1. Julie Jantzi, O.D.
Mallory Cranmer, O.D.
Neal Shastri, O.D.
Noushin Ahmed, O.D.
Seidenberg Protzko Eye Associates

2. Epidemiology
• ~15 per 100,000 in U.S. each year
• Causes 10% of blindness in U.S.
• Third leading cause of blindness in developed countries
• Prevalence varies by location, age, and date of study
• Highest among >65 years of age
• Females
• Chronic and unilateral
• Anterior Uveitis most common

3. Pathophysiology
• Inflammation of the uvea
• Infectious, traumatic,
neoplastic, autoimmune,
idiopathic
• Inflammatory response:
chemical mediators result
in vasodilation, increased
vascular permeability, and
chemotaxis of
inflammatory cells in eye.

4. Inflammatory Cascade
Photo Credit: Studyblue.net

5. Classification
Location
Duration
Type
Anterior Uveitis
Acute
Granulomatous
Intermediate
Uveitis
Chronic
Nongranulomatous
Posterior Uveitis
Panuveitis

6. Symptoms
• Redness
• Pain
• Photophobia
• Epiphora
• Blur
• Scotoma
• Floaters
Photo Credit: www.sunglasswarehouse.com

7. Clinical Signs
Anterior to Posterior

8. Eyelid
• Vitiligo
• Nodules
• Lesions
Photo credit: http://www.pcds.org.uk/clinical-guidance/vitiligo

9. Conjunctiva & Episclera
• Ciliary Flush
• Diffuse injection
Photo credit: http://www.mastereyeassociates.com/eyediseases-treatments/iritis---anterior-uveitis/

10. Cornea
• Keratic Precipitates
• Granulomatous
• Non-granulomatous
• Fibrin
• Pigment
• Corneal Edema
• Band Keratopathy*
Photo Credit:
http://www.optometricmanagement.com/articleviewer.aspx?artic
leid=71765

11. Anterior Chamber
• Cells
• Flare (serous)
• Pigment
• Hypopyon (purulent)
• Plasmoid (Fibrinous)
• Hyphema + hypopyon
(sanguinoid)

12. Grading

13. Iris
• Nodules
• Busacca
• Koeppe
• Posterior synechiae
• Heterochromia
• Granulomas
• Atrophy (stromal)*
• Cyclitic membrane
formation*

14. Angle
• Nodule (Berlin)
• Vascularization
• Peripheral anterior
synechiae
• Secondary Ciliary body
detachment*

15. IOP
• Hypotony
• Secondary Glaucoma*
(Van Bus-kirk EM: Clinical Atlas of Glaucoma. Philadelphia: WB Saunders, 1986.)

16. Vitreous
• Cells
• Flare
• Snowball Opacities
• Snowbanking
• Active
• Inactive
• Vitreal Strands
Photo credit: Mohawk Valley Retina

17. Retina
•
Retinal/choroidal
inflammatory infiltrates
•
Sheathing of arteries/veins
•
Retinal detachment
•
Schwartz syndrome
•
RPE hypertrophy/atrophy
•
Atrophy/swelling of retina,
choroid, optic nerve head
•
Macular edema
Photo Credit: Oculist.net

18. Major Complications
• Cataracts
• Glaucoma
• Band Keratopathy
• Cystoid Macular Edema

19. Differential Diagnoses
•
Infections
•
Non-infectious
•
Masquerade syndromes
•
Large cell Lymphoma, retinoblastoma, leukemia, malignant melanoma
•
Juvenile Xanthogranuloma
•
Pigment dispersion syndrome
•
Retinal Detachment
•
Retinitis pigmentosa
•
Ocular Ishchemic Syndrome

20. Non-Infectious Uveitis

21. ANTERIOR UVEITIS:
POSTERIOR UVEITIS:
•
•
Collagen Vascular Disease
•
White Dot Syndromes
•
Acute nongranulomatous Iritis
and Iridocyclitis
Chronic Anterior Uveitis
PANUVEITIS
INTRMEDIATE UVEITIS:
•
•
•
•
Sarcoidosis
Sympathetic Ophthalmia
•
Vogt-Koyanagi-Harada Syndrome
•
Behcet Disease
Pars Planitis
Multiple Sclerosis

22. Acute Anterior Uveitis
HLA-B27 diseases
Glaucomatocyclitic crisis
Lens associated uveitiis
Postoperative inflammation: IOL associated

23. HLA-B27 DISEASES
•
Class 1 surface antigen
•
Seronegative spondyloarthropathies are strongly associated with acute
anterior uveitis and HLA-B27
•
spondylitis and sacroiliitis
Include:
•
Ankylosing spondylitis
•
Reactive arthritis syndrome
•
Inflammatory bowel disease
•
Psoriatic arthritis

24. Ankylosing
Spondylitis
•
lower back pain and
stiffness
•
men, 20-40‟s
•
HLA-B27: 90%
•
dx: sacroiliac imaging
studies - “bamboo spine”
Ocular findings (40%):
•
acute anterior uveitis - fibrin
and hypopon not
uncommon

25. Reactive Arthritis Syndrome
•
Triad: nonspecific urethritis,
polyarthritis, and conjunctivitis
often accompanied by iritis
•
HLA-B27: 95%, young adult men
•
arthritis in knees, ankles, feet,
sacroiliitis in 70% of pts
Ocular findings:
•
Mucopurulent and papillary
conjunctivits, acute
nongranulomatous iritis in 10%
Keratoderma blennorrhagicum

