Congenital anomalies of uveal tract

Heterochromia of iris: variations in iris colour

Heterochromia iridium: color of one iris differs from other
Heterochromia iridis: one sector of iris differs from other
Acquired seen in: heterochromia, cyclitis, siderosis and
malignant melanoma of iris

Corectopia: abnormally eccentric placed pupil(normal

pupil is slightly nasal to centre)
Polycoria: more than one pupil
Congenital aniridia: congenital absence of iris; true
absence is very rare; usually a peripheral rim of iris is
present and this is called clinical aniridia where zonules
of lens and ciliary processes are visible; familial condtn

 Persistent pupillary membn:

represents the remanant of vascular sheath of
lens; c/b stellate shaped shreds of pigmented
tissue coming from ant surface of iris; float freely
in the ant chamber or attached to ant surface of
lens

Coloboma: absence of tissue of iris, ciliary

body and choroid
Typical: seen in infero nasal quadrant and occurs
d/t defective closure of embryonic fissue
Atypical: found in other positions
Complete coloboma extends from pupil to optic
nerve, with a sector gap occupying about one
eigth of circumference

Uveitis
Inflammation of uveal tissue only; but
often a/w inflammation of retina,
vitreous, sclera and cornea; and d/t
close association inflammation tends
to involve the uvea as whole

 Classification
Anterior uveitis

Inflammation of uveal tissue from iris

upto pars plicata of ciliary body
-Iritis, Iridocyclitis, Cyclitis

Intermediate uveitis

Iris + pars plicata

Post. Uveitis

Choroid and often retina;

chorioretinis

Pan uveitis

Inflammation of whole uvea

Acute uveitis

Sudden symptomatic onset; last upto

6wks 3 months

Chronic uveitis

Insidious and asymptomatic; >3mo

Suppurative

Pus

Non suppurative

Non granulomatous and

Granulomatous

Infective

Allergic

Toxic

Traumatic

Uveitis w/ noninfective systemic dzs

Idiopathic

Etiology of uveitis

Infective uveitis
Modes:

Types

Exogenous infection: penetrating injuries, perforation of

ulcer and ocular surgery
Secondary infection: acute purulent conjunctivits, keratitis,
scleritis,
retinitis,
orbital
cellulitis
and
orbital
thrombophlebitis
Endogenous infection: through bloodstream
Comments

Bacterial infections

Granulomatous; TB, syphilis, leprotic,

brucellosis
Pyogenic by staph, strep, pneumo.,
gonoco

Viral

Herpes simplex, Herpes zooster and CMV

Fungal

Aspergillosis, Candidiasis, Blastomycosis

Parasitic

Toxocariasis, Onchocerciasis, amoebiasis

Rickettsial

Scrub typhus and epidemic

Allergic

D/t microbial allergy

Anaphylactic uveitis
Atopic uveitis: airbone allergens
Autoimmune uveitis: Stills dz, RA, Wegners
granulomatosis, SLE, Reiters dz
Phacoanaphylactic
Sympathetic
HLA associated
HLA-B27= a/w ankylosing spondylitis and Reiters synd.
HLA-B5: Behcets dz
HLA-DR4 and DW15: Vogt kayanagi haradas dz

Toxic
Endotoxins: autotoxins or microbial toxins
Endocular toxins: from ocular tissues; blind eyes, retinal
hhg and RD
Exogenous toxins: inorganic, animal or vegetative origin
Traumatic
-d/t accidental or operative injuries to uveal tissues by
direct mechanical effects, irritative effects, microbial
invasion, chemical effects, sympathetic ophthalmia
Uveitis a/w noninfectious systemic dz: a/w
sacroidosis, PAN, RA, DM, Gout, Sclerosis, Psoriasis,
Lichen planus, Erythema nodosum
Idiopathic

Pathology
Suppurative uveitis:
d/t infection by organisms like staph, strep, pseudomonas,
pneumo., gonococcus, purulent inflamm of the uvea is the
part of endo or panophthalmitis
c/b outpouring of purulent exudate and infiltration by PMN
cells of uveal tissue, ant. Chamber, post chamber and
vitreous as a result whole uveal tissue is thickened and
necrotic filled with pus

