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A specific tissue type or gene, similar to a blood type, that is passed on from parents to their children. Glaucoma is a condition characterized by vision loss due to irreversible damage to the optic nerve.
Increased pressure occurs when the fluid within the eye, which is produced continuously, does not drain properly. Although normal pressure is usually between 12-21 mm Hg, a person might have glaucoma even if the pressure is in this range. OPEN-ANGLE GLAUCOMA (OAG) gets its name because the angle that allows fluid to drain out of the anterior chamber is open. ANGLE-CLOSURE GLAUCOMA (ACG) is a condition in which the iris is apposed to the trabecular meshwork at the angle of the anterior chamber of the eye.
Patients with uveitis are at increased risk of developing glaucoma because of the uveitis itself, and because of the use of corticosteroids which are the mainstay of uveitis treatment. Prostaglandins, which have been demonstrated to be present in the aqueous of eyes with uveitis, are known to cause elevated IOP without a reduction in outflow facility. Alteration of the protein content of the aqueous humor may be a cause of elevated IOP in uveitis. Having the characteristics of a granuloma; nodular inflammatory lesions, usually small or granular, firm, persistent, and containing compactly grouped mononuclear phagocytes. HLA-B27-associated uveitis occurs, we think, as a result of some germ or other triggering an autoimmune response. Watch this one minute video of a scene that could have come from science fiction as immune cells attack a harmless allergen as though it were a foreign invader. There is a class of medications that gain their therapeutic effect by suppressing the immune system. The goal of therapy is suppression of the immune inflammatory response, whether it is due to trauma, surgery, infection, or response to foreign or self-antigens, so that the integrity of ocular structures critical to good visual function is preserved. Immunosuppressive agents were, until recently, reserved for treatment of severe, sight-threatening, steroid-resistant uveitis or for use in patients who had developed unacceptable steroid-induced adverse effects.
The immunosuppressive drugs for which sufficient experience and information exists to warrant their use in treatment of ocular inflammatory conditions, by drug class, include the following: the alkylating agents (cyclophosphamide and chlorambucil), antimetabolites (azathioprine, methotrexate, leflunomide, and mycophenolate mofetil), antibiotics (cyclosporine-A, FK 506, sirolimus [rapamycin], and dapsone), receptor antagonists (etanercept and daclizamab [Zenapax] and immune-related adjuvants (bromocriptine, ketoconazole, and colchicine). Uveitis in children: 5% to 10% of the cases of uveitis occur in children under the age of 16. Recent (2001) epidemiological studies in the United States suggest that these figures may be underestimated by as much as 4 to 5 fold. After the eyes are dilated, an indirect ophthalmoscope provides the physician with a wider view of the retina. Intermediate uveitis is inflammation predominantly located in the anterior part (toward the front) of the vitreous. The term intermediate uveitis (IU) was suggested by the International Uveitis Study Group (IUSG) to denote an idiopathic inflammatory syndrome, mainly involving the anterior vitreous, peripheral retina, and ciliary body, with minimal or no anterior segment or chorioretinal inflammatory signs. Despite the fact that many studies suggest that IU tends to be one of the most benign forms of uveitis, severe complications secondary to chronic, indolent inflammation may arise, which may eventuate in blindness. The IOP in patients with active uveitis is most commonly decreased owing to impaired production of aqueous by the nonpigmented ciliary body epithelium. Factors that can affect IOP include the accumulation of inflammatory material and debris in the trabecular meshwork with obstruction of aqueous outflow, inflammation of the trabecular meshwork (trabeculitis), obstruction of venous return, and steroid therapy.
Iridocyclitis is a term used to denote inflammation in two parts ofthe uveal tract of the eye; the iris and the ciliary body.
When we say that someone has "green", or "brown", or "blue" eyes, we are describing the color of the iris.
