Anterior Segment: Test 1, Anterior Uveitis

Front 1

What is uveitis?

Back 1

A generic term for all types of intraocular inflammation affecting the uveal tract.

Front 2

What is the uvea?
What structures make it up?

Back 2

A pigmented vascular structure consisting of the iris, ciliary body and the choroid.

Front 3

What is the function of the uvea?

Back 3

To nourish the eye through the anterior and posterior ciliary arteries.

Front 4

What happens in the immune response?

Back 4

There is an influx of leukocytes and plasma molecules to the site of infection, antigen challenge or tissue damage.

The process involves chemotactic factors and cell migration and release of inflammatory mediators both locally and systemically.

Front 5

What two signs can lead to the dx of anterior uveitis?

Back 5

1) Cells: white blood cells in the anteior chamber.
2) Flare: haze in the anterior chamber caused by protein exudate.

Front 6

What are the five things that the classification of anterior uveitis is based on?

Back 6

1) Area of eye affected (anterior, intermediate, posterior, pan)
2) Course (acute, chronic, recurrent)
3) Pathology (granulomatous, non)
4) Laterality (bilateral, unilateral)
5) Causative agent (infectious, autoimmune, traumatic)

Front 7

What is granulomatous uveitis?

Back 7

Type IV hypersensitivity reaction in which granulomas are formed secondary to chronic antigenic stimulation.

Front 8

What are 2 examples of anterior uveitis?

Back 8

1) Iritis
2) Iridocyclitis (inflammation of the iris and ciliary body)

Front 9

What is an example of intermediate uveitis?

Back 9

Pars planitis

Front 10

What are 2 examples of posterior uveitis?

Back 10

1) Retinitis
2) Choroiditis

Front 11

What are the symptoms of uveitis?

Back 11

1) Red eye
2) Photophobia
3) Pain
4) Normal or decreased vision
5) Acute or insidious onset
6) May have accompanying systemic symptoms

Front 12

What is the grading for cells?

Back 12

Trace: 0-5 cells
Grade 1: 5-10
Grade 2: 10-20
Grade 3: 20-30
Grade 4: 30-50
Grade 5: >50

Front 13

T/F: Prolonged inflammation can lead to residual flare even following the resolution of he active inflammation.

Back 13

True

Front 14

What are some signs of uveitis?

Back 14

1) Conjuctival injection (primarily circumlimbal, "ciliary flush).
2) Patients will often complain of increased pain in the involved eye when light is shined in the uninvolved eye.
3) White blood cells and protein (flare) floating in the anterior chamber. If severe enough may see hypopyon (accumulation of WBC in the inferior angle)
4) Deposits of inflammatory cells on the corneal endothelium (keratic precipitates or KP) that vary in size and appearance)

Front 15

What do keratitis precipitates (KP) look like in granulomatous and nongranulomatous uveitis?

Back 15

1) Granulomatous: PK are larger and graysih "Mutton-fat"
2) Nongranulomatous: fine, whitish KP

Front 16

Describe the conjunctival injection that may be seen in uvietis.

Back 16

Primarily circumlimbal "Ciliary flush"

Front 17

What happens when you shine a light in the uninvolved eye with a patient who has uveitis.

Back 17

They often have increased pain in the eye with the uveitis.

Front 18

What happens if there is severe cells and flare?

Back 18

There may be hypopyon present. (Accumulation of WBC in the inferior angle.)

Front 19

What are deposits of inflammatory cells on the endothelium called?

Back 19

Keratic precipitates (KP)

Front 20

What happens in Arlt's triangle?

Back 20

Convection current in AC causes cells near iris to rise and fall near cornea.

Front 21

What are adhesions btw the iris and the lens called.

Back 21

Posterior synechia

Front 22

What are adhesions btw the iris and trabecular meshwork called?

Back 22

Peripheral anterior synechia.

Front 23

What can result from anterior synechia?

Back 23

Sub-acute to acute secondary angle closure glaucoma.

Front 24

What are two different types of nodules of inflammatory cells on the iris surface called?