 Non granulomatous uveitis

Occurs d/t physcial or toxic reactions often d/t hypersensitivity
Marked dilation and increased permeability of vessels,
breakdown of blood aq. Barrier with outpouring of fibrinous
exudate and inflitration by plasma cells, lymphocytes and
macrophages; usually diffuse
Iris waterlogged, oedematous, muddy w blurring of crypts and
furrow, mobility of iris is reduced, pupil same d/t toxic
constriction and engorgement of vessels of iris
Exudates and lymphocytes poured into ant chamber results into
aq. Flare and Kp at the back of cornea
Posterior synechia d/t exudate in post chamber
Cyclitic membrance at the back of lens in severe cases
Heals by necrotic point fibrosis> destruction

 Granulomatous uveitis:
d/t chronic inflammation by irritant forgein
body, hhg or necrotic tissue or non pyogenic
organisms of less virulence like TB, Syphilis,
Leptospirosis, Mycotic, Protozoal, Helminthic
Also seen in sarcoidosis, sympathetic ophthalmia
and Vogt kayanagi haradas dz
Similar to granuloma formation else where but
here the epithelioid and giant cells forms nodules
like Koeppe nodules near pupillary margin and at
the back of cornea called mutton KP

Anterior uveitis
Clinical features:
Acute or chronic
Pain; dull aching throbbing sensation worse at night
Redness; circumcorneal congestion
Photophobia and blepharospasm; reflex
mechanism
Lacrimation
Defective vision: slight blur to marked deterioration
d/t myopia, corneal haze, aq turbidity, pupillary
block, complicated catarct, vitreous haze, cyclitic
membrance, macular oedema, papillitis and
secondary glaucoma

 Signs:
Lid edema
Circumcorneal congestion
Corneal signs:
Corneal edema
Keratic precipitates:
Mutton fat; d/t epitheloid & giant cells in granulomatous; usually
few in number upto 15 which are greasy and waxy
Smaller & medium Kps: d/t lymphocytes in non granulomatous,
small discrete multiple may be hundres
Red kps: with RBCs + inflammatory cells
Old kps: sign of healed uveitis; either of above shrink, fade,
become pigmented and irregular in shape

Posterior corneal opacity

--Ant chamber signs:

Aq. Cells;
early feature and should be counted with oblique slit lamp
-= o cells, +/-=1-5 cells, +1= 6-10cells, +2= 11-20 cells, +3= 21-50
cells, +4= over 50 celss
Aq. Flare
d/t leakage of protein partices in aq humour; demonstrated on the slit
lamp examn by a point beam of light passed obliquely
In beam of light, they appear as a suspended and moving dust
particles= Brownian movement
Marked in granulomatous
0= no aq flare, +1= just detectable, +2=moderate flare, +3=marked
flare, +4= intense flare
Hypopyon, Hyphaema, Changes in depth and shape of ant chamber,
Changes in angle of ant chamber

Pupillary signs
Narrow pupil; d/t irriation of sphincter pupillae by toxins
Irregular pupil shape: d/t segmental post. Synechia
atropinised dilatation of pupil results into festooned pupil
Ectropion pupillae; eversion of pupillary margin
Pupillary reaction: sluggish or absent
Occlusio pupillae: completely occludes by exudates

when

 Iris signs:
Loss of normal pattern
Changes in iris colour; muddy in color during active phase
and hyperpigmented & depigmented cells in healed stage
Iris nodules:
Typically seen in granulomatous uveitis
Koeppes nodules; at pupillary bordermay initiate posterior
synechia
Busaccas nodules; near collarette, large but less common
than Koeppes nodules

Posterior synechiae; segmental, annular(seclusio pupillae,

iris bombe formn), total
Neovascularisation(rubeosis iridis)

Lenticular changes
Pigment dispersal on ant surface of lens
Exudates deposition
Complicated catarct; as a complication of persistent
iridocyclitis, bread cumb appearance of early posterior
subcapsular opacities

Changes in vitreous

Complications
1. Complicated cataract
2. Secondary glaucoma
I. Early glaucoma: d/t exudates clogging the trabecular meshwork
II. Late glaucoma: d/t pupillary block formed by posterior synechia

