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Dr. Anupama Karanth
www.ophthalclass.blogspot.com
International Uveitis Study Group (IUSG)



    ◦ Anatomic Classification of Uveitis

      Anterior
      Intermediate
      Posterior
      Panuveitis




                                           www.ophthalclass.blogspot.com
Infectious

    ◦ Bacterial / Viral / Fungal / Parasitic / Others


    Non-infectious

    ◦ Known/No known systemic association


    Masquerade

    ◦ Neoplastic / Non-neoplastic




                                                www.ophthalclass.blogspot.com
Non-infectious can be considered also as

    immune related causes

    Masquerade syndromes will be dealt with

    separately

    Idiopathic cause is included in all the uveitis





                                           www.ophthalclass.blogspot.com
Anterior uveitis



                                Immune
Idiopathic      Infectious
                                 related




                                 www.ophthalclass.blogspot.com
Intermediate uveitis




                                Immune
Idiopathic    Infectious
                                 related




                                 www.ophthalclass.blogspot.com
Posterior uveitis




                                 Immune
Idiopathic      Infectious
                                  related




                                  www.ophthalclass.blogspot.com
Panuveitis



                          Immune
Idiopathic   Infectious
                           related




                            www.ophthalclass.blogspot.com
Idiopathic           Infectious       Immune related


• Most common        • Herpes simplex   • HLA B27+/
                                          seronegative
• Diagnosis only     • Herpes zoster
                                          spondylo-
  after other        • Tuberculosis
                                          arthropathies
  causes are ruled   • Syphilis
  out                                   • Juvenile
                                          rheumatoid
                                          arthritis (JRA)
                                        • Lens or IOL
                                          related


                                              www.ophthalclass.blogspot.com
Immune
   Idiopathic        Infectious
                                        related

• Most            • Tuberculosis   • Sarcoidosis
  common          • Syphilis       • Multiple
• Only after                         sclerosis
                  • Lyme disease
  other causes
  are ruled out




                                        www.ophthalclass.blogspot.com
Infectious     Immune related
    Idiopathic

• Less common    • Toxoplasmosis   • Sarcoidosis
                 • Toxocariasis    • Collagen vascular
                                     diseases
                 • Herpes
                                   • Retinochoroidop
                  (ARN/PORN/CMV)
                                     athies
                 • Tuberculosis,
                   syphilis




                                        www.ophthalclass.blogspot.com
Idiopathic           Infectious       Immune related

• After ruling out   • Tuberculosis,     • Sarcoidosis
  other causes         syphilis          • Vogt – Kayanagi
                     • Lyme disease        – Harada
                                           syndrome
                     • Leptospirosis
                                         • Sympathetic
                     • Infectious
                                           ophthalmitis
                       endophthalmitis
                                         • Beh et
                                           syndrome




                                              www.ophthalclass.blogspot.com
List of diseases can be very long indeed


    Patient is NOT investigated for ALL the


    diseases
    Narrow down the differential diagnosis


    before ordering the lab tests




                                       www.ophthalclass.blogspot.com
Narrow down the differential diagnosis with


    ◦ Time course of disease
    ◦ Type of inflammation
    ◦ Characteristic pattern of the lesion
    ◦ Demographic data – age, sex, race, social history
    ◦ Associated systemic features




                                               www.ophthalclass.blogspot.com
Anterior uveitis is the most common type of


    uveitis
    Idiopathic form is the most common cause of


    anterior uveitis
    Infections are more common in posterior


    uveitis
    Sarcoidosis, tuberculosis and syphilis can


    present in any or all locations
                                         www.ophthalclass.blogspot.com
Acute

