A CERO EN REDONDOS PARA ARMADURAS

1. Visual Acuity. As has been mentioned earlier, most patients with uveitis would present with reduction in vision.

2. Intraocular Pressure. Most patients would typically present with a very soft or hypotonic eyeball as a result of involvement of the reduced aqueous humor production in the ciliary body as part of the inflammatory process. On the other hand, there are patients with prolonged uveitis who may have developed complications of the disease process, and thus present with elevation of their intraocular pressures, a condition otherwise referred to as secondary glaucoma.

3. Extraocular Muscle Movement. Since the extraocular muscles are usually not involved in the inflammatory process, patients would exhibit full movement on all directions of gaze.

4. Funduscopic Findings. Patients wherein the inflammation is confined to the anterior segment would

• Vasculitis – generally presents in patients with posterior uveitis and often comes in the form of perivascular sheathing or narrowing or obliteration of the retinal blood vessels.

• Granulomatous nodules – represents accumulation of inflammatory cells which may be located along the vitreous base or in the retinal pigment epithelium.

• Retinal Pigment Changes – generally represent areas of previously active inflammation; these lesions are typically referred to as retinal scars.

• Retinal Detachment – may come in the form of diffuse serous detachment of the retina or as multifocal areas of detachments.

Fig. 2. Cystoid macular edema Fig. 3. Perivascular sheathing

Fig. 4. Severe periphlebitis Fig. 5. Multiple retinal granulomas

Fig.7. Multifocal detachment of the retina Fig.6. Old syphilitic neuroretinitis

5. Slit lamp findings. Patients with uveitis, particularly those wherein the primary location of the

• Ciliary perilimbal flush. This is characterized as redness of the eye that is more marked in the area around the limbus and decreases towards the fornices of the eyes. Redness occurs as a result of congestion of the deeper ciliary blood vessels. This type of redness does not blanch with pressure, nor does it diminish with the use of vasoconstrictors. Figure 8 shows a typical picture of a patient with perilimbal flush as contrasted to a patient whose eye redness is secondary to conjunctival congestion (Figure 9) wherein redness is more diffuse in nature.

Fig. 8. Ciliary injection Fig,9, Conjunctival congestion

• Keratic Precipitates (KP’s). These are deposits of inflammatory cells on the corneal endothelium.

Although more often confined in the inferior portion of the cornea, they may also be diffusely distributed in certain forms of uveitis. Their appearance may also vary as to their size (fine or large) and degree of pigmentation (Figure 10). The size of KP’s provides the clinician with a clue as to the pathologic classification of the disease as will be further discussed in a later part. The presence of pigmentation, on the other hand, would generally indicate that the condition is a chronic one.

B A

B

Fig.10. Different kinds of Keratic Precipitates (KP’s)

A. mutton fat KP’s B. Medium sized KP’s C. old pigmented KP’s D.

old KP’s with ground glass appearance D B C

B

• Pupil abnormalities. Patients with anterior uveitis present with constricted irregularly shaped pupils as a result posterior synechiae formation or adhesions between the pupil and the anterior capsule of the lens (Fig 11). In some instances, an inflammatory membrane may also cover the pupil (Fig 12).

• Signs of Inflammation in the anterior chamber. As a result of the inflammatory process, patients may present with haziness in the anterior chamber due to the leakage of protein from leaking blood vessels. This is referred to as flare. One may also note the presence of inflammatory cells in the anterior chamber as a result of the inflammation. When there are a large number of cells in the anterior chamber, they accumulate and assume a level in the anterior chamber referred to as hypopyon (Fig. 13). Cells may also be observed in the retrolental area which may indicate that the inflammatory process involves the ciliary body as well.

Fig. 13. Hypopyon Fig.14. Koeppe nodules (located at the pupillary border

Fig.15. Busacca nodules in

iris stroma Fig.16. Fibrinous exudates in acute anterior uveitis

• Iris changes. The iris undergoes changes as a result of the inflammatory process. They become thinned out and may be referred to as moth-eaten in appearance. Nodules may also be present in the iris, either within the stroma, called Busacca nodules (Fig. 15) or in the pupillary margin, referred to as Koeppe nodules (Fig. 14). These nodules represent cellular aggregates of inflammatory cells.

6. Intermediate Uveit s F nd ngs. Patients with intermediate uveitis or wherein the inflammation involves the ciliary body or peripheral retina may present with haziness of the vitreous (Fig. 17) and one may note cells behind the lens on slit lamp examination. Fundus examination may reveal the presence of cellular aggregates in the periphery of the retina referred to as “snowbanking” (Fig. 16).

i i i

Fig. 18. Snowbanking Fig.17. Vitreous haze

ANCILLARY EXAMINATIONS for UVEITIS

Commonly, additional examinations may be requested to aid in the diagnosis of some conditions. The more commonly requested ancillary procedures include:

1. Ultrasound of the Eye

In most cases of uveitis, a view of the posterior portion of the eye is compromised due to the presence of anterior segment pathology. Ultrasonography gives the clinician a picture of the posterior segment. Uveitic conditions may present with the presence of a cataractous lens, vitreous condensations or haziness, choroidal thickening and retinal detachment upon ultrasonographic examination.

2. Fluorescein Angiography

Fluorescein angiography is a procedure wherein abnormalities in blood flow in the vasculature of the posterior segment of the eye may be detected. It also provides a method for detecting problems in the choroid and the retina. Some ophthalmologic conditions may present with typical fluorescein findings. Patients with

inflammation of the posterior segment may present with findings compatible with retinal edema, retinitis and areas of focal retinal detachment. Optic disc as well as macular problems may also be encountered in these patients.