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(c) Clinical Picture of posterior uveitis

(c) Clinical Picture of posterior uveitis. Clinical Features of Posterior uveitis. (A) Symptoms : The 2 main symptoms of posterior uveitis are: 1. Floaters : due to vitritis 2. Impairment of vision due to: - CME or - Active choroiditis involving the fovea. (B) Signs :

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(c) Clinical Picture of posterior uveitis

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  1. (c) Clinical Picture of posterior uveitis

  2. Clinical Features of Posterior uveitis (A) Symptoms: The 2 main symptoms of posterior uveitis are: • 1. Floaters: due to vitritis • 2. Impairment of vision due to: - CME or - Active choroiditis involving the fovea

  3. (B) Signs: ► Posterior uveitis is characterized by: (A) Vitreous changesIncluding: ● vitreous cells, opacities, and posterior vitreous detachment (PVD). ● Coarse opacities are usually the result of severe inflammation e.g. 'snow-balls' and 'cotton-balls' are characteristic of candidiasis and sarcoidosis respectively.

  4. (B) Fundus changes include: a. Choroiditis or chorioretinitis: characterized by yellow or greyish patches which may be unifocal (e.g. toxoplasmosis), multifocal (e.g. presumed ocular histoplasmosis), or geographical (e.g. cytomegalovirus retinitis) b. Vasculitis:is inflammation of retinal blood vessels. The retinal veins "periphlebitis" are most frequently involved, but the arterioles "periateritis" may be affected in some cases.

  5. Left: Acute focal Choroiditis; Middle: Old multifocal Choroiditis; Right: Active focal toxoplasma Choroiditis (arrow) near old scar

  6. Active retinal periphlebitis. Left: early involvement; Right: severe involvement

  7. ► The 3 main clinical types of posterior uveitis are: (1) Unifocal e.g. toxoplasmosis (left) (2) Multifocal e.g. ocular histoplasmosis (middle) (3) Geographical e.g. cytomegalovirus retinitis (CMV) (right). The 3 main clinical types of posterior uveitis

  8. Complications of iridocyclitis

  9. Sequelae & Complications of iridocyclitis • Adhesions (Posterior Synechiae) • Secondary glaucoma • Complicated cataract • Cyclitic membrane • Endophthalmitis & Panophthalmitis • Complications of longstanding iridocyclitis

  10. Adhesions (Posterior Synechiae) ● Are adhesions between the iris and anterior lens capsule: • Early: are fibrinous can be broken by strong mydriatic-cycloplegic eye drops as atropine • Later: become fibrous Festooned pupil

  11. Ring synechiae (seclusio pupillae) - Posterior synechiae extending for 360◦ of the papillary margin are known as 'seclusio pupillae', prevent the passage of aqueous from the PC to AC  forward bowing of the peripheral iris known as ‘ iris bombe ‘  elevation of the IOP secondary to closure of the angle by the peripheral iris ' secondary glaucoma'. • Occlusio pupillae - Pupil is closed by the inflammatory exudate

  12. Secondary glaucoma • Early: Angle block by plasmoid aquous,or hypopyon • Late: due to PAS, or Seclusio-pupillae with iris bombe´

  13. Complicated cataract • From toxins in the aqueous Posterior synechiae with complicated cataract

  14. Cyclitic membrane • An inflammatory membrane forms behind the lens stretching across the ciliary ring. • Caused by cyclitis • Contraction of the membrane can result in: • CB detachment suppresion of aq. Secretion  hypotony ending in atrophia bulbi • Tractional RD

  15. Endophthalmitis & Panophthalmitis • In suppurative cases

  16. Complications of longstanding iridocyclitis • a. band shaped keratopathy: commonest in children. • b. Rubeosis iridis & NVG • Absolute glaucoma • Atrophia bulbi: small shrunken soft globe due to cessation of aq. secretion

  17. Treatment of uveitis ● Aim of therapy ■ The aims of treating uveitis are: 1. To prevent vision-threatening complications 2. To relieve patient's discomfort 3. If possible, to treat the underlying cause.

  18. Drugs ■The drugs currently used in treatment of uveitis include: • 1. Mydriatics-Cycloplegics • 2. Steroids • 3. Cytotoxic drugs

  19. (1) Mydriatics-Cycloplegics ● Indications 1. To give comfort by relieving spasm of the ciliary and sphincter pupillae muscles which occurs in acute anterior uveitis. This can be achieved with atropine which is the most powerful cycloplegic available. 2. To prevent the formation of posterior synechiae 3. To break down posterior synechiae

  20. ● Preparations: • Atropine (1%) • Cyclopentolate (0.5%-1%) • Tropicamide (0.5%-1%) • Phenylephrine (2.5%,10%)

  21. (2) Steroids ● Steroids can be administered by the following routes: 1. Topical: in the form of drops and ointment 2. Periocular injection 3. Systemic (tablets)

  22. A .Topical steroids • ● Indications: anterior uveitis • ● Preparations: see table

  23. ● Complications of Topical steroid use: 1. Glaucoma in steroid responders 2. Cataract (PSC) with long-term use 3. Activation of herpes simplex infection 4. Corneal complications including corneal melting in severe cases (rare). 5. Systemic side effects with prolonged use especially in children.

  24. B. Periocular steroid injections ● Indications 1. Anterior sub-Tenon's injection - Severe acute anterior uveitis - As an adjunct to topical therapy (drops) in resistant cases - Poor patient compliance - At time of, and following surgery in eyes with uveitis. 2. Posterior sub-Tenon's injection - Intermediate uveitis - Some cases of posterior uveitis

  25. ● Preparations: see table 3 Technique of sub-Tenon's injection

  26. C .Systemic steroids ● Indications: uveitis resistant to periocular steroid injections.

  27. ● Complications of systemic steroids: • Depending on the duration of use as follows: 1. Short-term therapy • - Peptic ulceration (common) • - Mental changes (uncommon) • - Aseptic necrosis of the head of femur (rare) • - Hyperglycemic non-ketotic coma • 2. Long-term therapy • - Cataract (common) • - Cushingoid state (common) • - Limitation of growth in children (common) • - Reactivation of TB infection (now rare)

  28. (3) Cytotoxic drugs ● Indications 1. Potentially blinding (usually bilateral), steroid-resistant uveitis 2. Intolerable side effects from systemic steroid therapy. ● Preparations • 1. Cyclophosphamide • 2. Chlorambucil • 3. Azathioprine

  29. Lines of treatment of Acute iridocyclitis • Topical Treatment: • Systemic Treatment • Treatment of complications • Dark glasses

  30. Lines of treatment of Acute iridocyclitis • Topical Treatment: • Mydriatic-cycloplgics (Atropine sulphate) Benefits: • Relieves pain and headache from ciliary spasm • Dilates pupil  prevents posterior synechiae • Decreases permeability and exudation from inflamed iris vessels N.B. In adults drops & in chids ointment are used

  31. 2. Topical Steroids Benefits • Decrease the release of inflammatory mediators by stabilization of lysosomal membrane. • Decrease vascular permeability • Decrease the release of destructive leucocytic enzymes • Inhibits fibroblastic activity and diminish the formation of synechiae

  32. B. Systemic Treatment: • Systemic steroids (1 mg/kg/day) for severe cases • Immunosuppresants: for resistant cases • Causal ttt: e.g. anti TB drugs • Analgesics for pain C. Treatment of complications D. Dark glasses: for photophobia

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