Class date, April 21, 2020. DISEASES OF THE UVEAL TRACT. Topics of class

Materials for the for students’ classes

Class date, April 21, 2020

Theme 5: Diseases of vascular coat (uvea)

Materials on the topic of the practical class prepared assistant of the Department of ophthalmology Voronova N.N.

DISEASES OF THE UVEAL TRACT

Students should recognize the symptoms and ophthalmic signs of inflammations (uveitis): general considerations, anterior uveitis, posterior uveitis, endophthalmitis and panophthalmitis.

Perform examination of anterior segment for acute or chronic uveitis (slit lamp, magnifying lens); identification of ciliary injection, keratic precipitates, inflammatory cells, flare, fibrin, hypopyon, iris nodules, and anterior or posterior synechiae.

Topics of class

Congenital anomalies of uveal tract

Heterochromia of iris

Albinism

Corectopia

Polycoria

Congenital aniridia

Persistent pupillary membrane

Coloboma of the iris, coloboma of the choroid

Uveitis

Anatomical classification

1. Anterior uveitis.

2. Intermediate uveitis.

3. Posterior uveitis.

4. Panuveitis.

Clinical classification

1. Acute uveitis (Iritis and Iridocyclitis)

2. Chronic uveitis (Iritis and Iridocyclitis).

Pathological classification

1. Suppurative or purulent uveitis.

2. Non-suppurative uveitis.

Etiological (Duke ElderꞌS) classification

1. Infective uveitis

2. Allergic uveitis

3. Toxic uveitis

4. Traumatic uveitis

5. Uveitis associated with non-infective systemic diseases

6. Idiopathic uveitis

Signs and symptoms of anterior, intermediate, and posterior uveitis.

Infective uveitis:

a) exogenous infection (following penetrating injuries, perforation of corneal ulcer and postoperatively (after intraocular operations);

b) secondary infection (from neighbouring structures: conjunctivitis, keratitis, scleritis, retinitis, orbital cellulitis and orbital thrombophlebitis);

c) endogenous infections (caused by the entrance of organisms from some source situated elsewhere in the body, by way of the bloodstream) – play important role in the inflammations of uvea.

Allergic (hypersensitivity linked) uveitis:

a) Microbial allergy.

b) Anaphylactic uveitis.

c) Atopic uveitis.

Autoimmune uveitis (Still’s disease, rheumatoid arthritis, Wegener’s granulomatosis, systemic lupus erythematosus, Reiter’s disease)

– HLA-associated uveitis (HLA-B27: ankylosing spondylitis, Reiter’s syndrome; HLA-B5: Uveitis in Behcet’s disease; HLA-DR4 and DW15: Vogt Koyanagi Harada’s disease).

Anterior uveitis (Iridocyclitis)

Clinical features

Clinical features Symptoms:

1. Pain

2. Redness.

3. Photophobia and blepharospasm.

4. Lacrimation.

5. Defective vision

Signs of uveitis (slit lamp biomicroscopic examination):

Lid oedema;

Circumcorneal congestion;

Corneal signs: corneal oedema, keratic precipitates (KPs) and posterior corneal opacities.

Anterior chamber signs: aqueous cells; aqueous flare; hypopyon (sterile pus in the anterior chamber); hyphaema (blood in the anterior chamber); changes in depth and shape of anterior chamber; changes in the angle of anterior chamber.

Iris signs: loss

of normal pattern; changes in iris colour; iris nodules (Busacca nodule; Koeppe nodule); posterior synechiae; neovascularsation of iris (rubeosis iridis).

Pupillary signs: narrow pupil; irregular pupil shape; ectropion pupillae (evertion of pupillary margin); pupillary reaction; occlusion pupillae; seclusio pupillae.

Changes in the lens: pigment dispersal; exudates; complicated cataract.

Change in the vitreous.

Complications and sequelae of uveitis:

1. Complicated cataract.

2. Secondary glaucoma.

3. Cyclitic membrane (fibrosis of exudates present behind the lens).

4. Choroiditis.

5. Retinal complications.

6. Papillitis.

7. Band-shaped keratopathy.

8. Phthisis bulbi.

Differential diagnosis:

1. Acute red eye.

2. Granulomatous versus non-granulomatous uveitis: non-granulomatous associated systemic diseases (juvenile rheumatoid arthritis, Reiter’s syndrome, Behcet’s disease); granulomatous (associated diseases – sarcoidosis, tuberculosis, fungal).

3. Etiological differential diagnosis.

4. Acute atac of glaucoma

Treatment of iridocyclitis:

I. Non-specific treatment:

a) Local therapy:

1. Mydriatic-cycloplegic drugs.

2. Corticosteroids. 3. Broad spectrum antibiotic drops.

b) Systemic therapy:

1. Corticosteroids. 2. Non-steroidal anti-inflammatory drugs (NSAIDS).

3. Immunosuppressive drugs.

c) Physical measures:

1. Hot fomentation. 2. Dark goggles.

II. Specific treatment of the cause.

III. Treatment of complications:

1. Inflammatory glaucoma (hypertensive uveitis).

2. Post-inflammatory glaucoma.

3. Complicated cataract.

4. Retinal detachment.

5. Phthisis bulbi

Uveal melanoma.

1. Most common primary intraocular malignancy.

2. Variants: a) iris; b) ciliary body; c) choroidal.

3. Clinical presentation: a) asymptomatic vs. symptomatic;

b) pigmented vs. amelanotic.

4. Prognosis: a) size; b) cell type.

5. Treatment: a) non-surgical; b) surgical (enucleation).

6. Differential diagnosis: a) choroidal nevus; b) metastasis to eye;

c) retinal detachment.

LITERATURE

Main

1. Khurana, A. K. Comprehensive Ophthalmology

Additional

2. Kanski, J. J. Clinical Ophthalmology