In the name of Holy Allah, The Most Beneficent,

The Most Merciful

1
 COMPARITIVE STUDY OF UVEITIS AND ITS
COMPLICATIONS, PRESENTING IN OPHTHALMOLOGY
OPD OF HOLY FAMILY HOSPITAL RAWALPINDI

A report submitted in partial fulfillment of the requirement for the degree

of BSc. (honors) Optometry and Orthoptics.

Submitted by: Jawad Raza

Registration # 2014-RMC-0384-UHS

Course supervisor: Prof. Dr. Ali Raza

Head of Ophthalmology Department

Rawalpindi Medical College, Rawalpindi

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 Dedication

To my beloved parents, honorable teachers and supporting friends who encouraged me to

complete this research study.

Jawad Raza

3
 Declaration

I hereby declare that all the data during this study was collected by me and the data collection
was used only for academic purpose.

Jawad Raza

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 Certificate of Completion

This is to certify that Mr. Jawad Raza Roll No-15032 of B.Sc. (Hons) Optometry & Orthoptics
has completed this study on “Comparative study of uveitis and it’s complications in Holy
Family Hospital Rawalpindi.” successfully as a requirement for examination under our
supervision. He is found to his work. We wish his success in his life.

Date: _____________ ______

Course supervisor
Prof. Dr. Ali Raza
M.B.B.S, MCPS, F.C.P.S
Head of Ophthalmology Department
RMC & Allied Hospitals, Rawalpindi.

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 Acknowledgment

Firstly, I would like to thanks Allah Almighty for giving me courage to complete this research
project. I would like to thank my parents and brother for their constant encouragement and kind
support without which this project would not be possible.

Secondly, I would like to express my profound gratitude and deep regards to my

supervisor Dr. Ali Raza, coordinator Dr. Rasheed, my research/bio-statics professor Dr.
Rizwana and Professor M.Ibraheem and Dr.Sidra for their exemplary guidance, monitoring
and constant encouragement throughout the research project. The blessing, help and guidance
given by them time to time helped me to carry this long way journey.
I would also like to express my gratitude to the high authorities, principle, and to class
teachers of, Rawalpindi Medical College for their cordial support, valuable information and
guidance, which helped me in completing this task through various stages.
Lastly, I am obliged to participants of my research for their cooperation during the
period of my assignment.

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 Abstract

Objective: Main objective will be to do comparative study of uveitis and its complications.
Patients developing complications due to chronic uveitis of different age will be studied in the
period of six months.
Material and Method: 25 patients of different ages who suffered from acute and chronic
uveitis and developed complications due to chronic uveitis in Out Patient Department of Holy
family hospital Rawalpindi during 1st August 2018to 31th January 2019 were included in my
study after the detailed ocular examination, history and vision prognosis.

Results: Uveitis is a sight threating condition. I collected data of 25 patients of age group of
5-60 years depending upon the time available. 15 patients were female and 10 were male. It is
shown that the females are more frequently affected by uveitis. Cataract develops in most of
the cases in which uveitis remain untreated and become complicated. Slit lamp examination is
necessary to diagnose the disease.

Conclusion: This study showed that acute and chronic uveitis is an important problem in
people ages between 25-40 years. Females are affected more than males. It presents as
challenge to salvage useful vision in uveitis patients. Prevention, early presentation and proper
management help to restore vision and early rehabilitation of the patient.

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 Table of Contents

UNIT NO.1: INTRODUCTION .......................................................................................... 12

1.1 Background and History............................................................................................ 15

1.2 Epidemiology ............................................................................................................ 15

1.3 Etiology ..................................................................................................................... 15

1.4 Classification ............................................................................................................... 16

1.5 Investigation .............................................................................................................. 20

1.6 Management ............................................................................................................... 21

1.7 Complications............................................................................................................ 22

1.7.1 Cataract...................................................................................................................... 22

1.7.2 Glaucoma .................................................................................................................. 27

1.7.3 Cystoid Macular edema ............................................................................................. 30

1.7.4 Hypotony .................................................................................................................. 33

1.7.5 Band Keratopathy...................................................................................................... 34

1.8 Literature Review ..................................................................................................... 36

1.9 Aim ........................................................................................................................... 38