Back 24

1) Koeppe nodules: if located on the pupil margin.
2) Busacca nodules if located on the iris surface.

Front 25

If there is WBC in the anterior vitreous what could this be due to?

Back 25

1) Spillover from the anterior chamber.
2) Intermediate uveitis.

Front 26

If the uvietis is chronic what can this result in?

Back 26

Macular edema or ONH swelling.

Front 27

What needs to be done on all patients with uveitis?

Back 27

DFE to see if there are signs of posterior inflammation.

Front 28

Initially, will uveitis present with an increased or decreased IOP?

Back 28

Often decreased.

Front 29

Why is the IOP initially decreased in uveitis?

Back 29

Thought to be due to ciliary body inflammation causing reduced aqueous production.

May be in part due to increased prostaglandin release from inflammation causing increased uveoscleral outflow.

Front 30

What are some reasons for an increase in IOP with uveitis?

Back 30

1)Inflammatory cells may occlude the trabecular meshwork (plasmoid aqueous).
2) Trabecular meshwork may swell (Trabeculitis/Posner-Schlossman)
3. PAS formation blocking outflow. (Secondary angle glc.)
4. Posterior synechia causing pupillary block (Iris bombe)
5. Corticosteroid induced (Steroid responder)
6. Recovery of ciliary body causing increased aqueous production but TM is still inflammed causing decreased outflow; the eye is actually getting bigger.)

Front 31

What 2 conditions is seen in long standing uveitis?

Back 31

Cataracts and band keratopathy (esp in JRA).

Front 32

What type of cataracts are most likely present in long standing uveitis?

Back 32

PSC, but cortical opacities may also be seen.

Front 33

What is band keratopathy?

Back 33

The deposition of calcium at the level of Bowman's. In severe cases requires chelation therapy or mechanical scraping.

Front 34

When taking a history for uveitis, what things need to be asked?

Back 34

Onset of ocular episode, previous episodes, one eye or two, etc.

Front 35

If a patient has uveitis, what things do you want to look for on fundus exam?

Back 35

Snowbanking of cells, macular edema, signs of choroid or retinal inflammation.

Front 36

What is snowbanking of cells?

Back 36

Accumulation of vascular endothelial cells and fibroblasts on inferior pars plana.

Front 37

If a patient has uveitis, what things do you want to look for on slit lamp exam?

Back 37

1) K: signs of KP's
2) AC: cells, flare, fibrin
3) Iris: presence of iris nodules (Koeppe or Busacca), posterior synechia.
4) Lens: pig on ant. surface, significant cataract.
5) Vitreous: cells in ant or post vitreous.

Front 38

What are 12 causes of nongranulomatous uveitis?

Back 38

1) Trauma
2) Ankylosing spondylitis
3) IBD
4) Reiter's syndrome
5) Psoriatic arthritis
6) Glaucomatocyclitic crisis
7) Lens induced uveitis
8) Herpes
9) Post-op iritis
10) UGH syndrome
11) Bechet's disease
12) Lyme disease

Front 39

What are 6 rare causes of acute nongranulomatous uveitis?

Back 39

1) Mumps
2) Influenza
3) Adenoviris
4) Measles
5) Chlamydia
6) Tight CL

Front 40

What is ankylosing spondylitis associated with?

Back 40

Acute nongranulomatous uveitis.

Young adult men, low back pain, abnormal sacroiliac spine s-rays, elevated ESR, +HLA-B-27.

Front 41

What is a side effect of IBD?

Back 41

Chronic intermittent diarrhea often alternating with constipation.

Front 42

What is Reiter's syndrome assoc. with?

Back 42

Acute nongranulomatous uveitis.

Young adult men, conjuctivitis, urethritis, polyarthritis, maybe keratitis, elevated ESR, +HLA B-27

Front 43

What 2 conditions have +HLA B-27?

Back 43

Ankylosing spondylitis and Reiter's syndrome

Front 44

What is glaucomatocyclitic crisis?

Back 44

Acute IOP rise, open angle glaucoma on gonio, corneal edema, fine KP, fixed and mid-dilated pupil, iritis.