3. Cyclitic membrane: d/t fibrosis of exudates behind the lens

4. Choroidits
5. Retinal complications: CME, Macular degeneration, RD,
Secondary periphlebitis
6. Papillitis
7. Band shaped keratopathy
8. Phthisis bulbi: final end stage of dz, ciliary body is
disorganized and so aq. Production is hamperedeye is soft,
shrinks and eventually becomes a samll atrophic globe

DDx
Acute red eye
Acute congestive glaucoma
Acute conjunctivitis

Granulomatous vs Non granulomatous

Etiological ddx

Investigations:
Blood; TLC, DLC, ESR, Blood sugar levels, Blood uric
acid, Serological test for syphilis, toxoplasmosis,
histoplasmosis, test for ANA, RF, CRP
Urine Exam; for WBCs, pus cells, RBC and culture
Stool exam: for cyst and ova in parasitic
Radiological: for TB, sarcoidosis
Skin test: tuberculin, K velms test, toxoplasmin test

TX of
iridocyclitis

Specific tx:
Find out the
cause and tx is
2 started but non
specific is
1.
sufficient most of
Non specific txthe time
Local therapy
1. Mydriatic
cycloplegic
drugs: 1%
atropine 2-3
times a day,
2%
Hoomatropine/
1%
cyclopentolate
3-4 times a day
continued for
2-3 weeks
---0.25ml of
mydricain
2.
Corticosteroids

Systemic therapy
1. Corticosteroids
: high doses of
prednisolone
daily or
alternate day
therapy and
tapered In 6-8
weeks
2. NSAIDs:
phenylbutazon
e or
oxyphenbutazo
ne
3. Immunosuppre
ssive: mtx,
azathioprine,

Physical
measures:
1. Hot
fomentat
ion
2. Dark
goggles

TX of
complication
1. Inflammatory
glaucoma:
0.5% timolol
maleate
eyedrops 2ce
day and
tablet
acetazolamid
e 250mg
thrice a day
2. Post
inflammatory
glaucoma:
iridotomy
3. Complicated
catarct: lens
extraction
4. Retinal
detachment:
vitrectomy

Posterior uveitis
Refers to inflammation of choroid &
since outer layers of retina are in clost
contact with choroid and also depend
on it for nourishment, the resultant
lesion is always a chorioretinitis
Etiology and pathogenesis: same as
ant. Uveitis

Clinical types
Suppurative choroiditis: always a part of
endophthalmitis
Non suppurative choroiditis: granulomatous
or non granulomatous
Diffuse choroiditis
Disseminated choroiditis
Circumscribed or focal choroiditis

Central
Juxtacaecal e.g Jensens choroiditis
Ant peripheral choroiditis
Equatorial Choroidits

Signs and symptoms

Symptoms:
Painless condition
Defective vision:d/t vitreous haze
Photopsia: subjective sensation of flashes d/t
irriation of rods and cones
Black spots floating in fornt of eyes: exudative
clumps
Metamorphosia: distorted image perception
Micropsia
Macropsia
Positive scotoma

 Signs:
Vitreous opacities: middle or posterior
part; fine coarse, stringy or snowball
opacities
Features of patch of choroiditis
Active stage: pale yellow dirty white raise area
with ill defined edges
In atrophic or healed stage: sharply defined
and delineated; area shows white scleara
below the atrophic choroid and black
pigmented clumps at periphery of lesion

 Complications:
Extension of inflammation to ant. Uvea
Complicated cataract
Vitreous degeneration
Macular oedema
Secondary periphlebitis
RD

Tx. Broadly on the lines of ant. Uveitis

Endophthalmitis
Defined as inflammation of the inner
structures of eyeball i.e uveal tissue and
retina a/w pouring of exudates in the
vitreous cavity, ant. Chamber and
posterior chamber
Infective and Non infective
endophthalmitis

Infective endophthalmitis
Modes of transmission:
Exogenous; penetrating, perforating injuries,
perforation of corneal ulcer and intraocular
operationss
Endogenous; blood stream
Secondary; extension from orbital cellulitis,
thrombophlebitis and infected corneal ulcers