When the iris is inflamed, white blood cells (leukocytes) are shed into the anterior chamber of the eye where they can be observed on slit lamp examination floating in the convection currents of the aqueous humor. A state-of-the-art facility dedicated to the treatment of patients with all forms of eye disorders. This site complies with the HONcode standard for trustworthy health information: verify here. Anterior uveitis is the most common form of intraocular inflammation accounting for more than 90% of uveitis, and herpetic anterior uveitis either due to herpes simplex or varicella zoster virus infection accounts for 5% to 10% of all uveitis cases and is the most common cause of anterior infectious uveitis. Because not all clinicians have access to intraocular fluid analysis, awareness of the clinical symptoms of herpetic anterior uveitis is important for diagnosis and subsequent treatment.
Ocular involvement is virtually always unilateral, with patients suffering from blurry vision, photophobia, pain, and redness. The iritis may be nongranulomatous but is more often granulomatous with moderate size mutton fat keratic precipitates (Figure 16-1), often in a triangular shape, located on the inferior part of the cornea, and, in the case of active keratitis, collects frequently under the area of the corneal lesion. The diagnosis of herpetic anterior uveitis is usually based on the previously mentioned clinical features, but the gold standard is the isolation of the virus or viral antigens in intraocular liquid as aqueous humor, which is obtained after an anterior chamber tap or vitreous fluid in case of posterior involvement.
Confirmation of intraocular viral infection with or without viral replication relies on molecular techniques such as polymerase chain reaction (PCR). The pathogenesis of herpetic iridocyclitis is believed to involve active viral replication and the host immune responses. Topical corticosteroids and antiviral agents are commonly used to treat ocular ­herpetic disease. Concerning the use of oral acyclovir, the HEDS (herpetic eye disease control group) results suggest a benefit of oral acyclovir in the treatment of herpetic iridocyclitis in patients receiving topical corticosteroids and topical antiviral prophylaxis. I am not going to detail the viral retinopathies that are covered elsewhere in this work, but one must, for every anterior viral uveitis case, perform a dilated eye fundus to exclude any posterior involvement as an acute retinal necrosis or a progressive outer retinal necrosis syndrome. Glaucoma, by accepted general definition, is damage to the optic nerve produced as a result of the imbalance between the blood flow (and the pressure driving it) to the optic nerve, and the pressure in the eye, which can reduce flow of blood to the optic nerve.
That is why regular eye examinations, that includes pressure checks and examination of the optic nerve and vision field, are very important. When the iris is pushed or pulled anteriorly to block the trabecular meshwork, the outflow of aqueous from the eye is blocked, which causes a rise in intraocular pressure (IOP). When glaucoma is caused by other diseases or drugs, the condition is referred to as secondary glaucoma.The mechanisms by which uveitis leads to elevated intraocular pressure (IOP) are numerous and poorly understood.
Mechanisms of increased resistance to aqueous outflow with both acute and sub acute forms of uveitis usually are of the open-angle type and include obstruction of the trabecular meshwork by inflammatory cells or fibrin, swelling or dysfunction of the trabecular lamellae or endothelium, and inflammatory precipitates on the meshwork.
Increased levels of protein in the aqueous are a result of increased permeability of the blood-aqueous barrier, which leads to an aqueous that more closely resembles undiluted serum. Although corticosteroids have proven effective in relieving inflammation, prolonged administration can result in elevated IOP. Granulomatous inflammation is a distinctive type of chronic inflammatory reaction in which the predominant cell type is an activated macrophange with a modified epithelial-like appearance (epithelioid). Certain germs have proteins that "look" like part of the HLA-B 27 protein that is present on the surface of the cells of the body in patients who inherit the HLA-B27 gene.


Farsightedness occurs if your eyeball is too short or the cornea has too little curvature, so light entering your eye is not focused correctly. When this reaction occurs against substances or tissues within the body, it is called an autoimmune reaction. It combines groups of cells, the chemicals that control them, and the chemicals they release. Immunosuppressive therapy is also sometimes referred to as "chemotherapy" because some of the drugs in this class of medication were developed originally to fight cancer. The MERSI experience suggests that at least 2 years on immunomodulatory agents is necessary. Any autoimmune disease affecting the eye, regardless of the form of autoimmunity, will require immunosuppressive therapy; the components of the immune system reside not in the eye, but rather are systemic, and therefore, regulation of those components will require systemic therapy.
