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Anterior Uveitis: Signs, Symptoms & the Spondyloarthropathies. Optometry 8370 Jan. 22, 2008 Edward S. Jarka, O.D., M.S. General Background of Anterior Uveitis. The most prevalent form of intraocular inflammatory disease. Annual incidence of about 8 new cases per 100,000.

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anterior uveitis signs symptoms the spondyloarthropathies

Anterior Uveitis:Signs, Symptoms & the Spondyloarthropathies

Optometry 8370

Jan. 22, 2008

Edward S. Jarka, O.D., M.S.

general background of anterior uveitis
General Background of Anterior Uveitis
  • The most prevalent form of intraocular inflammatory disease.
  • Annual incidence of about 8 new cases per 100,000.
general background of anterior uveitis1
General Background of Anterior Uveitis
  • Pathophysiology:
    • Exact pathophysiology is not known.
    • Inflammation of the iris or ciliary body causes a breakdown of the blood ocular barrier.
      • This allows white blood cells and protein to leave the vessels and enter the aqueous (cell & flare).
    • Often Idiopathic, but sometimes associated with systemic disease.
classification of anterior uveitis
Classification of Anterior Uveitis
  • 2 Broad categories:

1) Granulomatous

      • Posterior
      • Follows active microbial invasion (tuberculosis, toxoplasmosis)

2) Nongranulomatous

      • Anterior (Iritis, Iridocyclitis)
      • Much more common (90% of all the uveitis seen).
clinical classification of anterior uveitis
Clinical Classification of Anterior Uveitis
  • Acute
    • Sudden onset of symptoms.
    • More common presentation.
  • Chronic
    • Long standing episodes.
    • Many recurrences.
    • Complications (Cataract and Glaucoma).
etiological classification of uveitis
Etiological Classification of Uveitis
  • Exogenous
    • Caused by trauma or microbes from outside sources.
  • Endogenous
    • Associated with systemic disease.
    • Infections (TB, Candida, H. zoster, …)
    • Idiopathic specific
anatomical classification of uveitis
Anatomical Classification of Uveitis
  • Anterior
  • Intermediate
  • Posterior
  • Panuveitis

*This is also the order of severity and likelihood of occurrence.

anterior uveitis patient presentation
Anterior Uveitis:Patient Presentation
  • History
    • Vital to the diagnosis and treatment of the condition.

1) Pain

- Dull aching pain of sudden onset.

- May radiate to periorbital region or temple.

2) Redness

- Perilimbal (Ciliary flush).

- Less commonly there can be severe redness involving the entire bulbar conjunctiva.

anterior uveitis patient presentation1
Anterior Uveitis:Patient Presentation
  • 3) Photophobia:
    • Can be severe or minimal
    • Usually sunlight worsens the patients pain more than artificial lighting.
  • 4) Visual Acuity:
    • Usually mild reduction (20/25 to 20/40)
    • Sometimes there is no visual complaint, other times it is the chief complaint.

5)Unilateral:

    • Granulomatous uveitis can be bilateral and differing severities.
    • Most episodes of Acute anterior uveitis (AAU) are unilateral.
the cornea in anterior uveitis
The Cornea in Anterior Uveitis?
  • Keratic precipitates (KP’s)
    • Clusters of WBC’s and protein adhered to the endothelium.
    • Usually small and tends to be in the lower half of the cornea (granulomatous tends to be larger and central – mutton fat KP’s).
  • Slight stromal edema
what happens to the anterior chamber in an anterior uveitis
What Happens to the Anterior Chamber in an Anterior Uveitis?

1) Flare (extra protein in the anterior chamber)

  • Usually graded on a zero to 4+ scale.
    • 0 absent
    • 1+ barely present
    • 2+ moderate
    • 3+ marked (iris detail is hazy)
    • 4+ intense (formed fibrin in A.C.)
what happens to the anterior chamber in an anterior uveitis1
What happens to the Anterior Chamber in an Anterior Uveitis?

