Ocular Disease III - Uvea

Anterior uveitis makes up __% of the different types of uveitis.

70

Intermediate uveitis makes up __% of the different types of uveitis.

10

Posterior uveitis makes up __% of the different types of uveitis.

20

Acute uveitis is ___ weeks or less.

6

Granulomatous uveitis is characterized by...

proliferation of large cells (epithelial giant-cell type), and has a systemic cause

T/F - Granulomatous uveitis is insidious.

True

T/F - Non-Granulomatous uveitis has a long course.

False - short

T/F - Non-Granulomatous uveitis is acute.

True

(Granulomatous/Non-Granulomatous) uveitis has more pain?

non

(Granulomatous/Non-Granulomatous) uveitis has more iris nodules?

granulomatous

(Granulomatous/Non-Granulomatous) uveitis has more KPs?

granulomatous (mutton fat)

(Granulomatous/Non-Granulomatous) uveitis has diffuse involvement in the fundus?

non

Exogenous uveitis is caused by...

external injury to uvea or invasion of microorganisms

T/F - Viral infection is considered an endogenous uveitis.

True

T/F - Parasitic infestation is considered an exogenous uveitis.

False - endogenous

T/F - Fungal infection is considered an endogenous uveitis.

True

T/F - Uveitis secondary to systemic disease is considered an exogenous uveitis.

False - endogenous

T/F - Idiopathic uveitis tends to occur more recently ("a couple days ago")

True

T/F - Systemic causes of uveitis tend to occur more recently ("a couple days ago")

False - more like months ago, waxes and wanes

Injection in uveitis is mostly...

"violaceous" circumlimbal injection in bulbar region, less in palpebral conj

vs conjunctivitis, which has injection in palpebral conj

T/F - Can have absence of injection in chronic anterior uveitis.

True

How do KPs look like?

WBCs that attach to inf 1/3 corneal endoth, due to convection current, accumulate base down triangular formation.

Fuch's can cause even distribution of KPs

First type of cell present in KPs?

Neutrophils

Chronic KPs tend to be what type of cell(s)?

transformed macrophages, lymphocytes

Large KPs (mutton fat) are made of...

clusters of epith cells and monocular macrophages

(The macrophages have one eye? I think he meant "mononuclear"?)

The three big mutton fat diseases...

sarcoid, syphillis, TB

Fresh KPs tend to appear ___ vs older, appear ____.

fresh = white and round

old = shrink, fade, pigmented

Think of white grapes turning into raisins

You see flare in the AC, but no cells. Should you stop the steroid Tx or not?

Stop steroid b/c flare with no cells means inflammation is gone

Recommend AT LEAST what steroid dosage freq if you see a uveitis?

Q1hr

When it comes to uveitis, steroids is the mainstay Tx - can you use any steroid?

No, must use strong ones (Pred Forte, Lotemax, etc), do not use weak ones (FML, etc)

Your pt, who is currently taking lotemax q1hr, dropped from a 3+ AC response to 2+. What is the appropriate Mx?

continue exact Tx because "there's still a fire" i.e. must continue aggressive Tx if you still see cells, which show that inflammation is still present

They key marker of inflammatory activity in the anterior seg is...

CELLS, not flare.

What is the next step if your uveitis pt is not responding to q1h pred forte?

q15 min

What is the next step if your uveitis pt is not responding to q15 min pred forte?

oral steroid

What is the next step if your uveitis pt is not responding to oral steroid?

IV steroid

Aqueous flare is described by...

iris visibility - how well you see the iris thru the haze

What causes flare?

Due to leakage of protein into aqueous thru damaged BVs. NOT necessarily a sign of active uveitis

T/F - Chronic flare alone is not a sign of active inflammation.

True

T/F - Flare always disappears along with cells in the AC.

False - flare may linger after cells have dissipated

What are Koeppe nodules?

iris nodules that are situated at the pupillary border - an accumulation of inflammatory cells in the iris

Think koeppe has a "P" for Pupil

T/F - Iris nodules can be permanent.

True - either permanent or can take years to go away

Iris nodules are considered an (acute/chronic) sign of uveitis.

chronic - takes years to build up

What are Busacca nodules? Are the more or less comman than Koeppe nodules?

