Diseases of Uvea for Medical Students – Free NExT, PLAB and USMLE Notes and MCQs

Diseases of Uvea for Medical Students - Free NExT, PLAB and USMLE Notes and MCQs

Diseases of Uvea for Medical Students: Let’s start with Opthalmology with its basic Diseases of Uvea. I made this blog useful mainly for undergraduate medical students and those who are preparing for NExT, PLAB, and USMLE exams.

First, there will be clear-cut exam-oriented points on Diseases of Uvea notes for Medical Students then at the bottom there will be a link to the Free online MCQs on Diseases of Uvea and these MCQs are specially made up for NExT, PLAB, and USMLE exams. Jump to,

Uveitis

Inflammation of uveal tract

  •  Iris – Iritis
  • Choroid – Choroiditis
  • Ciliary body – cyclitis

Classification

Anterior Uveitis

  • Iritis
  • Iridocyclitis (only Pars Plicata of CB) – 1st most common among Uveitis

Intermediate Uveitis

  • Pars planitis
  • Vitritis

Posterior Uveitis – 2nd most common

  • Choroiditis

Panuveitis

  • Sympathetic Ophthalmitis 
  • Vogt Koyanagi Harada Syndrome

 

Other classifications

  • Acute Uveitis 
  • Chronic Uveitis (Inflammation more than 3 months)

 

  • Granulomatous Uveitis – (TB, Syphilis, Sarcoidosis ).
  • Non granulomatous Uveitis

 

One must right all these things in the diagnosis. For Eg Acute Anterior Nongranulomatous Uveitis.

Anterior Uveitis

Causes

  • M/C – Idiopathic ( 50% )
  • HLB B-27 Spondyloarthropathies
    1. Ankylosing spondylitis ‘ FlipFlop‘ – Young male with low back pain with red painful eyes.
    2. Inflammatory Bowel Disease – Ulcerative colitis & Crohn’s disease
    3. Psoriatic Arthritis
    4. Reiter’s syndrome (Reactive Arthritis) – Triad of Conjunctivitis, Urethritis, and Arthritis
  • JRA – Juvenile Idiopathic Arthritis
    • Children < 16 (Particularly girls )
    • Pauciarticular, ANA positive, RF negative
    • C/ I to IOL
    • White eye Uveitis
    • Arthritis – Uveitis – Cataract

Symptoms

Acute painful, red eye with loss of vision.

Diseases of Uvea for Medical Students

Signs

  • Circum ciliary congestion (circumcorneal congestion)
    • Bluish red,
    • Radial rays
    • Anterior ciliary vessels congestion
  • Cells – Neutrophils ( WBC’s in the AC
    • The sign of Active Uveitis
    • The earliest sign of Active Uveitis
  • Flare – Severe uveitis
    • Turbid aqueous humor due to serum proteins from Ureal vessels
  • Keratic precipitates
    • Presence Cornea of N & L in the inferior cornea in the shape of a triangle (Arlt’s triangle)
    • Mutton-feetKPs (Granulomatous Uveitis)
  •  
  • Iris Nodules
    • Koppe’s (Pupillary margin) and Busacca’s nodules (Surface of Iris) – Granulomatous Uveitis
  • Synechiae
    • Iris attached to Cornea – Anterior synechiae – Because Angle blocked (No drainage of AH) – Leads to glaucoma
    • Iris attached to Lens – Posterior synechiae – Leads to cataract
  • Miosis
  • LOW TOP – Inflammed CB- Does not produce AH
  • Festooned Pupil – Anterior uveitis causing posterior synechiae
  • Hypopyon – Collection of pus in AC

Intermediate Uveitis

Rare, chronic, relapsing 

Causes

  • Idiopathic (70%) – Pars Planitis
  • Sarcoidosis
  • Multiple sclerosis

Symptoms

  • Floaters / Muscae (Black spots surroundings)
    • Neutrophils and WBC in Vitreous Humour
    • Myopic and Vitreoretinal pathology
  • Cystoid Macular Edema
  • Snowballs and snow banks

Posterior Uveitis

Choroiditis

Infection Causes

  • Toxoplasmosis – From cats
  • Tuberculosis
  • Toxocariasis
  • CMV, Herpes, HIV

Autoimmune Causes

  • Sarcoidosis
  • Poly Arteritis Nodosa
  • Scleroderma

Symptoms

  • Chorio retinitis
  • Vasculitis of retinal vessels
  • Vitritis

Signs:

  • Creamy yellow patches
  • CR, Vasculitis vitritis (headlight and fog )

Treatment for Uveities

For Anterior Uveitis

Topical steroids – DOC of AU

No degradation of ECM on Trabecular meshwork leads to Biological edema and causes Glaucoma

So more powerful steroid leads to more glaucoma

Dexamethazone ↑ glaucoma

Fluromethazone ↓ glaucoma

Cycloplegic – DOC for Acute Uveitis

  • Relaxes the ciliary spasm
  • Dilates the pupils and breaks the synechiae
  • Reduce vascularity of CB

Atropine ointments – 14 days – in children DOC (as Powerful ciliarytone seen in children)

Homatropine -3 days (Used)

Cyclopentolate – 1 day (Mostly used)

Tropicamide – 6 hours 

For Intermediate Uveitis

Steroid injections – Triamcinolone

  • subconjunctival
  • subtenon’s

No role for cycloplegics in Intermediate Uveitis as there is no pain and no posterior synechiae to break

For Posterior Uveitis

Antimicrobials for infectious disease

Spiramycin DOC For toxoplasmosis in pregnancy.

