Don’t think anterior

uveitis so simple!

32 yr old man with hypopyon uveitis- not

responding to topical and systemic steroid

WHAT IS YOUR DIAGNOSIS ?

AC tap showing microfilaria

8 year old girl, persistent hypopyon uveitis,not

responding to topical and systemic steroid

Anterior chamber tap done

AC tap showing basophilic cohesive tumour cells suggestive of Retinoblastoma

Hypopyon

55 year old man, developed bilateral hypopyon

Peripheral blood count showed chronic myeloid leukaemia

Ocular Immunology and inflammation September 2008

45 year old female

- pain,redness and dimness of vison

for 2 weeks

Had HIV infection with herpes zoster

ophthalmicus

21 year old girl, immunocompetent

Ant segment

Acute anterior uveitis

K.P.s – small to large

Raised IOP

Vitreous cells

Fundus: Acute Retinal necrosis

Always dilate and see the fundus including

periphery using depression to rule out ARN,

Pars planitis in anterior uveitis

Clinical Approach to

Anterior Uveitis

Dr Jyotirmay Biswas

Director of Uveitis and Ophthalmic pathology

Sankara Nethralaya

Chennai

Anterior uveitis

Iris, Ciliary body

ClassificationCLINICAL

Acute / Chronic / Recurrent / Healed

MORPHOLOGICAL

Granulomatous / Nongranulomatous

ANATOMICAL

Anterior / Intermediate/ Posterior/ Panuveitis

ETIOLOGICAL

Etiological Classification

1. Infectious

2. Noninfectious

3. Traumatic

4. Idiopathic

5. Masquerade syndromes

TB, Herpetic, Hansen’s disease

HLA B27 related, JIA related, Sarcoidosis,

Acute tubulointerstitial nephritis and uveitis

Surgical / Non surgical

Fuch’s, Posner-Schlossman

Juvenile xanthogranuloma, leukaemias,

retinoblastoma, IOFB

Age

Children - JIA, Infection, Masquerade - RB

Young Adults - FHU, Idiopathic

Middle Age - Reiter's, Ankylosing spondylitis,

Older Patients – Masquerade syndrome/ Infections

Any Age - Toxoplasmosis,

Sarcoidosis, TB, Syphilis.

Sex

Females - JRA

Males - Ankylosing spondylitis, Reiter's

Onset, Pattern of illness

Acute

Chronic

Recurrent

Healed

Duration

1st episode

Number of attacks

Recent episodes

Latest episode

Ocular History - Laterality

Unilateral : Fuchs

Traumatic

Herpetic

Lens related

Bilateral : JIA

Unilateral / Bilateral : Sarcoid

TB

Presenting complaints

Pain

Redness

Photophobia

Dimness of vision

History

Systemic History

General S/S – recent illness

Quick Review of systems

DM / HT / IHD / TB/ APD

Specific questions

Joint pains,joint swelling

Low backache

Skin rashes – Sarcoidosis, psoriasis, Hansen’s

disease, HZO

Recent illness – viral fever/ UTI

Recent dental procedures

In children – recent vaccination

Family History

Collagen vascular diseases

Ankylosing spondylitis

Contagious illnesses

Treatment History

Only eyedrops? – Steroids/ NSAIDs

Any oral medication - steroids/ NSAIDs

Duration of treatment

Current treatment / last dose

Any self medication

Any complications?

Glaucoma – treatment history; current medication

Surgery

Examination - External

Examination - External

Examination - External

Examination - Ocular

Congestion – circumcorneal/Scleral

Disciform keratitis

Corneal edema

BSK

KPs

Cornea

Keratic precipitates

Anterior Chamber – Cells/Flare

TABLE 4. The SUN Working Group Grading

Scheme for Anterior Chamber Flare

0 None

1+ Faint

2+ Moderate(iris &lens details clear)

3+ Marked(iris &lens details hazy)

4+ Intense(fibrin or plastic aqueous)

Grade Description

Grade 4 Flare - Fibrin

TABLE 3. The SUN Working Group Grading

Scheme for Anterior Chamber cells

0 <1

0.5+ 1-5

1+ 6-15

2+ 16-25

3+ 26-50

4+ >50

GradeCells in Field (1mm

by 1mm slit beam)

Iris nodules – Koeppe’s, Busacca’s

NON-GRANULOMATOUS UVEITIS

Onset - well defined

Course - acute

Injection - +++

Pain - +++

KP's - fine

Iris nodules - absent

Posterior segment -

rarely involved

HLA B 27 related uveitis

GRANULOMATOUS UVEITIS

Onset - insidious

Course - chronic

Injection - +

Pain - +

Iris nodules - +

KP's - mutton fat

Posterior segment –

may be involved

Sarcoid uveitis

HypopyonAnkylosing spondylitis

Behcets disease

Infection

Lens induced uveitis

Malignancy

HLA B 27 ant Uveitis

Hyphaema Viral uveitis

Trauma

Malignancies

Fuchs

Chronic uveitis with

rubeosis

Any severe uveitis

Post anterior

chamber taps

Sector atrophy - Iris

Complicated Cataract

IOL related

Always suspect Low grade endoph!

1 2 3 4 5 6 MW

160bp

52 year old being treated with steroids for chronic

postoperative uveitis for 2 years

Nested PCR from AC tap detected

P acnes targeting 16SrRNA region

AC

tap

+ control

Always suspect Low grade endoph!

Intraocular pressure

Low IOP – ciliary body

shut down

High IOP

High IOP

Chronic angle closure

glaucoma

Pupillary block glaucoma

Glaucomatocyclitic crisis

Viral – herpetic

Toxoplasma

Syphilis

Fuchs heterochromic

iridocyclitis

Steroid induced glaucoma

Cases

Naming and Meshing System

Chronic

Granulomatous

Anterior

Etiology – investigate for TB/Sarcoidosis

Chronic

Nongranulomatous

Anterior

Fuch’s

Acute

Non-granulomatous

Anterior

Etiology – investigate for HLA B 27

ANTERIOR UVEITIS

TOPICAL STEROIDS+

MYDRIATIC-CYCLOPLEGICS

NON RESPONDING

SYSTEMIC STEROIDS

IMMUNOSUPPRESSIVE AGENTS

NON RESPONDING

Summary

Take a uveitis oriented history

Complete eye and systemic exam

Identify the anatomic location of the primary

inflammation

Tailored lab investigations that can help

establish etiology and guide management of

the disease

THANK YOU

TABLE 3. The SUN Working Group Grading

Scheme for Anterior Chamber cells

0 <1

0.5+ 1-5

1+ 6-15

2+ 16-25

3+ 26-50

4+ >50

GradeCells in Field (1mm

by 1mm slit beam)

TABLE 4. The SUN Working Group Grading

Scheme for Anterior Chamber Flare

0 None

1+ Faint

2+ Moderate(iris &lens details clear)

3+ Marked(iris &lens details hazy)

4+ Intense(fibrin or plastic aqueous)

Grade Description

MPB64 IS6110NC2 NC1 4745 4747 4749 PC NC2 NC1 4745 4747 4749 PC 100BP

VRF 4747/14 – MS. Aruna devi MRD No : 3419441 Specimen : Actap (OD) Result : MPB64 – Positive IS6110 – Negative

PCR For Mycobacterium tuberculosis