Flashcards Uveitis
Flashcards Uveitis
Flashcards Uveitis
What are the signs of bleb-associated endophthalmitis and what is the treatment?;"•
Eye pain
• Poor vision
• Hypopyon
• Vitritis
• Treatment: Intravitreal antibiotics with or without
PPV"
What are the imaging and lab findings that help support the diagnosis of congenital
lymphocytic choriomeningitis (LCM)?;"• Brain imaging which classically shows
periventricular intracerebral calcifications (As
opposed to more diffuse calcifications in congenital
toxoplasmosis)
• Positive serologic testing for LCM virus IgM and IgG"
Under what CD4 count is a patient at risk for CMV retinitis?;"• CD4 count < 50
cells/mm3"
What is the mechanism of action and side effect profile of rituximab?;"• Monoclonal
IgG antibody directed against CD20
antigen on the surface of human B lymphocytes
• Side effects: depletion of B cells, reduction of IgG
and IgM levels for 6-12 months following therapy"
Which test may give false positive results for patients with ocular
leptospirosis?;"• Leptospirosis is a gram negative spirochete
• Therefore, it can cause falsely positive rapid
plasma reagin (RPR) or FTA-Abs"
Which types of posterior uveitis do NOT present with vitritis?;"• Presumed ocular
histoplasmosis syndrome
• Punctate inner choroiditis
• Progressive Outer Retinal Necrosis
• Serpiginous choroidopathy
• Subacute Sclerosing Panencephalitis"
What is the mechanism, route of administration, indication, and side effect profile
of cidofovir?;"• Cytidine nucleoside analogue that causes inhibition
of DNA synthesis
• IV administration
• Used for induction and maintenance therapy for
CMV retinitis
• Longer half life
• Side effects: renal damage, anterior uveitis,
hypotony"
What cells are targeted initially by HIV? How does HIV affect these cells?;"● CD4 T
cells
○ HIV decreases the number of CD4 cells
● Macrophages
○ HIV alters the function of macrophages"
What is leukotriene B4 and what is its effect?;"• Inflammatory mediator that causes
lysosomal
enzyme release and oxygen radical formation"
What is the classic presentation, exam findings, and fluorescein angiogram (FA)
pattern of punctate inner choroidopathy (PIC)?;"Presentation
• Typically a young, myopic, healthy woman with
bilateral changes
Exam findings
• Small 100-200 micron focal lesions confined to posterior
pole that can progress to atrophic/pigmentary
chorioretinal scars; minimal vitreous reaction
FA pattern
• Early hypofluorescence of inflammatory lesion with late
staining; early hyperfluorescence can also occur
especially if CNV is present
<img src='https://aao-resources-enformehosting.s3.amazonaws.com/resources/
Residents/Flashcards/images/content/uveitis_18.png'>"
What is the classic presentation, exam findings, and fluorescein angiogram (FA)
pattern of multifocal choroiditis (MCP)?;"Presentation
• Young, myopic woman with bilateral involvement
Exam findings
• Diffuse retinal lesions between 50-200 um with vitritis
• Peripheral chorioretinal streaks and peripapillary
atrophy, similar to ocular histoplasmosis syndrome
• Lesions are typically larger and more pigmented than
those seen in PIC
FA pattern
• Early hypofluorescence with late staining of active
lesions
<img src='https://aao-resources-enformehosting.s3.amazonaws.com/resources/
Residents/Flashcards/images/content/uveitis_19.png'>"
What is the classic presentation, examination, and IVFA findings of Acute Zonal
Occult Outer Retinopathy (AZOOR)?;"• Patient is classically a young, myopic woman
with
photopsias and progressive visual field loss that
begins as enlarged blind spot; unilateral 60% of
time at presentation
• Exam shows early lesions as multiple white-gray
dots with normal RPE. Later exam shows RPE
atrophy and hyperpigmentation resembling bony
spicules of RP
• Early IVFA findings may be normal, showing only
prolonged retinal circulation time; late IVFA
findings include hyperfluorescence and
hypofluorescence and window defects
corresponding to zones of RPE derangement
• DDx: MEWDS, RP, syphilis, DUSN, CAR"
Where are Koeppe nodules seen?;"Koeppe nodules are iris nodules located near the
pupillary margin"
Where are Busacca nodules seen?;"Busacca nodules are iris nodules seen in the iris
stroma"
Where are Berlin nodules seen?;"Berlin nodules are iris nodules seen in the
iridocorneal angle"
What are the risk factors for CMV retinitis and how does the virus infect the
retina?;"• Main risk factors: CD4 count < 50 cells/mm3, severe
systemic immunosuppression
• CMV remains latent in the host and may reactivate
if the host immunity is compromised. It can reach
