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ANTERIOR UVEITIS EXAM WITH CORRECT SOLUTIONS!!
what is uveitis?
- Inflammation of the uvea due to breakdown of the blood-aqueous barrier
what is the uvea?
- inner vascular coat of the globe
- Iris
- Ciliary body
- Choroid
how do we classify uveitis?
- location
- onset
- clinical pathology
- etiology
what are the different types of anterior uveitis?
- Iris: iritis
- Ciliary body: cyclitis
- Iris & ciliary body: iridocyclitis
what is acute uveitis?
- 90% of all uveitis cases
- Sudden onset and limited duration (< 3 months), completely resolves once attack is over
what is chronic uveitis?
- Uveitis recurs in less than 3 months after discontinuing treatment
- Can last months to years (> 3 months)
what is non-granulomatous uveitis?
- Immune cells involved: neutrophils, lymphocytes, plasma cells
- Keratic precipitates: small, stellate, white or pigmented
- Usually idiopathic, traumatic, postoperative, or HLA-B27 associated (with or without systemic disease)
what is granulomatous uveitis?
- Immune cells involved: macrophages, epithelioid cells (in addition to neutrophils, lymphocytes, and plasma cells) - Keratic precipitates: large, yellow, "mutton fat" endothelial deposits
- More chronic course
what are the causes of granulomatous uveitis?
- Infectious: Syphilis, Lyme, TB
- Tearing
- Blurred vision
- Blepharospasm
what are signs of acute anterior uveitis?
**- Circumlimbal injection: enlargement of episcleral vessels in the region of the CB
- Anterior chamber cells and/or flare -** Decreased or increased IOP - Pupillary miosis/sluggish pupillary response: spasm of iris sphincter muscle
what are symptoms of chronic anterior uveitis?
- Minimal symptoms
- May have symptoms of acute anterior uveitis during periods of exacerbation - Decreased VA: due to sequelae of chronic uveitis
what happens if anterior uveitis is left untreated?
- Corneal endothelial
- precipitates Iris nodules: ⚫ Busacca: iris stroma, granulomatous
⚫ Koeppe: pupillary margin, both granulomatous and non-granulomatous
- Posterior synechiae
- Peripheral anterior synechiae
- Band keratopathy
- Posterior Subcapsular Cataract (PSC) (common, could also be caused by steroids)
- Iris atrophy Iris heterochromia (Fuchs iridocyclitis)
- Neovascularization of the iris (NVI)
- Cystoid macular edema
- Secondary glaucoma
how does anterior uveitis cause secondary glaucoma?
- Inflammatory cells block aqueous outflow
- Posterior synechiae cause pupillary block
- Peripheral anterior synechiae cause angle closure
- Neovascular glaucoma
what techniques would you use to access the anterior chamber?
- 60-degree angle
- Light beam: 3mm long x 1mm wide
- High magnification
- Maximum illumination
- Dark room
what is flare?
- Pro-inflammatory serum proteins leak into AC and recruit WBC
- Can coalesce to form fibrin
what is the grading for flare?
- Masquerade syndromes (lymphoma, leukemia)
- Infectious keratitis (fungal, pseudomonal)
what are the types of keratic precipitates?
- stellate KPs
- Mutton-fat KPs
what are stellate KPs?
- Non-granulomatous
- White: neutrophils, lymphocytes, plasma cells
- Pigmented: iris melanocytes
what are mutton fat KPs?
- Granulomatous
- Composed of macrophages and epithelioid cells
what sex and diseases would be seen in patient hx for someone with anterior uveitis?
- JIA: girls
- Ankylosing spondylitis: men - Reiter's syndrome: men
what race and diseases would be seen in patient hx for someone with anterior uveitis?
- Caucasians: HLA-B27 related diseases
- African Americans: sarcoidosis
what ocular hx would be seen for someone with anterior uveitis?
- Prior red eye
- Prior use of "milky" drops
- History of trauma
- History of ocular surgery
what systemic hx would be seen for someone with anterior uveitis?
- Joint pain, lower back pain
- Skin rashes
- Oral/genital ulcers
what are the necessary test done for patients with anterior uveitis?
**- BCVA
- Pupils
- EOMs
- Slit Lamp Exam**
why may more frequent dosing of cycloplegics occur in acute anterior uveitis?
- Duration of cycloplegics in uveitic eye may be shorter due to presence of increased esterases in the AC - more frequent dosing may be necessary
- cyclopentalate
- homatropine
- what is the duration of action for each?
how do topical corticosteroid helps with anterior uveitis?
- Reduce pain
- Reduce inflammation
- Stabilize cell membranes
- Inhibit release of lysozyme by granulocytes
- Suppress circulation of lymphocytes
- Block phospholipase A2, which converts cell membrane phospholipids into inflammatory mediators (leukotrienes and prostaglandins)
what topical steroids are used for anterior uveitis? Maximal efficacy:
- Difluprednate 0.05% emulsion (Durezol): QID
- Prednisolone acetate 1% susp (PredForte): usually start with q1h or q2h, then taper once inflammation significantly reduced
when would oral steroids be used for anterior uveitis?
