UVEA & SCLERA UVEA & SCLERA JUAN S. LOPEZ, MD JUAN S. LOPEZ, MD Chief, Section of Uveitis Chief, Section of Uveitis Institute of Ophthalmology and Visual Institute of Ophthalmology and Visual Sciences Sciences St. Luke’s Medical Center St. Luke’s Medical Center
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UVEA & SCLERAUVEA & SCLERA
JUAN S. LOPEZ, MDJUAN S. LOPEZ, MDChief, Section of UveitisChief, Section of Uveitis
Institute of Ophthalmology and Visual SciencesInstitute of Ophthalmology and Visual SciencesSt. Luke’s Medical CenterSt. Luke’s Medical Center
CHOROIDCHOROID Very vascularVery vascular Between the retina Between the retina
and the scleraand the sclera The deeper the The deeper the
vessels, the larger vessels, the larger the caliberthe caliber
Drains via the vortex Drains via the vortex veinsveins
Bounded externally Bounded externally by the scleraby the sclera
Bounded internally Bounded internally by Bruch’s membraneby Bruch’s membrane
Nourishes the Nourishes the OUTEROUTER portion of the retina portion of the retina(inner portion supplied by (inner portion supplied by central retinal central retinal arteryartery))
POSTERIOR uveal diseasePOSTERIOR uveal disease Direct / indirect ophthalmoscopeDirect / indirect ophthalmoscope Slitlamp with special lensesSlitlamp with special lenses
UVEITISUVEITIS Inflammation of the uveal tract (1 or 3 Inflammation of the uveal tract (1 or 3
parts)parts) Usually affects people 20-50 y/oUsually affects people 20-50 y/o Usually unilateralUsually unilateral Various causes, some are idiopathicVarious causes, some are idiopathic CLASSIFICATION:CLASSIFICATION:
Floaters and blurring of visionFloaters and blurring of vision Pain, photophobia, redness usually Pain, photophobia, redness usually
absent or minimalabsent or minimal Most striking finding: VITRITISMost striking finding: VITRITIS ““snowballs” / “snowbanking”snowballs” / “snowbanking” Most common complications:Most common complications:
Most common causes of choroiditis Most common causes of choroiditis (immunocomptent patients)(immunocomptent patients) SarcoidosisSarcoidosis TuberculosisTuberculosis Vogt-Koyanagi-Harada SyndromeVogt-Koyanagi-Harada Syndrome
Viral illnessViral illness Mental depressionMental depression MalnutritionMalnutrition Sudden changes in temperatureSudden changes in temperature Breakdown in immune systemBreakdown in immune system
ManagementManagement Laboratory testing not required in the ff:Laboratory testing not required in the ff:
Mild uveitisMild uveitis 11stst episode episode
If with recurrent, severe, bilateral, granulomatous, If with recurrent, severe, bilateral, granulomatous, intermediate , posterior, diffuse uveitis or if fails to intermediate , posterior, diffuse uveitis or if fails to respond to standard therapy --- respond to standard therapy --- INVESTIGATE!INVESTIGATE!
