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101 Cards in this Set
- Front
- Back
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HLA system
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-MHC proteins found on surface of ALL nucleated cells.
-MHC proteins are HLA -Class 1 - antigen presentation to cytotoxic T cells CD-8 positive -Class 2 - antigen presentation to Helper T cells CD-4 positive |
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HLA associations
1. birdshot 2. POHS 3. Sarcoid 4. Reiters, ankylosing spondylitis, IBD, psoriatic arthritis, JRA 5. Behcet 6. Sympathetic ophthalmia and VKH 7. Pars Planitis 8. ARN |
1. birdshot A27
2. POHS B7 3. Sarcoid B8.B13 4. Reiters, ankylosing spondylitis, IBD, psoriatic arthritis, JRA B27 5. Behcet B51 6. Sympathetic ophthalmia and VKH DR4 7. Pars Planitis DR15 8. ARN DQ7 |
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Type 1 hypersensitivity
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Immediate hypersensitivity, IgE mediated.
Hay Fever, Hives, Vernal, Atopic, Giant Papillary Conjunctivitis |
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Type 2 hypersensitivity
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Cytotoxic mediated
Ocular Cicatricial Pemphigoid Mooren's Ulcer |
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Type 3 hypersensitivity
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Antibody (immune) complex mediated
1. stevens Johnson 2. scleritis 3. marginal keratitis 4. disciform keratitis 5. subepithelial infiltrate 6. wesselly ring 7. retinal vasculitis 8. phacoanaphylaxis |
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Type 4 hypersensitivity
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Delayed hypersensitivity
-Phlyctenule -graft rejection -contact dermatitis -interestitial keratitis -granulomatous diseases |
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Type 5 hypersensitivity
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Stimulating antibody
- MG - Grave's disease |
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List immunoglobulins and its charateristics
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IgG - most abundant, cross placenta, bind complement
IgA - important in viral infections, in secretions, joins J chain IgM - first to respond, biggest unit IgD - in newborns IgE - allergic reaction activates mast cells. |
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discuss the inflammatory pathoway
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1. Phospholipids converted to arachidonic acid by phospholipase A2 (Steroids can inhibit phospholipase A2)
2. arachidonic acid can be converted to cyclic endoperoxidase (PGG2, PGH2) by cyclooxygenase (inhibited by NSAIDS) 3. Arachidonic acid also can be converted to hydroperoxidase (5-HPETE, leukotrienes) by 5-lidoxygenase 3. cyclic endoperoxidase can be converted to thromboxanes, prostacyclin, PGE, PGF, PGD. |
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Retinal S antigen
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Protein found in the human retinal photoreceptors and pineal gland. Most potent uveitic antigen in the animal model. Produce uveitis when injected to non-ocular sites.
Birdshot, VKH, sympathetic ophthalmia respond against retinal S antigen. suggesting a autoimmune basis |
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lymphocytes
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1. All lymphocytes derive from stem cells in the bone marrow
2. B lymphocytes mature within bone marrow 3. immature T lymphocytes exit the bone marrow and go to thymus to mature Mature B, T lymphocytes then go to secondary lymphoid tissues (lymph nodes, spleen, mucosa, skin) |
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Etiology, causes for
1. episcleritis 2. scleritis |
1. episcleritis: idiopathic (most common), connective tissue disease (RA, polyarteritis, nodosa, SLE, wegeners), Gout, infections( HSV, HZV, Lyme, syphilis, Hep-B), others
2. Scleritis: connective tissue disease (RA, SLE, wegener's, relapsing polychondritis, reiters, polyarteritis nodosa, ankylsing spondylitis), gout, sarcoid, HTN, FB, infections(herpes, syphilis, TB, Lyme, parasite) |
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Episclritis
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inflammation of episclera, occurs in young adults, self limited, 33% BL, 67% recurrent. Assoc HZV, RA, gout.
Have sectoral(70%) or diffuse injection. with mild or no pain. Can have a nodule, chemosis, AC reaction Blanch with topical 2.5% phenylephrine treatment: mild steroid, topical vasocontrictor. if symptomatic > 3week work up systematically |
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Scleritis
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inflammation of the sclera, females more common, >50% bilateral. 50% assoc with systemic disease. (RA, wegener's, GCA, takayasu, relapsing polychondritis, sarcoid, ankylosing spondylitis, reiters, crohns, ulcerative colitis, syphillis, TB, leprosy, HSV, HZV, gout, rosacea.