26. Psoriatic Arthritis
•
Inflammatory arthritis occurs in 30% of
pts with chronic psoriasis
Inflammatory Bowel Disease
•
cutaneous changes, distal phalangeal
joint inflammation, ungula involvement
•
•
20% may have sacroiliitis
•
25% develop iritis
12% of ulcerative colitis pts
and 2.4% of Chrons
disease pts develop acute
anterior
•
20% have sacroiliitis
•
60% HLA-B27 positive

27. Glaucomatocyclitic Crisis
•
Recurrent unilateral mild
acute iritis
•
Elevated IOP, corneal edema,
fine KPs, low-grade cell and
flare, slightly dilated pupil
•
Duration: hours to days
•
Associated with HLA-B54

28. Lens-associated
Uveitis
•
•
Immune reaction to lens
material: granulomatous or
nongranulmatous
KPs can be small or large,
cells mild to severe, hypopon,
PS, elevated IOP, vitritis
Postoperative
inflammation:
IOL-associated
Mild inflammation to UGH syndrome
(uveitis-glaucoma-hyphema)
IOL implantation can activate
complement cascade, cellular deposits
on IOL, synechiae formation, capsular
opacification
•
Retained lens material
•
Phthisis bulbi, persistent uveitis,
or glaucoma often occurs in
these eyes
•
iris chafing caused by the edges or
loops of IOL – mechanical irritation and
inflammation

29. Drug Induced Uveitis
•
Systemic Drugs
1. Rifabutin
2. Bisphosphonates
•
Topical Drugs
1. Metipranolol
2. Miotics
3. Prostaglandins
3. Sulphonamides
4. Diethylcarbamazine
•
Intracameral Drugs
1. Cidofovir
5. Cidofovir (intravenous)
2. Antibiotics
3. Urokinase
•
Vaccines

30. Chronic Anterior
Uveitis
Juvenile idiopathic arthritis
Fuchs heterochromic iridocyclitis
Idiopathic iridocyclitis

31. •
most common systemic disorder
associated with iridocyclitis in
children
•
iritis develops within 5-7 yrs of
onset of joint disease
•
RF: female, pauciarticular onset,
ANA
•
negative RF
•
eye is usually white and uninflamed, some pts do not have
pain
•
Ocular findings: fine KPS, flare and
cells, posterior synechiae, cataract,
glaucoma, band keratopathy,
vitreous debris, ME, chronic
hypotony, phthisis
Juvenile Idiopathic
Arthritis

32. Fuchs
Heterochromic
Iridocyclitis
•
Unilateral uveitis,
heterochromia, iris stromal
atrophy, small white stellate
KPs scattered diffusely over
endothelium
•
synechiae almost never
forms but glaucoma and
cataracts often occur
•
Associations with
toxoplamosis, HSV, and
CMV infections

33. Idiopathic Iridocyclitis
•
In many cases of chronic iridocyclitis the cause is unknown

34. Intermediate Uveitis
Pars Planitis
Multiple Sclerosis

35. •
absence of infection and systemic
disease
•
85-90% of intermediate uveitis
cases
•
5-40 yrs, healthy individuals
•
associated with HLA-DR15 and HLADR51 alleles
Pars Planitis
Clinical Characteristics:
•
80% bilateral
•
Ocular manifestations: spillover into
anterior chamber, vitreous cells,
snowballs, peripheral phlebitis and
retinal venous sheathing
•
Ddx: Syphilis, lyme, sarcoidosis, MS,
toxicarasis, lymphoma

36. Multiple Sclerosis
•
30% of MS pts will get
uveitis
•
15% of pts with pars planitis
will eventually develop MS
•
women, 20-50 yrs
•
HLA-DR2 and DR15
•
Granulomatous anterior
uveitis, intermediate uveitis,
panuveitis

37. Posterior Uveitis
Collagen Vascular Diseases
Inflammatory Chorioretinopathies of Unknown Etiology

38. Collagen Vascular Disorders
Systemic Lupus Erythematosus
Polyarteritis Nodosa and Microscopic polyangiitis
Wegener‟s Granulomatosis

39. Systemic Lupus
Erythematosus
•
Multisystem autoimmune
connective tissue disorder
•
Type 3 hypersensitivity reaction:
Antibody-immune complexes
precipitate and cause further
immune response
•
Affects heart, nervous system,
joints, skin, lungs, blood vessels,
liver, and kidney
•
Women, 15-45 years
•
Labs: ANA
•
Malar “butterfly” rash -70-80%

40. Clinical findings
Ocular manifestations in 50%
•
Keratoconjunctivitis sicca
(20%)
•
Lupus retinopathy -CWS
•
Cutaneous lesions on the
eyelids
•
Scleral inflammatory
disease
•
Neuro-ophthalmic disorders
•
Retinal vasculopathy
•
In rare cases uveitis

41. Polyarteritis nodosa
and microscopic
polyangiitis
•
Systemic vasculitis –
necrotizing inflammation of
medium and small sized
arteries
•
40-60 yrs, men, hepatitis B
•
Ocular involvement in 20%
•
Mortality rate of untreated
PAN is 90% by 5 yrs
•
Labs: p-ANCA, ESR, CRP,
tissue biopsy

