Uveitis Flashcards
(145 cards)
1
Q
What does ACAID stand for?
A
Anterior Chamber- Associated Immune Deviation
-Affords the immune privilege of the internal eye
2
Q
First identified association between HLA genes and human disease?
A
HLA-B27 and Anterior Uveitis
3
Q
STRONGEST association between HLA genes and human disease ever described (224x risk)
A
HLA-A29 and Birdshot Chorioretinopathy
4
Q
Birdshot Chorioretinopathy: associated HLA subtype?
A
HLA-A29 (âABI the birdâ)
5
Q
HLA-B27: associated ophtha disease?
A
Acute Anterior Uveitis: Ankylosing Spondylitis and Reiterâs Syndrome (âBinugBoG na Reiterâ)
6
Q
HLA-B51/B5: associated ophtha disease?
A
Behçetâs Disease (âBEA Behçetâ)
7
Q
Vogt-Koyanagi-Harada Syndrome, Sympathetic Ophthalmia: associated HLA subtype?
A
HLA-DR4: (âDR. 4 Vicky Soâ)
8
Q
Specialized dendritic cells in the Conjunctiva
A
Langerhans Cells
9
Q
Hypersensitivity Type 1: Immediate/IgE-mediated diseases
A
Seasonal Allergic Conjunctivitis, Giant Papillary Conjunctivitis, Vernal Keratoconjunctivitis, Atopic Keratoconjunctivitis
10
Q
Hypersensitivity Type 2: Cytotoxic diseases
A
Moorenâs Ulcer, Mucous Membrane Pemphigoid
11
Q
Hypersensitivity Type 3: Immune Complex-mediated diseases
A
Stevens-Johnson Syndrome, Sjogrenâs Syndrome, Peripheral Ulcerative Keratitis, Scleritis
(Triple S PUK)
12
Q
Hypersensitivity Type 4: Delayed Hypersensitivity diseases
A
Giant Papillary Conjunctivitis, Vernal Keratoconjunctivitis, Atopic Keratoconjunctivitis, Sympathetic Ophthalmia, Phlyctenulosis, Contact Dermatoblepharitis, Graft Rejection
13
Q
Hypersensitivity Type 5: Stimulatory diseases
A
Thyroid-related Eye Disease
14
Q
Acute course
A
Sudden-onset and limited duration
15
Q
Recurrent course
A
Repeated episodes separated by periods of inactivity WITHOUT treatment ⼠3 months in duration
16
Q
Chronic course
A
Persistent Uveitis with relapse in < 3 months after DISCONTINUING treatment
17
Q
Worsening activity
A
2-step increase in level of inflammation OR
increase from Grade 3+ to 4+
18
Q
Improved activity
A
2-step decrease in level of inflammation OR decrease from Grade 1+ to 0
19
Q
Anterior Chamber Cells Classification
A
Marker of activity
0: <1
0.5+/trace: 1-5
1+: 6-15
2+: 16-25
3+: 26-50
4+: >50
20
Q
Anterior Chamber Flare Classification
A
- Not a marker of activity
- Protein transudation due to breakdown of the B-O-B
0: None 1+: Faint 2+: Moderate (Iris and Lens details CLEAR) 3+: Marked (Iris and Lens details HAZY) 4+: Intense (Fibrin or Plasmoid Aqueous)
21
Q
Vitreous Flare Classification
A
0: None
1+: Hazy RNFL details (Clear details of the Optic Disc and Vessels)
2+: Hazy details of the Optic Disc and Vessels
3+: Only the Optic Disc is visible
4+: Optic Disc NOT visible
22
Q
Granulomatous Morphology
What size of KP?
Nodules?
Severity?
A
- Large mutton fat KPs
- With Busacca, Koeppe and Berlin nodules
- Usually chronic and severe
23
Q
Large and mutton-fat keratic precipitates are made up of what?
