Uveitis

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Uveitis

Uveitis– inflammation of the choroid of the eyeball. Anatomically, the choroid of the eyeball is divided into the iris, the ciliary body and the choroid itself, located behind the ciliary body and making up almost 2/3 of the choroid (actually lines the retina from the outside). The blood supply to the choroid itself is carried out mainly by the posterior short ciliary arteries, and the iris and ciliary body are supplied by the anterior and posterior long ciliary arteries, i.e. the blood supply of these 2 sections comes from different sources, therefore the anterior and posterior sections of the choroid are traditionally affected separately, which caused the division of uveitis into anterior and posterior. The frequency is 0.3-0.5 cases per 1,000 population, approximately 40% of cases of uveitis occur against the background of a systemic disease. Predominant gender: with anterior uveitis, associated with the presence of HLA-B27 Ag in the blood, men get sick more often (2.5:1). Classification

    • According to the localization of the inflammatory process
    • Anterior uveitis (iritis, iridocyclitis) – inflammation of the iris and / or ciliary body
    • Posterior uveitis (choroiditis) – inflammation of the choroid proper
    • Intermediate uveitis (peripheral uveitis) – involvement of the ciliary body, peripheral sections of the choroid proper
    • Diffuse uveitis (iridocyclochoroiditis) – damage to both the posterior and anterior sections of the choroid
    • By etiology – exogenous (when infection enters from the damaged cornea, sclera, eye sockets, etc.) and endogenous (hematogenous transmission of infection, autoimmune mechanisms)
    • Downstream – acute, subacute, chronic (including recurrent)
    • By the nature of the inflammatory process – serous, purulent, fibrinous, hemorrhagic and mixed. Etiology
    • Viruses, bacteria, protozoa, fungi
    • Immune factors – suggest the involvement of autoimmune and immunocomplex mechanisms in diffuse connective tissue diseases
    • Idiopathic causes (approximately 25%). Genetic aspects. In 50-70%, HLA-B27 Ag is detected (with ankylosing spondylitis, Reiter’s disease). Risk factors – diffuse diseases of the connective tissue, foci of chronic infection.

Pathomorphology

    • Anterior uveitis. In the aqueous humor of the anterior chamber, protein (including fibrin), erythrocytes in case of hemorrhagic inflammation, pus, pigment are found. Synechia (fibrous adhesions between the iris and the lens) are also found. The iris is edematous, infiltrated. Possible clouding of the vitreous body due to the formation of connective tissue
    • Posterior uveitis. Edema of the optic disc, inflammation of the perivascular tissue of the retinal vessels.

Clinical picture

    • Anterior uveitis (approximately 80% of patients with uveitis)
    • Usually acute onset, most often unilateral (95% for HLA-B27-associated uveitis)
    • Complaints – decreased visual acuity and pain in the eyeball, aggravated by its palpation
    • Pericorneal or mixed injection, iris discoloration (greenish or rusty, fuzzy pattern)
    • Constriction of the pupil of the affected eye, the shape of the pupil is incorrect, the reaction to light is impaired
    • The presence of polymorphic precipitates or exudate in the anterior chamber on the endothelium of the cornea (from the side of the anterior chamber of the eye) (hypopion in the case of a purulent nature of the exudate, hyphema in the case of hemorrhagic), the occurrence of posterior adhesions of the iris is likely (fusion of the posterior plane of the iris with the anterior lens capsule). In some cases, adhesions can cause a circular fusion of the iris and lens, which leads to the infection of the pupil and an increase in intraocular pressure – secondary glaucoma and bombardment of the iris develop (protrusion into the anterior chamber of the eye in the form of a roller)
    • Manifestations of the underlying disease are possible both in the case of endogenous and exogenous origin of uveitis.
    • Posterior uveitis. In view of the close fit of the retina and its frequent involvement in the inflammatory process, the term chorioretinal is used in practice.
    • The beginning is traditionally imperceptible
    • Decreased visual acuity
    • Complaints – the appearance of photopsia (flashes before the eyes), metamorphopsia (distortion of the shape of objects), hemeralopia (blurred vision in poor lighting) with peripheral localization of the process
    • When examining visual fields – scotomas of various sizes (this research method does not require the participation of a qualified ophthalmologist, but allows suspecting choroiditis)
    • Characterized by the absence of pain, which greatly complicates the diagnosis.
    • Intermediate uveitis is an inflammatory infiltration of the vitreous body, exudation and formation of membranes that partially cover the ciliary body. The symptomatology resembles that of a posterior uveitis.

Laboratory studies are nonspecific (the disease is polyetiological). More often, signs of the underlying disease are detected (laboratory indicators are most informative for collagenoses).