the retina hematogenously and infect the vascular
endothelium which then spreads to retinal cells"
What are the risk factors for developing chronic uveitis in juvenile idiopathic
arthritis (JIA)?;"• Female sex
• Age at onset less than 6 years old
• ANA positivity
• Pauciarticular involvement: less than or equal to 4
joints involved during the first 6 months of disease
<img src='https://aao-resources-enformehosting.s3.amazonaws.com/resources/
Residents/Flashcards/images/content/uveitis_25_A.png'>
<img src='https://aao-resources-enformehosting.s3.amazonaws.com/resources/
Residents/Flashcards/images/content/uveitis_25_B.png'>"
How does Diffuse Unilateral Subacute Neuroretinitis (DUSN) differ from Ocular
Cysticercosis in relation to treatment response and lab work up?;"<img
src='https://aao-resources-enformehosting.s3.amazonaws.com/resources/Residents/
Flashcards/images/content/uveitis_26.png'>"
What were the main findings and conclusion of the Endophthalmitis Vitrectomy Study
(EVS)?;"• The EVS studied vitreous tap and inject versus pars
plana vitrectomy and inject in post-phaco eyes
with endophthalmitis
• The results showed that eyes that presented with
hand motion (HM) vision or better vision had
equivalent outcomes with tap and inject or PPV
and inject, but eyes with LP vision or worse had a
better chance of visual recovery after PPV with
injection
• Therefore, PPV with injection is recommended for
eyes with LP or worse"
What pathogen is Fuchs heterochromic iridocyclitis associated with and what are the
typical examination findings?;"● Associated with rubella virus; other studies have
found association with CMV, toxocara caniis,
toxoplasmosis, HSV
● Typical exam findings include:
○ Heterochromia
○ Iris stromal atrophy
○ Unilateral uveitis
○ Small diffuse KP’s
○ Lack of posterior synechiae
○ Unilateral PSC"
What is the rate of retinal reattachment after one surgery for RRD associated with
uveitis and what causes the increased failure?;"• Rate of reattachment in eyes with
uveitis is 60%
compared to 90% in eyes without uveitis
• Increased failure is likely due to proliferative
vitreoretinopathy, vitreous disorganization, and
poor visualization during surgery"
What is the pathogen that causes cat scratch fever and what is the classic triad of
presenting findings?;"Pathogen
• Bartonella henselae → a gram negative bacteria
transmitted via scratch, lick, or bite of an infected cat
Classic triad:
• Fever
• Lymphadenopathy
• Neuroretinitis"
The Endophthalmitis Vitrectomy Study (EVS) found which organisms to have the best
visual prognosis?;"• EVS found coagulase negative staph (S.
epidermidis, S saprophyticus) to have the best
visual prognosis
• 84% of cases had visual acuity of 20/100 or better"
The Endophthalmitis Vitrectomy Study (EVS) found which organisms to have the worst
visual prognosis?;"• EVS found enterococci to have the worst visual
prognosis
• 14% of cases had visual acuity of 20/100 or better"
What two main side effects should be monitored for during cyclosporine use?;"•
Hypertension
• Nephrotoxicity"
What are the common indications for rifampin and what is the main side effect of
rifampin?;"• Commonly used for tuberculosis, leprosy, and
legionnaires disease
• Side effect: Orange discoloration of urine, sweat,
saliva, and tears"
What are the common uveitic conditions with HLA type associations?;"• Birdshot:
HLA-A29
• Reactive Arthritis: HLA-B27
• Behcet Disease: HLA-B51
• VKH and Sympathetic Ophthalmia: HLA-DR4
• Intermediate Uveitis: HLA-B8, B51, DR2, D15
• Multiple Sclerosis: HLA-B27, DR2
• TINU: HLA-DQ in white North Americans, -DR14 in
Spanish"
What is the ideal dosing for hydroxychloroquine, what is the risk of toxicity over
time, and what are important risk factors for retinal toxicity?;"● Ideal dosing: 5
mg/kg of real body weight or less
● If used at this dose…
○ < 1% risk of toxicity during first 5 years
○ < 2% risk of toxicity up to 10 years
○ ~20% risk of toxicity after 20 years
● Important risk factors for retinal toxicity:
○ Daily dose > 5 mg/kg of real body weight
○ Duration of use > 5 years
○ Renal disease (cleared by kidney)
○ Tamoxifen use (risk of toxicity increased ~5x;
mechanism unknown)
○ Macular disease (interferes with screening
tests)"
What is the mechanism of steroid-induced ocular hypertension, how long does it take
to develop, and how long does it take to resolve?;"• Steroid causes outflow
reduction
• 1/3 population may be steroid responder
• Usually takes 3-6 weeks for response
• Return to pretreatment IOP levels within 10 days