1.10 Objective ................................................................................................................... 38

UNIT NO 2: MATERIALS & METHODS ......................................................................... 39

2.1 Subject ....................................................................................................................... 39

2.2 Study Design ............................................................................................................ 39

2.3 Study Location .......................................................................................................... 39

2.4 Duration of Study ...................................................................................................... 39

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 2.5 Sample Size ............................................................................................................... 39

2.6 Sample Technique ..................................................................................................... 39

2.7 Sample Collection ..................................................................................................... 39

2.8 Inclusion Criteria ....................................................................................................... 39

2.9 Exclusion Criteria...................................................................................................... 40

2.10 Study Methodology ................................................................................................... 40

2.11 Methods of Data Collection ...................................................................................... 40

2.12 Data Collection Tools & Procedure .......................................................................... 40

2.13 Informed Consent ...................................................................................................... 41

2.9 Statistical Analysis .................................................................................................... 41

Chapter 3 ................................................................................................................................ 42

3.1 Results ....................................................................................................................... 44

3.2 Gender Wise Distribution........................................................................................... 44

3.3 Age Wise Distribution of uveitic patients .................................................................. 45

3.4 Frequency of Complications .............................................................................................. 47

3.5 Discussion .................................................................................................................. 48

3.6 Conclusion.................................................................................................................. 48

3.7 Limitations ................................................................................................................. 48

3.8 Recommendations ...................................................................................................... 49

UNIT NO 4.............................................................................................................................. 50

4.1 References ................................................................................................................. 50

4.2 Performa .................................................................................................................... 57

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 List of Figures

1. Figure1. Anatomy of Human Eye............................................................. 13

2. Figure2. Anterior Uveitis (Iridocyclitis)................................................... 18

3. Figure3. Anterior Uveitis (Iritis) .............................................................. 18

4. Figure4. Intermediate Uveitis (Cyclitis) ................................................... 19

5. Figure5. Posterior Uveitis (Choroiditis) ................................................... 20

6. Figure6. Pan Uveitis ................................................................................. 20

7. Figure7. Post. Synechiae making Cataract Extraction difficult in

Iridocyclitis ............................................................................................... 24

8. Fugure8. Posterior Synechiae Formation ................................................. 25

9. Figure9. Pupillary Membrane Formation ................................................. 25

10. Figure10. Formation of Inflammatory Membrane around IOL .............. 26

11. Figure11. Pt with Pars planitis with giant cell PPT and Inflammatory

Membrane encasement of IOL ................................................................. 27

12. Figure12. Sector Iridectomy in Pts. With Chronic Iridocyclitis ............. 31

13. Figure13. Cystoid Macular Edema .......................................................... 32

14. Figure14. Patient with Chronic iridocyclitis & Hypotony ...................... 35

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 List of Tables

1. Table No. 1: Gender Wise Distribution ........................................................... 44

2. Table No. 2: Age Wise Distribution ................................................................... 45

3. Table No. 3: Frequency of Complications....................................................... 47

List of Charts

1. Chart1. Gender Wise Distribution .......................................................... 44

2. Chart2. Frequency of Uveitis among different Age groups..................... 46

3. Chart3. Frequency of Complications of Uveitis ...................................... 47

4. Abbreviations Used

IOL Intra-ocular lens

J.R.A Juvenile Rheumatoid Arthritis
C.M.E Cystoid Macular Edema
Pre-op Pre-Operative
Post-op Post-operative
V/A Visual acuity

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UNIT NO.1: INTRODUCTION
The eyes are wonderful sensory organs. It is the organ of vision and light perception. The
human eye is a spheroid structure that rests in a bony cavity on the frontal surface of the
skull. Like a camera, the eye is able to refract light and produce a focused image that can
stimulate neural responses and enable the ability to see (fig. 1). Eyes see all kinds of objects -
big or small, near or far, colors and dimensions. The human eye can distinguish about more
than 10 million colors [1] and capable for detecting a single photon [2].