42. Wegener‟s
Granulomatosis
•
Triad: necrotizing granulomatous vasculitis of upper and lower respiratory
tract, glomerulonephritis, necrotizing vasculitis of small arteries and veins
•
Involvement of paranasal sinuses is most characteristic feature
•
Ocular involvement in 50%:
-- orbital involvement: pseudotumor, cellulitis, dacryocystitis
-- anterior, intermediate, or posterior uveitis
--scleritis (necrotizing), uveitis, retinal vascular involvement
Dx: tissue biopsy, chest x-ray, CRP, ESR, c-ANCA

43. White Dot Syndromes
• Group of chorioretinopathies that are inflammatory in
nature presenting with discrete, multiple, yellow-white
lesions
• Symptoms: photopsia, blurred vision, floaters,
nyctalopia, enlarged blind spot
• Young females

44. •
Acute posterior multifocal placoid
pigment epitheliopathy (APMPPE)
•
Birdshot choroidopathy
•
Multiple evanescent white dot
syndrome (MEWDS)
•
Acute zonal occult outer retinopathy
(AZOOR)
•
Multifocal choroiditis (MCP)
•
Punctate inner choroidopathy (PIC)
•
Serpiginous choroiditis

45. Panuveitis
Sarcoidosis
Sympathetic Ophthalmia
Vogt Koyanagi-Harada Syndrome
Behcet Disease

46. Sarcoidoses
•
Multisystem non-caseating
granulomatous disorder of
unknown etiology
•
Intrathoracic : 90%, intraocular:
50%
•
Affect lymph nodes, skin, eyes,
CNS, bones and joints, liver, and
heart
•
African American, females, 20-50
years
•
Dx: chest x-ray, lymph node biopsy,
elevated ACE and lysozyme levels

47. Ocular Findings
•
can involve any ocular tissue
•
most common: Anterior
granulomatous uveitis
–mutton fat KP‟s, koeppe and
busacca iris nodules, synechiae
•
Posterior segment in 20% of
ocular sarcoidosis
--vitreous infiltration “string of
pearls” or “snow balls”
--granulomas seen in retinal,
choroid
--perivascular sheathing,
occlusive vascular disease
•
Eyelid granulomas
•
Conjunctival nodules
•
Lacrimal gland infiltration

48. Sympathetic Ophthalmia
•
Bilateral, diffuse granulomatous, non-necrotizing
panuveitis
•
Autoimmune inflammatory response toward ocular
antigens – delayed hypersensitivity to melanin
containing structures?
•
Occurs after surgery or trauma to an eye
•
2% of uveitis cases
•
Anterior Uveitis: mutton fat KPs, PS, thickening of
iris from lymphocytic infiltration
•
Posterior vitritis, dalen-fuchs nodules,
peripapillary choroidal lesions, exudative RD

49. •
Cell-mediated autoimmune process
driven by T lymphocyctes directed
against self-antigens associated with
melanocytes of all organ systems
•
Higher association in darkly pigmented
ethnic groups
•
4% of uveitis referrals in US
•
Chronic, bilateral, diffuse,
granulomatous panuveitis with
integumentary, neurologic, and auditory
involvement
Vogt-KoyanagiHarada Syndrome

50. Stages
Acute: bilateral granulomatous
anterior uveitis, vitritis,
thickening of choroid, edema
and hyperemia of optic nerve,
multiple serous retinal
detachments
Convalescent: “sunset glow”
fundus, skin changes: vitiligo,
alopecia, poliosis
Chronic recurrent: repeated
bouts of uveitis

51. Behcet Disease
• chronic, relapsing,
occlusive systemic
nongranulomatous
vasculitis of unknown
etiology
• recurrent oral ulcers,
skin lesions, genital
ulcers, ocular
inflammatory disease
(70%)
• can affect all portions
of uveal tract

52. Ocular Findings
80% bilateral
• Anterior uveitis:
hypopyon in 25% of
cases
• Posterior segment:
necrotizing retinal
vasculitis affects both
veins and arteries
• Optic nerve affected in
25% of pts
• Visual prognosis is
guarded -25% VA <
20/200

53. Infectious Uveitis
•Viral – Herpetic, CMV
•Fungal
•Protozoal - Toxoplasmosis
•Helminthic - Toxocara
•Bacterial – Syphilis, Lyme, Tuberculosis, other

54. Viral
• Herpes Simplex:
• Usually iritis is a keratouveitis but can be: corneal,
cutaneous, retinal
• arborized
• +/- KPs, +/- Hypopyon
• HSV-1 is generally oral-labial HSV-2 generally genital
infections, although crossover does occur.
Image: C. Blake Perry. Source: http://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/HSV-epithelial-keratitis.htm

55. Viral
• Herpes Zoster
•
•
•
•
72 hours PHN
¼ ocular involvement
Infiltrative pseudodendrites (negative stain)
Typically elderly and immunocompromised
Image:Yanoff, Myron, and Jay Duker. Ophthalmology. 3rdrd ed. N.p.: Mosby Elsevier, 2009. 223. Print.