Anterior scleritis 98%- 1. diffuse: most common 2. nodular: focal involvement, immobile nodule. 3. necrotizing: assoc with life threatning disease with 25% mortality rate. 4. posterior 2% painful, has orbital signs, exudative RD, B-scan can show T-sign Findings: diffuse or sectoral injection, tender, chemosis, scleral edema, scleral nodule, scleral thinning, AC rxn, keratitis, chorioretinal folds, serous RD in the posterior scleritis. |
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Scleritis diagnosis and work up
treatment |
Diagnosis: scleritis will not blanch with phenylephrine. Tests: CBC, ESR, RF, ANA, ANCA, VDRL, FTA-ABS, Uris acid, Bun/Cr, CXR, C-ANCA, P-ANCA
Treatment: oral NSAIDS, consider oral steroids (topical doesn;t work) or immunosuppresives. Never with subtenon's steroid injection will cause scleral melting. complication: keratitis, cataract, uveitis, glaucoma |
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DDx Optic nerve swelling and macular star
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1. lebers idiopathic stellate neuroretinitis
2. syphillis 3. HTN 4. trauma 5. measles 6. influenza 7. TB 8. coccidiomycosis 9. Cat-scratch disease 10. Papillitis 11. Papilledema 12. AION 13. DUSN work up: ESR, VDRL, FTA-ABS, lyme, bartonella serology, toxoplasna, toxocara, PPD FA: leaking disc, pericapillary staining, the macula will NOT leak |
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HLA B27 related diseases
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1. Ankylosing spondylitis
2. Reiters 3. Psoriatic arthritis 4. Inflammatory Bowel Disease 5. Post infectious or reactive arthritis 50-60% presenting with acute iritis may be HLA B27, most common acute, non-infectious hypopyon iritis, Pt with recurrent anterior non-granulomatous uveitis. Perform the HLAB27 test o confirm |
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Fuch's heterochromic iridocyclitis
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Occurs in young adults, unilateral. assoc with toxo chorioretinal scar. have blurry vision, present with stellate Kp, little AC reaction, no posterior synechea, iris atrophy (heterochromia), angle vessels that can bleed on gonia or cataract surgery or paracentesis.
Pathology-plasma cells in ciliary body treatment, responds poorly to steroids, complicated by glacuoma and PSC cataract |
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Inflammatory bowel disease
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HLA B27
uveitis is more common in ulcerative colitis than crohns Have conjunctivitis, KCS, episcleritis, scleritis, anterior uveitis, orbital cellulitis, optic neuritis Arthritis, erythema nodosum, pyoderma gangrinosum, hepatitis, sclerosing cholangitis |
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Psoriatic arthritis
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Assoc HLAB27
uveitis not occur in psoriasis without arthritis -conjunctivitis, anterior uveitis, dry eyes, arthritis, psoriatic skin, nail changes |
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Ankylosing spondylitis
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HLAB27, occurs in young men, have back pain, stiffness with inactivity.
anterior uveitis, episcleritis, scleritis arthritis in the sacroiliac joints, heart (aortic insufficiency, heart block), colitis, lungs (apical fibrosis, restricted chest expansion). work up with getting a sacroiliac x-ray look for sclerosis, narrowing of joints, ligamentous ossificaiton |
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reiter's syndrome
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HLA B27, Males more common
triad of conjunctivitis, urethritis, arthritis. Assoc with infection of chlamydia, yersenia, shigella, salmonella, ureaplasma urealyticum. Presents with mucopurelent conjunctitivis, keratitis, ant uveitis Diagnositc criteria: Major- urethritis, polyarthritis, conjunctivitis, keratoderma blenorragicum Minor: plantar fasciitis, achilles tendonitis, circinate balanitis, painless mouth ulcer, prostatitis, cystitis, spondylitis, tendinitis, recent diarrhea, iritis, keratitis |
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Juvenile rheumatoid arthritis
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most common cause uveitis in children <16yo. Most common form to cause ant uveitis RF- ANA+ pauciarticular girls (lower extremity joint invovlement and lack of wrist joint increases risk)
1. early onset: pauciarticular, girls, RF-, ANA+ 2. late onset: pauciarticular, boys, RF-, ANA- 3. Polyarticular: girls RF-, uveitis rare 4. stills disease: 60% male, RF- ANA- uveitis rare, fever, rash, organomegaly, polyserositis. Uveitis eye looks white and quiet, cataract, band K treat with topical steroids, cycloplegia. Prior to cataract surgery must have 3mo quiet AC, DO NOT IMPLANT IOL |
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JRA follow up timetable
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< 7yo:
Pauciarticular RF- ANA+ 3mo Pauciarticular RF- ANA- 6mo Polyarticular RF- ANA+ 3mo Polyarticular RF- ANA- 6mo systemic 12mo > 7yo: Pauciarticular RF- ANA+ 6mo Pauciarticular RF- ANA- 6mo Polyarticular RF- ANA+ 6mo Polyarticular RF- ANA- 6mo systemic 12mo |
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Pars planitis
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most common cause of intermediate uveitis
young adults, female > males Assoc with HLA DR15, MS causes floaters, decrease vision is cause by CME. Few Kps, anterior uveitis, snowballs. retinal periphlebitis, hyperemic disc pathology: snowballs, epitheliod cells, multi nucleated giant cells. snowbanks: fibrogial vascular elements cause: multiple sclerosis, sarcoid, toxoplasmosis, toxocariasis, syphillis, lyme treatment: main indication is CME, periocular and oral steroids, immunosuppresive agent, vitrectomy, cryotherapy to peripheral neovasc. complications: cataract, retrolenticular membrane, VH, TRD, CME, band k |