Less common than Koeppe nodules, located on surface or iris AWAY from pupillary border.

vs koeppe - think that it has a "P" for Pupil

Fuch's heterochromia irides involves color changes due to...

loss of iris architecture due to iris atrophy

#1 assoc dz of rubeosis irides? Others?

#1 = DM

Others = CRVO, ocular ischemic syndrome

Rubeosis irides is associated with what uveitis?

Fuch's uveitis syndrome (causes hypoxic environment thus neo)

What kind of synechiae can form during an acute ant uveitis attack?

posterior

How can you break posterior synechiae?

dilation

Your pt has posterior synechiae that cannot be broken w/ dilation. Mx?

Nothing - cannot break the strong synechiae or else cataract can occur

What Tx is used to break post synechiae? Why that specific Tx?

5% homatropine - allows iris to move/waver slightly

Atropine will immobilize iris and will allow new synechiae to form at that position

Uveitis can result in this type of cataract...

PSC (can be due to inflammation, steroid use, or combo of these factors)

T/F - PSCs due to steroids take a few weeks to develop.

False - takes about 6 months

PSCs in uveitis are caused by...

inflammation process, lysophosphytidyl choline, and macrophages

T/F - Ant capsular cataracts are common in uveitis.

False - less common vs PSCs, BUT can happen

T/F - Iridocyclitis involves more cells in the vitreous vs the AC.

False - equal distribution in vitreous and AC

What sign in the fundus should you always look for in any uveitis?

cystoid macular edema - more prevalent in intermed and post uveitis vs ant uveitis

In uveitis, IOP is first (incr/decr), then (incr/decr). Why?

decr first b/c inflamed CB results in decr aqueous production

incr later b/c cells and flare block TM, and also steroid use

What glaucoma drugs should you avoid in Tx incr IOP during uveitis?

Prostaglandins - inflammatory mediator

Pilo - miotic (which is the opposite of what you need to do, which is dilation with cycloplegic Tx!)

Snowbanking is characteristic of what kind of uveitis?

intermediate (pars planitis)

Why are threshold VFs not useful in active anterior uveitis?

blepharospasm (pain!)

ACE is an important test for what uveitis type(s)?

sarcoid

Chest x-ray is an important test for what uveitis type(s)?

sarcoid, TB, coccidiomycosis

(all affect lungs)

Chlamydial compliment fixation test is an important test for what uveitis type(s)?

Reiter's

Conjunctival biopsy is an important test for what uveitis type(s)?

sarcoid (granuloma)

Gallium scan is an important test for what uveitis type(s)?

sarcoid (granuloma)

Hand x-ray is an important test for what uveitis type(s)?

psoriatic or juvenile RA

HLA typing is an important test for what uveitis type(s)?

CRAP:
Crohn's
Reiter's
Ankylosing spondylitis
Psoriatic arthritis

Lacrimal gland biopsy is an important test for what uveitis type(s)?

sarcoid

PPD is an important test for what uveitis type(s)?

TB

Sacroiliac x-ray is an important test for what uveitis type(s)?

ankylosing spond

VDRL/FTA-ABS/MHA-TP are important tests for what uveitis type(s)?

syphyillis

CBC is an important test for what uveitis type(s)?

none really - nonspecific test for inflammation

ESR is an important test for what uveitis type(s)?

none really - nonspecific test for inflammation

ANA is an important test for what uveitis type(s)?

systemic lupus, JRA

CT scan is an important test for what uveitis type(s)?

Toxoplasmosis (possible brain invasion - encephalitis)

Liver function test is an important test for what uveitis type(s)?

toxocariasis (parasites)

Vitreal biopsy is an important test for what uveitis type(s)?

toxocariasis (eosinophils), fungal vs viral vs bacterial

Antitoxocara AB is an important test for what uveitis type(s)?

toxocariasis

(duh!)

Fluorescein angiography is an important test for what uveitis type(s)?

Beschet's dz (capillary dropout), histoplasmosis (CNVM @ macula)

ELISA is an important test for what uveitis type(s)?

CMV retinitis (AIDS)

*Skull x-ray is an important test for what uveitis type(s)?

toxoplasmosis (newborn skull has beaten metal appearance)

Stool evaluation is an important test for what uveitis type(s)?

toxocariasis

Ultrasound is an important test for what uveitis type(s)?