Fig. 1: Anatomy of human eye

The eyes sit in sockets within the bones of skull (known as the orbits), and are surrounded by
fibrous tissue, fat and muscles that help to protect them from damage. The eyes are also
protected by eyelids and eyelashes, which block out bright light and help to keep out dirt, dust
and other foreign objects. Lacrimal apparatus is a physiological system which is developed for
[3].
tears production and drainage Tears production occurs through the lacrimal gland that is
located in the orbit above the outside corner of each eye. Tears are swept across the front of

12
eyes each time when blink, and drain into ducts at the inner corners of the eyes. Tears not only
lubricate the eyes, but also work with eyelids and eyelashes to protect against dirt and infection.

The field of view of human eye measured from fixation point is about 600 superiorly ,500
nasally,700 inferiorly and 1000 temporally [4,5,6]. For both eyes combined(binocular) visual field
is 1350 vertical and 2000 horizontal [7,8].

Cornea is the transparent part of the eye made from collagen fibers. It is about ½ mm thick
and consists of five layers: Epithelium, Bowman’s membrane, Stromal, Decrement’s
membrane and the Endothelium layer. It has two main functions a) acts as a barrier that
prevents the germs, dirt and other harmful material from entering the inner eye b) the cornea
acts as the eye's outermost lens. It refracts light and contributing about two thirds of the eye
total optical power [9,10]. In humans, the refractive power of cornea approximately 43D [11].

The iris gives the eye its color. This color is genetically determined. It is made up of three
layers of connective tissue and muscle fibers: endothelium, stroma and the epithelium. The
main function of iris is to control the amount of light that enters into the eye. The high amount
[12].
of pigment blocks light from passing through iris to retina so restricting the light to pupil
In bright light the muscles contract causing the iris (the pupil) to constrict. In dim light or
darkness, the muscles of iris dilate allowing more light to pass into the eyes.

The pupil is the opening at the center of the iris that lets allows light to strike on retina [13].
It becomes narrower in bright light and wider in dark.

Anterior Chamber is a cavity between the iris and the innermost surface of cornea. It
contains watery fluid called aqueous humor that plays a major role to maintain eye IOP [14].

The lens is biconvex surface and positioned directly behind the iris. It is made of proteins
called crystalline. Lens also acts as a refractive surface and focus light onto the retina. Changing
the curvature of the lens allows focus on objects at different distances. The lens is encased in a
capsule and suspended within the eye by zonular fibers that are attached to equator of lens [15].
Lens continues to grow throughout a person life [16].

The vitreous gel (also known as the vitreous humor is a clear, thick, substance that fills
13
the center of the eye. Its composition is mainly water and makes up approximately 2/3 of the
eye's volume and shape to eye. It is contact with the retina and collagen fibers attach to vitreous
at optic disc and ora serrata [17]. It is attaches to the lens capsule and macula [18]. The gel volume
decreases with age and fluid volume increases with age [19] .

Retina is a sensory tissue of neural cells that lines the back of the inside of the eye. It
consists of sensory photoreceptor cells that capture light rays and convert them into electrical
signals which are transmitted by the optic nerve to the occipital region in brain. Retina is a part
[20,21].
of CNS and actually is a brain tissue Photoreceptors comprise two types of cells: rods
and cones. Each retina comprises approximately 125 million rods. Rods are sensitive to light
[22,23].
and can be activated by a single photon These are responsible for peripheral vision and
[24]
function best in dim light. There are approximately 6 million cones in a human eye and
these are more concentrated in the macula, most densely in the fovea. Cones are essential for
vision in bright light and for seeing colors. The outer layer of the retina is known as the retinal
pigment epithelium (RPE) layer. This layer helps nourish the photoreceptor cells and is
attached to the choroid which provides the RPE with this nourishment which includes oxygen.
Sensory layer containing rods and cones involves in phototransduction [25] bipolar cells collect
[26]
signals from rods and cones and transmit them to innermost layer of retina from where
ganglion cells send them to brain [27].

The macula is situated at the center of the retina. It is divided into many parts like
foveola, foveal avascular zone area [28]. It is responsible for central sharp vision and the
ability to see objects in detail. Its diameter is approx. 1.5mm.

The fovea is a small pit of around 0.3mm near the center of the macula which has the
highest concentration of cone cells and is free of rod cells.

