Disease of Uvea

Zhou xinxin
 reveiw: Aanatomy of Uvea

• The eyeball is
composed of
• the wall,
• the chambers
• the contents,
nerve, blood
vessels and
other tissues.
　 The wall of the globe divided into three
layers:
• Outer coat (fibrous tunic):
　　 cornea ， sclera ， corneoscleral
limbus

• middle coat (uvea)

　 iris ， ciliary body ，
choroid .

• inner coat (retina)

• The diseases of uvea include the
inflammation, the tumors and the
abnormalities.
• We learn the inflammation of uvea
(uveitis) in this class.
 Uveitis
• Uveitis is the inflammation of uvea. It is
one of the common disease of the eye. Its
cause is very complex.
• We can classified the uveitis as follow.
(1) according to the anatomical part, it is
divided into:①anterior uveitis, ②posterior
uveitis, ③intermediate uveitis ④ panuveitis
(2) according to the course, it is divided
into: acute, subacute and chronic uveitis.
(3) according to the cause, it is divided
into: ①infective uveitis. ② noninfective
uveitis inclued :special uveitis,
autoimmune uveitis , uveitis caused by the
systemic diseases, uveitis caused by
trauma and tumor .
(4) according to the pathology, it is divided
into: ①granulomatous uveitis: it is a
chronic proliferative inflammation, the
proliferation forming nodular is the
characters ② non-granulomatous uveitis:
it is a acute allergic reaction, no nodular
formed
(5) according to the character of exudates,
it is divided into: ①purulent uveitis: ②
exudate uveitis, inclued serous and
fibrinous
 1.Anterior uveitis
• Including iritis. iridocyclitis and anterior part cyclitis
• It is a common disease of the eye . In china . It accounts 50-60% in
uveitis.
• It is usually affects the young people.
• The both eyes always involved and it is easy to recurrent attacks.
• At the advanced stage .it can cause blindness because of the
complication.
• Etiological factors of this disease besides trauma. operation and
infection, are more to belong to endogenous. we must inquest the
case history carefully, perhaps can discover the related system
disease as rheumatism , tuberculosis, sarcoidosis 　 ( 结节病） and
so on.
Clinical Findings of anterior uveitis
(1)symptom

• Pain , Tearing and Photophobia

　 Caused by cliliary spasm ( cyclospasm 睫状痉挛 ) and the tissue
congestion, edema and toxin stimulating the ends of the trifacial 　
nerve （三叉神经） .

　 The pain most limited only in ocular part ,or may extend to
periorbit ,forehead and buccal （颊） part.

In acute case, The patient is difficult to open the eye

(Photophobia) and tearing.
Clinical Findings of anterior uveitis
(1)symptom
• Visual decrease
　　 Opaque aqueous humor . Keratic precipitate.
Corneal edema and pigmentary doposition on lens
surface. All of these can impede light passing through
normally.
　　 Ciliary spasm cause myopia.
　　 secondery glaucoma, Complicated cataract as well
as macular edema may induce blurred vision further.
Clinical Findings of anterior uveitis
（ 2 ） sign
• Ciliary injection
It is the injection near
limbus corneae .
Purplish red.
Must distinguish from
conjunctival injection
In the severity case , the
two exist simultaneous . We
call it mixed injection.
Frequently combined with
conjunctival edema.
Clinical Findings of anterior uveitis
（ 2 ） sign
• keratic percipitates ， KP
Formation :Because the barrier of blood vessels in
the iris and the ciliary body be destroyed by
inflammation, more Infectious cells and fibrin enter
aqueous humor. With constant convection influenced by
difference of temperature. The exudate gradually
deposits on corneal endothelium to form triangular
keratic precipitates in lower part of the cornea. Its base is
downward.
Clinical Findings of
anterior uveitis
(2)sign

• keratic percipitates ， KP
Divided into ：
Fine dusty KP: it is punctate
composed of lymphocyte and
plasmacyte( 浆细胞） commonly
seen in non-granulomatous uveitis .
“Mutton fat” KP: it is white,Like
small balls of “mutton fat” .composed of
epithelioid cells and macrophages.
commonly seen in granulomatous
uveitis.
• 左：粉尘状 KP 　　　　　　右：羊脂状
KP
Clinical Findings of anterior uveitis
（ 2 ） sign

