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Uveal Diseases

Uveal Diseases. Umut Aslı Dinç., MD., FEBO Associate Professor in Ophthalmology Yeditepe University Eye Hospital. Uveal Tract. Pigmented, vascular structure that lies between the sclera&retina Consists of: İris Ciliary body Choroid. Uveal Tract.

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Uveal Diseases

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  1. Uveal Diseases Umut Aslı Dinç., MD., FEBO Associate Professor in Ophthalmology Yeditepe University Eye Hospital

  2. Uveal Tract Pigmented, vascular structure that lies between the sclera&retina Consists of: • İris • Ciliary body • Choroid

  3. Uveal Tract • Supplies most of the ocular vasculature through the anterior and posterior ciliary branches of ophthalmic artery. • Produces aqeous humor • Controls accomodation at near • Supplies aqeous outflow by trabecular meshwork

  4. Uveitis • Inflammation of the uveal tract and adjacent structures. • Mostly the cause is unknown.

  5. Uveitis Classification • Anterior uveitis (iris and ciliary body) Iritis, anterior cyclitis, iridocyclitis • Intermediate uveitis (pars plana of ciliary body, anterior vitreus and peripheral retina) Posterior cyclitis, pars planitis • Posterior uveitis (choroid) Choroiditis, chorioretinits • Panuveitis

  6. Uveitis Classification • Acute uveitis • Chronic uveitis

  7. Acute Uveitis-Clinical Features • Pain • Redness • Photophia • Epiphora • Blurred vision • Floaters

  8. Chronic Uveitis-Clinical Features • Fewer or none of the acute symptoms • Periods of exacerbations and remissions

  9. Causes of Uveitis • Idiopathic • Infectious (bacterial, viral, fungal, parasitic) • Traumatic • Post-surgery • Tuberculosis • Sarcoidosis • Behçet’s disease • Spondiloartropathies • Inflammatory bowel diseases • Collagen vascular diseases • Medication

  10. History taking in uveitis • Present illness Onset, course, symptoms, laterality • Past ocular history Previous episodes, treatment, ocular trauma or surgery • Medical history Systemic disease (sarcoidosis, tuberculosis, syphilis, Juvenile rheumatoid artritis, AIDS, etc), maternal infection • Sexual history, intravenous drug abuse • Demograhic data Age, sex, race

  11. History taking in uveitis Review of symptoms • General-fever, wegit loss, malaise, night sweats • Rheumatologic-arthralgias, lower back pain, joint sitffness • Dermatologic-rashes, sores, alopecia, vitiligo, poliosis, insect bites • Neurologic-tinnitus, headache, meningism, paresthesias, weaksness/paralysis • GIS- diarrhea, bloody stools, aphtous ulcers • GUS-dysuria, discharge, genital ulcers, balanitis

  12. Uveitis-Clinical Features • Inflammatory cells in the anterior chamber • Keratic precipitates on corneal endothelium • Anterior synechiae (adhesions of iris to cornea) • Posterior synechiae (adhesions of iris to lens) • Inflammatory cells in the vitreous cavity (vitritis) • Sheating of retinal vessels • Optic disc or macular edema • Choroidal or chorioretinal infiltrates

  13. Anterior Uveitis • Anterior segment cells • Anterior segment flare

  14. Anterior Uveitis Scleral injection Keratic precipitates on corneal endothelium

  15. Anterior Uveitis • Posterior synechiae

  16. Anterior Uveitis • Idiopathic • Infectious (Herpetic uveitis, Bacteriel uveitis) • Traumatic • Fuch’s heterochromic iridocyclitis • Immune-mediated Behçet’s disease Seronegative spondiloartropathies (Ankylosing Spondylitis, Reactive (Reiter) Arthritis, Psoriatic Arthritis ) Inflammatory bowel diseases (Crohn disease, ulcerative colitis) Juvenile Rheumatoid Arthritis • Sarcoidosis • Tuberculosis • Toxic (Rifabutin, sulfonamides, cidofovir)