The optic nerve is 2nd cranial nerve that transmits visual information in the form of
electrical signals from the retina to the brain. It extends from optic disc to optic chiasma,
optic tract, lateral geniculate body, optic radiations into visual cortex [29,30]. The rods and
cones are not present in the area from where optic nerve emerges. This point is called optic
disc. This creates a blind spot in field of vision known as physiological blind spot or
14
physiological scotoma.

Background and History

Uveitis is inflammation of uveal tract that comprises iris, ciliary body and choroid. It
is a leading cause of blindness in US in 10-20% [31]. Uveitis is often idiopathic disease
but sometimes may be triggered by genetic factors, traumatic, immune or infectious
mechanism.
Predisposing Factors
• People with changes in certain genes.

• Smoking

Epidemiology

Uveitis is a large group of inflammatory diseases that involving the iris, the ciliary
body and choroid. Uveitis affects approximately 1 in 4500 people and most common
between the ages 20 to 60. According to the anatomical classification, about 50-90%
cases are related to anterior uveitis in western countries. In Asian countries this
proportion is about 28-50% [32]. 6-30 are posterior uveitis, 7-15% (average 12%) are
intermediate uveitis and 7-69% (average 20%) are pan uveitis. The most frequently
diagnosed entities are HLA-B27 related uveitis, acute anterior uveitis in herpes zoster
disease, toxoplasmosis, and sarcoidosis and pars planitis. It occurs more commonly in
older people.

Etiology

It has the following etiologies

 Eye injury or surgery

 An autoimmune disorder such as sarcoidosis or ankylosing spondylitis
 Eye tumors
 An infection such as herpes zoster, tuberculosis, toxoplasmosis, Lyme disease,

15
 syphilis, west Nile virus or cat scratch disease
 A cancer that effects the eyes such as lymphoma

1.1 Classification of uveitis

A clinical classification system of uveitis has been proposed by the International Uveitis
Study Group. Its purpose is to help in the diagnosis and evaluation of patients with uveitis.
Also used in conjunction with other classification systems it will also enable enrollment of

patients for clinical trials, and contribute to clinical guidelines. [33]

1. Based on duration
 Acute uveitis
 Chronic uveitis
2. Based on anatomical location
 Anterior uveitis
 Intermediate uveitis
 Posterior uveitis
 Pan-uveitis
3. Based on Histology
 Granulomatous Uveitis
 Non-Granulomatous Uveitis

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 Uveitis may be Anterior Uveitis i.e. Iritis and Iridocyclitis

Figure. 2 anterior uveitis (iridocyclitis)

Figure. 3 Anterior Uveitis (Iritis)

Signs & Symptoms: Pain, redness, photophobia, lacrimation, younger age at onset, high male
to female ratio, frequent unilateral alternating eye involvement, severe ocular symptoms during
activity, such as presence of fibrin in the anterior chamber, post-synechiae present, absence of
mutton fat keratic precipitates; high incidence of ocular complications [34].

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 Uveitis may be Intermediate Uveitis i.e. Cyclitis

Figure. 4 Intermediate Uveitis (cyclitis)

Intermediate uveitis is a type of an intraocular inflammation that involvs the anterior vitreous,
peripheral retina and the pars plana. The etiology is unknown but there are several associated
diseases: multiple sclerosis, idiopathic optic neuritis, sarcoidosis, thyroid diseases and
inflammatory bowel diseases. Symptoms include blurry vision, floaters and distortion of
central vision. Clinical Presentations, mild to moderate anterior chamber inflammation, thin
keratic precipitates in the inferior portion of the cornea, vitriitis, vasculitis in the peripheral
retina, intravitreal snowballs and snow banking [35].

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 It may be the Posterior Uveitis i.e. Choroiditis

Figure. 5 Posterior Uveitis (Choroiditis)

Intermediate uveitis is an intraocular inflammation involving the anterior vitreous, peripheral

retina and pars plana. The etiology is unknown but there are several associated diseases:
multiple sclerosis, idiopathic optic neuritis, sarcoidosis, thyroid diseases and inflammatory
bowel diseases. Symptoms are blurry vision, floaters.

Clinical presentation includes snowballs and snow banking in vitreous cavity [36].

