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Uveitis Prof. Faiz Shakarchi

Uveitis Prof. Faiz Shakarchi. Uveitis. Uvea. Iris Ciliary body Choroid. Iris. Posterior pigment epithelium Stroma Sphincter pupillae muscle Dilator pupilae muscle Function: Regulates amount of light enters the eye. Ciliary body. Anatomy

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Uveitis Prof. Faiz Shakarchi

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  1. Uveitis Prof. Faiz Shakarchi

  2. Uveitis

  3. Uvea Iris Ciliary body Choroid

  4. Iris • Posterior pigment epithelium • Stroma • Sphincter pupillae muscle • Dilator pupilae muscle • Function: • Regulates amount of light enters the eye

  5. Ciliary body Anatomy • Pars Plicata- ciliary processes • Pars Plana Histology • Posterior epithelium • Stroma Ciliary muscles Functions: 1- Secretion of aqueous humor 2- Accommodation

  6. Choroid Vascular layer Highest O2 tension in the body • Supplies O2 and nutrient to the photoreceptors • Thermo-regulator

  7. UveitisInflammation of the uveal tract

  8. 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.

  9. 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

  10. Classification: • Anatomical: • Anterior uveitis75% : 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.

  11. Classification • 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.

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

  13. Diagnosis of uveitis depends on: 1 -Clinical features (Main stone) Ocular 1- Laterality and Coarse; acute or chronic, recurrent 2- Anatomical site; Anterior, intermediate, posterior and panuveitis 3- Type; Granulomatous or non granulomatous Systemic manifestations 2–Supported by selected lab investigations according to the probable causes.

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

  15. 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

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

  17. Signs • Circum-corneal congestion

  18. 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

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

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

  21. Signs • Iris: • Iris atrophy • Rubeosis ( iris neovascularization). • Iris nodules • granuloma • (granulomatous uveitis)

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

  23. Ankylosing Spondylitits Idiopathic , chronic arthritis Young adults Male are affected more Arthritis; axial skeleton -sacroiliac joint and intervertebral joints 90% positive HLA-B27 25% of patients with AS have uveitis Anterior Uveitis Acute, Recurrent, Non-granulomatous

  24. Juvenile idiopathic arthritis Idiopathic, Chronic arthritis Children under 16 years. Females are affected more commonly Pauciarticular onset (less than 5 joints are involved) Polyarticular onset Still’s disease 80% positive for ANA sero-negative (for R.F.) 20% of children with pauciarticulae type have uveitis Bilateral, Chronic, non-granulomatous Ant. Uveitis painless, Complications: 1- Cataract 2- Band keratopathy .

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

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

  27. Intermediate Uveitis Signs: • Vitreous: cells, snow-balls snow banking

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

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

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

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

  32. 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

  33. Toxoplasmosis Treatment: Antiprotozoal drugs; Clindamycin, sulphonamides Steroids

  34. Pan uveitis: inflammation of the entire uveal tract.

  35. Behçet syndrome Idiopathic, multisystem disease characterized by recurrent episodes of oro-genital ulceration, uveitis and vasculitis

  36. Behçet syndrome • Diagnosis criteia: According to the international study group for Behjet's syndrome • 1- Recurrent oral ulceration characterized by painful 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

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

  38. Behjet’s disease

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

  40. Vogt Koyanagi Harada (VKH)   Systemic manifestations: Acute - Neurological and auditory manifestations: Headache, Tinnitus    Chronic-  Integumentary findings: followed central nervous system and ocular manifestations alopecia, poliosis and vitiligo

  41. Vogt Koyanagi Harada (VKH) • Bilateral, chronic, panuveitis Acute stage: non-granulomatous Multifocal serous detachment of sensory retina Disc swelling Bilateral exudative retinal detachment Chronic stage: granulomatous Depigmentation of the fundus; Vitilligo of the fundus Dalen Fuchs atrophic spots

  42. 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 uveitis develops following hematogenous spread from a primary latent focus and usually occurs without evidence of systemic TB. TB is endemic in Iraq

  43. Presumed TB uveitis • Clinical signs: • Chronic, Granulomatous, Panuveitis -Iris nodules or granuloma - Focal, multifocal choroiditis, -choroidal granuloma, - Retinal vasculitis.

  44. 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

  45. Red Eye

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