Disease of the Uvea

• Introduction
• Anatomical classification
• The uvea is the vascular layer of the eye and comprises the iris,
ciliary body and choroid .   
•   Uveitis, by strict definition implies an inflammation of the uveal
tract. However, the term is commonly used to describe many
forms of intraocular inflammation involving not only the uvea but
also the retina and its vessels.
    1) Anterior uveitis may be subdivided into:   
•    Iritis in which the inflammation primarily involves the iris.
 •    Iridocyclitis in which both the iris and the pars plicata of the
ciliary body are involved.

 
  2)  Intermediate uveitis is defined as inflammation
predominantly involving the pars plana, the peripheral retina and the
vitreous.
3) Posterior uveitis involves the fundus posterior to the vitreous
base.   
•    Retinitis with the primary focus in the retina.
   •    Choroiditis with the primary focus in the choroid.
   •    Vasculitis which may involve veins, arteries or both.
4)  Panuveitis implies involvement of the entire uveal tract without
a predominant site of inflammation.
  5)   Endophthalmitis implies inflammation, often purulent,
involving all intraocular tissues except the sclera.
   6)   Panophthalmitis involves the entire globe, often with orbital
extension
Anterior uveitis is the most common, followed by posterior, intermediate
and panuveitis
.

• Definitions
   1    Onset may be sudden or insidious.
   2    Duration of an attack may be either limited, if 3 months or less in duration, or persistent,
if longer.
   3    Acute uveitis describes the course of a specific uveitis syndrome characterized by
sudden onset and limited duration.
   4    Chronic uveitis describes persistent inflammation characterized by prompt relapse (in
less than 3 months) after discontinuation of therapy.
   5    Recurrent uveitis is characterized by repeated episodes of uveitis separated by periods
of inactivity without treatment lasting at least 3 months.
   6    Remission refers to inactive disease for at least 3 months after discontinuation of
treatment.
   7    Resistant   
  To steroids :if there is no clinical improvement despite 2 weeks of treatment with maximal
dose.
   To immunosuppressives :if there is no clinical improvement despite 3 months of treatment.
 Symptoms
• pain
• photophobia
• ocular redness
• epiphora
• blurred vision
• refractive error
• Cataract
• Floaters
• Macular oedema
 Examination- Anterior uveitis
• Vision usually only slightly decreased
• IOP is lower (cyclitis) or elevated (trabecular meshwork
blockage)
• Conjunctiva: perilimbal (ciliary) injection
• Cornea: Keratic precipitates (KPs)
– Small cellular (nongranulomatous iritis), usually in the inferior cornea
– Mutton fat KP (granulomatous AU)
– Stellate-shaped KPs are typical of Fuchs heterochromic iridocyclitis.
• Corneal stromal edema may be present
• Acqueous cells
• Flare
• Aqueous fibrinous exudate
• Posterior synechiae
•  Hypopyon
• Meiosis
In chronic case additional signs
• Iris atrophy
• Iris pseudorubiosis
• Iris nodules
Posterior segment finding depends on the type
and etiology of the disease
Keratic precipitates
 Causes of anterior uveitis
• Idiopathic causes

• Diseases associated with HLA-B27

• Ankylosing spondylitis
• Reiter's syndrome (reactive arthritis)
• Inflammatory bowel disease (ulcerative colitis, Crohn’s disease)
• Psoriasis

• Sarcoidosis
• Juvenile idiopathic arthritis
• Fuchs heterochromic iridocyclitis

• Infections
• Herpes zoster and/or herpes simplex
• Syphilis
• Lyme disease
• Tuberculosis
• Lens-associated uveitis
• Trauma
 Complications

– Secondary glaucoma
– A fall in IOP( hypotony) phthisis bulbi
( because of ciliary shutdown)
– Cataracts with synechia
– Iris atrophy
– Loss of vision
 Intermediate uveitis
(pars planitis)
Signs:
• Vitreous
– Cells in the vitreous
– Snow balls opacities inferiory
– Snow banking ( exudates over retina)
– Vitreous strands
• Retina
– Peripheral retinal periphlebitis
• Vascular sheathing
• Vascular occlusion
• Peripheral neovascularisation
– Cystoid macular oedema
 Causes of Intermediate uveitis

• Idiopathic
• Multiple sclerosis
• Sarcoidosis
• Intraocular lymphoma
• Infection
– Lyme disease
– Syphilis
– Toxocara
 Aetiology of Posterior uveitis
• Chorioretinitis with vitritis
– Focal
• Toxocara
• Toxoplasma
• CMV retinitis
– Multifocal
• Sarcoidosis
• TB
• Syphilis, toxoplasmosis (AIDS)
• Intraocular lymphoma
• Birdshot retinopathy,
– Diffuse
.,sympathetic ophthalmia

• Chorioretinitis without vitritis

• Oncocerciasis

• Retinal vasculitis
• Systemic lupus erythematosis
• Behcet disease
• Wegner granulomatosis
• Polyarteritis nodosa
• Idiopathic
 Aetiology of Posterior uveitis
• Toxoplasma
• Histoplasmosis
• Cytomegalovirus
• Toxocara
• Herpes simplex
• Syphilis
• Tuberculosis
• Candida 
• Oncocerciasis
 Differential Diagnosis Of Uveitis

• Masquerade syndromes
Neoplasms mimicking uveitis
• Ocular malignant melanoma
• Retinoblastoma
• Reticulum Cell Sarcoma ( Primary Intraocular Lymphoma )
• Leukaemia
• Lymphoma
• Ocular Metastasis
• Other
• Endophthalmitis
• Retinal detachment
• Intraocular foreign body
Large, yellow, subretinal infiltrates in an elderly
white woman with intraocular lymphoma.
 General Investigations
• ESR, C- Reactive Protein
• CBC
• CXR
• FBS
• Syphilis Serology- TPHA, VDRL
• Urine analysis ( Diabetes Mellitus )
• RF
 Principles of treatment

• General principles
• Treatment of immune-mediated uveitis
involves predominantly the use of anti-
inflammatory and immunosuppressive agents
 Mydriatic eye drops
to relief discomfort
To break recent synchae
To prevent futhure synchae formation
• Drugs :
• Tropicamide
• Cyclopentolate
• Homatropine
• Atropine
 Corticosteroid eye drops
Start with frquent dosing in cases of acute
disease then tapper.
Drugs:

• Dexamethasone
• Betamethasone
• Prednisolone
• Fluorometholone
Always look for Complications of treatment like
• High IOP
• Cataract
• Secondary infections