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 It may be Pan Uveitis i.e. inflammation of all parts of uveal tract

Figure. 6 Pan uveitis (inflammation of all parts of Uveal Tract)

Pan uveitis is the inflammation of the uveal tract of the entire eyeball. Diseases presented with
reduced visual acuity in both eyes and blurred vision without any other symptom. On
ophthalmologic observation it was found pan uveitis in both eyes. Retinal vessels showed
vasculitis [37].

Investigation:

The clinician must choose different ways for investigations [38]. Diagnosis is done by using slit
lamp examination with dilated pupil and lab tests.

Further investigations are

 Blood CP and ESR
 Blood Sugar
 Blood Uric Acid
 Serological tests for syphilis, toxoplasmosis and histoplasmosis
 Test for antinuclear antibody Rh factor and left eye cells (L.E)
 Enzyme Essay: serum angiotensin converting enzyme

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  Skin test include tuberculin and Toxoplasmin test.
 Radiological investigations include chest X-Ray sacroiliac joints and lumbar
pain

1.2 Management: [39]

Management of uveitis is medical as well as surgical.

 Medical
The aim is to
 Relieve the patient symptoms
 Treat the underlying cause
 Prevent complications
1) Mydriatics (cycloplegic drugs are used in all types of uveitis) e.g.,
• Atropine sulphate 1% eye drops or ointment 2-3 times daily
• Homatropine eye drops 2% drops 3-4 times daily
• Cyclopentolate eye 1% drops 3-4 times per day.

Its objectives are:

i. Comfort and rest to the eye by relieving spasm of ciliary body and iris
ii. Dilation of pupil to prevent posterior synechiae formation and break already formed
synechiae to avoid secondary glaucoma
iii. To reduce exudate formation by decreasing capillary permeability
2) Steroids are main stay in non-infective uveitis.
They are used as
i. Topical eye drops e.g. prednisolone or dexamethasone 4-6 times daily
ii. Topical eye ointment at bed time
iii. Periocular injection e.g. anterior subconjunctival injections are given in severe
cases
iv. Intravitreal steroid injections e.g. triamcinolone acetonide 4mg in 0.1 ml is
useful in uveitis associated with cystoid macular edema
3) Systemic NSAIDS are useful in uveitis associated with arthritis
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 4) Systemic steroids e.g. prednisolone 1-1.5 mg/kg body weight in divided doses are
useful in particular cases
5) Cytotoxic drugs are useful when uveitis does not respond to steroids or steroids are
intolerable. Drugs used are Azathioprine and Methotrexate.
6) Cyclosporin is powerful anti-t-cell immunosuppressive agent. It is used in steroid
resistance cases. It is a drug of choice in Bechet disease.
7) Antibiotics are used in infective cases in the form of topical drops.

 Surgical
1) Cryotherapy is now seldom used.
2) Laser photocoagulation is useful in eyes with neovascularization
3) Vitrectomy is used for the severe visual loss due to cystoid macular edema.

1.3 Complications of Uveitis:

The treatment of uveitis is often frustrating because of the many complications that
may arise as a result of inflammation and its treatment. The most frequent
complications are given below
 Cataract
 Glaucoma
 Cystoid Macular Edema
 Band keratopathy
 Endophthalmitis

1.2.1 Cataract
Cataract is a most common complication of uveitis. The development of cataracts is
common due to both the presence of intraocular inflammation and the most commonly
employed treatment with corticosteroids [40]. In addition, recent reports suggest that the
prevalence of cataract in pars planitis may be as low as 10% if steroid use is limited or
replaced by other forms of treatment, such as cryotherapy or immunosuppressive
therapy. However, most of the complications of uveitis are more difficult to treat.

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Management of Cataract:

When cataract develops, the management is more complex than in the non-uveitic patient. The
formation of posterior synechiae, presence of pupillary membranes, and inflammation of uveal
tract make the surgery more difficult, and the postoperative course is also difficult. Much
controversy still exists about the best method of managing the cataract in uveitis patients.
Ideally, an absolute control of inflammation should be obtained for at least 3 months before
surgery. Managing cataract is very challenging in case of uveitis [41].