A
Macrophages and Giant Cells
24
Q
Infectious etiologies of granulomatous uveitis
A
TTT Fudge Lasang Herpes Siya
TB, Syphilis, Toxoplasma, Toxocara, Herpes, Fungal, Leprosy
25
Non-Infectious etiologies of granulomatous uveitis
(Very sterile sterile man)
VKH, SO, Sarcoidosis, Masquerade
26
Non-Granulomatous morphology size?
Small to medium-sized Keratic Precipitates
27
Small to medium-sized Keratic Precipitates are made up of what?
PMNs (Neutrophils) & Lymphocytes
28
Diseases with red eyes
JIA-associated Uveitis, Fuchs Heterochromic Iridocyclitis, Posner-Schlossman Syndrome, Intermediate, Posterior uveitis
29
Uveitic diseases with hypopyon
Behçetâs Disease, HLA-B27-associated Uveitis, Herpes Zoster/Herpes Simplex Keratouveitis, Toxoplasmosis, Toxocariasis, Masquerade (Endophthalmitis, Retained IOFB)
(TT HHMB)
30
Differential of broad based posterior synechiae
Tuberculous uveitis
31
Occlusio Pupillae
membrane covering the entire pupil
32
Iris BombĂŠ
Anterior bowing of the Iris due to a pupillary block from either an occlusio or seclusio pupillae
33
Seclusio Pupillae
360-degree posterior synechiae
34
Location of Busacca nodules
Iris stroma
35
Location of Koeppe nodules
Pupillary border
36
Location of Berlin nodules
Angle
37
What are keratic precipitates?
Collection of inflammatory cells at the Corneal Endothelium
38
Stellate KP differentials
"HIT"
Intraocular Viral Infections (i.e. Herpes)
Toxoplasmosis
Fuchs Heterochromic Iridocyclitis
39
Etiologies of Band Keratopathy and Treatment
```
Chronic Inflammation (i.e. Childhood Chronic Iridocyclitis)
Silicone Oil in Aphakic patients
Hypercalcemia
Hyperphosphatemia
Hereditary
Exposure to Mercurial vapors
```
Tx: EDTA
40
What is a band keratopathy and where is it located?
Deposits of calcium in Bowman's layer
41
What comprises snowballs?
Epithelioid Cells and Giant Cells
42
What is a snowbank?
Accumulation of a FIBROGLIAL MASS over the Pars Plana and adjacent Retina; can have vessels crossing over it
43
MOST COMMON cause of decreased vision in Intermediate Uveitis in adults
Cystoid Macular Edema
44
MOST COMMON cause of decreased vision in Intermediate Uveitis in children
Optic disc edema
45
Diseases causing perivascular sheathing of arterioles
ARN, Toxoplasmosis
46
Diseases causing perivascular sheathing of venules
CMV
47
Entity causing candlewax drippings
Sarcoidosis
48
4 entities causing Retinitis + Vasculitis
Behçetâs, HSV, VZV, CMV
49
Disease causing geographic choroiditis + retinitis
TB
50
Diseases causing choroiditis + exudative RD
VKH, SO, CSCR
51
Give baseline uveitic workup
```
CBC w/ Platelet & Differential Count
ESR, CRP
Chest X-Ray, PPD, Quantiferon Gold, GeneXpert
VDRL/RPR, FTA-ABS
Urinalysis
FBS, AST, ALT, Crea
```
52
Special test to request for ankylosing spondylitis?
Sacroiliac Joint X-Ray
53
Special test to request for Granulomatosis with Polyangiitis?
c-ANCA (Proteinase 3)
54
Special test to request for Polyarteritis Nodosa?
p-ANCA (Myeloperoxidase)
55
Special tests to request for Viruses, Toxoplasma, Toxocara?
PCR of Intraocular Fluid/serum antigenemia
56
Special tests to request for Sarcoidosis?
Serum Angiotensin Converting Enzyme (ACE), Lysozyme, Kveim Test, Gallium scan, Chest CT-Scan
57
Why should steroids be given in the morning between 6-10AM?
To mimic the normal diurnal cycle and reduce the risk of adrenal suppression
58
What is the ideal glucocorticoid?
No mineralocorticoid activity
59
Complication if steroid dose decreased too quickly
Adrenal crisis
60
Steroids causing less IOP increasing effects?