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Multiple sclerosis
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Pars planitis occur bilateral 80%, present with band K, mild AC reaction, vitreous cells, PSC, epiretinal membrane, CME, periphlebitis, pars planitis, optic neuritis
Diagnosis: neuro exam, MRI head |
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Sarcoidosis
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Multisystem granulomatous disease, noncaseating granuloma. common in female and african american
eye finding: uveitis, ant uveitis, KP, iris nodules, lacrimal gland infiltration, KCS, episcleritis, scleritis, post uveitis (choroiditis with yellow nodules), retinal periphlebitis with candle wax, pars planitis, vitritis, retinal neovasc, optic nerve granuloma, cataracts, glaucoma, band K systemic: pulmonary, constitutional, skin, lymphadenopathy. pathology: non0caseating granulomas, langhan multinucleated cells. Diagnosis: high ACE, serum lysozyme, CXR, hilar adenopathy, gallium scan, lesion biopsy. treat: steroids. A +ACE, +CXR, blind biopsy 70% positive |
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systemic findings in sarcoidosis
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lungs: hilar adenopathy, diffuse fibrosis
skin: erythema nodosum, skin granulomas bone:arthralgia hepatosplenomegaly peripheral neuropathy diabetes insipidus hypercalcemia elevated serum gamma globulin parotid gland infiltration |
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Behcet's
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HLA B51, occurs in young males. chronic reccurent multisystem inflammation of occlusive vasculitis (non-granulomatous)
Triad oral ulcers, genital ulcers, inflammed eye. Eye: uveitis, conjunctivitis, quiet hypopyon, episcleritis, keratitis, vascular occlusion, retinal heme, exudate, CME, vitritis, TRD, ischemic Optic neuropathy, glaucoma, cataract pathology: circulating immune complex >50% diagnosis: clinical criteria, behcentine skin test, HLAB51, CXR (can show a pulmonary artery aneurysm) treatment: systemic steroids, chlorambucil, colchicine (helps prevent recurrence), cyclosporine, plasmapheresis |
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Behcet's criteria
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Major:
oral ulcers genital ulcers skin lesions (erythema nodosum) ocular disease (iridocyclitis, necrotizing retinal vasculitis, post synechea, glaucoma, cataract, TRD) Minor: Arthritis, GI lesions, occlusive vasculitis in major vessels, migratory thombophlebitis, CNS invovlement, pulmonary artery aneurysm, interstitial lung changes |
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Vogt-Koyanagi-Harada syndrome
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Uveoencephalitis causing bilateral diffuse granulomatous panuveitis, serous RD, disc edema, meningeal irritation, skin pigment change, hearing problems. Assoc HLA DR4
from autoimmunity to melanocytes. Common in asians, american indian, hispanic. have a decrease in vision, pain, photophobia, stiffneck, HA, deafness, tinnitus, vertigo, vitiligo, poliosis, alopicia presents with BIL granulomatous panuveitis, serous RD, rarely CME, ON edema, poliosis, later develops perilimbal vitiligo, dalen fuchs nodules, sunset fundus pathology: inflammation of choriocapillaris and retina. dalen fuchs nodules (between the RPE and bruchs). Diagnosis: LP, CSF pleocytosis. FA shows multifocal subretinal leakage, 1000 points of light. treatment: Steroids, cycloplegia, immunosuppresives |
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Treatment of VKH
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Acute stage: responsive to steroids and cycloplegia
recurrent episodes need immunomodulatory treatment secondary to resistance to steroids. - cyclosporine, azathioprine, mycophenolate mofetil, chlorambucil, cyclophosphamide |
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VKH clinical course
complications |
1. prodrome (HA, stiff neck, seizures, pain, decrease vision)
2. syndrome (uveitis, serous RD) 3. chronic stage (sunset fundus, dalen fuchs nodule, perilimbal vitiligo 4. recurrent: AC reaction, pigment changes, vitiligo, poliosis complications: cataract, glacuoma, CNV |
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Blebitis
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infection of filtering bleb, most common with staph.
Cause red eye, photophobia, discharge, marked conjunctival injection, seidel +, moderate AC cells and flare. no vitreal involvement. treatment: topical antibiotics, repair wound leak, observe for signs of endophthalmitis |
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sympathetic ophthalmia
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Bilateral granulomatous panuveitis occuring after a penetrating eye injury. can occur 10days -50years. due to immune sensitization to melanin. A T-cell mediated process. Present with koeppe nodules, mutton fat KP, retinal edema, dalen fuch nodules, disc edema.
pathology: diffuse, lymphocytic infiltration, choroid, epitheliod cells contain uveal pigment, granulomatous optic neuritis, dalen fuchs nodule. DOES NOT INVOLVE THE CHORIOCAPILLARIS. FA: multi hyperflourecence, sites of leakage. treat with steroids, immunosuppresives, consider enucleation is vision NLP. many eyes retain good vision. |
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Serpiginous choroidopathy
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Occur in the old, is chronic recurrent, indolent. affects the inner chorioretinal pigment epithelium.