Figure. 7 Posterior synechiae may make cataract extraction

difficult in this patient with chronic iridocyclitis

The choice of surgical technique is also controversial. The patients should be treated
preoperatively with topical steroid drops (prednisolone acetate or phosphate) at 4 times/ day
for at least three days before surgery. Sometimes, an oral steroid (usually prednisone 1
mg/kg/day) for 3 days, also prescribe to patients. Adequate pupillary dilation is much difficult
to achieve preoperatively due to presence of posterior synechiae and pupillary membranes. In
such cases, a laser peripheral iridotomy performed preoperatively or a surgical peripheral
iridectomy can be performed at the time of surgery. The posterior synechiae can then be lysed
with the aid of a cyclodialysis spatula; access is gained to the superior ones through the
peripheral iridotomy. If pupillary dilation still not achieved, straight or curved long-handled
23
retinal scissors can be used to fashion small membranotomies or sphincterotomies (1 to 2 per
clock hour), and viscoelastic material can be used to dilate the pupil. If adequate pupillary
dilation is still not achieved by these processes, iris hooks can be used to further dilate the
pupil. In many cases, iris hooks provide maximum dilation without the need for
sphincterotomies. The lens is then removed with the use of either phacoemulsification or
standard extracapsular techniques.

Figure. 8 Posterior Synechiae formation

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 Figure. 9 Pupillary Membrane Formation due to Uveitis

Implantation of an intraocular lens is controversial. There is much evidence that an IOL can be
safely implanted in cases of Fuchs' iridocyclitis and pars planitis. In contrast, most evidence in
cases of children with JRA is in favor of lensectomy/vitrectomy with no IOL. The use of an
IOL in uveitis of other etiologies is still uncertain, but an IOL should never be inserted in a
patient with inflammation that could not be adequately controlled preoperatively. If an IOL is
to be inserted, we prefer an all polymethyl-methacrylate lens to one with polypropylene haptics,
because this may, at least in theory, lessen the chance of postoperative inflammation. Recently
we had good postoperative results by using foldable acrylic lenses. Another way is placement
of the IOL in the capsular bag rather than the ciliary sulcus is also preferred because this may
lessen the risk of inflammation secondary to iris-haptic contact.

25
 Figure. 10 Formation of Inflammatory membrane around IOL

Occasionally, even in eyes with little or no preoperative inflammation, significant membranes

form around an IOL [42]. This may occur even in the absence of anterior chamber cell and flare
in the postoperative period. Although these cocoon- like membranes can be lysed with the Nd:
YAG laser, they tend to reform. Therefore, it is imperative to be vigilant in the first 6 to 12
weeks after surgery, aggressively treating any signs of inflammatory deposits on the IOL, even
in the absence of anterior chamber reaction.

Figure. 11 Patient with pars planitis with giant-cell precipitates and

inflammatory membrane encasement of IOL.

It has been suggested that pars plana vitrectomy may be warranted when vitreous cells and
debris might preclude good post-operative visual acuity. Although we do not perform pars
plana vitrectomy on all patients of uveitis with cataract, this procedure is only considered for
eyes with significant vitreous debris or inflammation.

26
The postoperative management is similar to that of nonuveitis patients, except that
inflammation is usually more severe and prolonged, often requiring depot steroid injections
and systemic anti-inflammatory treatment. The results of cataract surgery in uveitis patients
change according to the preoperative diagnosis. Patients with Fuchs' iridocyclitis normally do
well, with a visual acuity of 20/40 or better. Patients with pars planitis also show well results,
with 60% to 82% achieving a visual acuity greater than 20/40. Most pars planitis patients who
fail to achieve good visual acuity, because of cystoid macular edema. In these patients, more
aggressive anti-inflammatory treatment, both preoperatively and postoperatively, will improve
visual outcome.

Patients with JRA do not tend to have as good outcome as those with Fuchs' or pars planitis, a
visual acuity greater than 20/40 is achieved in only about 60% of patients. However, one study
using aggressive preoperative control of inflammation has reported a visual acuity greater than
20/40 in 75% of JRA patients. Finally, those patients with idiopathic and other forms of non-
granulomatous anterior uveitis tend to do well postoperatively, with almost 80% achieving a
visual acuity of 20/40 or better, again provided inflammation is well controlled preoperatively.