56. •
Viral
ARN
•
•
•
•
•
•
VZV>HSV>CMV
Immunocompetent
Starts unilateral but 36%Fellow eye
Within 6 weeks of onset
Painful, Floaters, LOV
Peripheral „creamy‟ necrosis that spread,
occlusive vascular involvement, Panuveitis
• Poor Prognosis, RD in 75%
• PORN
• VZV mainly
• Immunocompromised
• Posterior pole involved early
• Patchy confluent necrosis, weak or
absent uveitis, no vascular involvement
• Poor Prognosis, RD in 70%
Images: Baumal, Caroline et al. Duane‟s Ophthalmology ,2006.‟Acute Retinal
Necrosis and Progresive Outer Retinal Necrosis Syndromes Accessed online:
http://www.oculist.net/downaton502/prof/ebook/duanes/pages/v3/v3c028.html#ref

57. Viral
• CMV
•
•
•
•
•
•
•
CD4 <50-100
Most common opportunistic infection in AIDS
In congenital cases + birth defects
Before HAART ~30% of CD4<50
After HAART incidence decreased 75-80%
May start by looking like CWS (small infiltrates)
Perivascular hemorrhages, white necrotic retina, frosted
branches /vasculitis
Image: Yanoff, Myron, and Jay Duker. Ophthalmology. 3rdrd ed. N.p.: Mosby Elsevier, 2009. 796. Print.

58. Protozoal
• Toxoplasmosis
• Toxoplasma gondii
• Undercooked meat /cat feces
• Most common posterior uveitis in immunocompetent
individuals
• Often acquired in utero (0.2-1% of pregnancies)
• Further Trimester = increased chance of exposure, worst if
acquired early (spontaneous abortion)
• Majority do not develop ocular manifestations
Image: Tabbara. Khalid. „Toxoplasmosis‟. Duane‟s Ophthalmology 2006. Accessed online:
http://www.oculist.net/downaton502/prof/ebook/duanes/pages/v4/v4c046.html

59. Protozoal
• Toxoplasmosis
• „Headlights in the fog‟
• Focal chorioretinal scar with adjacent necrosis and dense
vitritis
• With AIDS may have multiple lesions
• Often self-resolving over months
• May use sulfadiazine, pyramethamine, steroids.
Image: Tabbara. Khalid. „Toxoplasmosis‟. Duane‟s Ophthalmology 2006. Accessed online:
http://www.oculist.net/downaton502/prof/ebook/duanes/pages/v4/v4c046.html

60. Helminthic Parasites
• Toxocaraisis
• Ingesting eggs of Toxocara
• Dogs >cats
• Acquired through soil, or uncooked food
• Particularly affects kids with pica
• Yellow white mass with tractional component, may have
vitritis.
• Often leads to TRD
• Treat uveitis, consider anti-helminthics (albendazole)
Image: Yanoff, Myron, and Jay Duker. Ophthalmology. 3rdrd ed. N.p.: Mosby Elsevier, 2009. 834. Print.

61. Bacterial
• Syphilis
•
•
•
•
•
•
Treponema pallidum
„Great Mimicker/Masquerader/Imitator‟
Enters through intact mucosa
Ocular Syphilis in 2‟ and 3‟ stages (2-6 mo after)
Uveitis most common ocular manifestation (up to 10%)
Affects immunocompetent or immunocompromised
Image: „Syphilis‟. WebMD. Accessed Online: http://www.webmd.com/sexual-conditions/guide/syphilis

63. Bacterial
• Syphilis
•
•
•
•
•
•
•
Dilated iris capillaries (iris roseola)
Chorioretinitis, „salt and pepper‟
Vasculitis, vitritis, neuroretinitis, CNV, optic neuritis
Granulomatous or non-granulomatous uveitis
Argyll Robertson
Interstitial Keratitis
Tests:
• Nontreponemal (VDRL / RPR)
• Treponemal (FTA-ABS / MHA- TP)
• Tx: Penicillin
Image: Yanoff, Myron, and Jay Duker. Ophthalmology. 3rdrd ed. N.p.: Mosby Elsevier, 2009. 800. Print.

64. Bacterial
• Lyme
•
•
•
•
•
Borrelia burgdorferi
1: rash (e. migrans)
2: dermatologic, neurologic, cardiac
3: Late arthritis, cranial and peripheral nerves
50% reported no hx of tick bite
Image: Sources for Rashes: Poster: "Looking for a Bull's-Eye Rash? Look again - erythema migrans can take many
forms. A collaborative effort between the Maryland Department of Health and Mental Hygeine and the Lyme
Disease Research Foundation of Maryland Maryland.http://www.bayarealyme.org/get-help/lymes-many-symptoms

65. Bacterial
• Lyme
1. Conjunctivitis early
2.Motility / CN palsies, optic neuropathy, PTC,
chorioretinitis, uveitis
3. Stromal keratitis, symblepharon
ELISA, Western Immuoblot
Tx: Doxycycline, amoxicillin, if needed ceftriaxone
Image: Pediatric Associates of Connecticut. „Tick Bites and Lyme Disease, Accessed Online:
http://www.pediatricdoc.com/newsletter.cfm?nid=625

66. Bacterial
• Tuberculosis
•
•
•
•
•
•
•
•
•
•
Mycobacterium tuberculosis
Incidence: Annually ~9.3 million patients worldwide
Communicable: inhaled aerosolized droplets
Primarily involves the lungs
Uveitis is common
Cough, fever, night sweats
Caseating necrotic granulomas
CXR
PPD / Mantoux testing
TB blood tests: interferon-gamma release assays (IGRAs)
Images taken from wikipedia . Accessed online: http://en.wikipedia.org/wiki/Tuberculosis_diagnosis

67. Bacterial
• Tuberculosis
•
•
•
•
Granulomatous anterior, intermediate or posterior uveitis
Vasculitis with choroiditis, or choroidal tubercles
Phlyctenular conjunctivitis
Tx: Rifampin, Isoniazid, Pyrazinamide, Ethambutol
Image: Yanoff, Myron, and Jay Duker. Ophthalmology. 3rdrd ed. N.p.: Mosby Elsevier, 2009. 808. Print.