• Anterior chamber flare

Caused by the blood-
aqueous barrier be
destroyed. more cells and
protein contents enter in
aqueous humor. When
observation with slite-lamp
microscope . Enhanced light
hundle may be seen like
white opacity .
Because the anterior
chamber flare also be seen
at the restoration stage,so It
can not mean the active
inflammation.
Clinical Findings of anterior uveitis
（ 2 ） sign
• anterior chamber cells
• In the active inflammation, The
inflammatory cells , red blood cells,
tumour cells and pigment cells enter
into aqueous humor .
• In uveitis, the cells mainly are
inflammatory cells.
• Slit-lamp examination can find the
same size grayish-white dusty granule.
rising near the iris, falling near the
cornea. It is a reliable sign for the
active inflammation .
• When a great quantity inflammatory
cells settle at the below of anterior
chamber,can form a fluid level,we call
it hypopyon.
Clinical Findings of anterior uveitis
（ 2 ） sign
• Changes of the
iris ：
　　 furrow becomes blurry
because of the
hyperemia and edema.
　　 Posterior synechia
The exudate and roliferation
make the adhesion
between the iris and the
anterior capsule of the lens.
A circle synechia will make
the aqueous humor can not
flow into the anterior chamber
and retains in the posterior
chamber. The iris is pushed
forward with a shape of
bulging called irris bomble.
 Clinical Findings of anterior uveitis
（ 2 ） sign
　　 Anterior syuechia ： It means the synechia between the iris and the posterior surface of the
cornea . If the synechia to happen in the chamber angle .we call it goniosynechia （前房角粘连） .
Clinical Findings of anterior uveitis
（ 2 ） sign

• Changes of the iris ：

Iris nodules ：
　　 Koeppe’s nodule ： it situated on
the surface of pigmented epithelium at
pupillary margin. It is non-granuloma
mainly, but also can be granuloma.
　　 Busacca nodule ： it is situated
near to the contractive furrows in
central part of the irris. It is granuloma
mainly.
　 Granuloma iridis ： situated in the
stroma of the irris, the single opaque
nodus, often existing in anterior uveitis
caused by nodule disease.
 Clinical Findings of anterior uveitis
（ 2 ） sign

• Change of pupil
　　 constriction of pupil:
the irris hyperenia and
edema, cells infiltration and
the stimulate of the
exudation’s toxicity could
cause the constriction of
pulil.
light reflection of iris will be
slow or disappearance .
The constriction of pupil is
an important sign of
indocyclitis.
Clinical Findings of anterior uveitis
（ 2 ） sign

　 Change of pupil
change of the shape ：
In the condition of
mydriasis, if there have
the part posterior
synechia and can’t be
dilated. We can see the
shape of the pupil
changed irregularity.
its shape may become
plum blossom-like , pear-
like or irregularity.
Clinical Findings of anterior uveitis
（ 2 ） sign

• Change of pupil
Seclusion of
pupil
it means the whole
circle posterior
synechia.
It not only can be the
synechia of pupillary
margin, but also can be
all the posterior facies
of irris synechia with the
anterior surface of lens.

　
Clinical Findings of anterior uveitis
（ 2 ） sign
• Change of pupil

Occlusion of pupil

a large amount of exudates

forms a membrane to cover on
the lens surface in pupillary
area.
Clinical Findings of anterior uveitis
（ 2 ） sign

• Change of lens ：
　　 The anterior surface of lens can be found the deposit of
pigment.

　　 when the fresh posterior synechia be pull away, we can find

the circle pigment deposit on the anterior surface of lens.