2) Cell – This is the hallmark of iritis

- Dark room, high magnification, 1mm x 1mm field

- Grading:

  • Trace 1 – 5 cells
  • 1+ 6 – 15 cells
  • 2+ 16 – 25 cells
  • 3+ 26 – 50 cells
  • 4+ 50 or more cells
how bad can the anterior chamber look
How Bad can the Anterior Chamber Look?
  • Fibroid:
    • Thick fibrous strands of protein.
    • Needs more aggressive treatment.
  • Can sometimes show a hypopyon:
    • This would be suggestive of HLA-B27 diseases.
the iris in anterior uveitis
The Iris in Anterior Uveitis

1)Posterior synechiae - which can lead to iris bombe’ and glaucoma.

2) Inflammatory nodules - in granulomatous conditions (Koeppe nodules). Severe cases (Busacca nodules).

3) Sector atrophy - suggestive of H. zoster involvement.

4) Heterochromia (Fuchs Heterochromia Iridocyclitis)

the lens in anterior uveitis
The Lens in Anterior Uveitis
  • 1) Precipitates:
    • These form on the anterior lens capsule.
  • 2) Posterior Subcapsular Cataracts (PSC’s).
    • Not seen in acute, first time anterior uveitis.
    • Their appearance is suggestive of repeated occurrences of Iritis.
the anterior vitreous in an acute anterior uveitis
The Anterior Vitreous in an Acute Anterior Uveitis
  • Cells
    • The result of spillover from the anterior chamber.
    • The primary site of inflammation may be the ciliary body (cyclitis).
treatment of the idiopathic anterior uveitis
Treatment of the Idiopathic Anterior Uveitis
  • 1) Cycloplegia:
    • Helps for the pain resulting from iris spasms and photophobia.
    • Also used to prevent the formation of posterior synechiae.
    • Stabilizes the blood-ocular barrier.
    • Cyclopentolate 1%, Homatopine 5%, Scopolamine
      • Used BID
    • Why not use Atropine 1%?
treatment of the idiopathic anterior uveitis1
Treatment of the Idiopathic Anterior Uveitis
  • 2) Topical Steroids
    • Best if used aggressively at the start of the condition.
      • Pred forte 1% or Econopred 1% QID is used for your common grade 1 Iritis.
      • Tailor the dosage to the severity of the presentation.
  • 3) Subconjunctival injection and oral steroids.
    • Used in severe or unresponsive cases.
what would be the typical oral dosage
What Would be the Typical Oral Dosage?
  • Prednisone 40 – 80mg QD

- This depends on the severity of the presentation.

- After a satisfactory response you taper over two to four weeks.

follow up for anterior uveitis
Follow Up for Anterior Uveitis?
  • Follow initially in 2 – 3 days.
    • Expect some improvement in symptoms, maybe little change in clinical appearance.
  • After resolution of the signs then taper the topical steroids and follow up 2 – 3 weeks after discontinuation of all medications.
  • Should the patient resume treatment if symptoms return?
review of a a u
Review of A.A.U.
  • Most often Idiopathic.
  • The Chief Complaints.
  • The Signs:
      • The Conjunctiva
      • The Cornea
      • The Anterior Chamber
      • The IOP
      • The Iris
      • The Lens
      • The Anterior Vitreous
  • Treatment.
the spondyloarthropathies
The Spondyloarthropathies
  • HLA-B27 associated diseases

1. Ankylosing spondylitis

2. Reactive arthritis (Reiter syndrome)

3. Inflammatory bowel disease

4. Psoriatic arthritis

  • These will be negative for Rheumatoid factor (RF)
    • Often referred to as seronegative arthritis.
  • Arthritis occur at entheses (are areas where tendon and other connecting tissues - join to bone).
what is the rheumatoid factor rf
What is the Rheumatoid Factor (RF)?
  • RF is an Antibody directed against an IgG forming an immune complex.

* This complex initiates inflammation.