68. Infectious
Endophthalmitis
• Endogenous (<10%)
• Systemic via blood stream
• Organisms causing endocarditis and GI tract are primary sources,
usually with sepsis, immunocompromise, IV drug abuse,
catheders.
• Typically less pain and inflammation, and can be bilateral
• Exogenous
•
•
•
•
Trauma, Surgery, Infection
Acutely is usually gram + (normal flora)
Decrease in occurrence over the last 30 years.
Bleb-associated may occur at any time.
• Acute 0.061-0.3%
• Delayed 0.2-18% (variable reports)
Image taken from „Endophthalmitis‟ by the American Academy of Ophthalmology 2013. Accessed Online:
http://www.aao.org/theeyeshaveit/red-eye/endophthalmitis.cfm

69. Infectious
Endophthalmitis
• EVS
• used <6 weeks, for cataract PO (Acute Onset)
• Blur (94%), red eye (82%), pain (74%), hypopyon
(86%)
• No view of retinal vessels in 79%
• Red reflex present in only 32%
• Immediate vitrectomy if LP or worse.
• B scan
• Tx: culture, Vancomycin/Amikacin/Ceftazidime +/Dexamethasone

70. Masquerade
Syndromes
Accounts for nearly 5% of all patients with uveitis at tertiary referral.
Neoplastic Masquerade
• Lymphoma
• Uveal melanoma
• Retinoblastoma
• Juvenile xanthrogranuloma
• Metastatic tumors
Nonneoplastic Masquerade
• Retinitis Pigmentosa
• Ocular Ischemic Syndrome
• Retinal detachment
• Intraocular Foreign Bodies
• Pigment Dispersion Syndrome

71. Lymphoma
• 5th to 7th decade of life
• 25% ocular involvement
• 15% ocular as initial presentation
• 56% with ocular involvement develop
CNS involvement
• Variable uveitic presentations
unresponsive to therapy
• Can mimic chronic uveitis

72. Lymphoma: Ocular Findings
• Benign reactive uveal
lymphoid hyperplasia
• Mobile, fleshy
episcleral/conj mass
• Retinal findings: classic
creamy-yellow sub-retinal
infiltrates with overlying
RPE detachments
mimicking sarcoid or
birdshot
• Anterior uveitis
• CME

73. Lymphoma
• Diagnosis
• MRI
• Cerebrospinal fluid
analysis
• Tissue diagnosis
(definitive method)
• Treatment
• Intravenous and
intravitreal methotrexate
• Radiation & IV
Cytarabine
• >60 years = chemo only
• <60 years = combination
radiation & chemo
• Prognosis = poor

74. Uveal Melanoma
• 5% ocular inflammation
• Episcleritis, ant/post
uveitis, endophthalmitis
Retinoblastoma
• 1-3 % with ocular
inflammation
• White pseudohypopyon
• Conjunctival chemosis
• Ultrasound: low internal
reflectivity
• Diffuse infiltrating variant
• 4-6 years old
• Limited visibility of fundus

75. Juvenile
Xanthogranuloma
• Occurs before age 1
• Red-yellow skin lesions
• Lesions can involve iris =
spontaneous hyphemas
• Skin of eyelid involved,
globe usually spared
• Treatment: topical,
periocular, systemic
steroids

76. Metastic Tumors
•
Adults
•
•
Metastic melanoma: brown
spherules in retina
Most common: Cutaneous
Melanoma
•
Others: white-yellow
•
Perivascular sheathing,
necrotizing retinitis, retinal
vasculitis
• Lung, GI, breast
•
Vitritis, serous detachment,
CME
•
Iris nodules, NVI, high IOP
•
Anterior uveitis
•
Bilateral and multifocal
•
Rare

77. Nonneoplastic
Masquerade
• RP
• Waxy disc pallor,
attenuation of arterioles,
bone-spicule mid-periphery
• +FHx
• Nyctolopia
• Vitritis, CME
• ERG depressed early
Source: http://www.rpfightingblindness.org.uk

78. Ocular Ischemic
Syndrome
• Males >65
• CC: decreased vision, mild
pain
• Corneal edema, A/C
reaction, flare>cells, NVI,
NVA,
• decreased IOP (ischemia),
high with NVG
• Mild disc edema, dilated
tortous veins
• mid peripheral hemes
• NVD/NVE
• FA
• Delayed arteriole filling
• Diffuse leakage
• Capillary non-perfusion
•
Carotid doppler > 90%
diagnostic
•
Treatment
• Endarterectomy
• Topical corticosteroids &
cycloplegics
• PRP for neo
• Anti-VEGF injection
• 5 year mortality rate of
patients 40%
• Transient improvement,
usually worsens

79. Retinal Detachment
• Chronic Peripheral
Rhegmatogenous
• AC reaction
• Vitreous inflammatory &
pigment cells
• Good vision, may worsen
due to CME
• Photoreceptor outer
segments may be present
in AC simulating
inflammatory response
• IOP elevated, OAG
• Schwartz syndrome
• DFE with scleral
depression
• Peripheral demarcation
lines, subretinal fluid,
retinal breaks, subretinal
fibrosis, peripheral cysts
http://gridironforgirls.blogspot.com

