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Flashcards in Uveitis and Metabolic Diseases Deck (70):
1

Types of Uveitis

1. Anterior

2. Intermediate

3. Posterior Uveitis

4. Panuveitis

5. Endophthalmitis

6. Panophthalmitis

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Uveitis Definition

Inflammation of Uveal tract ( May involves retina and vessels)

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Acute Uveitis

Sudden onset Limited duration

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Recurrent Uveitis

Repeated seperated by inactivity w/o tx 3 or >3/12

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Chronic Uveitis

Persistent Prompt Relapse ( if tx stopped)

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Remission Uveitis

Inactive for at least 3/12 after tx stops

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Patient history factors

1. Age 2. Race 3. Geo location 4. Past ocular history ( POH) 5. Past medical history 6. Hygiene & Diet 7. Sexual practice 8. Recreation drug use 9. Pets

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1. Age

Certain age groups prone to certain types of uveitis

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2. Race

Genetics

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3. Geographic location

Endemic spread over the world

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4. Past ocular history

Uveitis as a result of ocular trauma/ surgery ( Infection/ Inflammation)

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5. Past medical history

Infectious agents: TB, Syphilis Systemic Diseases Rx ( Prescriptions) eg. Corticosteroids

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6. Hygiene & Diet

Infection: Toxocariasis Taxoplasmosis

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7. Sexual practice

Sexual transmitted diseases Syphilis HIV

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8. Recreational drug use

Eg. Needles HIV infection Fungal Endophthalmitis

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9. Pets

Cats: toxoplasmosis & Cat-scratch diseases Dogs: Taxocariasis

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ACUTE ANTERIOR UVEITIS ( AAU) Characteristics

Most common Sudden onset Duration of 3/12 or less Easy to recognise ( Severe symptoms)

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AAU Symptoms:

Unilateral pain Photophobia Redness Lacrimation

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AAU Signs:

  •  Good at presentation
  •  Ciliary Injection: Vessels from EOMs may present through ophthalmic arteries 
  • Miosis ( Sphincter spasm) = Involuntary sudden contraction of sphincter papillae ==> Pupil constric
  • Endothelial dusting 
  • Aqueous flare ( Protein in AC) 
  • Hypopyon ( Pus- WBCs accumulated) 
  • Posterior Synechiae ( Adhesion of Iris into lens) 

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Sign? 

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Ciliary Injection

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Sign? 

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AAU
Miosis

( Sphincter Spasm) 

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Sign? 

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AAU 
Endothelial Dusting 

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Sign? 

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AAU
Aqueous cells in AC 

Show disease severity ( No. of cells) 

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AAU

 Grading of cells ?

No. of cells within slit beam

( 2mm long & 1mm wide )

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Signs? 

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AAU 

Aqueous flare 

( Protein leaking in AC) 
Grading

 

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Sign?

 

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AAU Hypopyon 

( Pus - WBCs in AC inferiorly forming horizontal level) 

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Signs

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AAU 
Posterior Synechiae

( adhesion of Iris to Lens) 

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AAU 
Course and Prognosis ?

  • If treated, inflammation ⇒ completely resolve (5-6 weeks)

► Excellent visual prognosis

  • Complications and poor visual prognosis are related to delayed or inadequate management
  • Steroid-induced in IOP may occur but glaucomatous damage is uncommon  

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CHRONIC ANTERIOR UVEITIS 

CAU 

 

  • Less common than AAU
  • Persistent inflammation- promptly relapses < 3/12, after discontinuation of tx
  • Gradual presentation: 
    many patients are asymptomatic until the development of complications (e.g., cataract, band keratopathy) 

 

 

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CAU 

Signs 

 

  • Aqueous cells & aqueous flare
  • Iris nodules
  • Keratic precipitates (KP) ⇔ Clusters of cellular deposits on the cornea 

 

 

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Sign?

 

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CAU 
Keratic Precipitate on Cornea 

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CAU

Causes and Prognosis ?