Toxocara (DDx vs retinoblastoma)

Viral culture is an important test for what uveitis type(s)?

HSV

Lumbar puncture (cell count, VDRL, gram stain, cytology, lyme) is an important test for what uveitis type(s)?

VKH syndrome

HLA-B27 spondylopathies have two common characteristics: ___ and ____. Name these spondylopathies.

uveitis and destruction of joints

CRAP (Crohn's, Reiter's, Ank spond, Psor arth)

Ankylosing spondylitis demographic (age, sex, race)?

20-40 yo caucasian males

Think of a stooped over McLovin from Superbad - skinny white caucasian (remember it involves anorexia)

Ankylosing spondylitis systemic signs/Sx...

lower back pain in AM relived by activity, stoop over to relieve pain, pain in chest cavity & difficult chest expansion, anorexia, fever, malaise

Ankylosing spondylitis is an (ant/int/post) uveitis that is (unilat/bilat)?

ant, unilat

T/F - Ankylosing spondylitis has rapid onset of pain and photophobia.

True

Episodes of ocular Sx in Ankylosing spondylitis lasts ___ weeks.

2-6

Uveitis in Ankylosing spondylitis is ___%

25-30

HLA B27 typing in Ankylosing spondylitis is present ___%

92

HLA B27 typing in Reiter's is present ___%

90

HLA B27 typing in Crohn's is present ___%

50

HLA B27 typing in Psoriatic Arthritis is present ___%

30

Uveitis in Reiter's is ___%

20 (in arthritic form)

Uveitis in Crohn's is __%

10-15

Uveitis in Psoriatic Arthritis is ___%

10

Alkaline phosphatase levels is useful in investigating...

Ankylosing spondylitis

*In Ankylosing spondylitis, what specific area should you x-ray?

sacroiliac joints

Final resort Tx for Ankylosing spondylitis?

radiotherapy to spine, mainstay for systemic Tx and physical therapy

Reiter's has what main Sx?

Conjunctivitis/iritis, arthritis, urethritis

"can't see, can't pee, can't dance with me"

The latter part can related to how pt has an STD (chlamydia)

Reiter's demographic?

Males age 18-40

Think of a guy in his sexual prime who can't see, can't pee, and can't dance very well

Reiter's types? Most prevalent?

Post dysenteric = Shigella, Yersinia, Salmonella

Articular = arthritis/iritis (10%)

Post veneral = conjunctivitis (30-60%)

T/F - Urethritis in Reiter's develops 7-14 days after sexual contact.

True

*Locations of lesions in Reiter's?

Tongue, mouth, penis

What is Keratodermal blenoragiticum?

Rashes in palms of hands and soles of feet, in Reiter's

Nail pitting can be found in...

Reiter's, Psoriatic Arthritis

Most common ocular presentation of Reiter's?

conjunctivitis - few weeks after sexual contact

Superior micropannus is characteristic of this syndrome...

Reiter's (if chlamydial)

Course of Reiter's?

2-6 wks

X-rays of what areas in Reiter's?

knees, ankles, feet, heels, achilles tendon, sacroiliac area

T/F - It is appropriate to do fecal culture for Reiter's.

True - if dysenteric type

*Systemic Tx of Reiter's?

Oral tetra, doxy, azithro

IBD demographic?

Jewish males from N. Europe

Think Adam Sandler needing to take a crap in Germany - yeah he's Jewish, remember the Chanukah song?

IBD systemic signs/Sx?

- Chronic intermittent diarrhea alternating w/ constipation
- abdominal cramps
- Anorexia, weight loss

IBD types?

Peripheral arthritis (knees/ankles which parallels bowel dz)

Spondylitis

IBD ocular signs/Sx?

- Ant uveitis at time of active dz
- Episcleritis possible
- Iritis, mild pain & photophobia
- Mild cells with moderate flare
- Synechiae formed quickly, broken easily

Of the HLA-B27 uveitis types, which is the only one that does not have lots of cells and flare?

IBD

A barium enema is useful for this uveitis...

IBD

*This uveitis requires supplemental vitamin __ in addition to systemic steroid Tx.

