Anterior Uveitis

10. Ciliary Flush

11. Anterior Uveitis:Patient Presentation • 3) Photophobia: • Can be severe or minimal • Usually sunlight worsens the patients pain more than artificial lighting. • 4) Visual Acuity: • Usually mild reduction (20/25 to 20/40) • Sometimes there is no visual complaint, other times it is the chief complaint. 5)Unilateral: • Granulomatous uveitis can be bilateral and differing severities. • Most episodes of Acute anterior uveitis (AAU) are unilateral.

12. The Cornea in Anterior Uveitis? • Keratic precipitates (KP’s) • Clusters of WBC’s and protein adhered to the endothelium. • Usually small and tends to be in the lower half of the cornea (granulomatous tends to be larger and central – mutton fat KP’s). • Slight stromal edema

13. Keratic Precipitates (KP’s)

14. KP’s

15. What Happens to the Anterior Chamber in an Anterior Uveitis? 1) Flare (extra protein in the anterior chamber) • Usually graded on a zero to 4+ scale. • 0 absent • 1+ barely present • 2+ moderate • 3+ marked (iris detail is hazy) • 4+ intense (formed fibrin in A.C.)

16. What happens to the Anterior Chamber in an Anterior Uveitis? 2) Cell – This is the hallmark of iritis - Dark room, high magnification, 1mm x 1mm field - Grading: • Trace 1 – 5 cells • 1+ 6 – 15 cells • 2+ 16 – 25 cells • 3+ 26 – 50 cells • 4+ 50 or more cells

17. How Bad can the Anterior Chamber Look? • Fibroid: • Thick fibrous strands of protein. • Needs more aggressive treatment. • Can sometimes show a hypopyon: • This would be suggestive of HLA-B27 diseases.

18. Fibroid Anterior Chamber

19. Hypopyon

20. The Iris in Anterior Uveitis 1)Posterior synechiae - which can lead to iris bombe’ and glaucoma. 2) Inflammatory nodules - in granulomatous conditions (Koeppe nodules). Severe cases (Busacca nodules). 3) Sector atrophy - suggestive of H. zoster involvement. 4) Heterochromia (Fuchs Heterochromia Iridocyclitis)

21. Koeppe Nodules

22. Busacca Nodules

23. Posterior Synechiae

24. Partial Posterior Synechiae

25. The Lens in Anterior Uveitis • 1) Precipitates: • These form on the anterior lens capsule. • 2) Posterior Subcapsular Cataracts (PSC’s). • Not seen in acute, first time anterior uveitis. • Their appearance is suggestive of repeated occurrences of Iritis.

26. Anterior Lens Capsule Pigment

27. Posterior Subcapsular Cataracts

28. The Anterior Vitreous in an Acute Anterior Uveitis • Cells • The result of spillover from the anterior chamber. • The primary site of inflammation may be the ciliary body (cyclitis).

29. Treatment of the Idiopathic Anterior Uveitis • 1) Cycloplegia: • Helps for the pain resulting from iris spasms and photophobia. • Also used to prevent the formation of posterior synechiae. • Stabilizes the blood-ocular barrier. • Cyclopentolate 1%, Homatopine 5%, Scopolamine • Used BID • Why not use Atropine 1%?

30. Treatment of the Idiopathic Anterior Uveitis • 2) Topical Steroids • Best if used aggressively at the start of the condition. • Pred forte 1% or Econopred 1% QID is used for your common grade 1 Iritis. • Tailor the dosage to the severity of the presentation. • 3) Subconjunctival injection and oral steroids. • Used in severe or unresponsive cases.

31. What Would be the Typical Oral Dosage? • Prednisone 40 – 80mg QD - This depends on the severity of the presentation. - After a satisfactory response you taper over two to four weeks.

32. Follow Up for Anterior Uveitis? • Follow initially in 2 – 3 days. • Expect some improvement in symptoms, maybe little change in clinical appearance. • After resolution of the signs then taper the topical steroids and follow up 2 – 3 weeks after discontinuation of all medications. • Should the patient resume treatment if symptoms return?