to 3 weeks after discontinuation of steroid"
Which antibiotics were used in the Endophthalmitis Vitrectomy Study and what was
their method of delivery?;"• Vancomycin-amikacin given intravitreally
• Vancomycin-ceftazidime given subconjunctivally
• Vancomycin-amikacin given topically"
What is the mechanism of action of tacrolimus and cyclosporine and how do they
differ?;"• Both are potent calcineurin inhibitors that block
T-cell signaling
• Cyclosporine is a product of fungus Beauveria nivea
• Tacrolimus is a production of Streptomyces
tsukubaensis
• Tacrolimus has equal efficacy for chronic uveitis,
but less risk for systemic hypertension"
What medications are associated with drug-induced uveitis and how is it treated?;"•
Rifabutin (used for mycobacterium avium)
• Systemic fluoroquinolones, especially moxifloxacin → induce
iris depigmentation and uveitis
• Bisphosphonates
• Sulfonamides
• Diethylcarbamazine (DEC) (used for onchocerciasis)
• Oral contraceptives
• Etanercept (anti-TNF) → new-onset uveitis, systemic
sarcoid-like syndrome
• BCG vaccine, flu vaccine, PPD
• Topical anti-glaucoma medications: metipranolol,
anticholinesterase inhibitors, prostaglandin F2alpha
analogues, brimonidine
• Drugs injected directly into the eye: urokinase, cidofovir,
anti-VEGF
Treatment
• Topical steroids and cycloplegics
• If unresponsive, stop or taper offending medication"
What are the anatomic types of uveitis listed in order from most to least
common?;"Anterior uveitis
↓
Panuveitis
↓
Posterior uveitis
↓
Intermediate uveitis
What geographic locations are the following types of uveitis associated with:
Behçet's disease, birdshot, VKH, TB, leptospirosis and toxoplasmosis?;"• Behçet's:
Turkey and China
• Birdshot: Western Europe
• VKH: Asia, American Indian, Mediterranean,
Middle East
• TB and leptospirosis: main causes of infectious
uveitis in India
• Toxoplasmosis: Southeastern Brazil"
What is the pathogenesis, ANCA type, the affected tissues, mortality, and treatment
of granulomatosis with polyangiitis?;"• Granulomatosis with polyangiitis is an
autoimmune, large vessel vasculitis that mainly
affects the sinus, lungs, kidneys, eyes, joints, skin,
and CNS
• Orbital involvement is a result of contiguous
spread from nasal sinuses
• 90% of all ANCA is c-ANCA, with specificity to PR3
• Untreated patients have a 1 year mortality rate of
80%
• Treatment: systemic steroids and
immunomodulatory therapy, cyclophosphamide"
What are the risk factors for post-traumatic endophthalmitis after a ruptured
globe?;"• Delay in closure > 12 hours
• Contaminated wound
• Retained foreign body (higher risk factor)
• Rupture of posterior capsule during surgery"
What are the best and worst IOL types and ideal location for a patient with history
of chronic uveitis?;"Best type of IOL
• Hydrophobic, acrylic 1-piece
Best location for IOL
• Posterior chamber (in-the-bag)
IOL type not recommended
• Silicone → associated with increased
inflammation; also silicone oil may be needed for
future retinal surgery"
What are the criteria for the clinical diagnosis of Tubulointerstitial Nephritis
and Uveitis Syndrome (TINU)?;"Criteria for clinical diagnosis of TINU:
• Abnormal serum creatinine or decreased
creatinine clearance
• Abnormal urinalysis: increased
beta-2-microglobulin, pyuria, hematuria,
eosinophils, proteinuria, white cell casts,
normoglycemic glycosuria
• Associated systemic illness: fever, weight loss,
anorexia, fatigue, arthralgias, myalgias
• Abnormal liver function, elevated ESR, eosinophilia"
What HLA type is associated with Tubulointerstitial Nephritis and Uveitis Syndrome
(TINU)?;"HLA-DRB1*0102"
What is the treatment and prognosis for Tubulointerstitial Nephritis and Uveitis
Syndrome (TINU)?;"• The treatment for TINU is prednisone 1 mg/kg/day
for 3-6 months followed by a slow taper
• Most patients recover normal renal function and
baseline visual acuity"
What are the cytokines produced by T helper 1 (Th1) cells?;"● Th1 cells produce:
○ IL-2
○ IL-12
○ IFN-gamma
○ TNF-beta
● Th1 cells also help B cells secrete IgG1 and IgG3,
and inhibit Th2 cells"
What is the etiology and what are the tissues involved, ocular findings, and
treatments for relapsing polychondritis?;"Etiology
• Autoimmune disease
• Widespread inflammation of cartilage
Most common tissues involved
• Auricular inflammation
• Arthropathy
• Nasal cartilage inflammation
Ocular manifestations (involved 50% of time):
• Scleritis
• Conjunctivitis
• Uveitis
• Retinal vasculitis
Treatment
• Systemic steroids
• Dapsone
• Methotrexate
• Cyclophosphamide"
