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UVEITIS
成大眼科
楊勝吉
Definition
 An inflammation of the uveal tract
 Uveal tract: iris, ciliary body, choroid
 Intraocular inflammation, not only theuvea,
but also adjacent structures
Classification
Aetiological: exogenous, endogenous
Pathological: granulomatous, nongranulomatous
Medical history
Systemic Evaluation
 Skin
 Joints
 Lung
 Neurologic
 GI
 GU
 etc
Symptoms
and Signs
Symptoms
 Redness
 Pain
 Photophobia
Signs
 Injection
 Keratic precipitate (KP)
 Iris nodule
 Koeppe, Busacca
 Lacrimation
 Cells (AC or Vitreous)
 Floaters
 Flares
 Decreased vision
 Posterior synechiae (PS)
 Choroiditis
 Retinitis
 Vasculitis
Fig. 11.2 Signs of acute
anterior uveitis. (A) Ciliary
injection; (B) miosis; (C)
endothelial dusting by cells;
(D) aqueous flare and cells;
(E) fibrinous exudate; (F)
hypopyon
Posterior
synechia
Keratic precipitates. (A)
Aggregate of inflammatory
cells on the corneal
endothelium; (B) large
‘mutton-fat’ keratic
precipitates; (C) ‘ghost’
keratic precipitates; (D) old
pigmented keratic
precipitates
Signs of
posterior uveitis.
(A) Retinitis; (B)
Choroiditis; (C)
vasculitis
Iris nodules in granulomatous anterior
uveitis. (A) Koeppe nodules; (B) Busacca
nodules
Cells & Flare
Cells: active inflammation
Flare: leakage of protein
Special investigations
 Indications
 Granulomatous inflammation.
 Recurrent uveitis.
 Bilateral disease.
 Systemic manifestations without a specific
diagnosis.
 Confirmation of a suspected ocular picture
which depends on the test result as part of the
criteria for diagnosis such as HLA-A29 testing
for birdshot chorioretinopathy.
Skin test
(A) Positive tuberculin skin reaction; (B)
strongly positive tuberculin skin reaction;
(C) positive pathergy test in Behçet
syndrome
Other tests
 Imaging:
 Fluorescein angiography (FA), Indocyanine green
angiography (ICGA), Optical coherence
tomography (OCT)
 Radiology
 Chest X-ray, Sacroiliac joint X-ray, CT and MR
 Biopsy
 HLA type
Treatment
 Mydriatics
 Steroids
 topical, periocular injection, systemic
 Calcineurin inhibitors:
 Cyclosporin, Tacrolimus
 Antimetabolites:
 Azathioprine, MTX,
Anterior uveitis
 Acute
 HLA-B27 related diseases
 Behcet syndrome
 Glaucomatocyclitic crisis
 Lens-associated uveitis
HLA-B27 Related
Diseases
 Seronegative spondyloarthropathies
 Ankylosing spondylitis
 Reiter syndrome
 Inflammatory bowel disease
 (enteropathic arthritis)
 Psoriatic arthritis
Ankylosing Spondylitis
 Acute iritis, Sacroiliitis and spondylitis
 HLA-B27
 General population: 5%
 Acute iritis: 45%
 AS: 90%
 Both AS & acute iritis: 95%
c. Circinate balanitis
d. Keratoderma blennorrhagicum
Reiter Syndrome
 Young adult male
 Classic triad
 Urethritis
 Polyarthritis
 Conjunctivitis (the most common) or acute iritis
Behcet Syndrome (1)
 Generalized occlusive vasculitis
 Posterior involvement > Anterior
 retinal vasculitis, hemorrhage, necrosis,
macular edema, ischemic optic neuropathy
(A) Major aphthous
ulceration; (B)
genital ulceration; (C)
superficial
thrombophlebitis; (D)
dermatographia
Behcet Syndrome (2)
 Skin lesion: erythema nodosum
 HLA-B51
 Young adults
 Recurrence
 Poor prognosis
Glaucomatocyclitic Crisis
(Posner- Schlossman Syndrome)
 Unilateral mild iritis: (low grade cells, flare)
 Markedly elevated IOP
 Recurrence are common