In the iridocyclitis after implant an intraocular lens(IOL), we

often can see effusion as spot film or lattice fibers on the surface of
the IOL . Also can form a membrane if the disease is vary serious,
we call it frontal membrane of IOL.
Clinical Findings of anterior uveitis
（ 2 ） sign

• Change of vitreous and posterior segment

of the eye ：
　　 In iricyclitis or anterior cyclitis, inflammatory cells
could be found in the anterior vitreous. And generally
without vitreous opacity.
The posterior segment of eye is always normal,
occasionally could be found cystoid macular edema and
optic disc edema.
Clinical manifestation of anterior aveitis
（ 3 ） complications
• Secondary glaucoma ： due to the meshwork is
blocked by imflammatory cells and pigmentary partides. Which also
may be indnced by posterior synechia ,by peripheral anterior
synechia of the iris, by secclusion of pupil . The way of aqueous
outflow is impeded to cause secondary glaucoma.
• Complicated cataract ： if imflammation is active
again and again for a long time . The character of aqueous humor
which nourishes the lens is affected. Nomal physiological
metabolism of the lens may be destoryed to cause complicated
cataract. If drop corticosteroid for a long time , it also can result
clouding of posterior lens capsule.
• Low IOP and atrophy ： if the inflammation
continues for a long time, it can cause ablatio corporis ciliaris or
atrophia.the generation of aqueous humor decreases and Low Iop.
anterior uveitis ：
diagnosis :
The diagnosis is mainly on the basis of clinical findings.
• If ciliary injection, miosis, KP and posterior synechia of the iris are
discovered, Iridocyclitis may be diagnosed. Among the total, the
aqueous flare and KP is especially important.
• If there no ciliary injection and new inflammatory change, only have
posterior synechia of the iris and pigmentary deposition on the lens
anterior capsule which suggests iridocyclitis had been suffered form.
• If the courses of disease in 6 weeks,we call it acute inflammation.
However if it is slow and longer than 6 weeks, we call it chronic
inflammation.
anterior uveitis ：
differential diagnosis:
　 it should be differentiated with acute conjunctivitis ,
acute angle closure glaucoma and intraocular tumor.
　　（ 1 ） acute conjunctivitis :pain, tesring ,
photophobia and ocular region injected. However the vision isn’t
　
decrease usually and the anterior segment of eye is normal.
　　（ 2 ） acute angle-closure glaucoma
： pain , tearing, photophobia, ocular region injected and hypopsia
and so on.but when this disease onset,it also have symptom as
pupil dilation, anterior chamber extremely shallow, intraocular press
extremely high and so on . This can help the differential diagnosis.
　　（ 3 ） intraocular tumor ： after necrosis of
retinoblastoma, severe endophthalmitis and hypopyon may be
induced. So it should be differentiated by history. Findings in
examination, calcific spot in x-ray picture, ultrasonic and
CTdiagnosis, it may be distinguished.
anterior uveitis
treatment
　 (1)mydriasis (dilating pupil)
• Very important ! To prevent posterior synechia of
the iris ! To diminish or to get rid of spasm of iris
sphincter muscle and ciliary muscles.
• If the anterior uveitis is acute and severe,
mydriasis may use 1-2% atropine ointment to
instill into the eye, 1-2 times daily . After 1-3
days to change to 2% homatropine ointment to
instill into the eye . 1-2 times daily.
anterior uveitis
treatment
• (1)mydriasis (dilating pupil)
• It is better to use 2% homatropine ointment to instill
into the eye in normal anterior uveitis.
• At the stage of recovery , we often use 0.5-1%
tropicamide solution to instill into the eye one times
daily.
• If the pupil is difficult to dilate duo to fresh posterior
synechia. Mydriatic mixture(mixed solution in equal
amout of 1% atropine .1% cocain . 0.1% adrenalin )may be
use in subconjuctival injection in a dosage of 0.1-0.2ml.
 Anterior uveitis
Treatment
　 (2) Glucocorticoid Gutta
• Can restrain inflam,reduce effusion.
• Use 0.1% DEX gutta as usual, emergency
and severe case can drop eyes every
15min, and every 1 hour after 4 times.
Reduce the times everyday according to
the disease condition after continuing
application some days.
• Other Glucocorticoid preparation can be
used too.
Anterior uveitis
Treatment
• (2) Glucocorticoid Gutta
• To reduce the complication of
Glucocorticoid, we should avoid to use
