ophthalmology

1. Uvea

2. Uvea
• Consists of
• Iris
• Ciliary body
• Choroid

5. Layers of iris

6. Anterior is pigmented posterior is non
pigmented

7. Histology of iris

10. Choroid

11. Arterial supply of uveal tract

17. Venous drainage through 4 vortex veins

19. • Superior vortex V drain into
superior ophthalmic V
• Inferior vortex V drain into
inferior ophthalmic V

20. Nerve supply of iris
• Sphincter pupillae & ciliary
muscles are supplied by
short ciliary nerve
(parasympathetic) post
ganglionic fibres
• Dilator pupillae by long
ciliary nerve (sympathetic)

21. Diseases of uveal tract

22. uveitis
• Inflammation of uveal tissue

23. Anatomical classification
• Anterior uveitis iris + pars plicata
• Intermediate uveitis pars plana
• Posterior uveitis choroid
• Panuveitis  all uveal tract

24. Clinical classification
• Acute <3 wks ,sudden symptomatic
• Chronic >3 wks,gradual
• Recurrent- recur after a period of 3 mths

25. pathological
uveitis
Non
suppurative
granulomatous
Non
granulomatous
suppurative

26. etiological
• Traumatic
• Toxic
• Infective
• Allergic
• Auto immune
• Other systemic d/s
• Idiopathic

27. infectious
• Exogenous
• secondary
• Endogenous
 Perforating injuries
 Perforated corneal ulcer
 Post operatively
Suppurative irido cyclitis Endophthalmitis /
panophthalmitis
Spread of infn 4m neighbouring
structures
acute purulent conjunctivitis.
keratitis, scleritis, retinitis, orbital
cellulitis and orbital
thrombophlebitis.
entrance
of organisms from some source situated
elsewhere
in the body, the bloodstream.

28. Types of infectious uveitis
• Bacterial
• Fungal
• Viral
• Parasitic
• rickettsial
Granulomatous (tb,syphilis,leprotic,brucellosis)
Pyogenic (streptococci,staph,pneumococci,gono)
HSV,HZV,CMV
systemic aspergillosis, candidiasis and blastomycosis.
toxoplasmosis,
toxocariasis, onchocerciasis and amoebiasis.
scrub typhus
and epidemic typhus.

31. Anterior uveitis
• Iris + pars plicata of ciliary body
Anterior
uveitis
iritis
Iridocyclitis
cyclitis
Inflmn of iris >> pars plicata
Inflmn of iris & pars plicata
Inflamn of pars plicata >> iris

32. symptoms
• Pain (due to rich nerve supply of sensory supply of ophthalmic
division of trigeminal N head ache,pain on forehead,scalp worse at
night
• Photophobia (edema of iris)
• Redness (circum corneal congestion)

33. Signs
• Circum-corneal congestion (inflmn  hyperaemia)

34. Anterior chamber
• Hypopyon
In severe iritis
↑PMNL exudated in to AC
sink to the bottom
hypopyon.

35. • Hyphaema
Due to spont. hge

36. Slit lamp examination
• Inflamn
• vasodilation
• exudation of protein rich (albuminous) in to AC
• plasmoid aqueous humour

37. aqeous flare  earliest sign
• Milky ‘flare’ or ‘aqueous flare’—
• Dust-like particles are seen moving in the beam of slit-lamp similar to Tyndall effect.
• leakage of proteins from damaged blood vessels

38. • Keratic precipitates (kp)
Inflamn 
inflammatory cells stick to endothelium

39. keratic precipitates
fine kps
• acute inflammation
• made of lymphoid cells
mutton kps
• granulomatous inflammation
• made up of macrophages

40. mutton fat KPs

41. fine KPs

42. stellate KPs

43. kps
Mutton fat
Small & medium
Red kps
Old kps
granulomatous
composed of epithelioid cells &
macrophages.
large,thick, fluffy, lardaceous
KPs, having a greasy
appearance.
few (10 to 15) in number
non-granulomatous uveitis
composed of lymphocytes.
small,discrete, dirty white
KPs are arranged irregularly
at the back of cornea.
Haemorrhagic uveitis.
inflammatory cells+RBCs
healed uveitis.
shrink, fade, become
pigmented and irregular in
shape (crenated margins).
ground glass appearance due
to hyalinization.