33. Review of A.A.U. • Most often Idiopathic. • The Chief Complaints. • The Signs: • The Conjunctiva • The Cornea • The Anterior Chamber • The IOP • The Iris • The Lens • The Anterior Vitreous • Treatment.

34. The Spondyloarthropathies • HLA-B27 associated diseases 1. Ankylosing spondylitis 2. Reactive arthritis (Reiter syndrome) 3. Inflammatory bowel disease 4. Psoriatic arthritis • These will be negative for Rheumatoid factor (RF) • Often referred to as seronegative arthritis. • Arthritis occur at entheses (are areas where tendon and other connecting tissues - join to bone).

35. What is the Rheumatoid Factor (RF)? • RF is an Antibody directed against an IgG forming an immune complex. * This complex initiates inflammation. • About 80% of patients with Rheumatoid Arthritis (RA) show a positive RF.

36. What is HLA-B27? • HLA (Human Lymphocyte Antigen) • A gene cluster (MHC) on chromosome 6 responsible for antigen markers found on the surface of lymphocytes. • Antisera is used to identify these antigenic markers on lymphocytes. • The presence of the B27 marker is statistically associated with these diseases.

37. I.) Ankylosing spondylitis • HLA-B27 appears in 80% - 90% of the patients (8% in general population). • Typically occurs in men in their 30’s. • Symptoms include back pain after inactivity. • It is chronic, usually progressive, and can be asymptomatic to crippling in severity.

38. What do you do if you Suspect Ankylosing Spondylitis? • Order serology for the HLA-B27 antigen. • Refer to rheumatologist for X-rays of the sacroiliac joints. • Monitor and treat the Acute Anterior Uveitis (AAU). • The AAU may be present without back pain.

39. II.) Reactive Arthritis(Reiter Syndrome) • HLA-B27 seen in 60% to 85% of patients. • Classically described as a triad - Urethritis, Conjunctivitis and Arthritis. • The arthritis usually involves the lower extremities (Achilles tendonitis). • The triad of symptoms follow enteric or urogenital infections (Numerous bacteria).

40. Ocular Findings in a Reactive Arthritis • Conjunctivitis - Bilateral and mucopurulent. - Follows the urethritis by about 2 weeks. - Cultures are usually negative. • AAU (20% of the patients) • Keratitis - Isolated or with the conjunctivitis

41. What do you do if you Suspect A Reactive Arthritis? • Treat the AAU. • Refer for proper treatment of associated bacterial infection and treatment of the arthritis.

42. Inflammatory Bowel Disease • 5% – 12% of patients with Ulcerative colitis will develop AAU (greater when associated with Ankylosing spondylitis). • UC involves mucosa & submucosa. • Rectal involvement & continuously proximal. • 2.4% of patients with Crohn’s disease will develop AAU. • CD involves all layers of the bowel. • Segmental involvement. • Treatment is aimed at controlling the inflammation (steroids).

43. What Else Might you See With Inflammatory Bowel Disease? • Peripheral corneal infiltrates. • Like any systemic inflammation will show an increase in the ESR.

44. ESR • Standardized in 1977 (Westegren) - 200mm tube, 2.5mm diam. With blood and anticoagulant. - Distance (mm) the column falls in 1hour. • Forces affecting the ESR: - Size of cells. - Viscosity of plasma. - Repellant forces between neg. charged RBC surface. • An indirect measure of inflammation.

46. C – Reactive Protein (CRP) • Owes its name to a protein with the ability to precipitate the pneumococcal C – polysaccharide. • Is an acute phase reactant in inflammation. • Provides a more immediate picture of the level of inflammation than ESR. • Peak levels in about 50 hours.

48. Psoriatic arthritis • Affects about 7% of patients with psoriasis. • Affects men and women equally. • Associated with HLA-B27 and HLA-B17. • Commonly involves fingers and shows nail pitting.

49. Psoriatic Arthritis

50. Psoriasis