Front 45

Describe how the lens can induce uveitis?

Back 45

After incomplete extracapsular cataract removal.
May be secondary to hypermature cataract.

Front 46

What do you want to expect after post-op iritis?

Back 46

AC reaction after surgery, must watch for endophthalmitis.

Front 47

What is endophthalmitis?

Back 47

Inflammation of the intraocular cavities (aqueous, vitreous humor) usually caused by infection.

Front 48

What does UGH syndrome stand for?

Back 48

Uveitis glaucoma hyphema syndrome

Front 49

What is UGH syndrome normally caused by?

Back 49

Usually secondary to irritation from IOL.

Front 50

What is Bechet's disease associated with?

Back 50

Young adults, acute hypopyon, iritis, apthous mouth ulcers, genital ulcerations, erythema nodosum.

If active disease present: + Bechet's skin puncture test, often retinal vasculitis.

Front 51

What is Lyme disease associated with?

Back 51

Acute nongranulomatous uveitis.

Tick bite, skin rash, arthritis symptoms.

Front 52

What are 3 conditions associated with chronic nongranulomatous uveitis?

Back 52

1) JRA
2) Chronic iridocyclitis of children
3) Fuch's heterochromic iridocyclitis.

Front 53

What is JRA associated with?

Back 53

Usually young females, eye may be white and without pain, often bilateral, iritis can occur before the arthritis, pauciarticular (fewer than five joints involved).

+ANA, -RF, elevated ESR.

Front 54

What does pauciarticular mean?

Back 54

Fewer than five joints involved.

Front 55

Describe how the lens can induce uveitis?

Back 55

After incomplete extracapsular cataract removal.
May be secondary to hypermature cataract.

Front 56

What do you want to expect after post-op iritis?

Back 56

AC reaction after surgery, must watch for endophthalmitis.

Front 57

What is endophthalmitis?

Back 57

Inflammation of the intraocular cavities (aqueous, vitreous humor) usually caused by infection.

Front 58

What does UGH syndrome stand for?

Back 58

Uveitis glaucoma hyphema syndrome

Front 59

What is UGH syndrome normally caused by?

Back 59

Usually secondary to irritation from IOL.

Front 60

What is Bechet's disease associated with?

Back 60

Acute nongranulomatous uveitis.

Young adults, acute hypopyon, iritis, apthous mouth ulcers, genital ulcerations, erythema nodosum.

If active disease present: + Bechet's skin puncture test, often retinal vasculitis.

Front 61

What is Lyme disease associated with?

Back 61

Acute nongranulomatous uveitis.

Tick bite, skin rash, arthritis symptoms.

Front 62

What are 3 conditions associated with chronic nongranulomatous uveitis?

Back 62

1) JRA
2) Chronic iridocyclitis of children
3) Fuch's heterochromic iridocyclitis.

Front 63

What is JRA associated with?

Back 63

Chronic nongranulomatous uveitis.

Usually young females, eye may be white and without pain, often bilateral, iritis can occur before the arthritis, pauciarticular (fewer than five joints involved).

+ANA, -RF, elevated ESR.

Front 64

What does pauciarticular mean?

Back 64

Fewer than five joints involved.

Front 65

What is chronic iridocyclitis in children associated with?

Back 65

Chronic nongranulomatous uveitis.

Usually young females, like JRA with no arthritis.

Front 66

What is Fuch's heterochromic iridocyclitis associated with?

Back 66

Chronic nongranulomatous uveitis.

Usually unilateral, diffuse iris stromal atrophy often causing a lighter colored iris, iris transillumination defects, blunting of iris architecture, fine KP over entire endothelium.

Vitreous opacities, glc, and cataracts are common.

Front 67

What is erythema nodosum?

Back 67

A skin inflammation that results in reddish, painful, tender lumps most commonly located in the front of the legs below the knees.

Front 68

What is sarcoidosis associated with?

Back 68

Chronic granulomatous uveitis.

Usually AA, usually bilateral, may have dense posterior synechiae, posterior uveitis, conjunctival nodules.