What are the ocular signs of Alport Syndrome?;"● Alport Syndrome, AKA hereditary
nephritis, has the
following ocular signs:
○ Anterior lenticonus
○ Posterior Subcapsular Cataract
○ Posterior Polymorphous Membrane
Dystrophy (PPMD)"
What is the mechanism of mycophenolate mofetil? How should it be taken? What are
the side effects?;"• Mycophenolate mofetil is a noncompetitive,
reversible inhibitor of inosine monophosphate
dehydrogenase which inhibits de novo purine
synthesis
• It should be taken on an empty stomach (1 hour
prior to eating or 2 hours after a meal) - taking with
food reduces absorption
• < 20% patients have adverse effects such as GI
upset, diarrhea, leukopenia"
What is Toxic Anterior Segment Syndrome (TASS) and what are the potential
causes?;"• TASS is postoperative anterior segment inflammation caused
by non-infectious substance that enters ant segment → toxic
damage to intraocular tissues
• Potential causes:
• Bacterial endotoxins or particulate contamination of
BSS
• Intraocular irrigating solutions with abnormal pH,
osmolarity, or ionic composition
• Denatured ophthalmic viscosurgical devices (OVD)
• Intraocular medications (antibiotics in irrigation
solutions or intracameral antibiotics)
• Topical ointment
• Inadequate sterilization of surgical instruments and
tubing
• Inadequate flushing of instruments between cases
resulting in build up of OVD
• Preservatives in medications used intraoperatively
• Metallic precipitate
• Starts within 24 hours of cataract surgery (infectious
endophthalmitis 2-7 days after surgery)"
What is the treatment and prognosis of Toxic Anterior Segment Syndrome (TASS)?;"•
TASS may result in permanent iris damage →
dilated pupil or irregular pupil that constricts and
dilates poorly; potential trabecular meshwork
damage
• Improves with steroids"
What patterns of distribution are most typical for CMV retinitis?;"• Perivascular
distribution is most typical for CMV
since the virus initially infects the endothelium of
blood vessels
• If retinitis is posterior, it typically has a fulminant
or hemorrhagic pattern
• If it is more peripheral it typically has a granular
pattern with less hemorrhage
• Frosted branch retinitis is another classic pattern"
What is the classic triad of measles? What other ocular problem can measles
cause?;"• Classic triad, the three C’s: Cough, Coryza (runny
nose), Conjunctivitis
• Systemic symptoms begin a few days before rash
which starts at the head and then spreads down
• Measles retinopathy: significant vision loss 1 week
after rash onset. Associated with retinal edema,
macular star, optic disc swelling, narrowed
arterioles, intraretinal hemorrhages. As the
retinopathy subsides, pigmentary retinopathy
resembling RP (bone spicules) or rubella (salt and
pepper) can be left. It is associated with permanent
VF loss"
What are the most common bacterial causes of endophthalmitis in each of the
following scenarios: acute postoperative, chronic postoperative, cutaneous
infection, endocarditis, liver abscess, bleb-associated?;"• Acute postoperative:
coagulase negative
Staphylococcus, Streptococcus species,
gram-negative organisms
• Chronic postoperative: Propionibacterium acnes,
Staphylococcus epidermidis, Corynebacterium
species
• Cutaneous infection: Staphylococcus aureus
• IVDU: Bacillus species
• Endocarditis: Streptococcus species
• Liver abscess (especially in Asia): Klebsiella
• Bleb-associated: Streptococcus species,
Haemophilus species, gram-positive organisms"
Above what threshold daily dose of prednisone should immunomodulatory therapy (IMT)
be used for chronic uveitis?;"• IMT should be used if ≥ 10 mg PO prednisone is
required for control of chronic uveitis"
What is the risk for developing chronic iridocyclitis based on joint involvement in
Juvenile Idiopathic Arthritis (JIA)?;"• Still disease (minimal joint involvement) →
rare
development of chronic iridocyclitis
• Polyarticular → ~10% will develop chronic
iridocyclitis
• Pauciarticular → ~85% will develop chronic
iridocyclitis"
What are the differences between Progressive Outer Retinal Necrosis (PORN) and
Acute Retinal Necrosis (ARN)?;"● PORN
○ Immunocompromised (CD4 < 50)
○ Absence of vitritis
○ Retinal vasculature minimally involved
○ Posterior pole involved early
● ARN
○ Immunocompetent
○ Presence of vitritis
○ Vasculitis
○ Posterior pole typically spared initially"
What is the most common type of primary CNS lymphoma?;"• Non-Hodgkin B Cell
Lymphoma makes up > 90% of
primary CNS lymphomas"
What immunomodulatory therapy causes drug-induced lupus? What are the clinical