Painless loss of vision. Presents with a geographic pattern with active edges, extends from disc in snake like pattern, mild AC reaction, vitritis, vascular sheathing, NVD, CNV have absolute scotomas from atrophic scars, FA: acute lesions stain. Treat with oral steroids, immunosuppresives. Commonly recurs |
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Birdshot choroidopathy
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HLA A29, occurs in females, middle age. Bilateral.
cause decrease vision, nyctalopia, color vision loss, peripheral field loss. Presents with cream colored depigmented spots, mild AC, vitritis, disc edema, optic atrophy, CME, CNV, epiretinal membrane. FA: perifoveal capillary leak with CME ERG: decrease scotopic response |
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Punctate Inner Choiodopathy
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Occurs in healthy,young myopic women. causes scotmoas and photopsias. find: small yellow, gray inner choroidal lesions, resolve in weeks to form atrophic scars. Can have CNV 40%, serous RD, no vitritis or AC cells.
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Multifocal choroiditis with panuveitis
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Occurs in young 20-50 yo, females. Find gray-white yellow lesions at level of choriod, RPE. have vitritis and AC cells. old lesions become atrophic and punched out. CNV is most common vision loss, CME.
FA: acute lesions block and fill early, stain late. late lesions have window defect with early hyper. treat with steroids. |
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Multiple evanecent white dot syndrome
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occurs in young, females. unilateral more common.
have decrease in vision, peripheral scotomas, photopsias, presnet with small white spots at posterior pole at level RPE. may have vitreous cells, RAPD optic nerve swelling. Visual field: enlarged blind spot FA: early hyper with wreath-like configuration. late staining of lesion, optic nerve. ERG: decrease A wave. |
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Acute posterior multifocal placoid pigment epitheliopathy
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Occurs in young, bilateral, M=F acute self limited, assc cerebral vasculitis.
-have flu like prodrome then decrease in vision Present with multi creamy yellow white plaque lesions <1DD size, at level of RPE. choriocapillaris. Lesions fade in 2-6 weeks causing a geographic RPE changes. mild vitritis, AC cells, rarely CNV. FA shows early blockage, late hyper, window defect in old cases. treatment: none, prognosis is good vision recovers. |
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Acute retinal pigment epithelitis
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occurs in young adults, unilateral, sudden decrease in vision. Find clusters of hyperpigmented spots in the macula surrounded by halos. No vitritis. FA shows blockage of spots with halos of hyperfluorecense. Resolves in 6-12 weeks, treatment: none
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acute zonal occult outer retinoapathy
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bilateral, F>M rapid visual field loss, photopsias, early minimal changes, late show retinal degeneration, pigment changes. Visual field shows scotomas that enlarge. ERG decrease in rod and cones
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Progressive outer retinal necrosis
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a variant of ARN that occurs in AIDS patients, is painless with minimal ocular inflammation. present unilateral than can become bilateral.
Present with multiple peripheral, central retinal opacification and infiltrate. has cracked mud appearance after resolution, vasculitis is not prominent. treat with a combination of foscarnet and gancyclovir. 67% NLP at 4 weeks and RD 90% |
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endoophthalmitis
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1. acute post op: < 6 weeks 90% occurs in 1st week
PPV has the highest surgery risk at .51%. Staph epidermitis and Staph aureous common organisms 2. Delayed post-op- P Acnes, anaeronic gram + rod or fungus. 3. bleb endophthalmitis - strep, h. influenza 4. trauma - bacilus, staph epi, occurs in 10% penetrating trauma 5. endogenous - candida, risk factosrs are immunosuppresion, indwelling cathater, IVDA, abdominal surgery, culture negative. IV drug abuser: staph, B cerous, candida |
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Candida enophthalmitis
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Most common fungus causing endogenous infection. Risks are: Hospitalization with GI surgery, bacterial sepsis, systemic antibiotics, indwelling cathaters, hyperalimentation, DM, immunosuppresion, neutropenia, organ transplant, IV drug abuser.
Findings: multiple bilateral, white well cicumscribed lesions in the post fundus assoc. with vitreous inflammation, vascular sheathing, retinal heme. blood cultures commoly negative. Treatment: 1. chorioretinal lesion with no itritis, fluconazole, voriconazole. 2. vitreous body invovled - intravitreal injection of ampho B , voriconazole 3. severe - IV ampho B 70% mortalitiy rate withing 1 year |
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Phacolytic glaucoma
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hypermature, morgaganian cataract, denatured lens protein leak form intact lens capsule.