1.2.2 Glaucoma:
Glaucoma is a frequent complication of uveitis, occurring in up to one fourth of patients
with chronic inflammation Glaucoma associated with uveitis is one of the most dreadful
complications of intraocular inflammation [43]. It is essential to measure the intraocular
pressure of the uveitis patient at each visit. Elevated IOP can be measured in any type
of uveitis, but most common in Fuchs' iridocyclitis, JRA-associated iridocyclitis, and
iritis secondary to herpes simplex and herpes zoster viruses. Glaucoma occurring with
chronic uveitis can be either secondary open angle or closed angle glaucoma. Careful
gonioscopy of the uveitis patient with elevated IOP is therefore critical in such cases.

Open-angle glaucoma is the most often seen in patients with chronic uveitis. The
anterior chamber angle may become blocked by debris and inflammatory cells.
Alternatively, trabecular meshwork may itself become inflamed, reducing outflow
27
facility. It has been postulated that the endothelial cells of the trabecular meshwork are
capable of phagocytosis and that during periods of inflammation these cells ingest
debris, migrate off the trabecular beams, and eventually may be lost. The loss of
endothelial cells causes a decreased outflow facility and an increased IOP.
Another mechanism that may be responsible for increased IOP in uveitis patients is
steroid response. IOP can raises in any route of steroid administration. But it is seen
most after topical use. The IOP rise seems to be dependent on the type and duration of
treatment, as well as on patient characteristics. It can be seen in up to 30% of the general
population after 3 to 4 weeks of treatment with topical steroids The IOP rise in
glaucoma patients tends to be faster and of a greater magnitude than in non-glaucoma
patients.
The mechanism responsible for steroid-induced ocular hypertension may result from a
stabilization of lysosomal membranes, which in turn could cause an increased
deposition of glycosaminoglycans in the trabecular meshwork, because lysosomal
enzymes are responsible for glycosaminoglycan breakdown.
Angle-closure glaucoma is another type of chronic uveitis. Inflammatory peripheral
anterior synechiae may close off the chamber angle, resulting in a raised IOP. The
chamber angle may also be occluded by rubeosis iridis, which can occur as a
consequence of chronic inflammation. Angle closure can also occur from pupillary
block, which arise when extensive posterior synechiae prevents the flow of aqueous
humor from the posterior to the anterior chamber. This results in iris bombe, because
aqueous fluid trapped in the posterior chamber causes the iris to be displaced anteriorly
and mechanically closing the angle. One final cause of angle-closure glaucoma in the
uveitis patient is anterior rotation of the ciliary body. This can occur secondary to ciliary
body swelling or extensive exudative retinal detachment.

28
Management of Glaucoma: [44]

Management of uveitis glaucoma requires careful diagnosis and management of both

uveitis and glaucoma. Before planning surgery, it is important to identify the
mechanisms of IOP elevation and to differentiate secondary open angle glaucoma,
secondary angle closure glaucoma with or without pupillary block. Uveitis negatively
affect the outcome of glaucoma surgery. Filtration surgery with the use of adjunctive
mitomycin C is the standard of care because of the risk of fibrosis of the filtration bleb.
Non-penetrating surgery is another option if the angle is open avoiding anterior
chamber entry and hypotony. Aqueous shunt implantations are another option and
could be suggested as a primary surgical procedure. Cyclophotocoagulation is best
avoided in uveitis because the ciliary body is compromised by cyclitis. This procedure
should be used carefully because patients with uveitis already have atrophic ciliary
epithelium, and the risk of permanent hypotony is increased with a cyclodestructive
procedure. The treatment of uveitic glaucoma totally depends on its etiology. Patients
with steroid-induced glaucoma may benefit from a change in medication from a more
potent steroid, such as prednisolone acetate, to one with a lesser effect on IOP like
fluorometholone alcohol or acetate. There are also newer topical steroid preparations,
such as rimexolone [45] that are purported to have less of an effect on IOP.
The medical management of uveitic glaucoma is similar to that of other types of
glaucoma, except that miotics and epinephrine-based compounds should be avoided
because they may increase inflammation and the risk of synechiae formation. If
glaucoma cannot be medically managed then argon laser trabeculoplasty should
probably be avoided. It has a low success rate in uveitic glaucoma and may cause a
significant increase in IOP and inflammation. The success rate of trabeculectomy is
lower in uveitic patients than in patients with primary open-angle glaucoma but it may
be increased with the use of antimetabolites. Postoperatively administered
subconjunctival 5-fluorouracil and intraoperatively administered mitomycin C have
been demonstrated to increase the success rate of filtration surgery in uveitic glaucoma.