findings and what is the prevention and treatment of drug-induced lupus?;"•
Infliximab → autoantibodies causing lupus-like
syndrome
• After extended period of time the effects include:
• Vascular thrombosis
• Congestive heart failure
• ANA positive
• Antibodies against infliximab which decrease
its effectiveness
• MTX or azathioprine can be used to prevent
development of autoantibodies and antibodies
against infliximab
• Other causes of anti-TNF-alpha associated drug
induced lupus: etanercept and adalimumab
• Treatment: withdrawal of drug → symptoms
resolve within 3 weeks to 6 months"
What are the most important characteristics to monitor when assessing the response
of CMV retinitis lesions to antiviral therapy?;"• Lesion size and degree of
activity at the border of
the lesion are most important factors to monitor
for response to therapy"
What are the presenting symptoms, ocular findings, and etiologic pathogens in
Whipple disease? How do you diagnose Whipple disease?;"• Whipple disease presents
with GI symptoms and
migratory polyarthralgias
• Ocular findings include bilateral panuveitis and
retinal vasculitis
• Associated pathogens are tropheryma whipplei
and actinomycetes bacterium
• Diagnosis by duodenal biopsy which shows PAS
positive organisms in macrophages within the
intestinal villi"
What is the threshold CD4 count below which HIV patients typically become
symptomatic? What is the CD4 count range in the asymptomatic phase of HIV? What is
the CD4 count range in a healthy adult?;"• CD4 count threshold for symptomatic HIV:
< 200
cells/mm³
• CD4 count in asymptomatic phase of HIV: 200 to
750 cells/mm³
• CD4 count in healthy adults: 600 to 1500 cells/mm³"
What is the mechanism of action of cromolyn sodium?;"• Cromolyn sodium inhibits
degranulation and
stabilizes mast cells and therefore inhibits the
release of mediators of inflammation
• Mast cell degranulation is triggered when IgE
molecules covering the surface of mast cells are
bridged by divalent antigen
• Full efficacy of cromolyn sodium is reached 5-14
days after therapy → not useful for acute
symptoms"
What is the treatment for ocular toxoplasmosis in the setting of sulfa allergy (SJS
reaction to sulfa drugs)?;"● Treatment options for ocular toxoplasmosis in the
setting of a sulfa allergy:
○ Oral clindamycin alone
○ IVI clindamycin plus dexamethasone
○ Azithromycin alone or in combination with
pyrimethamine"
What are the treatment options for ocular toxoplasmosis in patients without sulfa
allergies?;"• Triple therapy: pyrimethamine, sulfadiazine and
folinic acid with prednisone added 48 hours after
antibiotics coverage
• Triple sulfa: sulfadiazine, sulfamerazine,
sulfamethazine
• Bactrim DS (trimethoprim-sulfamethoxazole)
• Oral clindamycin (sole antibiotic)
• IVI clindamycin + dexamethasone
• Azithromycin alone or combined with
pyrimethamine
• Doxycycline
• Minocycline
• Atovaquone"
What is the cause of Progressive Outer Retinal Necrosis (PORN)? What are the exam
findings? What is the treatment?;"• PORN is a variant of necrotizing herpetic
retinitis
caused by VZV (most common) or HSV (rare) in
immunocompromised patients
• Exam shows retinal necrosis with lack of vitritis and
minimal retinal hemorrhages. It involves the
macula early on and lacks vasculitis. It also lacks
the granular border of CMV lesions
• Treatment: intravitreal and systemic ganciclovir or
foscarnet"
What are the screening and confirmatory tests for HIV?;"• HIV screening test:
Antibody detection by ELISA
• HIV confirmatory test: Western blot"
What is the most common ocular manifestation of congenital rubella syndrome? What
are the other associated ocular findings? What is the cause of poor vision in these
patients?;"• The most common ocular manifestation of
congenital rubella syndrome is pigmentary
retinopathy
• Other ocular findings:
• Cataract
• Microphthalmos
• Glaucoma
• Most common cause of poor vision is cataract and
microphthalmos. Retinopathy usually doesn’t
affect the vision
• Systemic manifestations of congenital rubella
syndrome:
• Deafness (most common)
• Cardiac malformations (patent ductus
arteriosus)
• Ocular findings"
Among which racial groups is VKH least common?;"• VKH is least common among
Caucasians and Africans"
What is the rate of endophthalmitis after PPV?;"• Rate of endophthalmitis after PPV
is 1 in 2000
• Rates are higher in diabetics and in retained
intraocular foreign bodies"
What was the purpose of the ESCRS endophthalmitis study? What were the findings?;"•
The ESCRS endophthalmitis study examined the