  • Inflammation persists for >3/12 (sometimes years)
  • Remissions and exacerbations are common
  • Prognosis is guarded
  • Complications can ensue (e.g., cataract, glaucoma) 
  • Further towards back → Harder to treat

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Posterior Uveitis 

  • Includes retinitis, choroiditis and retinal vasculitis
  • Often both retina & choroid involved
  • Symptoms: vary according to inflammation location
    Floaters
    Impaired central vision 

 

 

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RETINITIS 

( Posterior Uveitis) 

 

  •  Focal (solitary) or multifocal
  • Active lesions - whitish retinal opacities with indistinct borders due to surrounding oedema 

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CHOROIDITIS 

( Posterior Uveitis) 

  •  Focal, multifocal or geographic
  • Active choroiditis is characterised by a round, yellow nodule 

 

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VASCULITIS

( Posterior Uveitis) 

  • Can occur as a 1˚ condition or 2˚ to retinitis 
  • Affects Veins > Arteries
  • Active:  Yellowish or grey-white, patchy, perivascular cuffing 
  • Quiet:  Perivascular scarring 

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SPONDELOARTHRIPATHIES 

( Ankylosing Spondylitis) 

  • Strong rlts with Uveitis 
  • Inflammatory joint diseases of the vertebral column, associated with human leukocyte antigen HLA-B27
  • Patients with spondyloarthropathies often test +ve for HLA-B27
  • Prevalence of HLA-B27 varies markedly in the general population

6-8%: Caucasian 

4%: North African 

2-9%: Chinese 
0.1-  0.5%: Japanese 

24%: North Scandinavia 

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Ankylosing Spondylitis 

(AS) 

  • Inflammation, calcification and finally ossification of ligaments and capsules of joints 
  • Causes bony ankylosis of the axial skeleton
  • Typically affects males, about 95% of whom are HLA-B27 +ve
  •  Early adulthood 

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AS Prevalence 

  • 25% of patients with AS develop acute anterior uveitis (AAU)
  • 25% of males with AAU have AS
  • Either eye can be affected at different times 

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Uveitis in Juvenile Arthritis 
[ Juvanile Idiopathic Arthritis ] 

  • Inflammatory arthritis of at least 6/52 duration occurring before age 16
  • Affects girls more commonly than boys (3:2) 
  • Causes childhood anterior uveitis 

 

 

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 Juvanile Idiopathic Arthritis + Anterior Uveitis 

Symptoms ?

  • Usually asymptomatic ( uveitis is detected on routine slit-lamp exam) 
  • Even present with 4+ aqueous cells, rarely patients complain
    Occasionally c/o vitreous floaters 

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SARCOIDOSIS ?

  • Idiopathic granulomatous inflammatory disorder
  • Can affect one organ or many
  • Mostly affects:
    Lymph nodes
    Lungs
    Liver
    Spleen
    Skin
    Eyes 

 

 

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SARCOIDOSIS 
Ocular signs ?

  • AAU
  • Granulomatous CAU
  • Intermediate uveitis (uncommon)
  • Periphlebitis
  • Choroidal infiltrates 

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SARCOIDOSIS

Ocular signs 
Choroid?

Retina?
Optic nerve?

  • Multifocal choroiditis
  • Retinal granulomas
  • Choroidal granulomas
  • Retinal neovascularisation in the periphery
  • Optic nerve granulomas or papilloedema 

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Sign? 

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Sarcoidosis 

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Sign? 

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Sarcoidosis 

Multifocal Choroiditis 

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Sign?

 

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Saccoidosis 

Choroidal Granulomas 

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Sign?

 

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Sarcoidosis 

Optic nerve granulomas or papilloedema 

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Behcet syndrome ?

  • Idiopathic, multi-system disease
  • Recurrent episodes of orogenital ulceration & vasculitis
  • Ocular complications in 95% of men & 70% of womenEye complications occur within 2 years of oral ulcers appearing
  • Onset is usually in the 30s
  • Mostly affects people of Eastern Mediterranean & Japanese descent 

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Behcet Syndrome 

Ocular signs 

  • Recurrent AAU with hypopyon
  • Retinal infiltrates
  • Retinal vasculitis
  • Vascular leakage
  • Vitritis
  • OtherConjunctivitis, episcleritis, scleritis 

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Parasitic Uvetis 
TOXOPLASMOSIS 
Cause?

  • Caused by Toxoplasma gondiiAn intracellular protozoan
  • T. gondii = common cause of infectious retinitis in otherwise healthy individuals
  • Cats = definitive host of the parasite 

 

 

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TOXOPLASMOSIS 

Transmission?

Humans become infected with T. gondii:

  • By ingesting soil or infected animal faeces containing T. gondii cysts 
  • Accidental contamination of hands when disposing of cat litter
  • By consuming raw or undercooked meat containing T. gondii cysts
  •  mother to foetus when T. gondii is contracted during pregnancy 

⇒ CNS causing inflammatory response ( treated with corticosteroid) 

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TOXOPLASMOSIS 

Prognosis?