80. Intraocular FB
• Chronic inflammation
• Mechanical, chemical,
toxic, or inflammatory
inflammation of ciliary
body
• Gonio, ultrasound, CT of
eye/orbits
• Complications:
proliferative
vitreoretinopathy and
endophthalmitis
Pigment Dispersion Syndrome
• Pigment released from iris
and/or ciliary body
• Simulates anterior uveitis

81. Management and
Treatment
Cycloplegics and mydriatics
Corticosteriods
Immunomodulating Agents
Pressure-lowering medications

82. Cycloplegics
Mydriatics
• These opthalmic
preparations block the
responses of the iris
sphincter and the
accommodative muscle of
the ciliary body to
cholinergic stimulation,
producing pupillary dilation
(mydriasis) and paralysis of
accommodation
(cycloplegia)
• Tropicamide 1%,
cyclopentolate and atropine
have both properties
• Phenylephrine has only
mydriasis.
www.lookfordiagnosis.com/mesh_info.php?term=

83. Cycloplegics
Purpose:
•To break or prevent posterior
synechiae and to relieve ciliary
spasm induced photophobia.
•Short acting vs. long acting
cycloplegics
•Dosing depends on the extent
of inflammation
•(1-2xdaily atropine, 3xdaily
tropicamide and
phenylephrine)

84. www.opsweb.org/?page=Scien
tificExhibit
portalcodgdh.minsaude.pt/index.php/Dissecção
_
Posterior synechiae

85. Antigen-dependent lymphocyte activation and STEROID/NSAID
activation sites
Cunningham, Emmett. Practical approach to the use of corticosteroids in patients
with uveitis. Can J Opthalmol 2010; 45:352-8

86. Corticosteroids:
Produced through the
hypothalamus, pituitary and adrenal axis
(HPA) to control inflammation in uveitis
http://pubs.niaaa.nih.gov/publications/arcr
344/images/stephens01.png

87. Common uses of
corticosteroids
-Mainstay of initial therapy
Cunningham, Emmett. Practical approach to the use of corticosteroids in patients with
uveitis. Can J Opthalmol 2010; 45:352-8

88. Ocular Surface
Penetration
Durezol>Pred
Forte> FML
larrazabaleye.com/cvep.html
www.revoptom.com/content/c
/216
www.revoptom.com/content/c
/216
TOPICAL STEROIDS

89. Topical Steroids
Cunningham, Emmett. Practical approach to the use of corticosteroids in patients with uveitis. Can
J Opthalmol 2010; 45:352-8

90. Topical Steroids
•Suspension vs.
emulsion
•Concentration vs.
efficacy
www.pharmainfo.net/reviews/microemulsionsnovel

91. Potency
Cunningham, Emmett. Practical approach to the use of corticosteroids in patients with
uveitis. Can J Opthalmol 2010; 45:352-8

92. Adverse Effects of
Corticosteroids

93. Adverse Effects continued
www.amardeepeyecare.com/ptosis.html

94. continued
www.lpeyecare.com/eyeconditions/252-2

95. Intravitreal Injections
Cunningham, Emmett. Practical approach to the use of corticosteroids in
patients with uveitis. Can J Opthalmol 2010; 45:352-8

96. NSAIDS
•
www.uninet.edu/cin2001-old/conf/bala/bala.html
•
www.thedrugmonitor.com/coxi.html

97. Systemic NSAIDS
• Complications of prolonged use:
-myocardial infarction
-hypertension
-stroke (selective Cox-2 inhibitors)
www.mayoclinic.com/health/medic
www.ohioinjurylaw.com/ohioattorney/medical-mal

98. Immunomodulating
Medications (IMT)
• Antimetabolites
• T cell signaling Inhibitors
• Alkylating Agents
• Biologic response modifiers
www.riskindoc.com/new_psoria

100. Indications for IMT
 inadequate response of uveitis to corticosteroid therapy for greater than 3
months with doses exceeding 5-10mg/day.
 contraindications to corticosteroid use:
1. (diabetes, hypertension, peptic ulcer, GERD, immunocompromised
state, psychiatric conditions)
2. exacerbated side effects
3.chronic corticosteroid dependence
www.fortiusfitness.com/blog/steroi
d-side-effects

101. Precautions
 No infection present
 No hepatic or hematologic contraindications
 Close physician follow up
 Teratogenic
mamaprayed.blogspot.com/2012/08/if-you-give-m

102. Antimetabolites
•
Azathioprine, methotrexate, mycophenolate mofetil
•
Azathioprine (purine nucleoside analogue)
-interferes with DNA replication and RNA transcription
-found beneficial in VKHsyndrome, int. uveitis, Behcet uveitis, sympathetic
opthalmia and necrotizing scleritis
-GI side effects (nausea, upset stomach) are cause for D/C.
-CBC, LFT every 4-6 weeks.
-Thiopurine S-methyltransferase (TPMT) testing (metabolizes 6mercaptopurine,ie 6-MP)
www.lookfordiagnosis.com/mesh_info.php?term

103. Methotrexate
•
Folic Acid analogue
•
Inhibitor of dihydrofolate
reductase and it’s DNA
replication
•
Causes extracellular
accumulation of adenosine to
create an anti-inflammatory
effect.
•
Useful for JIA (first line choice
IMT treatment for
children), sarcoidosis, panuveiti
s, various other types of uveitis
•
Prospective study for IV inj. for
refractory uveitis and uveitic
CME.
www.humira.com/jia/what-is-jia.aspx

104. Mycophenolate Mofetil
• Inhibits inosine monophosphate dehydrogenase
and DNA replication
• Side effects: reversible GI distress, diarrhea;
20%pt. pop.
• CBC monthly
• 85% effectivity in chronic uveitis patients and a
good second choice IMT for children.