Fluorometholone, Rimexolone, Loteprednol
61
Common side effects of steroids
- Increase in IOP: mainly caused by outflow resistance
| - Cataract formation: Posterior Subcapsular type
62
Absolute indications of IMT
- Behçetâs Disease
- Vogt-Koyanagi-Harada Disease
- Sympathetic Ophthalmia
- Necrotizing Scleritis
- Rheumatoid Sclerouveitis
- Granulomatosis with Polyangiitis
- Polyarteritis Nodosa
- Relapsing Polychondritis
63
Relative Indications of IMT
- Intermediate Uveitis (esp. in children)
- Chronic Iridocyclitis
- Birdshot Chorioretinopathy
- Serpiginous Choroidopathy
- Multifocal Choroiditis and Panuveitis
- Juvenile Idiopathic Arthritis associated Uveitis
64
Steroids: Start ___, then ____
Start HIGH, then taper
65
IMTs: Start ____, then ____
Start LOW, then increase in dose
| -Given concurrently with steroids because full effects are seen within 2-3 weeks from intake
66
Antimetabolites and side effects
- Methotrexate: Hepatotoxicity
- Azathioprine: Hepatotoxicity and GI upset
- Mycophenolate Mofetil: GI upset
67
T Cell Signalling Inhibitors and side effects
- Cyclosporine: Nephrotoxicity and HTN
- Tacrolimus: Nephrotoxicity and HTN
- Sirolimus: GI upset
68
Alkylating agents and side effects
- Cyclophosphamide: HEMORRHAGIC CYSTITIS, MYELOSUPPRESSION, STERILITY, BLADDER CA
- Chlorambucil: MYELOSUPPRESSION, STERILITY, INCREASED RISK OF CA
69
Biologics and side effects
- Infliximab: TB REACTIVATION, MALIGNANCY
| - Rituximab: NEUTROPENIA
70
Treatment options for Cataract with No flare; Few Posterior Synechiae
Phaco, CCC, Acrylic IOL in the bag
71
Treatment options for Cataract with (+) Flare; >270-degree Posterior Synechiae
Pars Plana Lensectomy, Aphakic
72
Treatment options for JIA associated cataract
IMT, Phaco, +/- Acrylic IOL in the bag
73
How long should pre-treatment be done for cataract surgery?
3-6 months
74
When does exacerbation of inflammation post-op start?
3 days post-op
75
3 main complications of cataract sx post-op
Moderate anterior chamber reaction, hyphema, ocular hypertension
76
3 uses of atropine
(1) Decreases pain from ciliary spasm
(2) Prevents formation of posterior synechiae
(3) Stabilizes the blood-ocular barrier
77
MOST COMMON known cause of Acute Anterior Uveitis
HLA-B27 Associated anterior uveitis
78
HLA-B27 Associated anterior uveitis
More common in males or females?
____ Decade of life
Male predominance; 2nd-5th decade of life
79
Finding on sacroiliac xray of Ankylosing Spondylitis
Bamboo-spine deformity
80
Symptoms of Inflammatory LBP of ankylosing spondilitis
1. ) Morning stiffness > 30 minutes
2. ) Improvement of back pain with exercise but not with rest
3. ) Awakening from back pain during the second half of the night only
4. ) Alternating buttock pain
81
Ankylosing Spondylitis: RF positive or negative?
Negative
82
Reactive Arthritis/Reiter's Disease findings
Canât See (Conjunctivitis, Iritis, Keratitis), Canât Pee (Urethritis), Canât Climb a Tree (Arthritis)â
Other major findings: Keratoderma blenorrhagicum,
Balanitis circinata
83
Inflammatory Bowel Disease signs
Anterior Uveitis, Conjunctivitis, Peripheral Ulcerative Keratitis, Episcleritis/Scleritis, Vitritis, Retinal Vasculitis
84
What is the cause of HTN uveitis?
