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ANTERIOR UVEITIS
      Dr.Gayatree Mohanty
      KIMS, BBSR,Orissa
DEFINITION
Inflammation of the uveal
 tract from the iris upto the
 plars plicata
 of ciliary body
CLASSIFICATION
Iritis
Iridocyclitis
Cyclitis
CLINICAL FEATURES
Acute:   Symptoms more
 severe
Chronic: Signs more
 severe than signs
SYMPTOMS
   Pain: Acute
          Severe
          Radiates along V1 nerve distribution
          Worst at night
   Redness:
   Photophobia
   Lacrimation
   Diminution of vision
      a.Turbid aqueous        e. Sec. glaucoma
      b.Vitreous exudates     f.Ciliary spasm
      c.Exudates in pupillary
                   area        g.Complic. Cat
      d.CME
SIGNS

   Lid Edema
CILIARY CONGESTION
3. CORNEAL SIGNS:
 Corneal  edema d/t toxic endothelitis &
  increased IOP
 Keratitis precipitates:

    Cellular deposits on the corneal
  endothelium.
    Distributed in a base down triangular
  area inferiorly (Arlt’s triangle)
    Small, medium, large (mutton fat)
 Posterior corneal opacities
KERATITIC PRECIPITATE
AC SIGNS: AQUEOUS CELLS
AND FLARE
ANTERIOR CHAMBER SIGNS:
AQUEOUS CELLS
Early sign
On oblique illum.:3mm long 1mm wide slit
 with max light and magnifications
Grading:
0 :0 cell
+_ : 1-5 cell
1+ : 6-10 cells
2+: 11-20 cells
3+ : 21-50 cells
4+ : >50
ANTERIOR CHAMBER SIGNS:
AQUEOUS FLARE
D/t leakage of protein into the AC from the leaky
  vessels
On oblique illum.: a point of beam projected on the
  iris plane
Protein particles seen floating the beam of light:
  Tyndall phenomenon
Marked in NGU
Grading:
0 : No flare
1+ : Just detectable
2+: Moderate flare with clear detail view of iris
3+ : Marked flare with iris details not clear
4+ : Intense flare with no view of iris details
HYPOPYON: STERILE PUS IN AC
AC SIGNS
Hyphema:   Blood in AC
Irregular AC depth d/t
 synechia
Deposits of debris in AC
 angle
Anterior synechia
EXUDATES IN AC ANGLE
IRIS SIGNS
Loss  of normal pattern
Muddy in color in active
 stage & hyper/
 hypopigmented
Iris nodules: Aggregations
 of lymphyocytes and
 epitheloid cells.
KOEPPE’S NODULE; BUSSACCA’S
NODULE
POSTERIOR SYNECHIAE: ADHESION OF
POST.   SURF. OF IRIS TO ANT. SURF OF LENS
POSTERIOR SYNECHIAE:

Segmental
Annular
Total
SLUGGISH PUPILLARY REACTION
& MIOSIS
IRREGULAR PUPIL: FESTOONED
PUPIL
FIBRINOUS EXUDATE : OCCULSIO
PUPIL
ECTROPION PUPILLAE
LENS SIGNS
Pigment   dispersion on lens
 surface
Fibrin exudates on lens
 surface
Complicated cataract:
 Polychromatic lusture
 Bread crumb appearance
COMPLICATED CATARACT
Spillover anterior vitreous
 inflammation
Complications and
   Sequelae
COMPLICATED CATARACT
SECONDARY GLAUCOMA
Early glaucoma:
In active phase of disease
Due to exudates &
 inflammatory cells in AC angle
 blocking the TM
Decreased aqueous flow
 leading to increased IOP
 (Hypertensive Glaucoma)
EXUDATES IN AC ANGLE
Late  Glaucoma (Post
 Inflammatory Glaucoma):
D/t pupillary block (Seclusio
 Pupil/Occlusio pupil)
Causes Iris Bombe then
 occlusion TM
Decreased aqueous outflow
CYCLITIC MEMBRANE:
retrolental,
 fibrovascular
 membrane
 which
 stretches
 across the
 back of the
 lens
CHOROIDITIS
RETINAL SIGNS:
Cystoid Macular
 Degeneration
Macular Degeneration
Serous Retinal Detachment
Secondary Peripapilitis
 Retinae
RETINAL SIGNS: CYSTOID
MACULAR EDEMA
SEROUS RETINAL
DETACHMENT
PERIPHLEBITIS:
PAPILLITIS
BAND KERATOPATHY
PHTHISIS BULBI

Shunken         Disorganized
 eyeball
D/t chronic uveitis caused
 ciliary shock & reduced
 aqueous production….then
 hypotony….shrunken
 disorganized globe
DIFFERENTIAL DIAGNOSIS
1. Causes   painful red
   eye
2. Granulomatous & Non
   granulomatous Uveitis
3. Etiological D/d
CAUSES OF RED EYE
                 Acute             Acute              Acute
                 Conjunct ivitis   Iridocyclitis      Congestive
                                                      Glaucoma
Onset            Gradual           Usually gradual    Sudden


Pain             Mild discomfort   Moderate           Severe
                                   V 1 n. distribn.   Whole V n.
                                                      distrib.
Discharge        Mucopurulent      Watery             Watery