      Sudden onset, lasting up to 6 weeks

    Chronic

      Insiduous onset, lasting longer than 6 weeks

    Recurrent

      Repeated attacks with disease free intervals




                                             www.ophthalclass.blogspot.com
Acute


      Idiopathic anterior uveitis
      VKH syndrome

    Chronic


      JRA
      Tuberculous uveitis
      Sarcoidosis

    Recurrent


      Idiopathic anterior uveitis
      VKH syndrome

                                     www.ophthalclass.blogspot.com
Granulomatous            Non-granulomatous

Onset                  Insiduous                Acute

Keratic precipitates    Large, greasy           Fine
                        Mutton-fat, white       White coloured
                        Macrophages and         Lymphocytes and
                       epithelioid cells        plasma cells

Iris nodules                                    Generally absent
                        Koeppe (at pupillary
                       border)
                        Busacca (on iris
                       surface)


                                                         www.ophthalclass.blogspot.com
Granulomatous         Non-granulomatous

Fundus                                      Uncommon
                      Choroidal
                      nodules/granulomas

Course                Chronic               Maybe self limited

Posterior synechiae   Broad based           Fine

Causes                 Suggestive of few    Many anterior uveitic
                      specific conditions   diseases
                       More commonly        Not helpful in
                      infectious            formulating differential
                                            diagnosis


                                                       www.ophthalclass.blogspot.com
www.ophthalclass.blogspot.com
www.ophthalclass.blogspot.com
www.ophthalclass.blogspot.com
www.ophthalclass.blogspot.com
www.ophthalclass.blogspot.com
• Tuberculosis, syphilis
                • Sarcoidosis
                • Vogt – Koyanagi – Harada
Granulomatous
                  syndrome
    uveitis
                • Sympathetic ophthalmitis
                • Intraocular foreign body
                • Lens induced uveitis




                                           www.ophthalclass.blogspot.com
Children


      JRA (anterior)
      Toxocariasis (posterior)

    Adults


      Ankylosing spondylitis, Reiter syndrome (anterior)
      VKH, Beh et syndrome (panuveitis)

    Elderly


      Idiopathic
      Masquerade syndromes




                                                      www.ophthalclass.blogspot.com
Any age

   Toxoplasmosis

   Tuberculosis

   Sarcoidosis




                    www.ophthalclass.blogspot.com
www.ophthalclass.blogspot.com
Asians


      VKH, Beh et syndrome

    Blacks


      Sarcoidosis

    Whites


      Ankylosing spondylitis, Reiter syndrome
      HLA B27+


                                           www.ophthalclass.blogspot.com
Pets / cat feces
                      • Toxoplasmosis
      contact


Contaminated water
                      • Leptospirosis
  / rodent urine


    Farmers /
                      • Brucellosis
   veterinarians



                      • Tuberculosis, syphilis, HIV
History of exposure

                                           www.ophthalclass.blogspot.com

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Common Causes of Uveitis Part1

