Type of Uveitis and their important causes !!

Uveitis-


Uveitis is thought to be caused by an immune reaction.

Anterior non-granulomatous acute uveitis is associated with a variety of HLA-B27 related conditions, including:

Sacroiliitis •
Ankylosing spondylitis •
Reiter’s syndrome •
Psoriasis •
Ulcerative colitis •
Crohn’sdisease •
Some infections are associated with uveitis, and this is thought to be due to an immune reaction to the
organism. They include Herpes simplex and Herpes zoster.

Granulomatous anterior and posterior uveitis is associated with:

Behcet’s syndrome •
Sacroiliitis (usually bilateral) •
TB •
Syphilis •
Toxoplasmosis •
In AIDS •
Cytomeglovirus ◦
Human Syncitial Virus ◦
Cryptococcus ◦
Toxoplasma ◦
Candida ◦

Posterior uveitis may also be associated with autoimmune retinal vasculitis.

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OPHATHALMOLOGY-Fundoscopic Findings

1) Cherry red spots : 

– Tay sachs disease gm2 gangliosiosis type 1
-Niemann pick
-CRAO 
-Comotio retinae( berlins oedema)
-Fabers lipo granulomatosis
-Metachromatic leucodystrophy
-GM1 ganglidosis infantile form
-Sandhoff disease
-Sialidiosis

2) Roths spots

-Candidial chorioretinitis
-SABE 
-Leukemic deposits
-Anaemic retinopathy
-AIDS

3)Golden rain appearence

-Synchysis scintillans

4)Dome of champagne cork appearence 

-Papilloedema

5)splashed tomato appearence

-Ischaemic CRVO

6) Circular ring reflex

– Central serous retinoppathy

7) Honey comb appearence 

– CME

8) Tomato ketch up appearence 

– sturg weber syndrome

9) Candle wax appearence

– Sarcoidosis

10) Salt pepper appearence

– Congenital syphilis
– Rubella

RHEGMATOGENOUS RD : AIIMS MAY 2013

Q] All r risk factor for rhegmatogenous retinal detachment except …..[AIIMS MAY 2013]
[a] Myopia
[b] Pseudophakia
[c] Hypertension
[d] Trauma

ANS = [C] HYPERTENSION

What is RD ?

Separation of neuroepithelium and pigmentary epithelium of retina is called as RD. Subetinal fluid accumulates in the potential space between these two layers.

What r the types of RD ?

Based on mechanism of fluid accumulation , RD is classified into ….

[1] Rhegmatogenous( Primary RD) :  Most common type of RD. All RD are considerd to be rhegmatogenous untill prooved otherwise. The classical presenting feature is presence of photopsia and floaters although classical features are present in 60 % cases only . About 60 % of RD is seen in upper temporal quadrant. First symptom observed is photopsia in a particular field due to slight traction of retina which irritates neurosensory retina. Always due to formation of break in retina. The detached retina has convex and corrugated shape.

seen in MYOPIA , APHAKIA , PSEUDOPHAKIA, TRAUMA , INFLAMATION

[2] Tractional RD : Photopsia and floaters are absent as the traction develops slowly. The RD has a concave configuration.

seen in PROLIFERATIVE DM RETINOPATHY, EALES DISEASE, RETINOPATHY OF PREMATURITY, PENETRATING POSTERIOR SEGMENT TRAUMA, PROLIFERATIVE SICKLE CELL RETINOPATHY.

[3] Exudative RD( Secondary RD) : The patients present with decrease in vision and floaters. The RD has a convex and smooth configuration.

seen in CHOROIDAL TUMORS , POSTERIOR UVEITIS , SEVERE HYPERTENSION, PREECLAMPSIA .

NHL OF ORBIT / METS TO ORBIT ( AIIMS MAY 2013)

Q 1= MOST COMMON NHL OF ORBIT IS …..[AIIMS MAY 2013]

ANS =The most frequent histology of Primary Ocular Lymphoma is indolent (low grade neoplasm) NHL such as extranodal marginal B-CELL lymphoma Of MALT type[ ref : yanoff ophthalmology review pg 111/ 2nd ed]. It is unilateral in 75% cases and common age group is 50 -70.The standard treatment for non-Hodgkin’s orbital lymphoma is external beam irradiation therapy

Q2 ] ALL OF THE FOLLOWING TYPE OF LYMPHOMA ARE COMMONLY SEEN IN THE ORBIT EXCEPT…..[ AIIMS 2003]

[A] NHL mixed lymphocytic and histiocytic

[B] NHL lymphocytic ,poorly differentiated

[C] BURKITT

[D] HODGKIN LYMPHOMA

ANS = HODGKIN LYMPHOMA [ ref : spencers 4ed/ pg 2720 ]

In orbit practically all lymphoma are of NHL TYPE .

