Iridocyclitis

This talk was presented by Dr. Brajesh Choudhary in the IMA Hall on 28-04-2002. Handouts were distributed.

Classification

1. Uveitis -
   1. Anterior -
      1. Iridocyclitis (inflammation of the iris and ciliary body)
   2. Posterior (involvement of the choroid and the retina)
   3. Panuveitis (involvement of all the components)

Iridocyclitis

1. Acute (less than 2 weeks)
2. Chronic
3. Acute recurrent

OR

1. Primary
2. Secondary
   1. Sclerouveitis
   2. Keratoiritis

Salient features

Symptoms

• Pain
• Redness
• Photophobia
• Watering
• Reduced vision

Signs

• Vision
  • Dimunition of vision
• Lid
  • Oedema
• Conjunctiva
  • Congestion
  • Ciliary congestion
• Cornea
  • Oedema
  • Haziness
  • Descemet's membrane folds
• Endothelium
  • Dusting
  • KP's
• KP's
  • Fresh (whitish)
    • Small size
    • Medium size
  • Pigmented
  • Mutton fat
• Anterior chamber
  • Cells
    • Lymphocytes
  • Flare
    • Cells and proteins (exudate and/or transudate)
    • Grading 1 to 4
  • Hypopion
  • Hyphaema
• Iris
  • Muddy (Kryps and fissures obliterated
  • Heterochromia
  • Nodules
    • Koeppe (at margin)
    • Basacca
  • Occlusio pupillae (fibrin and inflammatory cells)
  • Synechiae
    • Posterior
    • Anterior (peripheral)
  • Seclusio Pupillae (iris bombe)
• Intra-ocular pressure
  • Low in acute stage or acute iridocyclitis
  • High later on
• Crystalline lens
  • Sub-capsular cataract to chalky white membranous cataract
• Vitreous, choroid, retina, optic nerve head
  • May be affected later on (pan-uveitis/complications)
  • Vitreous
    • Cells (lymphocytes/floaters)
    • Hemorrhage
    • Anterior vitreous membrane (cyclitic membrane)
    • Vitreous band (?cyclitic membrane)
    • Tractional bands
  • Choroid
    • Nodules
    • Focal vascular Sheathing
    • Choroiditis
  • Retina
    • Choreoretinitis
    • Nodules, focal spots
    • Macular Oedema
    • Holes and Retinal Detachment
  • Optic nerve head
    • Hyperemia
    • Blurring of disc margins
• Loss of vision/Loss of the eye
  • Phtisis bulbi
  • Quadrate eye
    • Bone formation
    • Malignant changes

Aetiology

1. Idiopathic (Primary)
2. Allergic
   1. Extrinsic
      1. Long journey (wind, insects)
      2. Strong allergens
   2. Intrinsic
      1. Tuberculous antigen
      2. Leprosy
3. Infective
   1. Bacterial
      1. Tuberculosis
      2. Syphillis
      3. Lepra
   2. Viral
      1. Herpes Simplex
      2. Herpes Zoster
      3. Rubella
   3. Fungal
      1. H. Capsulatum
      2. Candida albicans
      3. Coccidiomycosis
   4. Protozoal
      1. Toxoplasma gondii
      2. Toxocara carini
   5. Parasites
      1. Oncocerciasis
      2. Microfilarial
4. Traumatic
   1. Non-penetrating (insect)
   2. Penetrating
   3. Other eye (sympathetic ophthalmia)
5. Lens induced
   1. Phacolytic (hypermature cataract)
   2. Phacotoxic
   3. Phacoanaphylactic
6. Local causes
   1. Scleritis
   2. Keratitis
   3. Corneal ulcer
   4. Orbital cellulitis
7. Systemic and connective tissue disorders
   1. SLE
   2. Juvenile RA (Pauciarticular)
   3. Ulcerative collitis, Chrohn's disease
   4. Sarcoidosis
   5. Psoriatic arthritis
   6. Wegener's granulomatosis
   7. Polychondritis
   8. Ankylosing spondylitis
   9. Still's disease
   10. Reiter's disease (urethritis, arthritis, conjunctivitis)
   11. Diabetes Mellitus
   12. NOT ASSOCIATED WITH RHEUMATOID ARTHRITIS/GOUT

Diagnosis

The diagnosis is based on -

1. Symptoms
2. Signs
3. Investigations directed towards clinical suspission
4. History (urethritis in Reiter's, Herpes Z, Vitiligo (VKH syr.))
5. Blood (routine)
6. Urine - routine and microscopy
7. MT
8. CXR, Xray Sacro-iliac joint and Xray eye for intraocular FB
9. USG
10. ANA
11. ERG
12. FFA
13. Paracentesis
14. Vitreous aspiration
15. Specific tests -
    1. Skin test
    2. S. lysozyme (sarcoidosis)
    3. S. Calcium
    4. Protein electrophoresis
    5. FTA-ABS (Syphillis)

Variants

Glaucomatocyclitic crisis (Posner-Schlossman Syndrome)

Acute, unilateral, vague symptoms, signs minimal, but IOP up to 60 mm HG; attack for hours to days to months, between attacks all is normal, treatment is symptomatic only.

Fuch's heterochromic iridocyclitis

Triad of

• Heterochromia
• KP's
• Cataract

Progressive facial hemiatrophy (Parry Rohmberg Syndrome)

Ischaemic ocular inflammation

• Acute anterior ocular ischemia
  • Squint surgery
  • RD surgery
• In Takayasu disease (pulseless disease)

VKH SYR. (Uveomeningitis)

• Uveitis
• Meningitis (Headaches, neck stiffness)
• Auditory symptoms
• Exudative RD

Treatment

1. Symptomatic
   1. Rest
   2. Dark glasses
   3. Atropinization
   4. Corticosteroids
      1. Oral
      2. Topical
      3. Local
         1. Sub-conjunctival
         2. Sub-tenons
            1. Anterior
            2. Posterior
   5. Immunosuppressives
      1. Azathioprine
      2. Cyclophosphamide
2. Supportive
   1. NSAID's
   2. Immunostimulants
   3. Multivitamines
3. Specific
   1. Antibiotics
   2. Antifungals
   3. Antivirals
4. Surgery
   1. Iridotomy
      1. Sector - for pupillary block glaucoma
      2. Laser
   2. Other as per needed.

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