macrophages ingest lens material and block TM, milky substance in AC. Needs surgical removal or lens reduce inflammation pre-op with topical steroid, cycloplegic, and ocular hypotensive meds |
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difference between zoster keratitis and HS keratitis
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zoster:
active virus: yes appearance: branching, elevated lesions skin rash: V1 vesicular rash, scarring laterallity: unilateral HSV: active virus: yes appearance: branching, ulceratied lesion with terminal bulbs skin rash: vesicular rash in lids, no dermatome distribution laterallity: unilateral but can be bilateral in atopic or immunocompromized |
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HIV retinopathy
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Most common ocular finding in patients with AIDS
Microangiopathy in 50% patients cotton wool spots are most common finding asymptomatic, non-progressing. find: CWS, roth spots, hemorrhages, MA's early presbyopia, caused by inflammation of ciliary body with loss of accomadative amplitude. Diagnosis: HIV antibody test, CD-4 count, HIV viral load treatment: none, spontaneous resolution |
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Toxoplasmosis medications
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1. pyrimethamine: inhibits dihydrofolate reductase
2. sulfadiazine: blocks production of dihydrofolate from para-amino benzoic acid 3. clindamycin: antibiotic kills toxoplasma 4. bactrim: used as alternative 5. steroids |
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Toxoplasmosis
1. pathology 2. diagnosis 3. treatment |
Pathology: toxoplasma cysts, granulomatous choroiditis
Diagnosis: ELISA, IFA toxoplasma, IgG, IgM. treatment indication: decrease vision, severe vitreous inflammation, lesion threaten macula, papillomacular bundle or optic nerve. small lesions in the periphery can be observed and resolve on their own. Antibiotics kills tachyzoites not cysts Treatment: 1. Clindamycin (pseudomembranous colitis) 2. sulfadiazine 3. pyrimethamine - add folinic acid to prevent bone marrow suppresion with folinic acid. 4. bactrim an alternative 5. steroids |
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Acute Retinal Necrosis
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Acute confluent peripheral necrotizing retinitis from infection of VZV, HSV, CMV. characterized by occlusive arteriolitis, vitritis, multifocal yellow white peripheral retinitis
occur in immunocompetent Rapid onset, ocular pain, pain on EOM, redness, photophobia, floater, decrease vision, decrease visual field Presents: episcleral injection, iritis, granulomatous KP, vitritis, necrotizing retinitis posterior equator. Saw tooth demarcation between healthy and necrotic obliterative retinal arteritis. Within 2 months the necrotic retinal sloughs off causing a salt pepper pigment. 65-90% develop RRD. pathology: necrosis retina, arteriolar, choriocapillaris occlusion, necrotic retina slough to vitreous. treatment: acyclovir, gancyclovir, steroids, aspirin. *** watch the fellow eye since ARN can develop within 4 weeks. |
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Syphilis Uveitis
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A Panuveitis from infection with treponema pallidum. considered a nerurosyphillis and should be treated with neurological doses can be congenital or acquired
Congenital: cause intersititial keratitis, vessels meet in the center of the cornea (salmon patch), then atrophy causing ghost vessels, ant uveitis, ectopia lentis, argyll-robertson pupil, optic atrophy, chorioretinaitis (salt-pepper). systemically: cause death or in utero, hutchingson's teeth, face deformities, saber skins. Acquired: painless chancre, palmar rash, condyloma lata, lymphadenopathy, gummas, aortic aneurysm, CNS eye findings, panuveitis, iris papules/gummas, salt pepper chorioretinitis, optic neuritis, optic atrophy, argyl robertson pupil, ectopia lentis, interstitial keratitis Diagnosis: VDRL, RPR, FTA-ABS, LP for neurosyphilis. Treat with penicillin G 12-24 Million IV for 2 weeks. If allergic: doxycycline, erthromycin |
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lyme disease
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Caused by spirochete borrelia burgdorferi. cause bil eye involvement. affects the skin, CNS, heart, musculoskeletal system.
present with follicular conjunctiviits, chronic granulomatous iridocyclitis with posterior synechiae, vitreous cells, and keratitis. stage 1: follicular conjunctivitis stage 2:intraocular inflammation (intermediate uveitis) stage 3: keratitis TReat with IV ceftriaxone |
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Diffuse Unilateral subretinal neuroretinitis
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infection by roundworm in subretinal space. Ancyclostoma caninum, or baylisascaris procyonis
gray-white retinal lesions, optic nerve swelling, vitritis. Late findings: retinal vascular narrowing, diffuse RPE pigmentary changes, optic atrophy. causes wipe out syndrome. ERG- decreased. treat by lasering the worm. |
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CMV retinitis
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occurs in AIDS patients, CD-4 count <50 DNA virus progressive hemorrhage necrotizing retinitis involving all layers leads to RRD.
often asymptomatic, floaters, scotoma, presents with well circumscribed necrotizing retinitis. 1. brushfire 2. pizza pie fundus 3. frosted branch angittis pathology: infected retinal cells are enlarged --> necrosis --> atrophy. also have large owl eye in tranuclear inclusions Treat antiviral treatment, gancyclovir, foscarnet, cidofovir, surgery. Most common cause of congenital viral infection Peripheral CMV retinitis appears granular |
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CMV retinitis treatment
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IV ganciclovir, cidofovir, foscarnet used individually or combo. goal to get retina quiet
Side effects: 1. Gancyclovir: neutropenia, thrombocytopenia, anemia, renal toxic. do not use with zidovudine it will cause great myelosuppreson 2. Foscarnet - renal impaired, neutropenia, anemia, electrolyte imbalance 3. cidofovir - nephrotoxic, hypotony, iritis. use of protease inhibitor helpful. In RRD: if macula spared, perform barrier laser. Macula invovled, PPV, silicone oil, endolaser |
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cryptococosis
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yeast found in soil, pigeon feces ,acquired by inhalation in fungus. affects the CNS. disease is disseminated in immuncompromised.
