what is uveitis
inflammation of the uveal tract
clinical classification of uveitis
1) acute
- sudden onset
- severe to mod pain
- last 6-12wks with or without pain
2) chronic
- slow insidious onset
- lasts >6wks even with therapy
3) recurrent
>3 times in a year
aetological classification of uveitis
ENDOGENOUS
1) associated with systemic disease eg sarcoidosis, JRA
2) infections or infestations eg herpes zoster, toxoplasmosis
3) idiopathic
- specific eg fuchs uveitis syndrome
- non specific - none of the above (~25%)
EXOGENOUS
- external injury
- post eye sx due to risk of infection
anatomical classification of uveitis
1) anterior (~75%)
- iritis
- iridocyclitis
2) intermediate
- posterior ciliary body (pars plana), extreme periphery of retina and choroid
3) posterior
- retina and choroid
4) panuveitis - affects all of the above
epidemiology of anterior uveitis
- incidence 12 per 100,00
- most common type inw estern worlk - not as common in asian pop
- at least 50% of all cases - majority are idiopathic
- associations are:
- human leukocyte antigen HLA - B27 +ve - 55% of caucasion px with AAU are postive (10% of gen pop)
- ankylosing spondylitis
- fuchs heterochromic iridocyclitis
- herpes zoster
epidemiology of intermedate uveitis
- least common type - 1.5 per 100,000 per year
- mostly idiopathic
- recently recog association with human T cell lymphotropic virus type 1 (HTLV-1) -high prevalence in germany and brazil
- strong association bet pars planitis and MS
- more common in children and young adults - onset after age 40 is rare
epidemiology of posterior uveitis
- 1 to 3% of uveitis cases
- toxoplasmosis
- idiopathic
- more common in developing world
- toxoplasmosis in south america, tuberulosis in india, onchocerciasis in africa
- behcet disease, Vogt-Koyanagi-Harada disease (VKH)
epidemiology of panuveitis
- most common type of uveitis in south american, africa and asia
- mostly idiopathic
epidemiology (age and gender)
- most common in 20-6yrs (over 90%)
- some types may affect certain age groups more freq
- JIA (juvenile idiopathic arthiritis) associated uveitis more common in kids
- HLA - B27 AAU predominantly affects young adults
- uveitis masquerading synromes (eg intraocular lymphoma) more common in elderly px - may have lots of inflammation so we diagnose as uveitis, but could be something else eg a tumout
- no gender predisposition
the 7 symptoms of anterior uveitis
- red eye
- unilateral (usually in acute) - may be bilateral or change eye if chronic
- rapid onset if acute - but more gradual if recurrent eps
- mod to severe dull pain, usually reported as ‘behind the eye’, more severe if chronic
- vision reduced - ‘hazy’, more severe if chronic
- photophobia - milder if chronic
- epiphora
signs of anterior uveitis
- hyperaemia: ciliary flush - redness conc around limbus
- keratic preticipates
- cells and aqueous flare
- iris nodules
sometimes:
- miosis
- raised IOP
always check fundus - to rule out ret complications
anterior uveitis and keratic preticipates
- endothelial dusting - acute anterior uveitis
- medium -acute and chronic ant uveitis
- large - mutton fat, chronic uveitis
- old eg recurrent episodes - pigmented, chronic uveitis - can get Kruckenbergs spindle of Arlt’s triangle - pattern due to aqueous humour travelling in ant chamber
anterior uveitis and cells
- active inflammation
- wbc - rbc/pigment less common
- direction - pooling because of gravity in anterior chamber can get hypopyon
anterior uveitis and flare
- proteins leaked from damaged iris bv’s
- tyndall effect = light scattering by particles, very fine suspension
- with cells = active inflmmation
- without cells = no active inflammation
anterior uveitis and iris nodules
Bussaca
- whitish yellow lumps away from pupil border
- internal iris stroma
- always associated with granulomatous uveitis
Koeppe
- cellular aggregrates at pupil border
- may accumulate pigment over time
complication of anterior uveitis
- anterior synechiae bet iris and post cornea - causes a blockage to the outflow of agueous, leading to increased iop
- posterior adhesions bet iris and lens capsule
optometric management of first episode of ant uveitis
- refer to opthal urgent (within 1 week)
- if reduced VA, severe pain or raised iop = same day referral to opthal (could be because of flare, KPs)
- sunglasses for photophobia
- topical cycloplegic - helps slow down activity in iris etc - check ac depth first, to prevent synechia formation and symptomatic relief, cyclopentolate 1% tds
- analgesics
optometic management of subsequent eps of ant uveitis
- refer back to hes
- monitor for ocular complications
- iop check
- consider near add for cycloplegia eg ready readers
management by opthalmologist for anterior uveitis
- cycloplegia
- topical steroid eg gutt. dexamethasone 0.1% or gutt. prednisolone acetate 1%
- treat secondary glaucoma
- sub-tenons steroid injection may be required
- possible systemic immunosuppression
- referral for investigation of associations
what is intermediate uveitis
- chronic cyclitis; peripheral uveitis; pars planitis; vitritis
- chronic inflammation of peripheral retina - involvment of vitreous
- usually unknown aetiology - autoimmune/ms linked
symptoms of int uveitis
- bilateral 60-80%
- eye may be quiet
- hazy vision - corneal involvement, band keratopathy
- floaters
- reduced VA - secondary macular oedema
signs of int uveitis
- yellow exudates in peripheral retina - scleral indentation where opthal uses a metal tool to make taht part of the retina visible
- exudates may break off to form snowbanks - 99% inferior retina
- exudates may break off and float about in the vitreous
management of int uveitis
- refer to hes for soon appointment:
- steroid drops
- steroid injections
- immunosuppressives
- vitrectomy - vitreous is removed and alt is used to maintain shape of globe
complications of int uveitis
- secondary glaucoma
- posterior subcapsular cataract
- vitreous detachment/ haemorrhage
- retinal breaks/ tears/detachment
- optic disc oedema
- maular oedema
