ADENOVIRAL KERATOCONJUNCTIVITIS

1
(No Transcript)
2
RED EYE- UVEITIS

• Brig Mazhar Ishaq
• Advisor in Ophthalmology,
• Comdt Armed Forces Institute Of Ophthalmology,
• Rwp

3
DEFINITION OF UVEITIS

• Uveitis is the inflammation of the uveal tract

4
ANATOMICAL CLASSIFICATION

• ANTERIOR UVEITIS
• IRITIS
• IRIDOCYCLITIS
• INTERMEDIATE UVEITIS
• POSTERIOR UVEITIS
• PANUVEITIS

5
CLINICAL CLASSIFICATION

• ACUTE UVEITIS
• SUDDEN
• PERSISTS FOR UPTO 3 MONTHS
• CHRONIC UVEITIS
• PERSISTS LONGER THAN 3 MONTHS
• ONSET IS INSIDIOUS
• MAY BE ASYMPTOMATIC

6
AETIOLOGICAL CLASSIFICATION

• ASSOCIATED WITH SYSTEMIC DISEASE
• JUVENILE ARTHRITIS
• HLA-B 27 RELATED UVEITIS
• SARCOIDOSIS
• BEHCETs DISEASE
• VOGT-KOYANAGI-HARADA DISEASE
• INFECTIONS
• VIRAL
• VARICELLA ZOSTER
• HERPES SIMPLEX
• HUMAN T-CELL LYMPHOCYTIC VIRUS TYPE I
• RUBELLA VIRUS

7

• BACTERIAL
• SYPHILIS
• TUBERCULOSIS
• LEPROSY
• LYME DISEASE
• CAT SCRATCH DISEASE
• FUNGAL
• HISTOPLASMOSIS
• CANDIDIASIS
• ASPERGILLOSIS
• COCCIDIOIDOMYCOSIS

8

• INFESTATIONS
• OCULAR TOXOPLASMOSIS
• TOXOCARIASIS
• CYSTICERCOSIS
• TRAUMATIC
• PHACOANTIGENIC UVEITIS
• SYMPATHETIC UVEITIS
• IDIOPATHIC
• SPECIFIC
• NONSPECIFIC UVEITIS ENTITIES

9
PATHOLOGY

• VASODILATATION
• EXUDATION
• MIGRATION OF LEUCOCYTES
• CHEMOTAXIS

10

• LEUCOCYTES PARTICIPATING
• Neutrophil
• Basophils
• Eosinophil
• Macrophages
• Lymphocytes

11
ANTERIOR UVEITIS

• SYMPTOMS
• ACUTE ANTERIOR UVEITIS
• Photophobia
• Pain
• Redness
• Decreased vision
• Lacrimation

12
SYMPTOMS

• CHRONIC ANTERIOR UVEITIS
• MAY BE ASYMPTOMATIC
• MILD REDNESS
• FLOATERS

13
SIGNS

• Circumcorneal or ciliary injection

14
KERATIC PRECIPITATES

• Cellular deposits on corneal endothelium
• Most commonly form in the mid inferior zones

15
KERATIC PRECIPITATES

• ENDOTHELIAL DUSTING
• MYRIAD OF CELLS

16
KERATIC PRECIPITATES

• MEDIUM SIZED KPs
• IN MOST TYPES OF ACUTE AND CHRONIC UVEITIS

17
KERATIC PRECIPITATES

• LARGE KPs
• MUTTON-FAT KP
• ARE GREASY, WAXY IN APPEARANCE
• OCCUR IN GRANULOMATOUS UVEITIS

18
KERATIC PRECIPITATES

• OLD KPs
• ARE PIGMENTED
• MAY DEVELOP GROUND-GLASS APPEARANCE

19

• CELLS IN AQUEOUS
• INDICATIVE OF ACTIVE INFLAMMATION
• lt 5 CELLS \-
• 5 10 CELLS 1
• 11 20 CELLS 2
• 21 50 CELLS 3
• gt 50 4
• HYPOPYON

20
HYPOPYON
21
AQUEOUS FLARE

• Tyndall effect
• Graded as
• Faint
  1
• Moderate / iris details clear 2
• Marked iris details hazy 3
• Intense with exudate 4