 A diagnosis of exclusion
Lens-Associated Uveitis
 Phacoantigenic glaucoma
 Lens capsule injury (immune response to lens
protein)
 Mutton-fat KP, dense cells & flare, PS
 Phacolytic glaucoma
 Intact capsule, hypermature cataract
 Acute increase of IOP (clogging of TM by lens
protein & engorged macrophages)
 Lack of KP, PS
Chronic Iridocyclitis
 Juvenile rheumatoid arthritis
 Most common systemic disorder associated with
iridocyclitis in the pediatric
 Female/Male: 3/2
 Risk factors for iridocyclitis:
 female, pauciarticular onset, ANA (+)
 Often white & uninflamed in appearance
 Complications:
 cataract (84%), band keratopathy (70%), macular
 edema, vitreous debris, glaucoma, phthisis
Intermediate Uveitis
 Anterior vitreous cells:
 snowballs, snowbanking
 Retinal phlebitis
 Associated with sarcoidosis, multiple
sclerosis, Lyme disease, toxocariasis,
syphilis, tuberculosis, connective tissue
disease
Pars Planitis
 Most common form of intermediate uveitis
 < 40 y/o
 Bilateral (80%)
 Vitreous condensation, cellular
 infiltration in vitreous base
 Fluorescein angiography: diffuse peripheral
venular leaking
 Major cause of visual loss: cystoid macular
edema
Posterior segment
signs in intermediate
uveitis. (A)
Peripheral
periphlebitis and a
few snowballs
inferiorly; (B) inferior
snowbanking and
snowballs; (C)
severe snowbanking,
neovascularization
and inferior retinal
detachment
Posterior Uveitis
 Infectious
 Viral: Herpes, CMV, Rubella, Measles, HIV…..
 Fungal: Histoplasmosis, Candidiasis
 Protozoal: Toxoplasmosis
 Helminthic: Toxocariasis, Cysticercosis
 Immunologic
 Collagen vascular dz: SLE, PAN, Wegener
granulomatosis
 Retinochoroidopathies
 Masquerade conditions
 Endophthalmitis: Nocadia asteroids
Cytomegalovirus retinitis
Active toxoplasma retinitis.
Toxocara granuloma
Acute retinal necrosis (ARN)
 Classic triad
 Vitritis
 Occlusive retinal arteriolitis & periphlebitis
 Multifocal yellow-white peripheral retinitis
 Pts: typically healthy & not debilitated
 Varicella-zoster, herpes simplex, CMV
 Posterior pole tends to be spared
 Multiple posterior retinal breaks &
traction/RRD
 Ischemic optic neuropathy
 Poor prognosis
Ocular Complications in
AIDS
 Up to 70% of individuals with AIDS
 May be the first sign of disseminated systemic inf.
 Microangiopathy of retina
 Various opportunistic infections
 Kaposi sarcoma
 Lymphoma
 Squamous cell carcinoma of conjunctiva
 HIV retinopathy: most common
 Retinal hemorrhage, microaneurysm, cotton-wool spots
 CMV retinitis: most common opportunistic ocular
inf.
Panuveitis
 Infectious
 Bacterial: Syphilis, Tuberculosis, Lyme dz,
 Helminthic: Onchocerciasis
 Immunologic & granulomatous
 Sarcoidosis
 Sympathetic opthalmia
 Vogt-Koyanagi-Harada (VKH) syndrome
 Masquerade syndrome
 Neoplasms
Sympathetic Ophthalmia
 Bilateral granulomatous panuveitis occurring after




penetrating trauma
The traumatized :exciting eye and the fellow eye:
sympathizing eye
Diffuse and massive lymphocytic infiltration of the
choroid
65% of cases is between 2 weeks and 3 months after
initial injury and 90% of all cases occur within the first
year.
Treatment:
 Enucleation
 Topical treatment of the anterior uveitis with steroids and
cycloplegics resistant to this form of therapy (diagnostic
clue)
 Systemic steroids, immunomodulatory therapy
Sympathetic Ophthalmia