  17. Idiopathic anterior uveitis • Most common form of ocular inflammation • No systemic or ocular cause • Relief with topical steroids and cycloplegic drops

  18. Fuch’s heterochromic iridocyclitis • Unilateral • Heterochromia (lighter iris color is typical) • Vision loss secondary glaucoma and cataract

  19. Fuch’s heterochromic iridocyclitis Heterochromia due to iris atrophy

  20. Herpetic uveitis • Keratitis • Iris atrophy

  21. Herpetic zoster uveitis

  22. Behçet’s disease Key features • Uveitis (anterior, posterior) • Recurrent oral ulcers • Recurrent genital ulcers • Skin lesions Associated features • Erythema nodosum • Arthritis • İntestinal ulcers • Vascular lesions-thrombophlebitis, arteriel occlusions, aneurysms • CNS involvement

  23. Behçet’s disease • HLA-B51 • Pathergy test +

  24. Seronegative spondiloartropathies • HLA B27 + • Sacroiliac joint radiography

  25. Juvenile Rheumathoid Arthritis • Most frequently in RF (-), ANA (+), oligoarticular type • White eye • Band keratopathy • Posterior synechiae • Cataract

  26. Sarcoidosis • Noncaseating granuloma • Anterior and posterior uveitis • Bilateral hilar lymphadenopathy • Pulmonary parenchymal disease • Chest radiography • Serum ACE enzyme

  27. Sarcoidosis • Granulomatous reaction with iris nodules and mutton fat keratic precipitates

  28. Tuberculosis • Caseating granuloma • Anterior and posterior uveitis • Chronic inflammation • PPD test • Chest Radiography

  29. Tuberculosis • Granulomatous reaction with iris nodules and mutton fat keratic precipitates

  30. Intermediate Uveitis • Blurred vision and floaters • Typically bilateral • Vision loss secondary to cystoid macular edema • Pars planitis... idiopathic type

  31. Intermediate Uveitis • Vitreous snowballs • Snowbanking (exudation at pars plana)

  32. Intermediate Uveitis Perivascular sheating Vitreous snowball

  33. Posterior Uveitis • Vitritis • Choroiditis • Retinitis • Papillitis • Retinal detachment

  34. Posterior Uveitis • Viral (CMV, VZV, HIV in immunodeficiency) • Bacterial • Fungal (candida albicans, histoplasma capsulatum, coccidioides immitis) • Toxoplasmosis • Parasitic (toxocariasis, cysticercosis, onchocerciasis) • Syphilis • Behçet’s disease • Sarcoidosis • Tuberculosis • Syphilis

  35. Viral Posterior Uveitis CMV chorioretinitis

  36. Viral Posterior Uveitis Acute retinal necrosis secondary to HSV infection

  37. Viral Posterior Uveitis HIV chorioretinitis

  38. Fungal Posterior Uveitis Ocular candidiasis

  39. Toxoplasmosis • Toxoplasma gondii • Transmission by infected raw meat or congenitally via plasenta • Recurrent chorioretinitis and severe vitritis • Toxoplasma IgM, IgG and PCR

  40. Congenital Toxoplasmosis Nonactive chorioretinal scars

  41. Toxoplasmosis “Headlight in fog”

  42. Toxocariasis • Typical toxocara granuloma • Traction of macula, optic disc • Tx: steroids • Severe inflammation when microorganism dies.

  43. Sarcoidosis

  44. Tuberculosis Choroidal tubercule

  45. Behçet’s disease

  46. Syphilis Usually in acquired syphilis VDRL, RPR, FTA-ABs+

  47. Anti-inflammatory Therapy • Corticosteroids Topical drops/ periocular injection/ systemic) • Cytotoxic drugs Antimetabolites (azathioprine, methotrexate) Alkylating agents (cyclophoshamide, chlorambucil) • Immunomodulator agents (cyclosporin, tacrolimus) • Anti-TNF agents (etanercept, infliximab, adalimumab)

  48. Complications of Uveitis • Band keratopathy • Posterior synechiae • Cataract • Glaucoma • Cystoid macular edema • Optic atrophy

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