  • Recurrent episodes of inflammation are common
     Cysts rupture ⇒ release hundreds of tachyzoites → normal retinal cells
  • Recurrences ( between the ages of 10 and 35 years) 
    Average age 25 years 

 

 

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Toxoplasmosis 

Signs and Symptoms?

  • Unilateral sudden onset of floaters, vision loss & photophobia
  • Signs:
    Solitary inflammatory focus near old pigmented scar (satellite lesion)
    Sometimes multiple foci
    Vitritis: Hard to see the fundus and the inflammatory focus, although it may have a “headlight in the fog” appearance  

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TOXOCARIASIS ?

  • Infestation with intestinal roundworm of dogs (Toxocara canis)
  • Transmission :  accidental ingestion of soil or food contaminated with ova shed in dog faeces 

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TOXOCARIASIS 

Complications?

 

  • Chronic endophthalmitisOften patient presents b/w ages of 2 & 9 years with:

Leukocoria

Strabismus

Unilateral VA loss

Anterior uveitis& vitritis

Greyish-white exudateon peripheral ret 
 

  • Granulomas 
    Posterior pole
    Peripheral
    VA affected if it affects the macula and/or optic nerve

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Complication of which disease?

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Toxocariasis 
( Granulomas) 

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THYROTOXICOSIS 

(Metabolic disease) 

 

 

  • Hyperthyroidism
    = excessive secretion of thyroid hormones

 

  • Graves disease
    Most common subtype of hyperthyroidise
    ⇒ Autoimmune disorder (over-secretion of thyroid hormones) 
    More common females 

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THYROTOXICOSIS 

(Metabolic disease) 

Symptoms?

  • Onset: in 30s or 40s
  • Weight loss despite good appetite
  • Increased bowel frequency
  • Sweating
  • Heat intolerance
  • Nervousness
  • Irritability
  • Palpitations
  • Weakness and fatigue

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THYROTOXICOSIS

(Metabolic disease)
General Signs?

  • Goitre
  • Finger clubbing
  • Raised plaques on the legs 

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THYROTOXICOSIS

(Metabolic disease)

Symptoms in Eyes ?

  • Lid retraction & proptosis (Eye bulging forward) 
  • Chemosis 
    = Eye irritation, conjunctiva filled with fluild, swollen

 

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RHEUMATOID ARTHRITIS 

( Autoimmune systemic disease) 

 

  • Autoimmune systemic disease 
  • More common in females than males
  • Presents in the 40s with joint swelling

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RHEUMATOID ARTHRITIS 

( Autoimmune systemic disease)
Ocular signs?

 

  • Keratoconjunctivitis sicca 
  • Scleritis
  • Ulcerative keratitis

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SYSTEMIC LUPUS ERYTHEMATOSUS ( SLE)

(Metabolic disease)

 

  • Autoimmune, non-organ specific connective tissue disease 
  • Causes widespread vasculitisand tissue damage
  • Predominantly affects young females
  • Ocular signs:
    madarosis,
    keratoconjunctivitissicca,
    scleritis,
    peripheral ulcerative keratitis,
    retinal vasculitisand optic neuropathy 

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SJOGREN Syndrome 

( Metabolic disease) 

?

 

  • Autoimmune inflammation
    and destruction of lacrimal and salivary glands 
    ( dry tounge) 
     
  • Classified as primary when it exists in isolation, and secondary when associated with other diseases such as RA, SLE etc

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SJOGREN Syndrome 

( Metabolic disease) 

Signs?

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GIANT CELL ARERITIS !!! 
Symptoms ?

  • Inflammation of medium & large arteries
  • Patient usually presents in 70s or 80s with:
    Scalp tenderness, first noticed when combing the hair
  • Headache (frontal, occipital or temporal areas, or more generalized)
  • Jaw claudication = pain on speaking and chewing
  • Polymyalgia rheumatica
    ( Muscle pain and stiffness) 

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GIANT CELL ARERITIS !!! 
Signs ?

  • Superficial temporal arteritis is characterized by thickened, tender inflamed and nodular arteries which cannot be flattened against the skull

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GIANT CELL ARERITIS !!! 
Ocular Signs ?

  • Arteritic anterior ischaemic optic neuropathy (AION) most common symptom
  • Transient ischaemic attacks (amaurosis fugax) may precede AION
  • Cilioretinal artery occlusion
  • Central retinal artery occlusion
  • Diplopiatransient or constant c/b ischaemia of the ocular motor nerves or extraocular muscles

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Signs?

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Giant Cell Arteritis 
[ Arteritic Anterior Ischaemic Opic Neuropathy] 
AION