105. T Cell Signaling Inhibitors
Cyclosporine and tacrolimus:
•
Calcineurin inhibitors- disrupt
T-cell receptor signal
transduction and down regulate
IL-2 transcription and CD4 T
lymphocyte receptor expression.
Sirolimus:
•
Non-calcineurin inhibitordisrupts T cell signaling that
inhibits Ab production and Blymphocytes.
www.bdbiosciences.com/research/tcell/reg

106. Cyclosporine
• SE: Nephrotoxicity and systemic hypertension;
paresthesia,hypertrichosis.
• BP, CBC, serum creatinine monthly.
• Used for int. uveitis and posterior uveitis cases from
Behcets and VKH.
• Used in combination with corticosteroids for modest
improvement

107. Tacrolimus
• AE: nephrotoxicity
• Low dose and increased potency to cyclosporine
• Less risk of hypertension and hyperlipidemia
• Useful for chronic int. and posterior uveitis.

108. Sirolimus
• One open-label, prospective study it was found useful in
treatment for refractory noninfectious uveitis
• GI side effects
• Under active investigation for use in treating uveitis

109. Alkylating Agents
Cyclophosphamide
• Active metabolites alkylate purines in DNA and RNA, creating
impaired DNA replication and cell death
• Cytotoxic to dividing and resting lymphocytes
• AE:myelosuppression, hemorrhagic cystitis, sterility
Chlorambucil
• Interferes with DNA replication
• AE:myelosuppression, sterility
Treatment for int. uveitis, VKH, SO, Behcet
Significant AE: increased risk for malignancy (leukemia, various cancers)

110. Infliximab
Biologic Response
Modifiers
• Chimeric, monoclonal IgG1k antibody against TNFalpha
• Treatment for Behcet, sarcoidosis and VKH. Some HLA
B27 ant. uveitis
• Drug induced toxicity (lupus, systemic vascular
thrombosis, CHF, malignancy, demyelinating disease and
vitreous hemorrhage)
• +PPD, contraindication
• Adalimumab, less AE, same effectiveness

111. Alternative Therapy Under
FDA Investigation
• Rituximab:chimeric monoclonal antibody against CD20
positive cells (B lymphocytes)
• Daclizumab: monoclonal Ab to IL-2
• IFNalpha2a: antiviral, immunomodulatory and
antiangiogenic effects (leukopenia and thrombocytopenia
side effects)

112. Management/Follow up
• Encounter visit determines
extent of ocular inflammation
(ant., int., panuveitis, etc).
• Make a differential list and
send out for further pertinent
lab work to confirm/rule out
differentials.
super-trainer.com/fitness-business-becoming-a-bu

113. Anterior Uveitis
• Cycloplegic
• Steroid
• Dosage depends on severity
• Follow up in 2-3 days
• If 2-3 additional follow up
appt. prove no
improvement, referral to
uveitis specialist
medlibes.com/entry/anterior-uveitis

114. Intermediate/Posterior Uveitis
• Determine extent of
inflammation, if anterior
involvement, start on
cycloplegic and steroid.
• Refer to retinal specialist for
periocular steroid injections (if
deemed non-infectious)
• Intravitreal injections for
chronic anterior uveitis or
inflammation not responsive
to periocular injection
www.retinaeye.com/uveitis.html

115. Uveitic Treatment
Adverse Effects
• Steroid responders:
Need to lower IOP by utilizing beta blockers, alpha2
agonists,CAI, prostaglandins and their combinations
where appropriate.

116. Case #1
• 70+ yr old cauc. male
• Redness, mild pain, blurry
vision in the right eye.
• Slit lamp: 2+ AC WBC
reaction; florrid NVI,NVA,
corneal edema with descemet
folds; IOP 16mmHg OD

117. Differentials?
• Neovascular glaucoma
• OIS
• PDR

118. OIS!
• DFE: mid-peripheral blot hemorrhages
• No CME, NVD, NVE
• Tx: Prednisolone Forte q2hrs, Atropine BID OD
• Referral to retinal consult for PRP and possible injections of anti-vegf
• Contact PCP for carotid doppler, echocardiogram, EKG

119. Case #2
• 17 yr cauc. female
• CC:
redness, pain, photophobia, bl
urry vision
• Review of systems was
unremarkable
• Second episode, first episode
two years ago in GA.

