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91 Cards in this Set

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What is uveitis?
A generic term for all types of intraocular inflammation affecting the uveal tract.
What is the uvea?
What structures make it up?
A pigmented vascular structure consisting of the iris, ciliary body and the choroid.
What is the function of the uvea?
To nourish the eye through the anterior and posterior ciliary arteries.
What happens in the immune response?
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.
What two signs can lead to the dx of anterior uveitis?
1) Cells: white blood cells in the anteior chamber.
2) Flare: haze in the anterior chamber caused by protein exudate.
What are the five things that the classification of anterior uveitis is based on?
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)
What is granulomatous uveitis?
Type IV hypersensitivity reaction in which granulomas are formed secondary to chronic antigenic stimulation.
What are 2 examples of anterior uveitis?
1) Iritis
2) Iridocyclitis (inflammation of the iris and ciliary body)
What is an example of intermediate uveitis?
Pars planitis
What are 2 examples of posterior uveitis?
1) Retinitis
2) Choroiditis
What are the symptoms of uveitis?
1) Red eye
2) Photophobia
3) Pain
4) Normal or decreased vision
5) Acute or insidious onset
6) May have accompanying systemic symptoms
What is the grading for cells?
Trace: 0-5 cells
Grade 1: 5-10
Grade 2: 10-20
Grade 3: 20-30
Grade 4: 30-50
Grade 5: >50
T/F: Prolonged inflammation can lead to residual flare even following the resolution of he active inflammation.
True
What are some signs of uveitis?
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)
What do keratitis precipitates (KP) look like in granulomatous and nongranulomatous uveitis?
1) Granulomatous: PK are larger and graysih "Mutton-fat"
2) Nongranulomatous: fine, whitish KP
Describe the conjunctival injection that may be seen in uvietis.
Primarily circumlimbal "Ciliary flush"
What happens when you shine a light in the uninvolved eye with a patient who has uveitis.
They often have increased pain in the eye with the uveitis.
What happens if there is severe cells and flare?
There may be hypopyon present. (Accumulation of WBC in the inferior angle.)
What are deposits of inflammatory cells on the endothelium called?
Keratic precipitates (KP)
What happens in Arlt's triangle?
Convection current in AC causes cells near iris to rise and fall near cornea.
What are adhesions btw the iris and the lens called.
Posterior synechia
What are adhesions btw the iris and trabecular meshwork called?
Peripheral anterior synechia.
What can result from anterior synechia?
Sub-acute to acute secondary angle closure glaucoma.
What are two different types of nodules of inflammatory cells on the iris surface called?
1) Koeppe nodules: if located on the pupil margin.
2) Busacca nodules if located on the iris surface.
If there is WBC in the anterior vitreous what could this be due to?
1) Spillover from the anterior chamber.
2) Intermediate uveitis.
If the uvietis is chronic what can this result in?
Macular edema or ONH swelling.
What needs to be done on all patients with uveitis?
DFE to see if there are signs of posterior inflammation.
Initially, will uveitis present with an increased or decreased IOP?
Often decreased.
Why is the IOP initially decreased in uveitis?
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.
What are some reasons for an increase in IOP with uveitis?
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.)
What 2 conditions is seen in long standing uveitis?
Cataracts and band keratopathy (esp in JRA).
What type of cataracts are most likely present in long standing uveitis?
PSC, but cortical opacities may also be seen.
What is band keratopathy?
The deposition of calcium at the level of Bowman's. In severe cases requires chelation therapy or mechanical scraping.
When taking a history for uveitis, what things need to be asked?
Onset of ocular episode, previous episodes, one eye or two, etc.
If a patient has uveitis, what things do you want to look for on fundus exam?
Snowbanking of cells, macular edema, signs of choroid or retinal inflammation.
What is snowbanking of cells?
Accumulation of vascular endothelial cells and fibroblasts on inferior pars plana.
If a patient has uveitis, what things do you want to look for on slit lamp exam?
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.
What are 12 causes of nongranulomatous uveitis?
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
What are 6 rare causes of acute nongranulomatous uveitis?
1) Mumps
2) Influenza
3) Adenoviris
4) Measles
5) Chlamydia
6) Tight CL
What is ankylosing spondylitis associated with?
Acute nongranulomatous uveitis.

Young adult men, low back pain, abnormal sacroiliac spine s-rays, elevated ESR, +HLA-B-27.
What is a side effect of IBD?
Chronic intermittent diarrhea often alternating with constipation.
What is Reiter's syndrome assoc. with?
Acute nongranulomatous uveitis.

