www.ophthalclass.blogspot.com has the complete class and MCQs on uveitis for undergraduate medical students. Class 5 in the series of classes on uveitis deals with the common causes of panuveitis and briefly discusses their management. The clinical feature of each of the disease entities is explained with the help of case studies.

1. Dr. Anupama Karanth www.ophthalclass.blogspot.com Panuveitis

2. Classification of uveitis Anatomic Classification of Uveitis Anterior Intermediate Posterior Panuveitis Clinical Classification of Uveitis

3. Anatomic classification Panuveitis Primary site of inflammation: anterior chamber, vitreous, retina or choroid

4. Clinical Classification of Uveitis Infectious Bacterial / Viral / Fungal / Parasitic / Others Non-infectious Known/No known systemic association Masquerade Neoplastic / Non-neoplastic

5. Panuveitis

6. Definition It is a rare, bilateral, granulomatous panuveitis which occurs after penetrating ocular trauma to one eye, the injured eye is referred to as the exciting eye while the uninjured eye is the sympathizing eye. Sensitization to some intraocular antigen/s occurs and results in bilateral ocular inflammation Sympathetic ophthalmia

7. Penetrating injury is the precursor Commoner after non-surgical trauma than surgical trauma Incarceration of uveal tissue in the wound is a risk factor In 80% of cases, presentation is between 2 weeks to 3 months after injury May even occur after 50 years Sympathetic ophthalmia

8. Prodromal symptoms in the sympathizing eye (due to iridocyclitis) Photophobia Blurring to near objects (accommodation affected) Redness Early signs Keratic precipitates Retrolental cells and flare Sympathetic ophthalmia

9. Granulomatous iridocyclitis Mutton-fat KPs Plastic iridocyclitis Vitritis Multiple yellow white nodules in the choroid – Dalen-Fuchs nodules Thickening of uveal tract Papillitis Can result in blindness in both eyes Established disease in both eyes

10. Prophylaxis Enucleation of the injured eye before onset of sympathetic ophthalmia is the only way of prevention, usually within 2 weeks of injury ? Enucleation within 2 weeks of onset Therapy Corticosteroids – topical, periocular, systemic Antimetabolites and cyclosporine Therapy

11. A few other common causes of panuveitis….

12. 10 year history of recurrent bilateral granulomatous uveitis with waxing and waning exudative retinal detachments, on steroids and immunosuppressives… www.ophthalclass.blogspot.com http://www.aao.org/publications/eyenet/200804/am_rounds.cfm

15. Extensive pigment alterations in the fundus

17. Extensive pigment alterations in the fundus

18. Dalen-Fuchs like peripheral nodules

20. Diagnosis Classical clinical picture but rule out SO CSF lymphocytosis Management Vigorous use of steroids- local, periocular and systemic Immunosuppressives Vogt-Koyanagi-Harada disease

21. A 50 year old diabetic with blurry vision… http://www.aao.org/publications/eyenet/200710/am_rounds.cfm

22. Peripapillary atrophy

23. Peripapillary atrophy Areas of RPE atrophy with underlying large choroidal vessels visible

24. Peripapillary atrophy Areas of RPE atrophy with underlying large choroidal vessels visible Pigments in a bony spicule pattern adjacent to vessels

25. Hereditary Retinitis pigmentosa Sequelae of auto-immune disease Toxic etiologies Chloroquine, thioridazine Sequelae of infectious disease Tuberculosis Syphilis Lyme disease D/D Pigmentary retinopathies

26. RPR reactive and positive FTA-ABS…… syphilis

27. Secondary syphilis Granulomatous iridocyclitis Iris roseola, iris papulosa, iris nodosa Focal/multifocal choroiditis Retinitis, perivasculitis Papillitis, neuroretinitis Syphilis – the great masquerader

28. Management Ocular involvement to be treated as neurosyphilis CSF evaluation should be done in any syphilitic uveitis Penicillin G 2-5 million units IV 4th hourly – 2 weeks Steroids only after effective antibiotic therapy Syphilis – the great masquerader

29. A 35 year old male patient with blurry vision…

30. Hypopyon uveitis, nongranulomatous, vitritis

31. Core lab tests…Mantoux highly positive, Chest x-ray suggestive….Tuberculosis

32. Chronic iridocyclitis Granulomatous / nongranulomatous Choroiditis Focal / multifocal / choroidal tubercles Retinal vasculitis, vitritis, papillitis Difficulty - in establishing the diagnosis and ensuring treatment compliance Tuberculosis

33. A 46 year old lady with floaters… http://www.aao.org/publications/eyenet/200801/am_rounds.cfm

34. Granulomatous KPs, aqueous flare and cells

35. Infections Tuberculosis Syphilis Lyme disease Non-infectious Sarcoidosis VKH syndrome D/D granulomatous iridocyclitis

36. Chest x-ray, serum ACE…… elevated ACE, hilar lymphadenopathySarcoidosis

37. Granulomatous KPs Bilateral hilar lymphadenopathy Conjunctival follicles Noncaseatinggranuloma

38. Multisystem granulomatous disease Ocular findings Acute / chronic granulomatous iridocyclitis Vitreous snowballs Retinal periphlebitis, candle wax drippings Choroidal small or large granulomas Sarcoidosis

39. Suspect in any uveitis Chest x-ray or CT, serum ACE and lysozyme Biopsy from skin / conjunctiva / lacrimal gland Management Corticosteroids – topical, periocular and systemic Immunosuppressives may be required Sarcoidosis

40. Behçet’s disease Generalized occlusive vasculitis Four major criteria Oral aphthous ulcers Genital ulcers Skin – e.g. erythemanodosum Ocular inflammation Acute iritis with transient hypopyon Retinal arteritis, periphlebitis, vitritis Ocular disease recurrent and explosive Initial immunosuppressives indicated

41. Aphthous ulcers Hypopyoniritis Occlusive vasculitis Sheathing and optic atrophy