22

• AQUEOUS FLARE

23
IRIS NODULES

• KOEPPE NODULES
• SMALL
• SITUATED AT THE PUPILLARY BORDER
• BUSACCA NODULES
• LESS COMMON
• LOCATED AWAY FROM PUPIL

24

• KERATIC PRECIPITATES, POSTERIOR SYNECHIAE, AND
  KOEPPE NODULES ALONG THE PUPILLARY BORDER

25
COMPLICATIONS

• POSTERIOR SYNECHIAE
• SECLUSIO PUPILLAE
• IRIS BOMBE
• GLAUCOMA
• BAND KERATOPATHY
• CATARACT

26
COMPLICATIONS

• MACULAR ODEMA
• CYCLITIC MEMBRANE FORMATION
• PHTHISIS BULBI

27

• POSTERIOR SYNECHIAE

28

• IRIS BOMBE

29

• BAND KERATOPATHY

30

• CATARACT

31

• MACULAR ODEMA

32
INVESTIGATIONS

• Indications
• Recurrent granulomatous anterior uveitis
• Bilateral disease
• Systemic manifestations with out a specific
  diagnosis
• Confirmation of suspective ocular picture such as
  HLA-A29 testing in birdshort chorioretinopathy

33
NOT NECESSARY

• Single attack of mild unilateral acute anterior
  uveitis
• A specific uveitis entity
• When a systemic diagnosis compatible with the
  uveitis is already apparent

34
INVESTIGATIONS

• Obtain a history, attempting to define the
  etiology.
• Complete ocular examination, including an IOP
  check and a dilated fundus examination.

35
SKIN TESTS

• Tuberculin skin test(montoux Heaf)
• Intradermal inj of purified protein
• Positive
• Induration of 5-14 mm with in 48 hours
• Negative
• Excludes TB
• May occure in advanced disease

36
PATHERGY TEST

• Increased dermal sensitivity to needle trauma
• Behcet syndrome
• Rarely positive in absence of systemic activity
• Pustule formation

37
SEROLOGY

• SYPHILIS
• Non-treponemal tests
• RPR or VDRL
• Primary infection
• Monitor disease activity
• Response to therapy

38

• Immunofluorescent antibody test
• Haemagglutination test

39
Enzyme-linked Immunosorbent Assay (ELISA)

• Antibodies in aqueous (more specific)
• Other conditions (cat-scratch fever
  toxocariasis
• Antinuclear Antibody (ANA)
• In children with JIA who are at high risk of
  developing ant uveitis

40
ENZYME ASSAY

• Angiotensin converting enzyme (ACE)
• Nonspecific test
• Granulomatous disease like
• - Sarcoidosis (elevated in 80 in acute)
• - TB
• - Leprosy
• Lysozyme
• Good sensitivity but less speceficity for
  sarcoidosis

41
HLA TISSUE TYPING

• HLA type Associated disease
• B27 Spondyloarthropathies
• A29 Birdshot chorioretinopathy
• B51 Behcet syndrome
• HLA-B7 POHS APMPPE
• HLA-DR2

42
IMAGING

• Fluorescein angiography (FA)
• Retinal vasculitis
• CMO
• Indocyanine angiography (ICG)
• Better for choroidal disease

43

• Ultrasonography (US)
• It is useful in opaque media especially in
  excluding a RD or intraocular mass
• Optical coherence tomography(OCT)
• Detecting CMO
• Identify vitreoretinal traction as a mechanism of
  CMO

44
BIOPSY

• Histopathology still remains the gold-standard
• conjunctiva And Lacrimal gland
• - Sarcoidosis
• Aqueous samples
• - For (polymerase chain reaction) PCR
• - Viral retinitis (occasionally)
• Vitreous biopsy
• - Infectious endophthalmitis

45
RADIOLOGY

• Chest X-rays
• - To exclude TB and Sarcoidosis
• Sacro-illiac joint X-Rays
• - Diagnosis of spondyloarthropathy
• CT MRI
• - Sarcoidosis
• - Multiple sclerosis
• - Primary intraocular lymphoma

46
TREATMENT

• AIM
• Prevent vision threatening complications
• Relieve patients discomfort
• Treat the underlying cause
• FOUR GROUP OF DRUGS
• Mydriatics
• Steroids
• Cyclosporine
• Cytotoxic agents

47
TREATMENT

• Mydriatics
• To give comfort
• To prevent formation of posterior synechia
• To break down synechia
• Drugs (atropine, homatropine, scopolamine,
  tropicamide)

48
TREATMENT

• Steroids (mainstay of treatment)
• Topical administration
• Complications (glaucoma, posterior sub capsular
  cataract, corneal complications, systemic side
  effects)
• Periocular injections
• Severe acute anterior uveitis
• Adjuvant to topical/systemic
• Poor compliance
• Pre op

49
TREATMENT

• Systemic therapy
• Preparations
• Prednisolone 5mg
• Indications
• Rules
• Start with large dose then reduce
• Initial dose 1-1.5 mg/kg BW
• Before breakfast
• Taper off
• Less than 2 weeks abrupt stop

50
TREATMENT

• Side effects
• Short term
• Long term

51
TREATMENT

• Cyclosporin
• Steroid sparing agent
• Complications are hypertension and nephrotoxicity
• Cytotoxic drugs
• Potentially blinding bilateral reversible uveitis
• Intolerable side effects from systemic steroids
  therapy.

52
THANK YOU