Young adult men, conjuctivitis, urethritis, polyarthritis, maybe keratitis, elevated ESR, +HLA B-27
What 2 conditions have +HLA B-27?
Ankylosing spondylitis and Reiter's syndrome
What is glaucomatocyclitic crisis?
Acute IOP rise, open angle glaucoma on gonio, corneal edema, fine KP, fixed and mid-dilated pupil, iritis.
Describe how the lens can induce uveitis?
After incomplete extracapsular cataract removal.
May be secondary to hypermature cataract.
What do you want to expect after post-op iritis?
AC reaction after surgery, must watch for endophthalmitis.
What is endophthalmitis?
Inflammation of the intraocular cavities (aqueous, vitreous humor) usually caused by infection.
What does UGH syndrome stand for?
Uveitis glaucoma hyphema syndrome
What is UGH syndrome normally caused by?
Usually secondary to irritation from IOL.
What is Bechet's disease associated with?
Young adults, acute hypopyon, iritis, apthous mouth ulcers, genital ulcerations, erythema nodosum.

If active disease present: + Bechet's skin puncture test, often retinal vasculitis.
What is Lyme disease associated with?
Acute nongranulomatous uveitis.

Tick bite, skin rash, arthritis symptoms.
What are 3 conditions associated with chronic nongranulomatous uveitis?
1) JRA
2) Chronic iridocyclitis of children
3) Fuch's heterochromic iridocyclitis.
What is JRA associated with?
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.
What does pauciarticular mean?
Fewer than five joints involved.
Describe how the lens can induce uveitis?
After incomplete extracapsular cataract removal.
May be secondary to hypermature cataract.
What do you want to expect after post-op iritis?
AC reaction after surgery, must watch for endophthalmitis.
What is endophthalmitis?
Inflammation of the intraocular cavities (aqueous, vitreous humor) usually caused by infection.
What does UGH syndrome stand for?
Uveitis glaucoma hyphema syndrome
What is UGH syndrome normally caused by?
Usually secondary to irritation from IOL.
What is Bechet's disease associated with?
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.
What is Lyme disease associated with?
Acute nongranulomatous uveitis.

Tick bite, skin rash, arthritis symptoms.
What are 3 conditions associated with chronic nongranulomatous uveitis?
1) JRA
2) Chronic iridocyclitis of children
3) Fuch's heterochromic iridocyclitis.
What is JRA associated with?
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.
What does pauciarticular mean?
Fewer than five joints involved.
What is chronic iridocyclitis in children associated with?
Chronic nongranulomatous uveitis.

Usually young females, like JRA with no arthritis.
What is Fuch's heterochromic iridocyclitis associated with?
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.
What is erythema nodosum?
A skin inflammation that results in reddish, painful, tender lumps most commonly located in the front of the legs below the knees.
What is sarcoidosis associated with?
Chronic granulomatous uveitis.

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

Abnormal CXR, + gallium scan, elevated ACE.
What is syphilis associated with?
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
What is iris roseola?
Vascular papules on the iris.
What is TB associate with?
Chronic granulomatous uveitis.

+PPD, occasionally phlyctenular keratitis, sometimes posterior uveitis.
What two rare conditions is associated with chronic granulomatous uveitis?
Leprosy and brucellosis.
What are two masqueraders of uveitis?
Lymphoma and Luekemia.
What is suspect in posterior uveitis that does not respond well to treatment?
Lymphoma
What is suspect in children with bilateral uveitis that does not respond to treatment?
Luekemia
What are some other associations with AC reaction?
1) Rhegmatogenous RD
2) Posterior segment tumor (Retinoblastoma, malignant melanoma, leukemia)
3) Juvenile xanthogranuloma
4) IO foreign body
5) Sclerouveitis
What is sclerouveitis?
Uveitis secondary to scleritis.
What is juvenile xanthogranuloma associated with?
Under age 15, spontaneous hyphema, yellow-gray poorly demarcated iris nodule(s), slightly raised orange skin lesions.
What are the 4 most common causes of anterior uveitis?
1) Idiopathic (38-56%)
2) Spondyloarthropathies (21-23%)
3) JRA (9-11%)
4) Simplex/Zoster Keratitis (6-10%)
What is the most common cause of posterior uveitis?
Toxoplasmosis
What are the two most common causes of panuveitis?
1) Idiopathic (22-45%)
2) Sarcoidosis (14-28%)
What are some threats to vision/life of uveitis?
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
What is the work-up if unilateral, nongranulomatous uveitis develops for the first time AND history/exam are unremarkable?
No further work-up is usually pursued
What is the work-up if bilateral, granulomatous, or recurrent; and the history/exam are unremarkable?
Nonspecific lab series is ordered.
What is the work-up if the history/symptoms/exam point to certain etiology?
Work up is tailored according.
What are 3 reasons for using cycloplegia in uveitis?
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.
What cycloplegic agents do you want to use for uveitis?
Mild uvietis: cyclopentolate 1-2% tid

Moderate-to-severe: homatropine 5% , scopolamine .25% or atropine 1% bid-tid (most commonly Homatropine)
T/F: Cycloplegic drops have prolonged effect in healthy individuals, but the effect is diminished in the presence of inflammation.
True
If patient has 360 degree posterior synechia how would you treat it?
May need peripheral iridectomy.
What are routes of steroid therapy for uveitis?
Topicals
Periocular injection
Orals
How and what would you prescribe topical steroids for the tx of uveitis?
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.