44. Arlts triangle= kps are seen in triangular
fashion
In lower part of AC
due to gravity & convection current

46. neovascularisation of iris  rubeosis iridis

47. • Depth depends on synechie formn
• Angle of anterior chamber}
• in a/c stage  cells
• In c/c stage  anterior peripheral synechiae

48. Changes in Iris
• Loss of normal pattern
in a/c stage
Water logging & edema
In c/c stage
Iris atrophy
Loss of normal
pattern

49. • Colour change
• Muddy in colour } in active stage
• Depigmented / hyperpigmented }in c/c stage

50. • Iris nodules
• Koeppe’s nodules }small and situated at the pupillary border
• Busacca’s nodules }larger and located away from the pupil.

52. Posterior synechiae
• Fibrin rich exudate  Adhesion of postr surface of iris to antr surface
of lens capsule
• Segmental
• Ring / annular synechiae
• Total postr synechiae

53. Segmental synechiae
• Adhesion at some points only

54. Festooned pupil
• d/t segmental synechia on dilation
will show festooned pupil

55. Annular posterior synechiae
• Pupillary margin is tied to lens capsule (secclusio pupillae)
• Iris bombe —The iris become bowed forewards due to collection of
aqueous in the posterior chamber
• Funnel shaped ac
On dilation with mydriatic the pupil
dilated irregularly and looks like
festive paper decoration.

56. Occlusio-pupillae or blocked pupil
Exudates organize across the pupillary area
↓
impaired vision & raised tension.

58. Total posterior synechiae
• In severe cyclitis
• exudates which may organize tying down the iris to the lens capsule.

59. Cyclitic membrane
a cyclitic membrane may form behind the lens.

60. Pupillary changes
Miotic pupil
• Edema of iris(water logging)extravasation of fluids
• Extravasated fluid contain irritantscontrn of sphincter pupillae
Reacting sluggishly to light

61. Ectropion pupillae
Contrn of organizing exudates
↓
Pigment epithelium on its posterior surface may be pulled upon to
anterior surface
↓
Patches of pigment on antrr surface

62. Pupillary reaction
sluggish or may even be absent

63. • Occlusio pupillae

64. Changes in lens
• Complicated secondary
cataract
• bread crumb or polychromatous
• Pigment deposition in a/c
• Exudates deposition
• pseudoglioma

65. Changes in vitreous
• exudates and inflammatory cells } acute iridocyclitis.

66. Intraocular tension
• In active stage
presence of exudates and inflammatory cells in the anterior chamber
↓
clogging of trabecular meshwork
↓
resulting in the decreased aqueous drainage
↓
rise in intraocular pressure (hypertensive uveitis).
• In later stage
due to pupillary block (secclusio/occlusion) Secondary glaucoma
atrophy of the ciliary body } Phthisis bulbi (hypotony)

67. Complications & sequelae
• Secondary glaucoma
• Complicated cataract
• Cyclitic membrane
• Choroiditis
• Phthisis bulbi
• Pappilitis
• Band shaped keratopathy in children with stills d/s
• Retinal  cystoid macular oedema, macular degeneration, exudative
retinal detachment and secondary periphlebitis retinae

68. • band shaped keratopathy in c/c uveitis

69. metamorphopsia in macular edema

70. dds
• a/c congestive glaucoma
• a/c conjunctivitis
Acute
Conjunct
ivitis
Acute
Iridocycliti
s
Acute
Congestive
Glaucoma
Onset Gradual Usually
gradual
Sudden
Pain Mild
discomfort
Moderate
V 1 n.
distribn.
Severe
Whole V n.
distrib.
Discharge Mucopurule
nt
Watery Watery
Colored
haloes
+/- -- +++
Vision Unaltered Impaired Severely
impaired
Congestion Conjunctival Ciliary Ciliary
IOP Normal Normal
usually
Markedly
raised
Constitution
al symptom
Assoc.
Absent Little Prostration
& vomiting

71. Investigations
• Haematological investigations
• • TLC and DLC
• • ESR
• • Blood sugar
• • Blood uric acid
• • Serological tests for syphilis, toxoplasmosis, and histoplasmosis.
• • Tests for antinuclear antibodies, RF, LE cells, C-reactive proteins, etc.
• 2. Urine examination }
• WBC, pus cells, RBC and culture to rule out urinary tract infections.
• 3. Stool examination
• cyst and ova to rule out parasitic infestations.
• 4. Radiological investigations
• X-rays of chest, paranasal sinuses, sacroiliac joints and lumbar spine.
• 5. Skin test—
• tuberculin test, Kveim’s test (sarcoidosis) and toxoplasmin test.