Causative organisms
Bacteria: Staph, Strept, Pseudomonas, Pneumococci
and Corynebacterium also propionibacterium and
actinomyces
Fungi: asperigllus, fusarium, candida, etc

Non infective
endophthalmitis
Refers to inflammation of inner structurs
d/t certain toxins or toxic substances
Post operative sterile endophthalmitis : d.t
chemical adherent to IOL, or chemicals
adherent to instruments
Post traumatic sterile endophthalmitis : toxic rxn
to retained intraocular foregin body e.g pure copper

Intraocular tumour necrosis: masquerade

syndrome

Phacoanaphylactic endophthalmitis: lens protein

is the cause in Morgagnain cataract

Clinical picture
Symptoms: occurs within 7 days of operation and is c/b
ocular pain severe, redness, lacrimation, photophobia
and marked loss of vision
Signs:
Lids: swollen and red
Conjunctiva: chemosis and marked circumcorneal congestion
Cornea: edematous, cloudy and ring infiltration
Edges of wound: yellow and necrotic and wound may gape
Ant. Chamber: hypopyon, soon full of pus
Iris: edematous and muddy
Pupil: yellow reflex d/t purulent exudates in vitreous
Vitreous exudate: late stage yellowish white mass is seen through
fixed dilated pupil; amaurotic cats eye reflex
IOP: raised in early stages but in severe cases falls d/t destruction
of clilary process

Tx

Antibiotic therapy
Steroid therapy
Supportive therapy
Vitrectomy

Intravitreal
antibiotics
and diagnostic tap
This forms the
main stay of
treatment of acute
bacterial
endophthalmitis
1. It is performed
transconjunctiv
ally under
topical
anesthesia from
the area of pars
plana, vitreous
tap is made f/b
intravitreal
injection
2. Combination of
2 antibiotics;
First choice:
Vancomycin +
ceftazidime
Second choice:
Vancomycin +
Amikacin
Third choice:

Antibiotic therapy

Subconjunctival
injection
1. First
choice:Vancomy
cin +
ceftazidime
2. Second choice:
Vancomycin
+
cefuroxime

Topical antibiotic
therapy
1. Used frequently
3omins to 1
hourly
2. 2 drugs are
prefered
Vancomycin
or
cefazoline
Amkikacin
or
tobramycin

Systemic therapy
1. Ciprofloxacin IV fb oral doses
2. Vancomycin IV and ceftazidime IV
3. Cefazoline and amikacin IV

 Steroid therapy
Limit the inflammation and is used after
24-48 hrs of extensive use of antibiotics
IVit Dexamethasone
Subconjunctival inj. Of dexa
Topical dexa
Systemic steroids: oral steroids after 24
hrs by prednisolone high doses

 Supportive therapy
Cycloplegics
Antiglaucoma drugs

Vitrectomy: if the px doesnt improve

with the above therapy for 48-72 hrs
or when the px presents with severe
infection with VA= PL

Panophthalmitis
Intense purulent inflammation of the whole
eyeball including the tenons capsule
Usually begins either as purulent ant or
post
uveitis
endophthalmitispanophthalmitis
Etiology
Acute bacterial infection
Mode of infection and causative organisms as
same as endophthalmitis

s/s
Symptoms:
Severe ocular pain and headache
Complete loss of vision
Profuse watering
Purulent discharge
Marked redness and swelling of eyes and
Associated with constitutional symptoms
like fever and malaise

 Signs:
Lids: swollen and hyperemic
Eyeball: sllightly proptosed, ocular movements are
painful and limited
Conjunctiva: marked chemosis and ciliary as well as
conjunctival congestion
Cornea: cloudy and oedematous
Ant chamber: full of pus
Vision: completely lost and perception of light is absent
IOP: markedly raised
Globe perforation occur at limubus and pus comes out,
IOP falls then

 Complications:
Orbital cellulitis
Cavernous sinsus thrombosis
Meningtitis or encephalitis

Tx.
Little hope of saving such eye and the pain and
toxemia demands for its removal
Anti inflammatory and analgesic should be started
immediately
Broad spectrum antibiotics to prevent further spread
Evisceration