MAINSTAYSMAINSTAYS of therapy: of therapy: Corticosteroids (oral/topical)Corticosteroids (oral/topical)
To control inflammationTo control inflammation CycloplegicsCycloplegics
To prevent synechia formationTo prevent synechia formation To reduce pain secondary to ciliary spasmTo reduce pain secondary to ciliary spasm
Chemotherapeutic agentsChemotherapeutic agents
Goals of Treatment:* Control inflammation* Prevent complications
SCLERASCLERA Fibrous outer Fibrous outer
protective coating protective coating of the eyeof the eye
by by episcleraepisclera (fine (fine elastic tissue with elastic tissue with numerous blood numerous blood vessels) vessels)
Thinnest at the Thinnest at the insertion sites of insertion sites of rectus musclesrectus muscles
SCLERASCLERA 3 Vascular Layers:3 Vascular Layers:
Conjunctival vesselsConjunctival vessels Vessels within Tenon’s Vessels within Tenon’s
capsule capsule Maximal congestion in Maximal congestion in
episcleritisepiscleritis Blanches with topical Blanches with topical
phenylephrinephenylephrine Deep vascular plexusDeep vascular plexus
Maximal congestion in Maximal congestion in scleritisscleritis
Phenylephrine has NO Phenylephrine has NO EFFECT on these EFFECT on these vesselsvessels
EPISCLERITISEPISCLERITIS
Common, benign, self-limitingCommon, benign, self-limiting Affects young adultsAffects young adults Unilateral redness with mild Unilateral redness with mild
discomfort, tenderness and wateringdiscomfort, tenderness and watering 2 types:2 types:
congested nodulecongested nodule Longer time to Longer time to
resolveresolve With recurrent With recurrent
attacks, sclera may attacks, sclera may appear more appear more translucent (should translucent (should not be mistaken for not be mistaken for scleral thinning)scleral thinning)
Scleral translucency
EPISCLERITISEPISCLERITIS
Management:Management: Not requiredNot required Simple lubricants / Simple lubricants /
vasoconstrictorsvasoconstrictors Topical steroidsTopical steroids Oral NSAIDS for severe recurrent Oral NSAIDS for severe recurrent
or prolonged inflammationor prolonged inflammation
SCLERITISSCLERITIS Edema and cellular infiltration of the Edema and cellular infiltration of the
entire thickness of the scleraentire thickness of the sclera Systemic associations present in about Systemic associations present in about
50% of patients (Rheumatoid Arthritis is 50% of patients (Rheumatoid Arthritis is the most common)the most common)
May be surgically inducedMay be surgically induced May be infectious caused by spread from May be infectious caused by spread from
a corneal ulcera corneal ulcer•Deeper lesionDeeper lesion•Violaceous vesselsViolaceous vessels•Unilateral or bilateralUnilateral or bilateral•Hallmark: EYE PAINHallmark: EYE PAIN•Associated with connective tissue Associated with connective tissue vascular diseasevascular disease
SCLERITISSCLERITIS
Anatomical Classification (based on Anatomical Classification (based on the primary anatomical site)the primary anatomical site) ANTERIOR SCLERITIS (98%)ANTERIOR SCLERITIS (98%)
For steroid-resistant patientsFor steroid-resistant patients Combined therapy Combined therapy
Pulsed intravenous Pulsed intravenous methylprednisolone 500-1000 mg and methylprednisolone 500-1000 mg and cyclophosphamide 500 mgcyclophosphamide 500 mg
ANTERIOR NECROTIZING ANTERIOR NECROTIZING SCLERITIS WITH INFLAMMATIONSCLERITIS WITH INFLAMMATION
ANTERIOR NECROTIZING ANTERIOR NECROTIZING SCLERITIS WITHOUT SCLERITIS WITHOUT
INFLAMMATIONINFLAMMATION Also known as Also known as scleromalacia scleromalacia perforansperforans
Typically occurs in Typically occurs in women w/ long women w/ long standing rheumatoid standing rheumatoid arthritisarthritis
Usually bilateralUsually bilateral Progressive exposure Progressive exposure
of uvea due to scleral of uvea due to scleral thinningthinning
TREATMENT IS TREATMENT IS INEFFECTIVE !!!INEFFECTIVE !!!
POSTERIOR SCLERITISPOSTERIOR SCLERITIS UncommonUncommon Often confused with other inflammatory and Often confused with other inflammatory and
neoplastic conditionsneoplastic conditions 2/3 of cases are unilateral2/3 of cases are unilateral Most common symptoms are pain and visual Most common symptoms are pain and visual
Treat as anterior necrotizing scleritisTreat as anterior necrotizing scleritis Young patients without associated systemic Young patients without associated systemic