potential benefit of intracameral antibiotics
(cefuroxime) instilled at the end of cataract surgery
in preventing post-op endophthalmitis
• It found that intracameral antibiotics reduced the
risk of endophthalmitis 5-fold
• The incidence of post-op endophthalmitis in eyes
receiving intracameral antibiotics was 0.07%"
What type of Behçet's has the highest mortality?;"• Neuro-Behçet's has the highest
mortality with a
mortality rate up to 10%
• Neuro-Behçet's presents with headaches, strokes,
CN palsies, and dementia"
How do you describe Langhans giant cells and in what type of disease process are
they usually found?;"• Langhans giant cells are formed by a fusion of
epithelioid cells with their nuclei arranged in a
horseshoe shape
• They occur in many granulomatous conditions,
most notably in TB"
What ocular problems can be associated with pars planitis?;"● Pars planitis is
typically bilateral (80% of the time),
but may be asymmetric
● Other ocular problems that can be associated with
pars planitis include:
○ CME (most common cause of decreased
vision)
○ Spontaneous vitreous hemorrhage
○ Tractional and rhegmatogenous retinal
detachments"
How long does Retisert (fluocinolone acetonide) intravitreal implant work, what is
it used for, and what are the associated side effects?;"● Retisert releases steroid
for a median period of 30
months
● It is indicated in chronic non-infectious posterior
uveitis
● Side effects include:
○ All phakic patients will develop a cataract
○ 30% will require glaucoma filter after 2 years
of implantation"
What is the pathophysiology of a Type V hypersensitivity reaction and what are some
examples?;"• Type V hypersensitivity reactions are caused by
stimulatory hypersensitivity antibodies that react
with specific cell surface receptors and depress or
stimulate cell function
• Examples include Graves disease and myasthenia
gravis"
What is the pathophysiology of a Type I hypersensitivity reaction and what are some
examples?;"• Type I hypersensitivity reactions are caused by
pre-formed IgE antibodies bound on mast cell
receptors that react to the offending agent
• Binding causes degranulation of the mast cell and
histamine release
• Examples include anaphylactic, allergic, or atopic
reactions"
What is the pathophysiology of a Type III hypersensitivity reaction and what are
some examples?;"• Type III hypersensitivity reactions are caused by
immune-complex deposition in tissues which
activate complement and other effector systems
• Examples include serum sickness, SLE, and RA"
Are patients with inflammatory bowel disease and sclerouveitis typically HLA-B27
positive or negative?;"• Patients with inflammatory bowel disease and
sclerouveitis are typically HLA-B27 negative
• They can also have joint pain that resembles RA
and do not develop sacroiliitis, unlike IBD with
acute iritis"
Are patients with inflammatory bowel disease and acute iritis typically HLA-B27
positive or negative?;"• Patients with inflammatory bowel disease and
acute iritis are typically HLA-B27 positive and
develop sacroiliitis"
What are the typical classes of medication used to treat HIV?;"• Nucleoside reverse
transcriptase inhibitors (NRTI)
• Non-nucleoside reverse transcriptase inhibitors
(NNRTI)
• Protease inhibitors (PI)
• Fusion inhibitors
• Entry inhibitors
• Integrase strand transfer inhibitors"
What are the presenting symptoms, lab results, imaging findings in birdshot
retinochoroidopathy?;"• Birdshot retinochoroidopathy, AKA vitiliginous
chorioretinitis, is an inflammatory condition that
presents most commonly in caucasian women past the
4th decade of life with decreased vision, floaters,
nyctalopia, dyschromatopsia, glare, photopsias,
bilateral vitritis, cream colored depigmented lesions ¼
to ½ DD in size, most numerous in posterior nasal
fundus and around the optic nerve radiating towards
the periphery
• ICG shows multiple hypofluorescent spots more
numerous than those apparent on slit lamp
examination or IVFA
• ERF shows prolonged 30 Hz flicker implicit times,
diminished B wave (abnormal Muller and bipolar cells)
compared to A wave amplitude
• It is incompletely responsive to steroids alone and
requires early IMT"
What is the cause of delayed-onset (chronic) endophthalmitis and what are the signs
and work up?;"● Delayed-onset (chronic) endophthalmitis is
typically caused by propionibacterium acnes
● Ocular signs include
○ Granulomatous KPs
○ Small hypopyon
○ Mild vitritis
○ Appearance of posterior capsule opacity
● Work up:
○ Cultures, IVI antibiotics
○ If not responsive to IVI antibiotics, vitrectomy