Abnormal CXR, + gallium scan, elevated ACE.

Front 69

What is syphilis associated with?

Back 69

Chronic granulomatous uveitis.

Maculopapular rash (often on palms and soles), iris roseola (vascular papules on the iris), IK (interstitial keratitis/ghost vessels).

+VDRL, RPR, FTA-ABS

Front 70

What is iris roseola?

Back 70

Vascular papules on the iris.

Front 71

What is TB associate with?

Back 71

Chronic granulomatous uveitis.

+PPD, occasionally phlyctenular keratitis, sometimes posterior uveitis.

Front 72

What two rare conditions is associated with chronic granulomatous uveitis?

Back 72

Leprosy and brucellosis.

Front 73

What are two masqueraders of uveitis?

Back 73

Lymphoma and Luekemia.

Front 74

What is suspect in posterior uveitis that does not respond well to treatment?

Back 74

Lymphoma

Front 75

What is suspect in children with bilateral uveitis that does not respond to treatment?

Back 75

Luekemia

Front 76

What are some other associations with AC reaction?

Back 76

1) Rhegmatogenous RD
2) Posterior segment tumor (Retinoblastoma, malignant melanoma, leukemia)
3) Juvenile xanthogranuloma
4) IO foreign body
5) Sclerouveitis

Front 77

What is sclerouveitis?

Back 77

Uveitis secondary to scleritis.

Front 78

What is juvenile xanthogranuloma associated with?

Back 78

Under age 15, spontaneous hyphema, yellow-gray poorly demarcated iris nodule(s), slightly raised orange skin lesions.

Front 79

What are the 4 most common causes of anterior uveitis?

Back 79

1) Idiopathic (38-56%)
2) Spondyloarthropathies (21-23%)
3) JRA (9-11%)
4) Simplex/Zoster Keratitis (6-10%)

Front 80

What is the most common cause of posterior uveitis?

Back 80

Toxoplasmosis

Front 81

What are the two most common causes of panuveitis?

Back 81

1) Idiopathic (22-45%)
2) Sarcoidosis (14-28%)

Front 82

What are some threats to vision/life of uveitis?

Back 82

1) Increased IOP leading to glaucomatous changes in the optic nerve.
2) Secondary angle closure
3) Cataract
4) Cystoid macular edema with longstanding or chronic inflammation
5) Systemic association

Front 83

What is the work-up if unilateral, nongranulomatous uveitis develops for the first time AND history/exam are unremarkable?

Back 83

No further work-up is usually pursued

Front 84

What is the work-up if bilateral, granulomatous, or recurrent; and the history/exam are unremarkable?

Back 84

Nonspecific lab series is ordered.

Front 85

What is the work-up if the history/symptoms/exam point to certain etiology?

Back 85

Work up is tailored according.

Front 86

What are 3 reasons for using cycloplegia in uveitis?

Back 86

1)Reduction of pain/photophobia (paralysis of ciliary muscle).
2) Break or prevent posterior synechia
3) Helps to reestablish the blood-aqueous barrier within the iris.

Front 87

What cycloplegic agents do you want to use for uveitis?

Back 87

Mild uvietis: cyclopentolate 1-2% tid

Moderate-to-severe: homatropine 5% , scopolamine .25% or atropine 1% bid-tid (most commonly Homatropine)

Front 88

T/F: Cycloplegic drops have prolonged effect in healthy individuals, but the effect is diminished in the presence of inflammation.

Back 88

True

Front 89

If patient has 360 degree posterior synechia how would you treat it?

Back 89

May need peripheral iridectomy.

Front 90

What are routes of steroid therapy for uveitis?

Back 90

Topicals
Periocular injection
Orals

Front 91

How and what would you prescribe topical steroids for the tx of uveitis?

Back 91

Typically Prednisolone Acetate 1%, (Pred Forte 1%) not phosphate as it does not penetrate k well.
Dosed based on severity of uveitis; qid for mild up to q 1 hr for mod to severe
Typically q 1-2 hrs until resolved.
Taper slowly, depending on the length of treatment.