Most common fungal meningitis Most common fungal eye infection HIV/AIDS Present with multifocal chorioretinitis, yellow white lesions post equitorial fundus. have vitritis, vascular sheathing, exudative RD, papilledema, granulomatous AC rxn. pathology: organism stains india ink, culture of fungus from CSF. treatment: ampho B, oral flucytosine |
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Pneumocytosis chorioditis
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Occurs in AIDS Patients
due to pneumonitis carinii chorioditis with multifocal orange nummular lesions. lesion contains cyst of pneumocytis assoc. inhaled pentamidine (prophylaxis PCP) treatment: bactrim, atavoquone, pentamidine, dapsone |
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toxoplasmosis
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infection by toxoplasma gondii, usually congenital, infection in early pregnancy. most common cause post uveitis, most common cause pediatric uveitis. tachyzoites cause inflammation. cause retinal coagulative necrosis and granulomatous choroiditis w/ vitritis. intraretinal cyst can cause reccurent disease. classic finding: inactive chorioretinal scar in the post pole often the macula. active lesions fluffy white, head light in fog, adjacent to old scar. pathology will have round toxoplasma cysts. diagnosis with ELISA, toxo IgG, IgM
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Toxoplasmosis treatment indication and treatment
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indications:
1. decrease vision 2. severe vitrous inflammation 3. lesion threatens macula, optic nerve, papillomacular bundle ** peripheral lesions can be observed Use of antibiotics kill tachyzoites in active phase but not the cysts Treatment: clindamycin, sulfadiazine, pyrimethamine, (can use bactrim). steroids. |
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Ocular toxoplasmosis
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Infection with 2nd stage larval toxocara canis. due to eating contaminated soil.
Ocular larva migrans. Unilateral, solitary lesion. Does not complete life cycle, so not found in stool. Presentatation does not depend on age. 1. Age 2-9 chronic endophthalmitis: exudation filling vitreous cavitiy, cyclitic membrane causing globe destruction 2. Age 6-14- localized granuloma, local granuloma in macula eye is quiet, strabismus, not progressive 3. Age 6-40 preipheral granuloma, dense fibrotic strand to disc --> strabismus not progressive. can present with leukocoria, TRD can occur preipheral granuloma --> temporal macula drag causing XT. diagnosis: AC tap for eosinophils, ELISA for toxocara. Treat: Steroid, cycloplegia, vitrectomy for RD, antihelmitic not helpful. |
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Presumed ocular hisplasmosis
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common in young adults, 20-45yrs. occur in estern, midwestern US. Assoc: HLA B7, primary tissue target choroid. Triad: peripapillary atrophy, histo spots, CNV, not vitritis
Risk of CNV: 1% with normal disc, macula, 25% risk in 4 yers if not normal. CXR can show calcifications treatment: consider laser or submacular surgery for extrafoveal and juxtafoveal lesions, subfoveal lesions with verteporfin ocular PDT. |
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Propionibacterium Acnes
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Gram positive rod anaerobic
can become trapped in capsular bag white plaque in posteroir capsure classic. cause granulomatous uveitis delay onset enophthalmitis >6weeks Treatment: vancomycin, cephalosporin. resistant to aminoglycoside (gentamycin) Require removal of capsular bag and possile IOL vitrectomy, post capsulectomy, intravitreal vancomycin |
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Whipple's disease
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Infection with tropheryma whippeli (gram + bacillus), cause uveitis, retinal vasculitis, systemically cause malabsorption, diarrhea, arthritis.
pathology: biopsy intesinal wall or vitreous show PAS positive macrophages in lamina propria of microvilli of intestine treat with bactrim. |
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Onchocerciasis
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Infection with oncocerca volvulos. larvae matures in human. Adult worm lives in fibrous subcutaneous nodules. female worm give birth to microfilariae which migrate to all the body (direct blood invasion) transmitted by the black fly.
Second leading cause of blindness in the world. 1st is trachoma. live microfilarea cause no inflammation, dead ones cause granulomatous inflammation and scarring. HAve intraocular (AC) microfilariae, anterior uveitis, sclerosiing keratitis, scleritis, chorioretinitis, optic neuritis, cataract, PAS, glaucoma, peripheral VA loss, nyctalopia. Diagnosis: Skin snip, place in media look for microfilariae. treatment Ivermectin, suramin, |
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Ophthalmomyasis
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direct ocular invasion by fly larvae (maggots). It can invade the AC, posterior segment, subretinal space.