with partial or entire capsular bag removal
and IOL removal are usually the next step"
What are the predominant symptoms of intermediate uveitis?;"• Floaters and blurred
vision are the predominant
symptoms of intermediate uveitis"
What is immune recovery uveitis (IRU) and how does it present?;"• IRU occurs in
patients with CMV retinitis who
recover their immune status through use of HAART
therapy
• It presents with anterior or intermediate uveitis
and CME
• CME can be resistant to treatment
• Cidofovir causes > 10-fold risk of developing IRU"
What are the types of pauciarticular Juvenile Idiopathic Arthritis (JIA)?;"● Type 1
Pauciarticular JIA:
○ Girls < 5 years old, ANA positive, chronic
uveitis
● Type 2 Pauciarticular JIA:
○ Older boys that end up developing HLA-B27
related uveitis, acute and recurrent uveitis"
How do you diagnose primary intraocular lymphoma (PIOL)?;"● Gold standard for
diagnosis of PIOL:
○ Cytological identification of lymphoma cells
within the eye via vitreous, retinal, or
subretinal biopsy
○ Biopsy shows large, pleomorphic, scant
basophilic cytoplasm and large nuclei
○ It has a high false negative rate
● Cytokine analysis will show high levels of IL-10
○ IL-10:IL-6 ratio > 1 is suggestive of PIOL
● Molecular analysis (PCR)
● Immunophenotyping: abnormal immunoglobulin
kappa or lambda light-chain predominance"
What are the risk factors, symptoms and treatment of leptospirosis?;"● Risk factors
for leptospirosis:
○ Exposure to natural reservoir for leptospira:
livestock, horses, etc
○ Being in tropical environment
○ More common in Hawaii, accounts for > 50%
USA cases
● Initial disease:
○ 1 month after incubation phase
○ Patient develops acute fever, chills, vomiting,
diarrhea, muscle aches
● Severe septicemic leptospirosis:
○ Severe liver and renal dysfunction
● Caused by a spirochete so false positive RPR or
FTA-antibodies are possible
● Treatment: intravenous penicillin G for 1 week"
What are the respective vectors and diseases pertaining to the following pathogens:
onchocerca volvulus, leishmania, leptospira interrogans?;"• Onchocerca volvulus:
female black fly, endemic in
sub-Saharan Africa; onchocerciasis/river blindness
• Leishmania: sandflies, leishmaniasis
• Leptospira interrogans: infected when in contact
with animal urine, high risk for sewer workers,
veterinarians, farmers"
Who is at highest risk for osteoporosis?;"• Postmenopausal women and men older than
50
years taking 7.5 mg/day or more of steroids for
longer than 3 months"
What are the treatment options for Lyme disease?;"• Oral Amoxicillin 500 mg TID
• Oral Doxycycline 100 mg BID
• Oral Cefuroxime 50 mg BID
• Selected macrolides
• IV Ceftriaxone 2 g IV daily
• IV Penicillin G 18-24 million U per day IV divided q4
hours"
What are the stages of Lyme Disease and their associated ocular involvement,
respectively? What testing should be performed if there is severe intraocular
inflammation?;"• Stage 1: local disease, follicular conjunctivitis
• Stage 2: disseminated disease, uveitis, anterior,
intermediate (most common), posterior, panuveitis
associated with granulomatous anterior, papillitis,
choroiditis, vasculitis, exudative RD
• Stage 3: persistent disease, keratitis, uveitis less
commonly
• Severe intraocular inflammation should be
considered a sign of CNS involvement, thus lumbar
puncture should be obtained
• Treatment: oral amoxicillin or doxycycline; IV
ceftriaxone (for CNS involvement)"
What are the stages of syphilis and their associated ocular involvement?;"•
Primary: 3-4 weeks after exposure, painless
chancre at inoculation site
• Secondary: 4-8 weeks after primary chancre, rash,
condyloma late, systemic symptoms
• Latent: early is < 1 year after infection, late is > 1
year after infection
• Tertiary: 1-10 years after infection, ocular syphilis,
neurosyphilis, cardiovascular problems, gumma
(granulomas, rare)"
What are the ocular complications of HIV?;"• HIV retinopathy (most common, 70% of
AIDS)
• Opportunistic viral/bacterial/fungal infections
• Kaposi sarcoma
• Lymphomas of retina/adnexa/orbit
• Squamous cell carcinoma of the conjunctiva"
What is the virology of the Chikungunya virus and what ocular problems does it
cause?;"• The Chikungunya virus is a single-stranded RNA
virus from the genus Alphavirus, family Togaviridae
• Spread to humans by infected mosquito
• Causes anterior uveitis and retinitis
(focal/multifocal/confluent retinitis)"
What are the causes of cecocentral scotomas (a blind spot between the physiologic
blind spot and the point of fixation)?;"• Toxic optic neuropathy