Now, instead of being regarded as merely steroid sparing, these drugs are often used as first-line agents for a variety of disease with destructive ocular sequelae. Other names previously used in the literature to describe this entity include chronic cyclitis, peripheral uveitis, vitritis, cyclochorioretinitis, chronic posterior cyclitis and peripheral uveoretinitis. Of 1,237 patients with uveitis referred to the Immunology and Uveitis Service of the Massachusetts Eye and Ear Infirmary over a 10-year period, 162 (13%) were classified as IU. This however, is not always true because final IOP is also based on the facility of outflow and episcleral venous pressure.
For unknown reasons, elevated IOP is frequently associated with infectious uveitis, for example, herpetic uveitis.
It derives its name from combining iritis (inflammation of the iris) and cyclitis (inflammation of the ciliary body). The most common reason for its placement is an acute attack of narrow angle glaucoma or the risk of such an attack. It is the colored ring of tissue suspended behind the cornea and immediately in front of the lens. Iris color varies from light blue to dark brown, depending on the amount of pigment produced in the melanocytes. Inflammation in the iris is more correctly classified as anterior uveitis because there is also, often, inflammation of the ciliary body.
These cells can be counted and form the basis for rating the degree of inflammation.See, also, UVEITIS.
On slit-lamp examination, we may find an active keratitis, corneal scaring, or normal cornea. Posterior synechiae, loss of the function of the sphincter muscles, and atrophy of the iris are responsible for a distorted pupil. Serological testing for anti-HSV is a useful epidemiological tool but is not diagnostically helpful in an individual patient. The sensitivity of PCR to detect viral DNA can reach 80% to 96%, and it requires a small quantity of intraocular fluid. Topical corticosteroids control the iridocyclitis and also acutely decrease intraocular pressure owing to their anti-inflammatory effects on trabecular meshwork. They should be used in concomitance with corticosteroid drops to prevent recurrent epithelial keratitis. A controlled trial of oral acyclovir for the prevention of stromal keratitis or iritis in patients with herpes simplex virus epithelial keratitis.
Anterior uveitis with sectoral iris atrophy in the absence of keratitis: a distinct clinical entity among herpetic eye diseases. In most instances, this imbalance of forces occurs as a result of pressure in the eye that is too high. A clear fluid, the aqueous humor, flows continuously in and out of this space and nourishes nearby tissues. In general, Iridocyclitis affects both aqueous production and resistance to aqueous outflow, with the subsequent change in IOP representing a balance between these two factors.
This elevated protein content may, in fact, lead to aqueous hypersecretion and IOP elevation. A granuloma is a focal area of granulomatous inflammation consisting of an aggregation of macrophanges (some of which may be epithelioid cells or may fuse into syncytium-like multinucleated giant epithelioid cells), which may or may not be surrounded by a collar of mononuclear leukocytes, principally lymphocytes and occasionally plasma cells.
And if such a person has the bad luck to come into contact with one of those certain germs at some point in life, the person's immune system will, of course, attack and kill the germ; but it may also then inappropriately begin to "see" part of the HLA-B27 protein as also being foreign or germ-like, and attack it too, producing damage to the patient's own cells. Examples include such autoimmune disorders as rheumatoid arthritis, lupus, sarcoidosis, and inflammatory bowel disease. The immune system is a complex network of specialized cells and organs that has evolved to defend the body against attacks by "foreign" invaders. The dose of these drugs, when used to treat inflammation inside the eye, is much smaller than the dose used to treat cancer. The idea is to allow the patient's immune system to re-learn how to behave itself properly instead of being hyperactive, inappropriate, or aggressive. Such therapy is typically designed to suppress the overly aggressive immune system, allowing the body to eventually re-regulate itself, with the result often being that after the patient has been kept on systemic medications to suppress the inappropriate immune response for a finite length of time (for example, one year), medication can then be tapered and stopped without recurrence of the autoimmune attack.