  • About 80% of patients with Rheumatoid Arthritis (RA) show a positive RF.
what is hla b27
What is HLA-B27?
  • HLA (Human Lymphocyte Antigen)
    • A gene cluster (MHC) on chromosome 6 responsible for antigen markers found on the surface of lymphocytes.
    • Antisera is used to identify these antigenic markers on lymphocytes.
    • The presence of the B27 marker is statistically associated with these diseases.
i ankylosing spondylitis
I.) Ankylosing spondylitis
  • HLA-B27 appears in 80% - 90% of the patients (8% in general population).
  • Typically occurs in men in their 30’s.
  • Symptoms include back pain after inactivity.
  • It is chronic, usually progressive, and can be asymptomatic to crippling in severity.
what do you do if you suspect ankylosing spondylitis
What do you do if you Suspect Ankylosing Spondylitis?
  • Order serology for the HLA-B27 antigen.
  • Refer to rheumatologist for X-rays of the sacroiliac joints.
  • Monitor and treat the Acute Anterior Uveitis (AAU).
      • The AAU may be present without back pain.
ii reactive arthritis reiter syndrome
II.) Reactive Arthritis(Reiter Syndrome)
  • HLA-B27 seen in 60% to 85% of patients.
  • Classically described as a triad

- Urethritis, Conjunctivitis and Arthritis.

  • The arthritis usually involves the lower extremities (Achilles tendonitis).
  • The triad of symptoms follow enteric or urogenital infections (Numerous bacteria).
ocular findings in a reactive arthritis
Ocular Findings in a Reactive Arthritis
  • Conjunctivitis

- Bilateral and mucopurulent.

- Follows the urethritis by about 2 weeks.

- Cultures are usually negative.

  • AAU (20% of the patients)
  • Keratitis

- Isolated or with the conjunctivitis

what do you do if you suspect a reactive arthritis
What do you do if you Suspect A Reactive Arthritis?
  • Treat the AAU.
  • Refer for proper treatment of associated bacterial infection and treatment of the arthritis.
inflammatory bowel disease
Inflammatory Bowel Disease
  • 5% – 12% of patients with Ulcerative colitis will develop AAU (greater when associated with Ankylosing spondylitis).
      • UC involves mucosa & submucosa.
      • Rectal involvement & continuously proximal.
  • 2.4% of patients with Crohn’s disease will develop AAU.
      • CD involves all layers of the bowel.
      • Segmental involvement.
  • Treatment is aimed at controlling the inflammation (steroids).
what else might you see with inflammatory bowel disease
What Else Might you See With Inflammatory Bowel Disease?
  • Peripheral corneal infiltrates.
  • Like any systemic inflammation will show an increase in the ESR.
slide44
ESR
  • Standardized in 1977 (Westegren)

- 200mm tube, 2.5mm diam. With blood and anticoagulant.

- Distance (mm) the column falls in 1hour.

  • Forces affecting the ESR:

- Size of cells.

- Viscosity of plasma.

- Repellant forces between neg. charged RBC surface.

  • An indirect measure of inflammation.
c reactive protein crp
C – Reactive Protein (CRP)
  • Owes its name to a protein with the ability to precipitate the pneumococcal C – polysaccharide.
  • Is an acute phase reactant in inflammation.
  • Provides a more immediate picture of the level of inflammation than ESR.
  • Peak levels in about 50 hours.
psoriatic arthritis
Psoriatic arthritis
  • Affects about 7% of patients with psoriasis.
  • Affects men and women equally.
  • Associated with HLA-B27 and HLA-B17.
  • Commonly involves fingers and shows nail pitting.
ocular findings in psoriatic arthritis
Ocular Findings in Psoriatic Arthritis
  • Conjunctivitis
  • AAU

- Less often than AS or RS.

  • Keratitis

- Infiltrates appear raised just inside the limbus.

case 1
Case 1

35 year-old male with complaints of an acute red left eye.

VA: OD) 20/20 OS) 20/30

What questions do you ask?

What entrance tests do you perform?

Describe you slit lamp approach.