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ANATOMY
Consists of: iris anteriorly; ciliary body and choroid posteriorly; in continuity with each
other
Definition: Pigmented highly vascular layer lying between retina and sclera
Concerned with:
1. Nutrition of eye ciliary body epithelium secretes aqueous humour
2. Maintenance of outer retina from choroidal circulation
Uveitis: inflammation of uvea; damage may occur to vascular epithelium in this tissue >
breakdown of blood-aqueous barrier
CLASSIFICATION
Iritis
inflammation of iris; anterior uveitis
Cyclitis
Inflammation of ciliary body; intermediate uveitis
Choroiditis Inflammation of choroid; posterior uveitis
Iridocyclitis
Inflammation of iris and ciliary body
Retinochoroiditis/chorioretinitis
Inflammation involving retina and choroid
-
Anterior uveitis
Most symptomatic
Pain
Photophobia
Red eye
Observe cells and flare
Non-granulomatous allergic type
reaction
More acute; sudden onset
No posterior involvement
Small keratic precipitates
EG: Ankylosing spondylitis
Posterior uveitis
Less symptomatic
Less pain
Cells in vitreous
Granulomatous
Insidious onset
Retina and choroid involved
Larger keratic precipitates
EG: Sarcoidosis, toxoplasmosis
*Uveitis question
Differentiate between iridocyclitis and chorioretinitis (6)
Signs and symptoms most likely associated with iridocyclitis or chorioretinits: red eye,
insidious onset, cells and flare, pain, small KPs, large KPs, vitreous haemorrhage,
photophobia
PUPIL ABNORMALITIES
Causes of bilateral LND
1. Neurosyphilis
2. Type 1 diabetes
3. Parinauds syndrome
4. Myonic dystrophy
5. Familial amyloidosis
6. Encephalitis
7. Chronic alcoholism
Sx:
a. Dilated pupil
b. decreased accommodation (proximal blurred vision)
c. minimal light reflex
signs:
a. classic vermiform reaction of iris sphincter under slit lamp
b. Slow and tonic redilation (residual miosis)
c. May have LND
d. Deep tendon reflex absent/reduced
Aet:
Recent cold/viral infection, especially upper respiratory tract
Denervation of post-ganglionic nerve supply to sphincter > lesion in ciliary
ganglion (knocks out PSM)
Diagnosis:
Instill 1 drop of 1.125% pilocarpine in each eye (stimulates PSM innervation)
Affected pupil will contract in 30m due to denervation sensitivity
Normal pupil wont react
*Adies Pupil Question
Twenty two year old woman > decreased vision at near + okay distance vision + mild cold +
slight cough + unequal pupil size(10)
a. Most likely conditions and other possible clinical findings
b. Ophthalmic preparation used to confirm diagnosis. Explain
ACQUIRED ABNORMALITIES
- First two conditions: observed with iris transillumination due to fundus reflex shining
through iris
- All can be observed with gonioscopy in viewing the angle
1. Pseudoexfoliation syndrome:
Presentation: 20%; Usually unilateral; more common in females
Signs:
Grey/white precipitates on and within anterior lens capsule
Characterized by appearance of central circular area of normal lens capsule,
surrounded by clear ring, surrounded by circular grey area > seen clearly
once pupil is dilated > Bulls eye appearance
Flaky dandruff material is histochemically of amyloid material
Tip of iris rubs on amyloid and pigment is released into aqueous > deposited
into TM > TM becomes more pigmented, but no amyloid seen in TM
Amyloid can be deposited onto corneal endothelium > more inferiorly due to
convection currents > Krukenberg spindles
Zonules weakened > on dilation, IOP goes up
Aet:
Thought to be related to aging abnormality of generalized basement
epithelial membrane cells
More commonly seen in fair/Scandinavian patients
Complication:
20% develop pigmentary glaucoma
2. Pigment Dispersion syndrome:
Aet: Occurs more frequently in young myopic males
Clinical:
Zonular rubbing > shedding of iris pigment into aqueous > TM
Iris transillumination and Krukenbergs spindles
Pigment seen as darkly pigmented band in filtration portion of TM > confined
to relatively smooth bordered circumscribed band
20% develop pigmentary glaucoma
Ocular
involveme
nt
Presentati
on
Visual loss
Tx
Systemic
manifestat
ion
c. Reiters syndrome:
Prevalence Men 20-40y
Ocular
(4) Acute anterior uveitis arthritis urethritis/dysentery sometimes
involveme conjunctivitis
nt
Presentati
Bilateral
on
Systemic
affects peripheral joints (knees)
manifestat
ion
Aetiology
May be related to chlamydial infection
Test
HLA B27 present
d. Ulcerative colitis:
Def
Inflammatory disease of distal colon and rectum
Aet
1. Crohns disease (inflammation of uvea and colon, and arthritis)
2. Behcets disease (Causes oral and genital ulcers blood test: HLA
B51)
3. Sarcoidosis (5% of all anterior uveitis; more associated with
posterior uveitis)
CLINICAL PRESENTATION
Most common symptoms:
1. Pain (sharp) often sudden onset
2. Blurred vision (slight) from corneal oedema or aqueous debris
3. Extreme photophobia
4. Tearing
5. Red eye
Most common signs:
1. Circumlimbal flush:
Vascular dilation and injection typically centred around peri-limbal conjunctival tissue;
grade of injection lessens posteriorly towards fornices
2. Blepharospasms:
Spasms of lid;
eye is uncomfortable, especially in bright lights;
difficulty keeping eyes open
3. Miotic pupil:
DT inflammation;
iris swells and pupil diameter is reduced;
doesnt always happen and pupil does still react
4. Inflammatory cells:
WBC (leucocytes, polymorphs, macrophages, lymphocytes);
cross vascular endothelium to float in aqueous;
high number > pus formed > hypopion
Cells circulate, agglutinate and become deposited on corneal endothelium > KP
Inflammatory cell finding NB in Dx of anterior uveitis
Observation difficult > can use slightly longer beam than conical