Subretinal invasion- larvae travel through fundus leaving criss cross tracks of the atrophied RPE. death of organism cause inflammation |
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parinaud's oculoglandular syndrome
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Monocular granulomatous conjunctivitis. has necrosis and ulceration of follicles. present with fever, malaise, lymphadenopathy
pathology: follicles, granulomas caused by: cat scratch, tuleremia, spirotrichosis, TB, syphillis, LGV, actinomyces, mononucleosis, rickettsia, ccocidiomycosis. |
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Cat scratch disease
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due to bartonella henselae
find retinal granuloma, neuroretinitis treatment: can spontaneously resolve. consider oral antibiotics (doxycycline, rifampin) |
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bleb associated endophthalmitis
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Organism Strep, H Flu, Staph epi, Have infected bleb, intraocular inflammation with hypopyon, vitritis, prognosis is poor with profound vision loss. EVS study is not applicaple, study show that Tap and inject patients seem to do worst than PPV.
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cysticercosis
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infection with tapeworm taenia solium, T.saginata. Humans are definite host.
Adult worms lives in small intestine, larvae travel to eye cause a cystic subretinal or intravetreal lesion. HAve mass lesion or exudative RD Treat with vitrectomy |
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Study: Collaborative Ocular Melanoma Study
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Evaluate treatment options for choriodal malignant melanoma.
3 groups 1. small: ht 1-3mm base 5-16mm: not randomized, treatment at discretion 2. medium: ht 2.5-10mm, base <16mm, euncleation vs plaque 3. large: ht >10mm, base >16 enucleation vs radiation + enuc conclusion: 1. small tumors: 5 yr motality rate 6% 2. using plaque therapy there is high risk of VA loss, the survival is unchanged plaque vs. enuc 3. large - preenucleation radiation does not change survival |
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Choriodal melanoma
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Most common primary intraocular malignant tumor.
Risk factors: ocular melanocytosis, sun exposure, caucasian, neurofibromatosis, dysplastic nevus, BDUMP. Types: Spindle A (benign nevi) Spindle B (+mitotic figures) epitheliod (most malignant, prominent nucleus) mix cells (spindle with epitheliod) Examine vortex vein to rule out any extension. Transilumination- melanomas cast shadow. FA: double circulation. A-scan low internal reflectivty. B-scan solid mushroom, biconvex. MRI- T1 bright treatment: enucleation indicated for large size, ON invasions, macula, poor VA plaque therapy: medium size good va. |
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choroidal melanoma
1. prognostic factors 2. metastasis risk, sites 3. metastasis work up |
Prognosis factors
Cell type: (eputheliod is worst) size: large and diffuse bad location variability nucleolar size intratumor vascular networks presence of necrosis metallothionein levels (indicate metastatic potential, poor survival) metastasis: via vortex veins, risk size >2mm, nerve proximity, VA symptoms, growth Metastasis site to: liver 92%, skin, lung, brain, Optic nerve. Metastasis work up: Abd exam, LFT, CXR |
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intraocular FB
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Copper:
>85% suppurative endophthalmitis <85% chalcosis, kayser-fleisher, sunflower cataract, retinal degeneration, reversible if FB removed Steel: contains iron, siderosis bulbi Organic- severe granulomatous response |
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priamry intraocular lymphoma
(reticular cell lymphoma) |
Non-hodgkins b cell lymphoma, large cell. In elderly, bilateral. multifocal have blurry vision, flaoters, dementia. Find creamy white diffuse sub RPE and vitreous infiltrate. AC reaction, hypopyon, vitritis, glaucoma, exudative RD, leopard skin pattern.
diagnosis: CT scan, LP, vitreous biopsy treatment: chemo, XRT (intrathecal methotrexate, IV cytotoxic agents, whole brain ocular irradiation). Prognosis poor, dead in 2 years |
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Kaposi sarcoma
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common in immunocompromised (AIDS) and mediterranian descent
malignant soft tissue, sarcoma. present as a violaceous nodule, plaques, red mass. casue lid distortion, edema, entropion. Present in the conjunctiva also pathology: proliferation of capillaries, endothelial cells, fibroblast-like cells treat with excision, RT, Chemo, paclitaxel |
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uveitis glaucoma hyphema
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occurs in anterior chamber IOL, or posterior IOL. The lens edge, loop cause iris root irritation. IOL physically irritates the iris and ciliary body.
-nongranulomatous inflammation of the AC. hyphema, PAS, CME, corneal endothelial damage. elevated IOP |
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Posner schlossman syndrome
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recurrent anterior uveitis and increase IOP. self limited, cause unilateral pain. present with mild AC reaction, little to no KP, high IOP, no synechea on gonio
treat with topical glaucoma medications. steroids to control the inflammation |
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phacoanaphylactic endophthalmitis
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type 3 hypersensitivity reaction
previous rupture of lens capsure, followed by latent period, re-exposure to lens protein during surgery casues a zonal granulomatous uveitis. Assoc with trauma, surgery. Cause severe uveitis with hypotony, secondary open angle glaucoma, choriodal detachment. pathology: zonal pattern, epitheliod histiocytes. treatment is removing lens is medical therapy fails |
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idiopathic uveal effusion
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occurs in healthy, middle age males is chronic reccurent
cause decrease vision, metamorphopsia, scotomas. cause serous RD, choroidal ciliary body attachment. Mild vitritis, RPE changes. leopard spots. key finding is a shifting serous RD B-scan- thick sclera, seroud RD FA: no leakage treat with steroids, immunosuppression but don't work that effectively. scleral resection, quadrantic partial thick scleral windows. |
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schwartzs syndrome
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High IOP assoc with RRD, photoreceptors of outer segments migrate transvitreally into aqeous and block TM, resolves after RD repair
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Ddx diffuse Kps
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Fuch's heterochromic iridocyclitis
sarcoid syphillis keratouveitis toxoplasmosis |
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what causes VDRL false positive?