Colored haloes   +/-               --                 +++


Vision           Unaltered         Impaired           Severely
                                                      impaired
Congestion       Conjunctival      Ciliary            Ciliary
CAUSES OF RED EYE (CONTD)
             Acute             Acute             Acute
             Conjunct ivitis   Iridocyclitis     Congestive
                                                 Glaucoma
Tenderness   Absent            Marked            Marked


Pupil        Normal            Small,irregular   Dilated,
             Reacting          Sluggish          vertically oval &
                               reacting          fixed
Media        Clear             Hazy d/t          Hazy d/t corneal
                               KP,flare &        edema
                               pupillary
                               exudate
Anterior     Deep              Deep/ may be      Very shallow
chamber                        irregular
Iris         Normal            Muddy             Edematous
CAUSES OF RED EYE (CONTD)
               Acute             Acute            Acute
               Conjunct ivitis   Iridocyclitis    Congestive
                                                  Glaucoma

IOP            Normal            Normal usually   Markedly raised



Constitutional Absent            Little           Prostration &
symptom Assoc.                                    vomiting
GRANULOMATOUS & NON-
GRANULOMATOUS UVIETIS
                        Granulomatous      Non- Granulomatous



Onset                   Insiduous          Acute


Pain                    Minimal            Marked


Photophobia             Slight             Marked


Ciliary Congestion      Minimal            Marked


Keratitic Precipitate   Large Mutton Fat   Fine
GARANULOMATOUS & NON- GRANULOMATOUS
 UVIETIS
              Granulomatous         Non- Granulomatous




Iris nodule   Koeppe’s & Bussaca’s Absent
              nodules

Posterior     Thick & broad based   Thin & tenous
Synechiae

Fundus        Nodular lesion        Diffuse lesions
WORK UP
 Hematological Examination
 TLC/DC: Gross idea of inflammatory response of body

 ESR: r/o Chronic infection

 Blood sugar: r/o DM

 Blood Uric Acid: r/o Gout

 Seological Test: Syphilis, toxoplasmosis &
  histoplasmosis
 Test for:

 AntiAntinuclear Antibodies         CRP
 Rh factor                          Anti-streptolysin O
 LE cells
WORK UP
 Urine Examination:
 For WBC, Pus cells, RBS

 Culture : r/o Urinary tract infection

 Stool Examination

 For Cysts & ova to r/o parasitic infestations.

 Radiological Investigation

 CXR,Paranasal sinus, Sacroiliac joints,Lumbar
  spine.
 Skin Tests:

 Tuberculin test, Kveims test & Toxoplasmin test.
TREATMENT:
Non-   specific treatment
Local therapy
Systemic therapy
Specific Treatment
T/t of Complications
NON-SPECIFIC TREATMENT:
LOCAL THERAPY

Cycloplegics
Corticosteroids
Broad   spectrum
 antibiotics
1.CYCLOPLEGICS
Short acting cycloplegics:
Tropicamide 1% e/d (3hrs)
Cyclopentolate 1% e/d(24hrs)
Long acting cycloplegics
Homatropine 2% e/d(4days)
Atropine sulphate 1% e/d (7-
 14days)
MODE OF ACTIONS OF CYCLOPLEGICS
Relieves  pain: Relieves spasm of
 iris sphincter & ciliary m.
Prevents posterior synechiae
 formation
Breaks posterior synechiae
Reduces hyperemia & vascular
 permeability which reduces
 exudation
2.CORTICOSTEROID: TO
REDUCE INFLAMMATION
Commonly used steroids:
Long acting:
 Dexamethasone
 Betamethasone
 Hydrocortisone
 Prednisolone
 Triamcinolone
Short acting:
 Fluoromethalone
 Loteprednol
 Fluocinolone
ROUTE OF ADMINISTRATION:
Topical: Eye drops or eye
 ointments
       6times a day
Anterior subtenon injection
       For severe cases
BROAD SPECTRUM ANTIBIOTIC
   Doesn’t have much role in anterior uveitis
SYSTEMIC THERAPY

Corticosteroids
Non-Steroidal     Anti-
 inflammatory
 Drugs(NSAIDS)
Immunosupressives
CORTICOSTEROIDS
Indication:   Intractable anterior
 uveitis
Prednisolone: 1mg/kgbdwt & taper
 gradually according to response
Side effects: Glaucoma &
 Cataract
NON- STEROIDAL ANTI-
INFLAMMATORY DRUGS:

Used   when steroid are
 contraindicated or not
 tolerated.
Phenylbutazone &
 oxyphenylbutazone
IMMUNOSUPPRESSIVES
In corticosteroid resistant or
 intolerant cases
In specific inflammations:
Behcet’s syndrome
Sympathetic ophthalmitis
VKH
Pars planitis
SPECIFIC TREATMENT
Tuberculosis:   ATT
Parenteral
 Penicillin:Syphilis
HSV: Acyclovir
TREATMENT OF
COMPLICATION:
 Inflammatory Glaucoma:
Timolol 0.5% BD & T.Acetazolamide 250mg BD
Contraindicated are Latanoprost & Pilocarpine.
 Post-inflammatory Glaucoma(d/t ring
  synechiea):
Laser iridotomy
 Complicated Cataract:
Cataract sx. After 3mths of quiet period.
 Retinal Detachment:
Anterior vitrectomy
 Phthisis bulbi
Enucleation

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