Patients must be adequately immunosuppressed yet be spared the potentially serious consequences of drug toxicity. In the Unites States, uveitis has an estimated prevalence of about 38 cases per 100,000 population, and an incidence of 15 cases per 100,000 population.
When immune system cells and molecules invade tissues and organs as part of an immune system response, the collection of immune system cells and molecules at a target site is broadly referred to as inflammation.
Although the majority of cases are idiopathic and the patients have no systemic disease, a significant association between intermediate uveitis and sarcoidosis, multiple sclerosis (MS ), and Lyme disease is widely accepted.
IU may or may not be associated with specific infections (Lyme disease, toxocariasis, Whipple's disease, cat-scratch disease) and noninfectious diseases (multiple sclerosis and sarcoidosis). The disease seems to affect patients primarily from childhood through the fourth decade, but it has also been reported in older patients. Ocular hypertension, sometimes leading to glaucoma, has been reported in approximately 8% of patients with IU.
Repeat measurements should be taken at each visit because the effects of uveitis on IOP can vary over the course of the inflammatory episode. Iridocyclitis may also be referred to as anterior uveitis, or a form of intermediate uveitis, depending upon the classification system employed by the physician.Chronic, nongranulomatous Iridocyclitis is an important complication of juvenile rheumatoid arthritis.
The blue color results from the absorption of light with long wavelengths and the reflection of shorter blue waves, which can be seen by the observer. Those viruses can cause a wide spectrum of ocular disease, which comprises a number of clinical presentations: blepharitis, keratoconjunctivitis, dendritic epithelial keratitis, geographic or trophic herpetic corneal ulceration, stromal keratitis, and intraocular inflammation. However, in the absence of unclear evidence of current or past HSV infection, the diagnosis requires clinical suspicion and astute observations borne of such suspicion.


The iris atrophy, which results from ischemic necrosis of the stroma, is characterized by a defect at the level of the iris pigment epithelium, has well-defined edges, and can be only seen with transillumination. A less widely used method for the diagnosis of herpetic uveitis is the Goldmann-Witmer (GW) coefficient.
However, topical and oral antihypertensive agents may be necessary to control the pressure especially initially.
Unless the pressure at the front of the eye is controlled, it can damage the optic nerve and cause vision loss. Inflammation of the ciliary body usually leads to reduced aqueous production, and combined with increased uveoscleral outflow often seen in inflammatory states, hypotony (low intraocular pressure) often is a consequence.
Several theories have been proposed to explain this phenomenon, including accumulation of glycosaminoglycans in the trabecular meshwork, inhibition of phagocytosis by trabecular endothelial cells, and inhibition of synthesis of certain prostaglandins. This then must be treated, calmed down, with steroids, and if it keeps coming back again and again, other medications may be needed as well. When functioning properly, it fights off infections by agents such as bacteria, viruses, fungi, and parasites. Children and adults are treated successfully with these medications for chronic eye inflammation that recurs upon withdrawal of steroid. Immunomodulation suppresses this over activity and inappropriateness, making (artificially) the immune system behave more normally. Sometimes resumption of the attack does occur, in which case the patient must be re-treated. In the hands of physicians trained in their use and monitoring, the administration of immunosuppressive agents appears to produce fewer serious adverse effects than does chronic use of systemic steroids. However, both inflammation and repair may be potentially harmful, as is commonly seen in allergic and autoimmune diseases. The term pars planitis has been retained and used to describe the characteristic exudates that can be seen on the pars plana in some patients with IU, and may or may not represent a distinct clinical entity. Intraocular herpetic inflammation can be divided into 2 major entities, anterior uveitis with or without active epithelial keratitis or interstitial keratitis and viral retinopathy, which were described in both immunocompetent and immunocompromised patients. Anterior uveitis secondary to HSV or VZV occurs in association with active or inactive corneal involvement, but anterior uveitis without associated corneal changes also occurs as an isolated entity. It is in the specific search for such pathology via retroillumination that most ophthalmologists fail due to their lack of clinical suspicion for viral uveitis. This coefficient compares the ratio of anti-herpes antibody in serum and aqueous humor with the ratio of total immunoglobulin G in serum and aqueous humor, and is considered positive if the ratio is greater than 3.