  • 2. International Uveitis Study Group (IUSG)  ◦ Anatomic Classification of Uveitis  Anterior  Intermediate  Posterior  Panuveitis www.ophthalclass.blogspot.com
  • 3. Infectious  ◦ Bacterial / Viral / Fungal / Parasitic / Others Non-infectious  ◦ Known/No known systemic association Masquerade  ◦ Neoplastic / Non-neoplastic www.ophthalclass.blogspot.com
  • 4. Non-infectious can be considered also as  immune related causes Masquerade syndromes will be dealt with  separately Idiopathic cause is included in all the uveitis  www.ophthalclass.blogspot.com
  • 5. Anterior uveitis Immune Idiopathic Infectious related www.ophthalclass.blogspot.com
  • 6. Intermediate uveitis Immune Idiopathic Infectious related www.ophthalclass.blogspot.com
  • 7. Posterior uveitis Immune Idiopathic Infectious related www.ophthalclass.blogspot.com
  • 8. Panuveitis Immune Idiopathic Infectious related www.ophthalclass.blogspot.com
  • 9. Idiopathic Infectious Immune related • Most common • Herpes simplex • HLA B27+/ seronegative • Diagnosis only • Herpes zoster spondylo- after other • Tuberculosis arthropathies causes are ruled • Syphilis out • Juvenile rheumatoid arthritis (JRA) • Lens or IOL related www.ophthalclass.blogspot.com
  • 10. Immune Idiopathic Infectious related • Most • Tuberculosis • Sarcoidosis common • Syphilis • Multiple • Only after sclerosis • Lyme disease other causes are ruled out www.ophthalclass.blogspot.com
  • 11. Infectious Immune related Idiopathic • Less common • Toxoplasmosis • Sarcoidosis • Toxocariasis • Collagen vascular diseases • Herpes • Retinochoroidop (ARN/PORN/CMV) athies • Tuberculosis, syphilis www.ophthalclass.blogspot.com
  • 12. Idiopathic Infectious Immune related • After ruling out • Tuberculosis, • Sarcoidosis other causes syphilis • Vogt – Kayanagi • Lyme disease – Harada syndrome • Leptospirosis • Sympathetic • Infectious ophthalmitis endophthalmitis • Beh et syndrome www.ophthalclass.blogspot.com
  • 13. List of diseases can be very long indeed  Patient is NOT investigated for ALL the  diseases Narrow down the differential diagnosis  before ordering the lab tests www.ophthalclass.blogspot.com
  • 14. Narrow down the differential diagnosis with  ◦ Time course of disease ◦ Type of inflammation ◦ Characteristic pattern of the lesion ◦ Demographic data – age, sex, race, social history ◦ Associated systemic features www.ophthalclass.blogspot.com
  • 15. Anterior uveitis is the most common type of  uveitis Idiopathic form is the most common cause of  anterior uveitis Infections are more common in posterior  uveitis Sarcoidosis, tuberculosis and syphilis can  present in any or all locations www.ophthalclass.blogspot.com
  • 16. Acute   Sudden onset, lasting up to 6 weeks Chronic   Insiduous onset, lasting longer than 6 weeks Recurrent   Repeated attacks with disease free intervals www.ophthalclass.blogspot.com
  • 17. Acute   Idiopathic anterior uveitis  VKH syndrome Chronic   JRA  Tuberculous uveitis  Sarcoidosis Recurrent   Idiopathic anterior uveitis  VKH syndrome www.ophthalclass.blogspot.com
  • 18. Granulomatous Non-granulomatous Onset Insiduous Acute Keratic precipitates  Large, greasy  Fine  Mutton-fat, white  White coloured  Macrophages and  Lymphocytes and epithelioid cells plasma cells Iris nodules Generally absent  Koeppe (at pupillary border)  Busacca (on iris surface) www.ophthalclass.blogspot.com
  • 19. Granulomatous Non-granulomatous Fundus Uncommon Choroidal nodules/granulomas Course Chronic Maybe self limited Posterior synechiae Broad based Fine Causes  Suggestive of few  Many anterior uveitic specific conditions diseases  More commonly  Not helpful in infectious formulating differential diagnosis www.ophthalclass.blogspot.com
  • 25. • Tuberculosis, syphilis • Sarcoidosis • Vogt – Koyanagi – Harada Granulomatous syndrome uveitis • Sympathetic ophthalmitis • Intraocular foreign body • Lens induced uveitis www.ophthalclass.blogspot.com
  • 26. Children   JRA (anterior)  Toxocariasis (posterior) Adults   Ankylosing spondylitis, Reiter syndrome (anterior)  VKH, Beh et syndrome (panuveitis) Elderly   Idiopathic  Masquerade syndromes www.ophthalclass.blogspot.com
  • 27. Any age  Toxoplasmosis  Tuberculosis  Sarcoidosis www.ophthalclass.blogspot.com
  • 29. Asians   VKH, Beh et syndrome Blacks   Sarcoidosis Whites   Ankylosing spondylitis, Reiter syndrome  HLA B27+ www.ophthalclass.blogspot.com
  • 30. Pets / cat feces • Toxoplasmosis contact Contaminated water • Leptospirosis / rodent urine Farmers / • Brucellosis veterinarians • Tuberculosis, syphilis, HIV History of exposure www.ophthalclass.blogspot.com