- Severe anterior uveitis
- Posterior uveitis
- Must rule out systemic infection prior to initiating oral steroids
do topical NSAIDs have a big role in anterior uveitis?
how do oral NSAIDs help with anterior uveitis?
- Oral: may reduce recurrence of non-granulomatous uveitis Mechanism
- Inhibit cyclo-oxygenase enzyme
- Do not inhibit phospholipase A2, which produces leukotrienes responsible for attracting WBC into the AC
when would you use immunomodulators for anterior uveitis? -Considered for non-infectious uveitis that is recalcitrant or non-responsive to steroid treatment
when would you use biologic response modifiers for anterior uveitis?
- Antibodies and antibody-derived proteins: block activity of bioactive mediators of the immune response Indications
what would treatment of herpes zoster uveitis?
- Topical steroids with oral antiviral
- Acyclovir 800mg 5x/day
- Cycloplegia
- IOP lowering agents
what would treatment of herpes simplex uveitis be?
- Topical steroids with oral antiviral
- Acyclovir 400mg 5x/day
- Cycloplegia
- IOP lowering agents
what is syphilis?
- Multisystem bacterial infection caused by Treponema pallidum bacterium
- Ocular manifestations occur in acquired and congenital infections
- Transmission is transplacental or via sexual contact
- The "great masquerader"
what are the stages of syphilis?
- Primary: painless ulcer at inoculation site, heals spontaneously 1-2 months later
- Secondary: treponemal load is largest, generalized rash and lymphadenopathy, occurs
4-10 weeks after primary lesion
- Latent: occurs within 1+ year after initial infection; can progress to tertiary
- Tertiary: granulomatous lesions of mucus membranes, cardiovascular damage (coronary arteries and aorta), neurosyphilis
what does anterior uveitis caused by syphilis look like?
- Granulomatous inflammation of any ocular structure
- Ocular syphilis usually occurs at least 6 months after primary infection
- Most ocular involvement occurs during secondary, latent, or tertiary stages
what bloodwork is done for syphilis?
- RPR or VDRL: screening tests, detect non-treponemal antibodies, present in early infection
- FTA-ABS or MHA-TP: specific treponemal tests – positive after primary infection, used as confirmatory test when screening test is positive
what would treatment for syphilis be?
what stages of syphilis does uveitis occur?
- secondary
- latent: most common
- Ocular: topical steroids, cycloplegia
what is tuberculosis?
- Granulomatous infection
- Primarily affects the lungs
- Natural history: exposure to TB may lead to
- Non-infection: 70-90%
- Infection: 10-30%
- Latent: never develop TB
- Active: necessitates treatment; once treated, the patient is cured from the bacterium
what would workup of TB be?
- Labs: PPD, QuantiFeron Gold blood test
- Imaging: chest X-ray
what are the non-infectious causes of acute anterior uveitis?
- Idiopathic: 50% of all uveitis cases
- Traumatic/postoperative
- HLA-B27 associated uveitis - Inflammatory/autoimmune systemic disorders
- Masqueraders
what is HLA-B27?
- Human cells contain surface markers to allow the body to differentiate native cells from foreign material
- Human Leukocyte Antigen (HLA) molecules present antigenic peptides to T lymphocytes to initiate immune response
- HLA-B27 is a specific marker whose genome is located on Chromosome 6
- Present in 1-8% of the population
- Predisposes patients to certain autoimmune diseases (seronegative spondyloarthropathies)
what is the strongest known genetic risk factor for the development of acute anterior uveitis?
- HLA-B
- 26-fold increased risk of developing AAU
- Younger patients (20-40), first presentations during young adulthood
- M > F (2.5:1)
what does anterior uveitis look like for patients with HLA-B27 defect?
- Acute onset
- Unilateral
- Non-granulomatous
- Recurrent attacks with more severe inflammation
- More likely to have hypopyon
genitourinary or GI tract
- Younger males (15-35)
- Classic diagnostic triad:
- Arthritis: 98%
- Urethritis: 74%
- Conjunctivitis: 58%
- Anterior uveitis: 3-12%
what does uveitis look like in patients with Rieiter's syndrome?
- Acute, chronic, or recurrent
- Non-granulomatous
- Associated urethral discharge
what would workup for reiter's syndrome be?
- Labs: HLA-B27, ESR, C. trachomatis
- ROS: ask about urethritis, arthritis, conjunctivitis
- Referrals: urologist for urethral cultures and urine analysis, rheumatologist
what disease are included in inflammatory bowel syndrome?
- crohns
- ulcerative colitis
- 60% are HLA-B27 positive
what would symptoms of inflammatory bowel disease be?
- abdominal pain
- diarrhea
- weight loss
- fever
- fatigue
- joint pain
what would workup of inflammatory bowel disease be?