Special Studies

    • Biomicroscopy with anterior uveitis – edema, discoloration of the iris, the presence of precipitates on the posterior plane of the cornea or exudate in the anterior chamber of the eye, posterior adhesions of the iris
    • Ophthalmoscopy with posterior uveitis – turbidity in the vitreous, grayish or yellowish foci of various shapes and sizes with edema and hyperemia within (phenomena of perifocal inflammation), retinal vessels above them are not interrupted. Edema and hyperemia of the optic disc are possible. In the later stages, atrophic changes in the choroid appear – it becomes pale and sometimes pigmented.
    • Additional research methods can reveal signs of the underlying disease (for example, X-ray of the spine in ankylosing spondylitis).

Differential Diagnosis

    • Anterior uveitis
    • Conjunctivitis
    • Episcleritis
    • Scleritis
    • Keratitis
    • Acute glaucoma
    • Posterior uveitis
    • The initial phase of retinal detachment
    • Tumors of the choroid.

Treatment:

Mode. An urgent consultation with an ophthalmologist is necessary, since quite often uveitis progresses rapidly with the development of dangerous complications. Tactics of conducting

    • Anterior uveitis
    • Treatment of the underlying disease.
    • Antibacterial agents.
    • Anti-inflammatory drugs: NSAIDs, glucocorticoids, cytostatics – depending on the etiology of uveitis
    • Prednisolone acetate – 2 drops of 1% suspension in the sore eye

first after 4 hours, and then, as improvement improves, reducing the daily dose

    • Dexamethasone sodium phosphate 0.1% solution in eye drops.
    • Drug cycloplegia, which prevents the formation of posterior adhesions of the iris and contributes to the rupture of already formed
    • Drugs of choice: homatropine hydrobromide, 2 drops of 2% solution in the sore eye 2 r / day or if necessary after 3 hours, scopolamine hydrobromide, 2 drops of 0.25% r-ra up to 3 r / day
    • Alternative products: adrenaline, cocaine
    • The introduction of atropine is not recommended, especially with severe exudation.
    • When the inflammatory process subsides – absorbable products in the form of electrophoresis or phonophoresis (enzymes).
    • At the back uvete
    • Treatment of the underlying disease
    • Antibacterial agents
    • Anti-inflammatory drugs: NSAIDs, glucocorticoids, cytostatics – depending on the etiology of uveitis.
    • Contraindications
    • Hypersensitivity to the product
    • Drug-induced cycloplegia is contraindicated in patients with concomitant angle-closure glaucoma or a predisposition to it.
    • Precautions
    • Homatropine hydrobromide can have a resorptive anticholinergic effect, especially in infants and toddlers
    • Topical application of glucocorticoids can cause an increase in intraocular pressure. With prolonged use, the development of cataracts and exacerbation of herpetic keratitis, sometimes occurring under the mask of iritis, are likely.

Complications

    • Deposits of precipitates on the plane of the cornea and lens cause a decrease in acuity or complete loss of vision in the diseased eye.
    • Increased intraocular pressure due to posterior synechia of the iris and the development of angle-closure glaucoma
    • Cataract
    • Vasculitis with vascular occlusion, retinal infarcts
    • Optic disc edema
    • Retinal disinsertion. Course and forecast
    • Depends on the underlying disease
    • Acute iridocyclitis traditionally lasts 3-6 weeks, chronic forms tend to recur in the cold season
    • With central chorioretinitis or atrophic changes in the retina, visual acuity deteriorates significantly.

Concomitant pathology

    • Viral infections: HIV, HSV, Herpes zoster virus, cytomegalovirus
    • Bacterial infections: tuberculosis, leprosy, syphilis, leptospirosis, brucellosis, Lyme disease, Whipple disease
    • Parasitic infections: toxoplasmosis, acanthamoebiasis, toxocariasis, cysticercosis, onchocerciasis
    • Fungal infections: histoplasmosis, coccidioidomycosis, candidiasis, blastomycosis, cryptococcus-goats
    • Autoimmune diseases: ankylosing spondylitis, Behçet’s disease, Crohn’s disease, therapeutic hypersusceptibility, interstitial nephritis, juvenile rheumatoid arthritis, multiple sclerosis, psoriatic arthritis, Reiter’s disease, relapsing polychondritis, sarcoidosis, Sjögren’s syndrome, SLE, ulcerative colitis, vasculitis, vitiligo
    • Isolated eye diseases, eg acute retinal necrosis, phacogenic uveitis, choroiditis, sympathetic ophthalmia, eye trauma
    • Masking syndromes: leukemia, lymphoma, retinitis pigmentosa, retinoblastoma. Age features
    • Children. Most often, uveitis has an infectious etiology. Allergic reactions and mental stress can serve as a triggering factor.
    • Elderly. Inflammatory reactions characteristic of anterior uveitis are often erased in systemic diseases.

See also Conjunctivitis, Retinal detachment, Primary angle-closure glaucoma, Scleritis, Cataract

ICD

    • H20 Iridocyclite
    • NZO Chorioretinal inflammation