120. Review of Systems
• General - Weight loss, fatigue, fever Skin - Rash, nodules, changes in
nails
• Neck - Lymphadenopathy
• Respiratory - Cough, wheezing
• Cardiac - Chest pain/discomfort, dyspnea
• Gastrointestinal - Hepatomegaly, diarrhea, frequent bowel movements
• Genitourinary - Delayed secondary sexual characteristics
• Musculoskeletal - Muscle or joint pain, arthritis, back pain, limitation
of motion
(refer to uveitis.org for more information and questionnaire)

121. Differentials?
• JIA, lyme disease, lupus, sarcoid
• ?????
• Ran pertinent lab tests for her age (CBC c diff.,ANA, ACE,
Lyme titer,ESR,RF, HLA B27)
• Durezol q2hrs, Atropine BID OD. Pledget of 10%
phenylephrine to break posterior synechiae
• CBC with diff., lyme titre, RF, ANA, ACE, serum lysozyme
• Blood results…negative. Consult with uveitis specialist.

122. Case 3

123. Chief Complaint
• 46 year old WM
• Redness OS x 5 days, gradually getting worse
that is constant throughout the day
• (+) photophobia, epiphora
• ( - ) eye pain, flashes, floaters, cold sores
• He was seen at Patient First 3 days ago where
they diagnosed him with shingles over the left
eyelid, noting ocular involvement
• Treated with 20 mg Pred, mild pred taper and 1
gm of Valtrex tid x 10 days

124. History
• Medical History
• Hypertension, GERD
• Treated with Omeprazole and Diovan
• Family Medical History
• Unremarkable

125. Examination
• VA sc 20/25 OD, OS, OU
• OD unremarkable findings
• OS
• Lid: vesicles along upper
forehead & nose, lid
erythema, small hordeolum
• Conj: nasal injection

126. Examination
• Cornea
• Punctate Epithelial Keratitis
• Inferior stromal haze
• Anterior Chamber
• Cells – WBC 2+
• ( - ) Flare
• IOP 16, 19 mm Hg
• Fundus
• Unremarkable OU

127. Examination
• Fundus Unremarkable, OU

128. Assessment
1. Redness/Discharge of
Eye OS
1. Educated patient on
findings
2. H. Zoster
Keratoconjunctivitis OS
2. Neomycin ung on
vesicles, BID
3. H. Zoster Iridocyclitis, OS
3. Pred Forte TID, OS
4. H. Zoster of Eyelid
4. Cool compresses and
antibiotic ung on vesicles

129. Follow Up: 2 days later
• Patient now complains
of eye pain in the
morning
• Thinks it is getting
worse
• Currently taking pred
forte tid OS and will
finish Valtrex the
following week

130. Examination: 2 days
•
VA sc 20/25 OD; 20/40 OS PHNI
•
OD unremarkable
•
OS Lid: Vesicles along upper
forehead & nose with lid
erythema, hordeolum on superior
lid
•
Cornea
• Prominent pseudodendrites
•
Anterior Chamber
• 2+ WBC
•
IOP 16, 27
•
Fundus: Unremarkable OU

131. Assessment: 2 days
1. Zoster, Eyelid OS
1. Continue ointment
2. Zoster Iridocyclitis, OS
2. Continue pred forte tid,
atropine instilled in office
Due to increased IOP:
Combigan OS bid
RTO 1 week

132. Follow up: 1 week later
• Currently on pred forte TID, Combigan BID, OS
only
• Finished Valtrex
• Feels improvement

133. Examination: 1 week
• VA sc 20/25 OD, 20/40-2
PH 20/25-, OS
• OD unremarkable
• OS
• Lids: healed vesicles, mild
ptosis
• Conjunctiva: Trace injection
• Cornea: Pseudodendrites
with endothelialitis inferiorly
• Anterior Chamber: 2+ WBC
• IOP 17, 20

134. Assessment: 1 week
1. Redness/discharge of
eye OS
1. Injection improved, less
tearing
2. H. Zoster of eyelid OS
2. Complete resolution
3. Zoster iridocyclitis
3. Durezol QID, atropine in
office (increased IOP);
continue combigan BID
OS
4. H Zoster
keratoconjunctivis
4. Pseudodendrites stable

135. Follow up 2 weeks later
• Patient reports improvement
• VA sc 20/30 PH 20/25 OD, OS
• OD unremarkable
• OS
•
•
•
•
Lid: no vesicles
Conjunctiva: trace injection
Cornea: punctate staining
Anterior chamber: KP‟s less
evident
• IOP 16, 18 mm Hg

136. Assessment: 2 weeks
1. H Zoster Iridocyclitis, OS
1. Improvement with quiet
A/C, IOP stable
--Continue Combigan BID OS
--Taper durezol over 2 weeks,
then D/C
--RTO 5 weeks

137. Follow up 5 weeks later
• Patient currently on
Combigan BID OS only
• VA sc 20/25 OD; 20/30
• OD unremarkable
• OS
• Conjunctiva: tr injection
• Cornea: punctate staining
• Anterior chamber: NO cells
• IOP 16, 18 mm Hg
• Assessment
• H. Zoster Iridicyclitis
• No signs of recurrent
inflammation; IOP well
• D/C combigan
• Follow up 1 month for IOP
check

139. References
• Cunningham, Emmett. Practical approach to the use of corticosteroids
in patients with uveitis. Can J Opthalmol 2010; 45:352-8
• Moorthy, Ramana. Intraocular Inflammation and Uveitis.American
Academy of Opthalmology. Section 9. pgs 98-116.
• http://www.uveitis.org/uveitis-questionnaire
• http://emedicine.medscape.com/article/1209891-clinical
• “Care of the Patient with Anterior Uveitis,” Optometric Clinical Practice
Guideline. American Optometric Association.