IBD - requires Vit A (poor absorption of vit A in IBD thus hypovitaminosis A)

Low vit A also affects mucin layer thus dry eye

Psoriatic Arthritis demographic?

Male = female, almost exclusively caucasian

Arthritis of interphalangeal joints of hands/feet, nail pitting, Auspitz's sign, sausage digits, and oncholysis are characteristic of...

Psoriatic Arthritis

What is Auspitz's sign? Found in?

Silvery plaques (pinpoint) that bleed if peeled, found in Psoriatic Arthritis

What is Oncholysis? Found in?

Separation of nail from nail bed, found in Psoriatic Arthritis

Ocular signs/Sx of Psoriatic Arthritis ?

Iritis that flares with arthritis (10%), mild pain and photophobia, early synechiae

Key factors in Psoriatic Arthritis Dx is...

Hx of psoriasis and x-ray of hands/feet

Behcet's demographics?

Eastern Mediterranean or Japanese male 18-40 yo.

Think of two young businessmen - an Iraqi man shaking hands with a Japanese man, both with ulcers

Okay it's a stretch, but remember what Dr. Hillier said about visual imagery and memory...

Obliteration vasculitis is the underlying cause of...

Behcet's - BV inflammation so bad that no longer transmits blood

Oral (aphthous ulcers) and genital ulceration, skin lesions (ant legs, face, neck, buttocks), and bilateral uveitis/iridocyclitis characterizes...

Behcet's

Behcet's has a (unilat/bilat) uveitis?

bilat

Behcet's has an (sudden/gradual) onset of uveitis?

sudden ("explosive")

Transient (hypopyon/hyphema) in Behcet's?

hypopyon

Behcet's course?

2-4 wks - may stop abruptly

Post seg signs in Behcet's?

Retinal vasculitis - hypoxia - neo (hemes, exudates, vitritis)

Macular involvement possible w/ poor visual prognosis (capillary closure aruond macular area)

Behcet's Tx?

- Initially topical steroids & cycloplegics
- Later (w/ retinal vasculitis) - systemic steroids
- Immunosupp agents

Tacrolimus and Tumor Necrosis Factor are Tx for this uveitis...

Behcet's

The ONLY uveitis where you do not Tx steroid...

Traumatic iritis

You cannot use steroid with traumatic iritis, but how are you supposed to get rid of the cells and flare? Why so?

Cycloplegic will decr cells b/c it will relieve the irritation that is causing the cells and flare

The key factor in Dx HZV uveitis is...

rash - MUST be present b/c can't have HZV uveitis without rash

Prevalence of ocular involvement with HZV?

2/3 pts

Anterior uveitis due to HZV is caused by...

vascular occlusion and ischemia

T/F - Glaucoma is possible with HZV.

True - severe glaucoma accompanies uveitic inflammation

Synechiae are (infrequent/frequent) in HZV uveitis.

frequent

Uveitis begins __ wks after HZV skin lesions appear.

1-2

Describe how the iris looks in HZV uveitis. Why?

Ischemia due to vascular occlusion causes sectoral iris atrophy

Both hyphema and hypopeon is possible in this uveitis...

HZV

HZV under 40 yrs old caused by ___.

immunosuppression

40-60 usually normal imm status

T/F - Viroptic and Acyclovir are the mainstay Tx for HZV.

False - do NOT use viroptic, only use for HSV

IV Acyclovir is appropriate for...

immunosuppressed or severe HZV pts

T/F - Do NOT use steroid on HZV.

False - can use topical and oral steroid, as long as you're sure there's no HSV

watch for oral steroid in elderly, can cause stroke

What type of glaucoma med is okay with uveitis?

B-blockers, CAIs

NOT Pilo or PGs

Two types of HSV uveitis?

1) Sterile trigeminal iritis - due to overuse of steroid (irritated cornea)

2) HSV infection inside AC - due to spread into AC

Giemsa stains are useful in what type of uveitis?

HSV

PAP is useful in investigating what type of uveitis?

HSV (intracellular eosinophilic inclusion bodies)

T/F - Topical steroids in uveitic HSV are usually not needed for the uveitis.

True - hold off 48 hours if needed

T/F - Topical steroids are good for stromal HSV.