72. treatment
• atropine
• mydriatic & cycloplegic
• topical steroid

73. • most common complication in recurrent anterior uveitis  secondary
complicated cataract

74. Intermediate uveitis
• Pars planitis + most
peripheral part of retina
• also a/w vitreal
inflammation (hyalinitis)
• snow ball + snow banking
is seen on fundoscopic
examination
• floaters(classical
symptom) +

75. snow banking in ora serrata ininferior
quadrant

76. snow ball opacities

77. • complications
• macular edema (most common cause is intermediate uveitis)

78. • rx of intermediate uveitis
• systemic steroids

79. Posterior uveitis
Choroiditis(diffuse/focal)
↓
the outer layers of retina depend upon the choroid for nutrition
↓
inflammation of retina (chorio-retinitis).

80. complications
• exudative retinal detachment in postr uveitis

82. Clinical forms of uveitis
• Granulomatous choroiditis
direct organismal infection.
Localised accmln of c/c inflammatory cells
• Non granulomatous choroiditis or exudative choroiditis
Nonspecific
Acute cellular infiltration + exudation

83. granulomatous uveitis
• sarcoidosis
• TB
• leprosy
• syphilis
• VKH disease
• herpes simplex

87. band shaped keratopathy is seen a/w JRA

88. fuchs heterochromic iridocyclitis
2 different colours of iris in eyes

90. posner schlossman syndrome
• glaucomatocyclitic crisis
• hypertensive uveitis
• recurrent uveitis (nongranulomatous anterior ) with glaucoma (open
angle)
• mild nongranulamatous anterior uveitis severe rise of IOP (50-
60mmHg)
• rx
• rx uveitis
• donot give pilocarpine or latanoprost (contraindicated)

93. periphlebitis in sarcoidosis can lead to candle
wax dripping

95. dalen fuchs nodule are also seen

96. perilimbal vitiligo  suguiras sign

97. bilateral retinal depigmentation of fundus 
sunset glow fundus

98. dalen fuchs nodule
• seen in sympathetic ophtalmoplegia &VKH disease
• granulomatous deposits b/w retinal pigment epithelium & Bruchs
membrane

104. evisceration is contraindicated in
• sympathetic ophthalmitis  enucleation is done
• intraocular maligances

105. toxoplasmosis
• unilateral non granulomatous
• anterior & posterior uveitis
• focal necrotising retinochoroiditis

106. choreoretinitis in toxoplasmosis

107. head light in fog appearance
• haziness d/t vitritis
• headlight appearance is by choreoretinitis

108. HIV associated uveitis
• most common manifestation  microangiopathy with cotton wool
spots
• most common viral infection  CMV
• mainly causes posterior uveitis
• severe retinal vasculitis haemorrhages & opacification sauce & cheeze retinopathy
• aka pizza & pie retinopathy
• brush fire retinopathy vasculitis extends along blood vessel to reach optic N like fire
• most common fungal infection  Cryptococcus

109. cotton wool spots in HIV retinopathy

110. sauce & cheese retinopathy / pizza pie
appearance

111. brush fire retinopathy

112. herpes simplex associated uveitis
• granulomatous anterior uveitis  extensive iris atrophy

113. lisch nodules in Neirofibromatosis

115. iris pearls in leprosy

116. iris crystals in c/c uveitis
• Ig crystals  Russell bodies

118. ophthalmia nodosum
• granulomatous uveitis d/t
caterpillar hair

119. masquerade syndrome
• conditions which mimic uveitis
• intraocular malignancies
• leukemia
• lymphoma
• amyloidosis

120. uveal effusion syndrome
• thickened sclera interfere with outflow of aqueos humour
• nanophthalmos hypermetropia

121. heterochromia iris is also seen in
• c/c iritis
• horners syndrome
• wardenberg syndrome
• fuchs iridocyclitis

122. rubeosis iridosis
• CRVO
• proliferative diabetic retinopathy
• c/c iridocyclitis

123. phthisis bulbi
• result of c/c uveitis
• intraocular tension is reduced due
to decreased aqueous humour
formation
• marked thickening of sclera
• intraocular clacification

124. panophthalmitis
• inflammation of all structures including tenons capsule

125. endophthalmitis
• inflammation of inner layer ie uveal tissue retina vitrous humour &
aqueous humour
• outer coat is usually spared
• causes
• exogenous
• endogenous

126. endophthalmitis
• lacrimation
• severe ocular pain
• redness
• conjunctival &
circumcorneal congestion
• photophobia
• amourotic cats eye reflex
• hypopyon

127. choroidal neovascularisation
• age related macular deneration  MC cause
• angioid streaks
• choroidal rupture
• pathological myopia

128. MC in
Children JRA
Young adults HLA B27 associated uveitis (a/w AS)
Older adults Idiopathic
Over all MC Idiopathic