Due to Trabeculitis or PAS formation
85
3 Conditions with HTN uveitis
1. Fuchs Heterochromic Iridocyclitis
2. Posner-Schlossman Syndrome
3. Herpetic Uveitis (HSV, VZV, CMV)
86
FUCHS HETEROCHROMIC IRIDOCYCLITIS
(+) Formation of abnormal vessels in the anterior chamber angle (fine & fragile)
- Diffuse white stellate KPs
- Mild Anterior chamber cellular reaction
- Mild increase in IOP
- Diffuse Iris stromal atrophy
- NO Posterior synechiae formation
- +/- Vitritis
- Cataract formation is common
87
Hyphema formation during intraocular surgery
AMSLER- VERREY SIGN
88
Treatment for FHI
Steroids, anti-glau (Avoid PGA), cataract sx
89
Posner Schlossman Syndrome pathology
Glaucomatocyclitic process
90
Posner Schlossman Syndrome presentation
- Unilateral, recurrent attacks of markedly elevated IOP and very mild anterior chamber cellular reaction
- NO posterior synechiae formation or posterior segment involvement
91
Treatment for Posner Schlossman Syndrome
- Topical Corticosteroids
- Topical Anti-glaucoma medications (PGAs are avoided)
- Surgical intervention if indicated
92
Herpetic anterior uveitis presentation
- Iritis, Iridocyclitis, Keratouveitis
- Stellate KPs at Arlt's triangle
- Diffuse/sectoral iris atrophy
93
Hutchinson Sign
- Indicate Nasociliary nerve involvement and a greater likelihood that the eye will be affected
- In VZV keratouveitis
Tx:
HSV & VZV:
-Oral Acyclovir 400mg 5x/day - HSV; 800mg 5x/day - VZV
-Oral Valacyclovir 500mg 3x/day - HSV; 1g 3x/day - VZV
- Oral Acyclovir (as maintenance for chronic & recurrent
cases) - 800mg/day
-Topical Corticosteroids, Topical Mydriatic-Cycloplegic
94
CMV Anterior Uveitis presentation and treatment
What is the pattern of the KPs?
Topical, oral, intravitreal tx?
Endotheliitis (KPs form a coin-shaped pattern)
TX:
-Topical Ganciclovir gel - recommended first-line treatment;
-Topical Corticosteroids
-Oral Valganciclovir 900mg 2x/day for 6 weeks, then
maintained at 450mg 2x/day
-Intravitreal Ganciclovir
95
Treatment of herpetic anterior uveitis
- Epithelial: Topical Anti-viral + Oral Prophylaxis (BID)
- Stromal/Endothelial: Topical Anti-viral + Topical Corticosteroids + Oral Prophylaxis (BID) + Topical Cycloplegics
- Keratouveitis: Topical Anti-viral + Topical Corticosteroids + Oral Acyclovir (400mg 5x/day for HSV; 800mg 5x/day for VZV) + Topical Cycloplegics
96
Juvenile Idiopathic Arthritis-associated Uveitis risk factors
- Pauciarticular or Oligoarticular type of JIA (⤠4 joints involved) -RF negative, ANA positive
- Female predilection
- Younger age of onset of Arthritis (< 5 years old)
97
Juvenile Idiopathic Arthritis-associated Uveitis most common presentation
Chronic iridocyclitis
98
Complications of JIA
- Band Keratopathy
- Posterior Synechiae formation
- Cataract formation
- Glaucoma or Hypotony
- Macular Edema
99
Screening for JIA should be done every ____ months
Every 2 months from onset of arthritis, for 6 months
100
JIA Treatment
- Topical or Periocular Corticosteroids (Systemic if severe)
- Topical Cycloplegics
- IMTs (Methotrexate, Azathoprine, Mycophenolate mofetil, Cyclosporine)
- Cataract surgery for visually significant cataracts (3 months quiet)
101
Scleritis commonly associated with _____
Predominance?