NOTE POINTS :

[1] Most common orbital tumor in children = capillary hemangioma.

[2] most common intraorbital , extraocular malignant tumor in children = rhabdomyosarcoma.[ AIIMS 92, 97]

[3] most common primary  malignant intraocular tumor of childhood is = retinoblastoma.

[4] most common intraorbital  tumor in adults is secondary metastasis.

[5] most common intraocular  tumor in adults is malignant melanoma.[AIIMS 93]

[6] most common intraocular tumor in all age group is =malignant melanoma.[AIIMS 95]

[7] most common cause of orbital metastasis in adults is bronchial Ca in males & breast in females.

Q3] Most common gynaecological tumor with intraocular mets is [AIIMS MAY 2013 ]

ANS = BREAST

[8] most common cause of orbital metastasis in children = neuroblastoma.[AIIMS 93,94,95]

REF :[1] PARSON’S 20ED/PG 360 [2] YANOFF REVIEW 2ND ED PAGE 111

COMPLICATIONS OF CATARACT SURGERY [ PART I]

COMPLICATIONS OF LOCAL ANESTHESIA

Peribulbar block is usually preferred over retrobulbar. So most commonly used method is peribulbar [PGI 98]. It consists of infiltration of anesthetic agent around the globe [PGI 98].

Q) why retrobulbar is not preffered ?

as it involves infiltration of anesthetic material behind the globe ,it carries risk of damage to optic nerve and bleeding from retroorbital blood vessels.

OTHER COMPLICATIONS; 1)Globe perforation 2)oculocardiac reflex ) intracranial spread of anesthetic agent leading to seizure.

Q) What is oculocardiac reflex ?

cardiac arrythmias arising from traction on extraocular muscles or pressure on eyeball. Trigeminal nerve acts as its afferent and vagal as its efferent. it can occur during any eye surgery but is most common during  strabismus surgery on peditric patient.(page 763 lange clinical anesthesiology 3rd ed).

Q) which of the following increase IOP ?

A] NITROUS OXIDE

B] THIOPENTONE

C] SUCCINYLCHOLINE

D] PANCURONIUM

ANS; [C] ref page 763 lange clinical anesthesiology 3 ed)

COMPLICATIONS DURING OPERATION;

1] Superior rectus muscle laceration and/or hematoma during applying bridle suture . NOTE ; temporal clear corneal incision eliminate the need of working over brow and so bridal suture is not required. it is done in phako.

2]  complications that may occur during creation of self sealing valvular sclero corneal tunnel incision which is made in SICS and PHAKOEMULSIFICATION. (a) button holing of anterior wall (b) premature entry into anterior chamber (c)scleral disinsertion.(q)= NOTE; if any of these occur the dissection at that site is abandoned and dissection is started at new site.

3] injury to cornea which leads to post oprative corneal edema.

Q] Which of following do not predispose to post operative corneal edema?

a)intraop mechanical endothelial trauma from instruments

b) prolonged postoperative elevation of  IOP

c) incomplete removal of the viscoelastic substance

d) none

ANS; [C] incomplete removal of viscoelastic substance do not lead to corneal endothelial loss. so it will not lead to post op corneal edema. [ref ; OPTHALMOLOGY REVIEW, YANOFF 2ND ed page 49]

4] IRIS INJURY and IRIDODIALYSIS and intraop IRIS PROLAPSE. CAUSES OF INTRAOP IRIS PROLAPSE (a) entering anterior chamber too posteriorly near iris root  (b) patient use of systemic tamsulosin for their urinary problem (c) impending choroidal effusion or expulsive hemorrhage.

5] anterior capsulorhexis : if a small capsulorhexis is made it predisposes to (A) posterior capsular tear and nuclear drop (B) zonular dehiscence. [ khurana 4thed page 198]

NOTE: deep anterior chmber should be maintained during anterior capsulorhexis which prevents tension on anterior zonules and there by prevents zonular dehiscence. it also prevents radial tear in ant capsule during capsulorhexis.

6] POSTERIOR CAPSULAR RUPTURE; As posterior capsule is removed in ICCE so it can never occur in ICCE [PGI 95]. it can lead to nuclear drop into posterior vitrous especially in PHACOEMULSIFICATION. It can also lead to posterior loss of lens fragments.

MANAGEMENT; If nuclear drop occurs it should be managed by vitroretinal surgeon.

Q] What will u do if a lens remnant is noted in the inferior vitrous compartment postoperatively in a “quiet  eye” ? if signs of inflamation is absent as here then patient can be followed up with topical steroids as the lens material will get absorbed with time . [ref; opthalmology review ,yanoff, page61]. if signs of inflamation is present it shows impending phacoanaphylactic endopthalmitis or phacolytic glaucoma.

PART 2 COMING SOON