True - b/c if on stroma = blindness!

Also good for disciform HSV

T/F - Viroptic and Acyclovir are the mainstay Tx for HSV.

False - Acyclovir no use for simplex, unless for kids

BVDU is a Tx for what type of uveitis?

HSV (bromovinyldeoxyuridine)

Topical steroids can be used in this type of HSV. What must be done first?

Disciform. Must sterilize first - give pt 1-2 days topical viroptic then begin steroid Tx

Most common type of uveitis?

Idiopathic

*In older pts, you must rule this out before saying a uveitis is ideopathic.

tumor

Idiopathic uveitis demographic?

Male=female, 18-50 yo

Idiopathic uveitis typically (bilat/unilat)?

unilat - almost all the time

T/F - Idiopathic uveitis typically has little to no flare.

True

What type of uveitis should you definitely NOT over treat?

JRA

JRA demographic?

Little girls

*Subgroups of JRA with uveitis risks?

1) Systemic JRA - low
2) Polyarticular JRA - low
3) Pauciarticular JRA - HIGH

T/F - Five or fewer joints affected = pauciarticular JRA.

False - four or fewer

T/F - JRA is an idiopathic, seropositive form of arthritis in children.

False - seronegative (Rheumatoid negative)

JRA involves a (unilat/bilat) iridocyclitis)

bilat

T/F - JRA involves white, quiet eyes but with pain and photophobia.

False - white, quiet, NO pain or photophobia

In JRA, a positive ANA increases the risk of...

uveitis

Why would you want to do a CXE/ACE in JRA pts?

R/O sarcoidosis, which mimics JRA (but remember JRA is in kids)

Complications of JRA?

Cataracts, glaucoma, band keratopathy, phtisis bulbi

Band keratopathy is found in this uveitis...

JRA

Tx band keratophathy in JRA?

EDTA

*What is critical in the Mx of JRA?

- Follow pts regularly
- Do NOT overtreat
- Only Tx exacerbations, reduce down to trace cells, don't have to remove all b/c chronic inflammation

An add is appropriate for this type of uveitis?

JRA - due to loss of accom (iridocyclitis)

Mainstay of systemic JRA Tx?

NSAID, steroids (avoid aspirin in kids)

T/F - Cyclosporin is indicated for JRA.

False - contraindicated (bladder cancer)

Mx of AC rxn in JRA?

May need to live with a few cells in AC so only Tx exacerbations with steroid - NO long term steroid use despite chronic inflammation!

Fuch's HI demographic?

Male = Female, 3rd-4th decade

T/F - Fuch's has a possible assoc w/ histo or toxo

True

Classic presentation of Fuch's HI?

Heterochromia of iris - can be diff in both eyes or within one eye

In Fuch's HI, eye becomes ___ in blue-eyed pts.

bluer

Most Fuch's HI pts have (unilat/bilat) presentation.

unilat

Describe what happens to the iris in Fuch's HI.

Iris stroma becomes "blurred" (loss of detail), appears "buffed down", and lose Fuch's crypts

T/F - Eyes are injected but no pain in Fuch's HI.

False - rare redness and pain

What extent of AC rxn in Fuch's HI?

low grade

T/F - Vitritis is possible in Fuch's HI.

True

What usually brings in Fuch's HI pts?

Secondary cataracts and VA loss

T/F - Synechiae is characteristic in Fuch's HI.

False - no synechiae, makes sense b/c low grade cells & flare

Complications of Fuch's HI?

Glaucoma

You definitely don't Tx steroids with Traumatic iritis - what other uveitis should you be cautious with in using steroids?

Fuch's HI - b/c may hasten cataract development

Sarcoidosis demographic?

Blacks in Atlantic gulf coast states, ages 20-40

Think Shawn Marion who plays for Miami Heat (FL is an Atlantic gulf coast state, duh)

Hallmark sign in Sarcoidosis? Where found?

Noncaseating granuloma - in conj, parotid gland, lacrimal gland, lungs

__% Sarcoidosis pts have ocular sequellae.

50

Systemic Sarcoidosis Sx?

fever, fatigue, dyspnea (makes sense b/c granuloma in lungs and chest X-ray to Dx), weight loss

Sarcoidosis = bilat/unilat?

bilat iridocyclitis

Sarcoidosis has synechiae?