Systemic vasculitides
(Rheumatoid Arthritis, SLE, GPA, PAN, Relapsing Polychondritis)
Female
102
New name of Wegener's Granulomatosis
Granulomatosis with Polyangiitis (GPA)
103
Triad of GPA
1. ) Necrotizing Granulomatous vasculitis of the upper and lower respiratory tract
2. ) Focal Segmental Glomerulonephritis
3. ) Necrotizing vasculitis of small arteries and veins
(+) c-ANCA
104
Polyarteritis Nodosa most common symptom
```
Mononeuritis Multiplex
(Weight loss (> 4kg), Livedo reticularis, Testicular pain,
Increased Diastolic BP, (+) Hepatitis B infection)
```
(+) p-ANCA
105
Most common symptom of scleritis
Severe boring pain
106
Hue of scleritis and episcleritis
Scleritis: Bluish purple due to deep vascular involvement
Episcleritis: Bright red hue
DOES NOT BLANCH with 10% Phenylephrine instillation
107
Types of anterior scleritis
- Non-Necrotizing - Nodular (localized)
- Non-Necrotizing - Diffuse (extensive)
- Necrotizing - Extreme pain and tenderness; severe vasculitis with scleral thinning
- Scleromalacia Perforans-painless; avascular sclera; scleral thinning
108
Posterior scleritis presentation
What sign on ocular UTZ?
Thickening of the sclera posterior to rectus muscle insertions
âT-signâ on Ocular Ultrasound (retrobulbar edema surrounding the Optic Nerve)
109
Tx of anterior scleritis
Anterior Non-Necrotizing - Diffuse: Oral NSAIDs, Topical/Oral Corticosteroids
Anterior Non-Necrotizing - Nodular, Anterior Necrotizing & Posterior Scleritis: Oral Corticosteroids with IMT (Cyclophosphamide, Azathioprine)
110
Intermediate uveitis: unilateral or bilateral?
Bilateral
111
What haplotype is associated with intermediate uveitis?
HLA DR15
112
Primary complaint of intermediate uveitis and cause?
BOV and/or floaters due to vitritis and CME
113
What are always present in intermediate uveitis?
Vitreous cells in vit and peripheral retina
114
Other manifestations of intermediate uveitis?
Snowballs and vitreous flare
115
Exudate accumulation on the pars plana
Pars planitis
116
Pars planitis
snowbank and snowball formation over the pars plana and ora serrata
117
What comprises a snowbank formation and where is its location? How is it best seen?
Fibroglial mass
inferiorly
Scleral depression or 3-mirror gonioscopy to see neovascularizations
118
Pars planitis compared to other intermediate uveitis:
Worse _____
More severe _____
Worse _____
Worse vitritis
| More severe macular edema Worse prognosis
119
How does vitreous hemorrhage occur in pars planitis?
Result of NVs from vitreous base, pars plana or peripheral retina, crossing over the formed snowbank extending through breaks in the Inner Limiting Membrane of the vitreous base
120
4 Step Approach for intermediate uveitis
1. Intravitreal or Periocular Corticosteroid injection (FIRST LINE) +/- Oral NSAIDs or Systemic Corticosteroids
2. ) Pars Plana Cryotherapy or Transpupillary Thermotherapy
3. ) Pars Plana Vitrectomy
4. ) Immunomodulatory Therapy
121
True or false: Topical Steroids are effective for phakic patients
False
122
What is the first line drug of immunomodulators for IU and indication?
Cyclosporine for those who are resistant to corticosteroid therapy or require chronic corticosteroid treatment
123
Other name for VOGT-KOYANAGI-HARADA SYNDROME?
Uveomeningitis
124
VKH pathology?
Systemic, autoimmune disease where the main targets are the melanin- containing cells of the eyes, ears, meninges, skin
125
VKH is a bilateral, chronic, ______ panuveitis with ________ involvement
Bilateral, chronic, granulomatous panuveitis with choriocapillaris involvement
126
Male or female predilection for VKH?
| Which decade of life?