• Nutritional optic neuropathy
• Leber hereditary optic neuropathy"
What is sympathetic ophthalmia, its presentation, and the most common cause?;"•
Thought to be caused by penetrating injuries or
intraocular surgery
• Granulomatous panuveitis that is bilateral and
asymmetric (more severe in injured eye)
• Presentation: Mutton fat KP’s, difficulty with
accommodation, photophobia, iris thickening,
posterior synechiae, elevated IOP, mid-equatorial
yellow white lesions (Dalen-Fuchs nodules), exudative
retinal detachments, and retinal perivasculitis
• It spares the choriocapillaris
• Earliest stages the choroid has accumulation of
eosinophils
• Most common cause is PPV (0.12% of PPV’s)
• 90% of cases occur within 1 year of injury, but range is
2 weeks to 50 years"
What is the pathology in the Autoimmune Regulator (AIRE) deficient mice model of
uveitis?;"• In AIRE Deficient Mice self-tolerance does not
occur in the thymus because they lack the
necessary transcription factor
• Therefore autoreactive T cells are not deleted and
the mice develop autoimmunity that causes a
posterior uveitis"
What are the respective fundus autofluorescence patterns associated with multifocal
choroiditis, Acute Zonal Occult Outer Retinopathy (AZOOR), and Acute Posterior
Multifocal Placoid Pigment Epitheliopathy (APMPPE)?;"• Multifocal choroiditis:
multiple
hypoautofluorescent spots that correspond with
the chorioretinal atrophy
• AZOOR: central hypoautofluorescence with
peripheral hyperautofluorescence
• APMPPE: Hyperautofluorescent areas correspond
with blockage on the IVFA"
What is the epidemiology, presenting symptoms, exam findings, IVFA findings, and
prognosis for Acute Posterior Multifocal Placoid Pigment Epitheliopathy
(APMPPE)?;"• APMPPE prevalence is equal among men and women
• Patients present with loss of vision, central or
paracentral scotomas, and photopsias, usually
preceded by a viral prodrome
• Exam findings include large 1-2 DD yellow-white
placoid lesions in the posterior pole
• IVFA shows early hypofluorescence of lesions, late
staining lesions involute over several weeks and leave
behind significant RPE alterations
• Associated with HLA-B7, DR2
• Associated with immune-driven vasculitis → cerebral
vasculitis
• Prognosis is good with most patients recovering 20/40
or better vision with residual defects
• Of note the fundus appearance is indistinguishable
from syphilis"
What are two syndromes seen in sarcoidosis and what are they characterized by?;"●
Lofgren Syndrome:
○ Erythema nodosum, febrile arthropathy,
bilateral hilar adenopathy, acute iritis
○ Responsive to systemic steroids
○ Good prognosis
● Heerfordt syndrome
○ AKA uveoparotid fever
○ Uveitis, parotitis, fever, facial nerve palsy"
What are the two antineutrophil cytoplasmic antibodies and what disease is each
associated with?;"● c-ANCA/proteinase3 ANCA
○ Associated with granulomatosis with
polyangiitis
● p-ANCA/myeloperoxidase ANCA
○ Associated with microscopic polyangiitis or
Churg-Strauss"
What is varicella zoster sine herpete?;"• Varicella zoster sine herpete is anterior
uveitis secondary to VZV without skin lesions"
What are the risk factors for ocular involvement in Candidemia?;"● Risk factors for
ocular involvement in Candidemia:
○ Hospitalization
○ Recent GI surgery
○ Bacterial sepsis
○ Systemic antibiotics
○ Indwelling catheter
○ Hyperalimentation
○ Debilitation disease
○ Immunomodulatory therapy
○ Prolonged neutropenia
○ Organ transplantation"
What is Diffuse Unilateral Subacute Neuroretinitis (DUSN) and the most common
causative organisms?;"• DUSN is a multifocal chorioretinitis caused by a
nematode
• Exam shows vitritis, optic nerve swelling, multifocal
inflammation of retina and RPE
• Inflammatory lesions are multifocal, gray-white
color, around 1 DD in size; sometimes s-shaped
nematode is visible in subretinal space
• Definitive treatment: direct photocoagulation of
organism
• Common organisms: ancylostoma canine (dog
hookworm), baylisascaris procyonis (raccoon
roundworm, T canis)"
Which serotypes of C. trachomatis are associated with trachoma, adult and neonatal
inclusion conjunctivitis, and lymphogranuloma venereum, respectively?;"• Trachoma:
serotypes A-C
• Adult and neonatal inclusion conjunctivitis:
serotypes D-K
• Lymphogranuloma venereum: serotypes L1, L2,
and L3"
What is the classic triad of Behcet disease?;"• Recurrent aphthous oral ulcers
(most common)
• Genital ulcers
• Recurrent uveitis"
What is the differential diagnosis for elevated IOP and uveitis?;"• Herpetic
• Toxoplasmosis
• Syphilis
• Sarcoidosis"