Yes - less if acute, more if chronic

Describe the pain & photophobia of Sarcoidosis?

mild

*Sarcoidosis has this key ocular sign: ____. Other ant ocular signs?

Mutton fat KPs

Also iris nodules, crypts are missing (fuzzy teddy bear iris). Cataracts and glaucoma are complications

Candle wax drippings are characteristic of this uveitis and is found...

Sarcoidosis, found in post seg (venule exudates)

What are Dalen-Fuch's nodules, and found in?

Choroidal lesions found in Sarcoidosis

Also found in Sympathetic Ophthalmia at level of RPE

Vitreous snowballs, candle wax drippings, perivenous sheathing, and CME are all found in this uveitis...

Sarcoidosis

T/F - NVD is possible in Sarcoidosis

True (15%)

T/F - APD is possible in Sarcoidosis

True - possible optic disc swelling

What nerve palsy is possible in Sarcoidosis?

Facial nerve

What is the key test in Dx Sarcoidosis?

Chest x-ray (hilar/paratracheal adenopathy)

ACE and gallium scan will give false negative Sarcoidosis if...

pt taking steroids

Cyclosporin A is effective in this uveitis in pts intolerant to oral steroids...

Sarcoidosis

Sarcoidosis f/u and how often for exam?

- f/u 3-7 days
- Asymptomatic q6 mos,
- Steroid Tx pts q3 mos
- Kids q1-3 mos

HIV infection can cause a resurgence of this uveitis...

Syphilitic Iridocyclitis

Syphilitic Iridocyclitis is acquired...

in adult life or in utero

Salt & pepper fundus, hutchinson teeth, frontal bossing, depressed nasal bridge, nerve deafness, linear scars at angles of mouth, mental retardation, recurrent arthropathy are characteristic of...

Congenital Syphilitic Iridocyclitis

Hutchinson teeth is seen in...

Syphilitic Iridocyclitis

Frontal bossing is seen in...

Syphilitic Iridocyclitis

What is the Hutchinson Triad, and what dz is it found in?

Notched incisors, deafness, interstitial keratitis

In Syphilitic Iridocyclitis

Stages of Syphilis (acquired)?

1) Primary: chancre (painless!), large lymph nodes, 3 wks after sex
2) Secondary: skin/mucous memb lesions, large lymph nodes, sore throat, fever 1 mo- 6 mos after primary
3) Latent: nothing
4) Tertiary: Argyll Robertson pupils, CV dz, tabes dorsalis, general paresis

Ocular signs of congenital Syphilis?

- Iridocyclitis (any or all degrees of inflam)
- Interstitial keratitis
- Chorioretinitis
- Optic atrophy

Ocular signs of acquired syphilis (in each stage)?

1) Primary: chancre on eyelid or conj
2) Secondary or tertiary: iridocyclitis, optic neuritis, chorioretinitis, retinal vasculitis
3) Tertiary: optic atrophy, old chorioretinitis, chronic iritis, Argyll-Robertson pupil

When does the chancre on eyelid or conj occur in acquired syphilis?

primary stage

When does optic neuritis occur in acquired syphilis?

secondary or tertiary stage

When does the Argyll-Robertson pupil occur in acquired syphilis?

tertiary stage

When does the iridocyclitis occur in acquired syphilis?

secondary or tertiary stage

False negatives in RPR or VDRL occur in...

Primary, latent, and tertiary syphilis

No systemic Tx is indicated for syphilis if...

FTA-ABS negative

If you see FTA-ABS positive and VDRL positive, syphillis Tx involves...

oral antibiotics (penicillin)

Syphilitic Iridocyclitis f/u and frequency of eye exam?

3-7 days, every 6 mos

Posner-Schlossman is aka...

Glaucomatocyclitic crises

Posner-Schlossman demographic?

Young-middle age adults, males=females

Key sign in Posner-Schlossman?

Very high IOP (40-60 mmHg)

(DDx vs angle closure)

Posner-Schlossman = bilat/unilat?

unilat

Posner-Schlossman Sx?

Severe pain w/ little photophobia

Posner-Schlossman pupil is dilated or constricted?

dilated (note different from other uveitis)

You can DDx closed angle vs Posner-Schlossman by...