TB – ATT

CMV – Grancyclovir

HIV – HAART therapy

Systemic steroids for non-infection (3 months only) cause S/E moon face.

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Fuch’s Heterochromic Iridocyclitis

Idiopathic, chronic, unilateral, low-grade Anterior Uveitis

Rubella virus cause

  • Heterochromia
  • cataract
  • Diffuse, stellate KPs (Herpetic Iridocyclitis)

Minimal symptoms – Floaters, discovered when loss of vision – cataract, Posterior synechiae never present

Amsler’s sign – Paracentesis induces Hyphema

Topical/systemic steroids should be avoided (S/ E – Glaucoma)

Vision-threatening complications

  • Cataract
  • Glaucoma,
  • Vitreous opacification.

Posner Schlossman Syndrome/ Glaucomatocyclitic Crisis

  • Rare, recurrent, unilateral attacks of uveitis in young to middle-aged males
  • Mild attacks of uveitis with minimal flare, white KPs- markedly out of proportion to the uveitis
  • ↑ IOP – Corneal edema – mild loss of vision.
  • Between attacks, the eye is normal.
  • Association with CMV is seen.
  • Anti glaucoma drugs, tropical steroids.

Ocular Manifestations in HIV

Commonest manifestation – Retinal microangiopathy – cotton wool spots (HT &DM), hemorrhages, microaneurysms

Commonest ocular infection – CMV retinitis

Commonest systemic infection – Tuberculosis

Commonest tumor – Kaposi’s sarcoma

Lymphoma

OSSN – Ocular Surface Squamous Neoplasia

CMV Retinitis

M/C cause of blindness in AIDS

CD < 50 cells /ml

CMV Retinitis incidence: 30% in pre HAART < 5% in HAART

Floaters, Photopsiae, loss of vision

3 patterns – Pizza pie, Brush Fire, Frosted branch angiitis.

DOC – HAART, Oral valgan cyclovir

Immune Recovery Uveitis

Para doxical worsening of intraocular inflammation- improved immunity HAART

M/C complication of HAART

The immune system recovers – attacks CMV – ocular inflammation prominent in vitreous

Risk factors – CD4 count 100 cells 1μL, IV cidofovir

  • Floaters,
  • Photopsiae,
  • Redress,
  • Pain,
  • Posterior synechice,
  • Hypopyon,
  • IRV between
  • cataract,
  • vitriis,
  • Optic disc edema
  • EpiRetinal membrane.

Rx =) Periocular and intravitreal steroids.

Opportunistic Infections of Eye

2 Bacteria – TB, Syphilis

2 Fungus – cryptococcus, candida

2 Viral – Herpes zoster, CMV

2 Parasite – Pneumocystis, Toxoplasmosis

Ocular Sarcoidosis

25% sarcoidosis have ocalar involvement 

Colored races I scan dinavians

A/I/P/ Pan Uveitis

Bilateral, granulomatous, chronic uveitis

7 ocular signs

  • Mutton Fat KRS
  • Tent shaped PAS/Berlin nodules In TM
  • Vitreous opacities – String of Pearl
  • Candle wax drippings (Tache de bougie)

Chest x-ray – Best investigation.

Elevated ACE and soluble IL 2 receptors.

The topical steroid with cycloplegic

 M/C cause of Loss of Vision of cystoid macular edema

Sympathetic ophthalmitis

Bilateral, granulomatous, pan uveitis

Trauma (Penetrating/perforating injury)

CB injury – Uveal pigment – Act as FB (Antigen) – Auto Ab produced – Granulomatous Inflammation (Uveitis ) – Sympathetic ophthalmitis – another eye

Metallic Foreign body 

Injury to CB a maximum – amount of Sympathetic Opthalmitis within 2 weeks to 2 months

Dalen Fuch’s Nodules – lymphocytes in the macula

M/C in children

Earliest Symptom

Photophobia

Accomodation failure (loss of NV)

Earliest Sign

Retrolental flare

Mutton fat KPs

Hypotony

Treatment

Enucleation within 14 days of trauma

Repair the injured eye

Systemic steroids

PL -ive, 6/6

6/60, 6/6

PL -ive, HM (+)

Vogt Koyanagi Harada syndrome

Bilateral, granulomatous, panuveitis

Neurological /auditory in volvement in Pigmented races in absence of ocular trauma or surgery

Young famales 20- 50

Symptoms

Prodromal mimics viral infection, neck stiffness, infection, hearing loss, headaches, tinnitus, vertigo

Acute – Panuveitis with serous retinal detachments.

Chronic convalescence – Poliosis, vitiligo, alopecia, depigmentation of choroid – sunset glow.

Chronic recurrent – recurrent granulomatous Anterior uveitis, mutton fats-kPs.

Ocular signs

B/L Panuveitis / Posterior Uveitis with multifocal choroiditis – serous Retinal Detachments – optic disc Hyperemia & edema

Perilimbal vitiligo – Sugiura’s sign

Treatment – High dose systemic steroids

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