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rheumatoid arthritis
anticardiolipin antibodies |
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conditions with dalen fuch's nodules
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sympathetic ophthalmis
VKH sasrcoid TB |
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ddx hypopyon
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HLA B27 uveitis
infections (keratitis, endophthalmitis) FB behcet's VKH malignancy toxic (rifabutin) |
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ddx uveitic glacuoma
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HSV
HZV posner schlossman fuch's heterochromic iridocyclitis sarcoid toxoplasmosis (rare) syphilis (rare) sympathetic ophthalmia (rare) |
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cyclophosphamide
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cytotoxic alkylating agent
cross links with DNA and inhibits mRNA transcription. prevent DNA synthesis side effect: hemorrhagic cystitis (oral > IV). sterility, bone marroe suppresion. prevent hemorrhagic cystitis with increase water intake |
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cyclosporine
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blocks production of IL-2, Il-2 receptors, inhibits lymphocyte proliferaiton. inhibit t-cells
Is renal toxic, HTN, paraesthesia, increase ESR, hypertrichosis, liver toxic, hyperurecemia tacrolimus, serolimus: also T cell inhibitors |
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cytotoxic meds
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antimetabolites:
1. methotrexate:a folate analgue, inhibits folate metabolism, inh enzyme dehydrofolate reductase. inh T-cell function. Cause leukopenia, thrombocytopenia, liver, lung, kidney toxic. teratogenic 2. Azathioprine- purine analgoue Alkylating agents: 1. chlorambucil: interact with 7 guanine DNA, prevent DNA synthesis, adverse effect bone marrow suppresion, sterility, slowest acting 2. cyclophosphamide - cause hemorrhagic cystitis, bone marrow suppression, prevent hemorrhagic cystitis with high water intake |
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steroids
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antiinflammatory and immunosupressive by inhibiting release of arachidonic acid.
phosphate- poor penetration alcohol- penetrates cornea acetate-best corneal penetration subconj/subtenons inj: produce increase ocular penetration and longer duration. higher IOP IOP elevation potential. 1. dexa 2. prednisolone 3. fluoromethalone 4. hydrocortisone 5. tetrahydrotriamcinolone 6. medrysone steroid with less high IOP potential: FML, rimexolone, loteprednol |
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relative potencies of steroids
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1. cortisone .8
2. hydrocortisone 1 3. prednisone 4 4. triamcinolone 4 5. prednisolone 5 6. dexamethasone 25-30 7. betamethaxone 25-30 8. fluoromethalone 40-50 9. fluocinolone 240 |
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steroid ocular effects
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cataracts
high IOP delay in wound healing secondary infection scleral thinning |
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systemic steroid side effects
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adrenal insufficiency
hyperglycemia HTN hypolalemia peptic ulcer delay in wound healing superinfection emotional liability psychosis growth retardation muscle atrophy osteoporosis aseptic necrosis of hip hirsutism wt gain cushinnoid pseudotumorcerebri |
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mydriatic and cycloplegic agents
list in increasing duration most allergic |
1. tropicamide
2. cyclopentolate 3. homatropine 4. scopalamine 5. atropine mydriatic effect last longer than cycloplegic effects Atropine assoc with follicular conjunctivitis and skin rash. phenylephrine only mydriatic. 10% soln assoc with severe HTN, cardiovascular, neuro reaction. avoid in children and in people with heart disease. |
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absolute indications for early immunomodulatory therapy
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behcets
necrotizing scleritis sympathetic ophthalmoa chronic recurrent VKH |
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what is most common cause of intermediate uveitis?
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idiopathic disease
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West Nile Virus
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characterized by acute onset fever, myalgia, arthrlagia, HA, conjunctivitis, lymphadenopathy, and maculopapular rash or roselar rash. can cause meningitis, encephalitis. ocular symptoms pain, photophobia, conj redness, bluury vision. characterized by multifocal chorioretinitis, nongranulmatous anterior uveitis and vitreous cellular inflammation. Chorioretinal lesion in periphery with linear arrays following chorioretinal vessels. on FA can excibit a target like lesion with central hypoflourecence.
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retinal vasculitis affecting venules
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sarcoidosis, MS, birdshot, eales
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retinal vasculitis affecting arterioles
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SLE, polyarteritis nodosa, necrotizing herpetic retinitis
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What is needed prior to starting infliximab therapy?
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check PPD, can cause disseminated TB, in those with undetected TB.
CHF, lupus like syndrome, MS like disease can also occur. |