Closed angle = older pts, no cells in AC, closed angles

P-S = young-middle age, trace cells in AC, wide open angles

If IOP >60 mmHg in Posner-Schlossman, you can see...

edematous cornea

*Tx Posner-Schlossman?

Topical beta blocker (decr IOP!), topical steroid (decr cells in AC)

NO PILO!

T/F - Since the pt is already dilated, cycloplegic is not appropriate for Posner-Schlossman.

False - can use if pt is symptomatic

If IOP is extremely elevated, Tx for Posner-Schlossman?

CAI

If dangerously high and can harm ONH - Hyperosmotic agents

What should you absolutely NOT use in Posner-Schlossman?

Pilo, b/c trabeculitis

Remember pilo pulls on ciliary muscle, pulling on scleral spur, which pulls on TM (ouch!)

T/F - Ant seg lasers can cause uveitis, but post seg lasers don't.

True - ant seg lasers hit area and cause shock waves that irritate CB; post seg lasers hit area and shock waves are absorbed

T/F - Uveitis possible in ALT and SLT.

True

Ocular presentation of laser induced uveitis?

cells w/ little flare, Hx of recent laser procedure (YAG), pseudophake (YAG)

*Key factor in Dx laser induced uveitis?

Hx (YAG)!!!

T/F - Pars planitis is ideopathic in etiology.

True

Pars planitis demographics?

Young adults

T/F - Pars planitis occurs mostly in caucasians.

False - no race predilection

*In pars planitis, should consider these systemic diseases...

MS, sarcoidosis, lyme dz, toxocariasis

Pars planitis = unilat/bilat?

bilat

Key sign in Pars planitis?

snowbanking - inferior ora serrata

Pars planitis Sx?

Blurred vision and floaters with NO pain or photophobia

T/F - Snowballs possible in Pars planitis

True - inferior vitreous

What can happen in chronic Pars planitis?

CME

T/F - Pars planitis can affect accommodation.

True - makes sense b/c zonules originate in pars plana, which is inflamed

What complications are possible from Pars planitis?

PVDs, vitreous hemes, RDs, retinal tears (all inter-related!)

Also peripapillary edema

Mx of Pars planitis that has 20/30 VA?

No Tx for 20/40 or better

Mx of Pars planitis due to CME with 20/40 or worse VA?

Topical steroid, periocular stroid, oral steroid

If fail, cryotherapy, vitrectomy, immunosupp agents

Frequency of eye exam for Pars planitis?

q3-6 mos

Toxoplasmosis causative agent?

Toxoplasma gondii (protozoan)

Most common post uveitis in US?

toxoplasmosis

Toxoplasmosis demographics?

<55 yrs old

*Definite host of Toxoplasmosis?

Members of cat family

*How do humans contract Toxoplasmosis?

Ingest infected food - undercooked raw meat, oocyst from hand (kitty litter), raw milk (rare)

Also skin penetration, transplanted transmission

Tachyzoite is the (active/inactive form) of Toxoplasmosis, Bradyzoite is the (active/inactive) form.

active, inactive

Think Tachycardia is an Active heart, Bradycarida is an Inactive (less active) heart

What causes activation of Toxoplasmosis?

lowered imm sys

(dormancy can last for yrs)

T/F - Systemic infection usually seen in congenital type Toxoplasmosis.

False - acquired

Highest percentage of acquired Toxoplasmosis infection in what population?

AIDS pts

Systemic Sx of acquired toxoplasmosis?

Cold-like Sx persisting over time, fever, malaise, HA, sore throat, myalgia, blurred vision

T/F - The first born gets the Toxoplasmosis infection, then the rest of the mother's children do not get it.

True - b/c antibodies develop for 1st child in mother, then subsequent children do not get it

What trimester(s) is/are the highest risk of congenital Toxoplasmosis?

2nd & 3rd

1st trimester usually spontaneous abortion

Key signs/Sx of congenital Toxoplasmosis?

3 Cs: convulsions, calcifications, chorioretinitis

Possible hydrocephalus & beaten metal appearance of skull

You see white-yellow lesions in the retina. What main ocular sign would you look for to DDx this as Toxoplasmosis vs Histoplasmosis?