Cells graded 1-4:
1. No cells; Trace 1-3 cells
2. 4-10 cells
3. 15-20 cells
4. Too many to count
5. Most ever seen
5. Flare:
Sign of protein leakage from damaged iris BV
Sign of persisting vascular damage, especially after disappearance of cells
Shows as homogenous fog-like appearance in slit-lamp beam
Graded from 1-4; most severe when aqueous becomes fibrinoid
6. Keratic precipitates
Formation, see 4
Classic sign of uveitis
Found on corneal endothelium
Debris form sticky residue > convection pattern inferiorly on inferior cornea due to
currents and gravity
May disappear after Tx (steroids) or stay and pick up pigmentation
7. Synechiae:
a. Anterior: adhesion between cornea and iris
b. Posterior:Adhesion between iris and anterior lens
More likely to occur with anterior uveitis
Irregular pupil shape may result, especially under dilation
If iris is attached all the way around (to lens surface), aqueous will not circulate
normally > iris protrudes forward > iris bombe
8. Intra-ocular pressure:
Anterior uvea inflamed > shuts down ciliary body > pressure initially goes down (35mmHg) = first sign
Over time, floating debris blocks TM > secondary glaucoma
Steroid Tx may cause (iogenic) glaucoma
9. Iris nodules:
Accumulation of leucocytes on iris surface
Yellow-white
Usually associated with granulomatous uveitis or systemic disease
Two types:
1. Busacca nodules: larger; on surface of iris
2. Koeppe nodules: smaller; at pupil edge/margin
PHARMACEUTICAL APPLICATIONS
Use of diagnostic drugs in differentiation of pupil abnormalities
Refer to notes from Ocular Pharmacology in third year, particularly those on ocular antiinflammatory meds
PHARMACEUTICAL APPLICATION
Drugs used in management of posterior uveitis
Traditional management:
1. Topical or systemic corticosteroids
2. Cycloplegics
Severe uveitis unresponsive to steroids/ px with complications:
Immunosuppressants
First line therapy in px with Behcets disease involvinig posterior segment, Wegener
granulomatosis and necrotizing clerritis
Diseases are associated with systemic vasculitis, and treatment with
immunosuppressants can improve outcomes
Immunomodulatory therapy used where long-term Tx with systemic corticosteroids is
necessary:
1. Serpiginous choroiditis
2. Birdshot choroiditis
3. Vogt-Koyanagi Harada disease
4. Sympathetic ophthalmia
5. Juvenile idiopathic arthritis
VEGF
Full-length humanized anti-vascular endothelial growth factor monoclonal antibody
bevacizumab
Trerats refractory CME and neovascular complications of uveitis
Serial injections may be necessary and long-term tolerability and safety of med is
unknown
Tx of
Cycloplegics
Symptoms and complications of inflammation tempered with topical cycloplegics
Short-acting drops (cyclopentolate) and long-acting drops (atropine) used to:
1. decrease photophobia caused by ciliary spasm
2. break up/prevent formation of posterior synechiae
Corticosteroids
Uses:
1. Inhibit arachidonic acid release from phospholipids
2. Inhibit transcription and action of cytokines
3. Limits B- and T-cell activit
4. Indicated in inflammatory diseases of non-infectious cause
Routes of administration: (3) topical periocular systemic
Best route and dose determined for each patient
Minimum amount needed to control inflammation should be used to reduce
complications
Complications:
Serious adverse effects, esp with high doses and long-term use
Immunosuppressive agents commonly used for chronic or sight-threatening uveitis
A. Topical corticosteroids
Use: Anterior uveiis
Frequency: Depending on severity of inflammation, ranges from hourly to every other
day
Drug of choice: 1% prednisolone acetate (Precipitate > shake well before use)
Complication: May cause ocular hypertension > px monitored at 4-week to 6-week
intervals
B. Periocular corticosteroids
Use: When more posterior effect is necessary or when compliance is an issue
Route: Transseptal or sub-Tenon approach to deposit long-lasting steroid around eye
(deep transseptal injections may cause less ocuar hypertension than sub-Tenon)
Method: Initially treat px with topical steroid for 3-4 weeks prior to periocular to
identify steroid responding px
Complications: Not to be used in px with infectious uveitis or scleritis > scleral
thinning and possible perforation
Drug of choice: Triamcinolone acetonide
Triamcinolone
Uses:
1. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and
reversing capillary permeability
2. Used as intra-vitreal injection for retinal oedema
Immunosuppressive agents: 3 main categories of therapy:
1. Antimetabolites (3) azathioprine methotrexate mycophenolate mofetil
2. T-cell suppressors (2) cyclosporine - tacrolimus
3. Cytotoxic agents (2) cyclophosphamide chlorambucil
Alkylating agents
Most agents take several weeks to achieve efficacy, therefore initially used in conjunction
with oral corticosteroids
Once disease is under control, corticosteroids can be tapered
C. Systemic corticosteroids
Use: When systemic disease is present that also requires treatment, or for visionthreatening uveitis poorly responsible to other methods of delivery
Route: Oral or intravenous therapy
Complications: short-term and long-term adverse effects of corticosteroid use
considered
Drug of choice: Prednisone (oral)*
*Prednisolone (Pred Forte)
Uses:
1. Acute inflammations following eye surgery or other types of insults to eye
2. Decreases inflammation and corneal neovascularization
3. Suppresses migration of polymorphonuclear leukocytes
4. Reverses increased capillary permeability
5. Bacterial infections> concomitant use of anti-infective agents mandatory
Shake well before use