Alternatively, one may use valacyclovir 1 g 3 times per day or famciclovir 500 mg 3 times daily. Pressure above that without optic nerve damage is typically called "ocular hypertension." Evidence of optic nerve damage, either through inspection of the nerve or through demonstration of abnormalities on visual field testing, is then defined as glaucoma. When the fluid reaches the angle, it flows through a spongy meshwork, like a drain, and leaves the eye.
If closure occurs intermittently or gradually, ACG may be confused with chronic open-angle glaucoma.
When it malfunctions, however, it can unleash a torrent of diseases, from allergy to cancer to uveitis.The immune system evolved because we live in a sea of microbes. Only physicians trained and experienced in the use of these medications should prescribe them. The goal of such treatment is not to over-suppress the immune system as is sometimes required in treating transplant or cancer patients; rather, the immune system is modulated, re-regulated, until it stops attacking the eye(s). Immunosuppressive agents represent the final rung in our stepladder approach to the medical treatment of ocular inflammatory disease (see treatment algorithms).
Components of both innate (essentially neutrophiles, other ganulocytes, macrophanges, and the complement system) and specific immunity (B and T lymphocytes through their antibodies and cytokines) may not only damage inflamed target issues but also may participate in the "innocent bystander injury" of surrounding normal tissues. The International Uveitis Study Group classification schema for uveitis has been widely adopted for clinical and research purposes. Approximately 70% to 90% of cases are bilateral, albeit asymmetric, with symptoms frequently being confined to one eye. Increased intraocular pressure is found in 90% of the patients, and trabeculitis is considered as the principal cause. The GW coefficient is more useful in immunocompetent patients because of the high false-negative rate in immunocompromised hosts. Despite significant advances in research and therapeutics, the prevalence of blindness secondary to uveitis has not been reduced in the past thirty years; it remains the third leading cause of preventable blindness in the world. It separates uveitis by anatomical location of the disease, according to the major visible signs, in the various segments of the eye: anterior uveitis, intermediate uveitis, posterior uveitis, and panuveitis.
Previous studies suggest that cataract formation tends to be less severe in patients who have been treated early with immunosuppressive drugs, rather than corticosteroids. Then, there is a whole category of uveitis called "idiopathic" -- this basically means that the cause is unknown; that is, that the uveitis cannot be associated, at the time of evaluation, with a particular systemic illness. The human body provides an ideal habitat for many of them and they try to break in; because the presence of these organisms is often harmful, the body's immune system will attempt to bar their entry or, failing that, to seek out and destroy them. Since some systemic illnesses present first with symptoms only in the eyes, patients should be retested periodically for systemic illness if inflammation is persistent. Sometimes the immune system's recognition apparatus breaks down, and the body begins to manufacture antibodies and T cells directed against the body's own constituents-cells, cell components, or specific organs.
Optic nerve involvement is not uncommon in IU (3% to 20%) and is observed more often in children than adults.
So-called "idiopathic uveitis", as with other forms of uveitis, can be difficult to treat and can be vision-robbing. Such antibodies are known as autoantibodies, and the diseases they produce are called autoimmune diseases. The sight-threatening complications of uveitis include glaucoma, damage to the retina, and macular edema. Multiple sclerosis (MS) has been reported to develop in 7.4% of patients with pars planitis. Because the risks are small and manageable if the medications are prescribed and monitored by an expert in these matters, and the benefits are enormous, i.e. This is why doctors advocate getting away from that plan of treatment, and moving on to non-steroidal agents.



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