White-yellow lesions WITHOUT cells = histo

T/F - Photophobia and pain are characteristic of Toxoplasmosis

False - none usually

Signs of Toxoplasmosis in eye?

Floaters, hazy vitreous that obscures bright foveal reflex ("headlights in fog"), white yellow lesions, vitreous scaffolding (precipitates on post vitreal face)

Other = possible scars in other eye, disc edema if lesion at/near ON; retinal vasculitis, vein occlusion if lesion on BVs

Late sequellae = CME and SRNVM (CNVM)

Congenital Toxoplasmosis involves elevation of which Igs? Acquired?

Congenital = IgA, IgM
Acquired = IgG, IgE

"CAM AGE"

New Toxoplasmosis infection involves which Ig? Reactivation?

New = IgM
Reactivation = IgG\

Think N is close to M in alphabet

Why is fluorescein angiography useful in Toxoplasmosis Dx?

R/O SRNVM (CNVM)

You notice a Toxoplasmosis lesion in the peripheral retina, near the ora serrata. There is no AC rxn. Worried, you ask the staff doc if this needs Tx, but the Dr. says no Tx required. Why?

Tx Toxoplasmosis lesions only if on/near macula, ONH, or BV; otherwise, let "burn out" b/c Tx may be more painful than it's worth. If AC rxn, can Rx topical steroid and cycloplegic

Why do you see floaters in Toxoplasmosis and not Histoplasmosis?

Toxo is a chorioretinitis, while histo is only a choroiditis.

Think of the retina - it's next to the vitreous so inflammatory material can get to vitreous. The choroid has the retina between it an the vitreous.

You must Tx Toxoplasmosis if it is ___ DD from the ___ or ___, or if it is near or on a ___.

2-3, ONH, macula, BV

What drug inhibits the conversion of folinic acid to folic acid? What is this used for? What other drugs are used in combo with this drug?

Pyrimethamine (Daraprim) used for Toxoplasmosis

Toxoplasmosis parasite likes folic acid so cut off its food supply with this

Use this drug with Folinic acid (critical in platelet formation) and Sulfadiazine (decr PABA to Folic Acid conversion)

When is it appropriate to start oral steroid Tx in Toxoplasmosis? How about periocular steroid?

Start after initiation of antibiotic Tx

NEVER use periocular steroids

Clindamycin can be used for this type of uveitis. *What should you watch out for when using this?

Toxoplasmosis. Watch out for Pseudomembranous colitis, b/c can mimic GI distress often caused by antibiotics, but DDx because freq bowel mvt with bloody stool

Trimethoprim/sulfametroxazole is an alternate Tx for this uveitis.

Toxoplasmosis. Can be used w/ or w/o clindamycin and predinsone

Zithromax has had some success in treating this uveitis...

Toxoplasmosis

Mepron (Atovaquone) is used for this uveitis. Why is it unique?

Toxoplasmosis. Kills toxo AND bradyzoites

Your AIDS pt has an active Toxoplasmosis near the ONH. What Tx should you NOT use to Tx the toxo?

Steroid - should not be given to immunocompromised pts

Why is it important to use Folinic acid as an adjunct Tx with Daraprim (Pyrimethamine)?

Daraprim decr platelet count

Folinic acid helps incr platelets

Watch CBC and Platelet count every ___ in Toxoplasmosis. Platelet count should not go below ___.

1-2x week, 100,000

Pts with Toxoplasmosis on Daraprim should not take this supplement.

Folic acid

Adjunct surgical Tx of Toxoplasmosis?

Cryotherapy, laser, vitrectomy

What is an appropriate substitute for Clindamycin when Tx Toxoplasmosis?

Tetracycline

Pyrimethamine should never be given to...

pregnant women

aka Daraprim - used for Toxoplasmosis

Risk factors for Candidiasis uveitis?

IV drug use, HIV, cancer pts, long term steroid users, long term indwelling catheter (hemodialysis)

Plaque-like lesions on oral mucosa (leukoplakia) with skin fold infections are characteristic of...

Candidiasis uveitis

Sx of Candidiasis uveitis?

Decr VA, floaters, pain

T/F - No decr VA in Candidiasis uveitis

False - can have decr VA