Female
| 20-40
127
Systemic manifestations:
Meninges: _____
Ears: ______
Skin:______
Meninges: Headache, orbital pain, stiff neck (CSF pleocytosis)
Ears: Auditory deficits
Skin: Vitiligo (60-65%), Poliosis (80-90%), Alopecia (70-75%), should not precede the onset of the ocular manifestations
CHECK AXILLA
128
Ocular manifestation of VKH
- Acute granulomatous manifestation with mutton fat KPs and iris nodules
- ON swelling
- Exudative non rhegmatogenous detachment
- Dalen Fuchs nodules (Nummular chorioretinal depigmented scars)
- Sunset glow fundus
- Sugiura's sign
129
Perilimbal vitiligo in VKH
Suguira's sign
130
Cause of sunset glow fundus?
Chorioretinal depigmentation from RPE loss & perturbation
131
Phases of VKH
Prodromal, acute uveitic, convalescent, chronic recurrent
132
Prodromal phase clinical features
Headache, Fever, Nausea, Vomiting, Meningismus, Vertigo, Auditory Disturbances, Sensitivity of Skin or Scalp to touch (Hyperesthesia), CSF Pleocytosis
133
Acute uveitic phase clinical features
Sudden-onset bilateral granulomatous panuveitis, multiple focal serous retinal detachments, choroidal thickening, optic disc edema
134
Convalescent phase clinical features
Ocular: Perilimbal Depigmentation (Sugiura Sign), Chorioretinal Depigmentation (Sunset Glow Fundus), Nummular Chorioretinal Depigmented Scars; Systemic: Vitiligo, Poliosis, Alopecia
135
Chronic Recurrent
Complications: Cataract, Posterior Synechiae, Glaucoma, Band Keratopathy, RPE proliferation, Subretinal Fibrosis, CNVM formation
136
Diagnostic criteria: Early manifestations of VKH
1. Evidence of diffuse Choroiditis (Focal areas of Subretinal Fluid or Bullous Serous RD)
2. Both of the following (if with equivocal fundus findings)
a.) Fluorescein Angiography:
Focal areas of delay in choroidal perfusion > Multifocal areas of pinpoint leakage > Large placoid areas of Hyperfluorescence > Pooling within Subretinal Fluid > Optic Nerve Staining
b.) Ultrasonography: Diffuse choroidal thickening WITHOUT evidence of Posterior Scleritis
137
Diagnostic criteria: Late manifestations of VKH
1. History suggestive of prior presence of findings from 3A and either both 2 &3 below,
or multiple signs from 3
2. Ocular Depigmentation: Sunset Glow Fundus or Sugiuraâs Sign
3. Other Ocular Signs: Nummular Chorioretinal Depigmented Scars, RPE Clumping or migration, Recurrent or chronic anterior uveitis
138
Differentials of VKH
Non-Infectious
-Sympathetic Ophthalmia (SO), Behçetâs Disease (BD), Sarcoidosis, Central Serous Chorioretinopathy (CSCR), Retinochoroidal mass (i.e. Retinoblastoma, Lymphoma)
Infectious
-Tuberculosis, Syphilis, Bartonellosis
139
Treatment for VKH
High dose systemic corticosteroids - MAINSTAY
Early treatment (about 2-3 weeks from onset of symptoms), 1-1.5 mg/kg/day
Maintained for 2-4 weeks then tapered gradually and maintained for at least 6 months
Others:
Topical corticosteroids, cycloplegics, IMTs
140
When can sympathetic ophthalmia occur?
Within 1 year
141
Part that is spared in sympathetic ophthalmia?
Choriocapillaris
This is due to production of anti-inflammatory
molecules by the RPE > TGF-β & RPE protective protein > suppress generation of superoxides by phagocytes
142
4 Initial symptoms of SO
1. Photophobia
2. Decreased accommodation
3. Redness
4. Pain
143
Treatment for SO
1. High-dose systemic corticosteroids for 3 months - FIRST LINE; tapered over the next 3-6 months
2. Immunomodulatory therapy 3. Enucleation > Evisceration
144
Differentiate SO and VKH
VKH
- No history of trauma or surgery
- Plasma cells observed
SO
- History of trauma or surgery
- Plasma cells observed
- Sparing of choriocapillaris
145
Characteristic of Behcet's Disease
Obliterative/occlusive vasculitis involving both arteries & veins