systemic administration and subconjunctival
injection as far as possible.
• But if the papilloedema and cystoid macular
edema appear. the systemic administration
and the tenon’ s capsule injection is needed.
Anterior uveitis
Treatment
• (3) non-steroidal anti-inflammatory drug
• Can block the prostaglandin and the
leukotriene to educe anti-inflammatory action.
• Be obvious side-effect to the traumatic and
postoperative anterior uveitis.
• General eye drop: 0.5% indomethacin ,0.1%
antifani, 0.1% pranoprofen.
• Oral medication is not necessary as usual.
Anterior uveitis
Treatment
• 　 (4) Etiological treatment
• If we can identify the etiopathogenisis, we
should treat in the field.
• 　 (5) Complication treatment
• Secondarg glaucoma: Drip liquid medicine
which can drop the intraocular press . Oral or
intravenous medication can decrease the
intraocular tension. It should be treated earlier
by operation or laser therapy if pupil block.
Anterior uveitis
Treatment
• (5) Complication treatment
• Complicated cataract: Perform the
cataract extraction and implant intraocular
lens after the inflammation be controled.
Attention to the preoperative and
postoperative antiinflammatory treatment.
 2 、 Intermediate uveitis
• Intermediate uveitis is the generic name of a
set of phlegmasia and proliferating affections
which involves ciliary body applanatio part,
vitrina basilar part, peripheral retina and
chorioid.
• Almost insultus below 40 years,and have
similar between male and female.It always
involves both eyes, and has a feature as
invasion delitescence and chronic course of
disease.
Clinical situation of Intermediate
uveitis
• （ 1 ） Symptoms
• In the earlier period,the symptoms are slight. It
just can be felt that there`s shadow before the eyes,
vision blur, temporary myopiosis. And some maybe
have ophthalmalgia and red eyes. If complications
like macular oedema and cataract appear, the vision
may decrease observably.
• （ 2 ） Physical signs
• Corporis vitrei nivea
• Ciliary body truncus part snowbank-form change
（ Particular change of Intermediate uveitis ）
• Inferior peripheral retinitis 、 retinal vasculitis and
peripheral retino-choroiditis
• （ 3 ） Complications
• Macular oedema, Cataract
intermediate uveitis
diagnosis
• According to the pink clinical situation
• It should be highly suspected to be the
intermediate uveitis about the
teenager`s noncausal macular,
oedema,complic cataract,etc.
Intermediate uveitis
Treatment
• 　　 It could do nothing to when the symptom and affection is
aslo slight,but should be symptomatic treated If the eyesight is
lower than 0.5 point or the hyaloid cataract is manifest.
• 　（ 1 ） Point partly or inject corticosteroid behind the apsule
of tenon, and compounding systemic administration if the
condition is serious.
• 　（ 2 ） If it didn`t use,and the pathogenetic condition
aggravated further,we could consider to using immune
depressant systemicly. Using amboclorin is the first
choice ， then cyclosporin,cyclophosphamide,etc.
• 　 （ 3 ） Ciliary body evenness part`s condense therapy and
laser therapy are particularly suitable for that whose
circumjacent part have new vascular proliferation.
 3. Posterioruveitis
• Posterioruveitis is the generic name of
a set of phlegmasia affections which
involves chorioid , retina , retinal
vessel and corpus vitreum.
• It clinically contains choroiditis ,
retinitis , choroidoretinitis , retino-
choroiditis and retinal vasculitis,etc.
Clinical situation of
Posterioruveitis
• 　（ 1 ） Symptoms
• Hypopsia,shadow before the eyes and blindspot,flare,etc. The
degree of the hypopsia is depended on the macular area is
damaged or not and the degree of the damage.
• 　（ 2 ） Physical signs
• Inflammatory cells and cloudiness in the corpus vitreum 。
• Focal chorioid and retina`s infiltrating focus of infection 。
• Retinal vasculitis
• Retina and macular`s edema
•
• Posterioruveitis is the generic name of a set of phlegmasia
affections which involves chorioid 、 retina 、 retinal vessel
and corpus vitreum
Posterioruveitis
Diagnosis
• According to the pink clinical situation
• FFA is conducive to the decision of the
retina and its vasculitis
• ICGA is conducive to the decision of
the choroid and its vascular lesion
Posterioruveitis
Treatment
• Etiological treatment If we can identify
the etiopathogenisis ， we should treat
it aiming directly at the
etiopathogenisis.
• Broil disease response control We can
use corticosteroid 、 immune
depressant.