29
 Like other forms of pupillary block, uveitic pupil-block glaucoma is treated with a laser
peripheral iridotomy. In uveitis patients, there is a tendency for iridotomy to close
because of the inflammatory reaction. We therefore tend to fashion multiple, large
iridotomies, often using the argon laser as well as the Nd: YAG laser. In heavily
pigmented eyes, which often have a more marked inflammatory reaction, a surgical
peripheral iridectomy may be required.

Figure. 12 Sector iridectomy in patient with chronic iridocyclitis.

1.2.3 Cystoid Macular Edema: [46]

Cystoid macular edema (CME) can cause much visual loss and is one of the major
causes of legal blindness in patients with uveitis. It can complicate with any type of
acute or chronic, anterior or posterior uveitis. When uveitis is mild and of short
duration, CME may respond to treatment used to control the intraocular inflammation.
Sometimes, patients may need more aggressive treatment with local and systemic
steroid therapy and other immunosuppressive drugs. In CME retinal and sub retinal
neovascularization, preretinal membranes, macular ischemia, and macular holes can
also occur. Chronic CME and its sequelae are a significant cause of visual morbidity
and probably account for the majority of cases of low visual acuity (20/40) in uveitis
patients. The main symptoms experienced by patients with CME are decreased vision

30
 and metamorphopsia, often with marked fluctuations in acuity. The diagnosis of CME
is often difficult and may require careful stereoscopic examination at the slit lamp with
a contact, Hruby, 78 or 90 D lens. For cases in which the diagnosis is not clear,
fluorescein angiography is a helpful tool. This demonstrates leakage from perifoveal
capillaries, with or without the characteristic petaloid hyper fluorescence in the late
phases of the angiogram.

Figure. 13 Cystoid Macular Edema

The pathogenesis of uveitic CME is not completely understood, but it seems to be related to a
disturbance in the blood-retinal barrier; however, other factors such as vitreoretinal traction
may also be involved. The cause of the breakdown of the blood-retinal barrier is unclear, but it
may be the result of action by inflammatory mediators, such as cytokines and arachidonic acid
metabolites.

31
Management of C.M.E:

Macular edema is another cause of visual loss in patients with uveitis. Chronic macular
edema can lead to permanent retinal damage and atrophy therefore treatment should be
initiated early and continue until complete resolution occur. Corticosteroids are the mainstay
of therapy and can be given topically, periocular or through intravitreal injection. Other
treatments including intravitreal anti-VEGF (vascular endothelial growth factor), intravitreal
methotrexate and systemic antitumor necrosis factor agents have also demonstrated efficacy
in treating inflammatory macular edema in these cases [47].

Prostaglandins have been implicated in the development of uveitic CME, the use of systemic
NSAIDs in its treatment is theoretically appealing use in uveitis. Topical NSAIDs have shown
much promise in aphakic and pseudo phakic CME. If there is no significant rise in IOP with
topical steroids, posterior sub Tenon injections of steroid (e.g. Triamcinolone diacetate or
triamcinolone acetonide) are probably the best choice of treatment. The injections are
[48]
performed using the technique described by Smith and Nozik , in which the injection is
placed in the posterosuperior sub Tenon space with a short 25-gauge needle. This placement
facilitates delivery of the drug (which is believed to be absorbed transsclerally) to the macular
area. The injections are repeated every 3 weeks until a response is obtained, or until three
injections have not resulted in any improvement. Thereafter, the injections are repeated every
few months as needed. Patients who cannot tolerate or do not respond to steroid injections may
benefit from systemic steroids, although their use in most cases should be limited to a
maximum of 6 months because of their numerous side effects. There is evidence that
cryotherapy of the pars plana results in a decrease in vitritis and presumably CME in patients
with pars planitis who have neovascularization of the vitreous base and pars plana [49]. Although
this treatment may be beneficial in selected patients, one must remember that it carries the risk
of complications such as retinal detachment and proliferative vitreoretinopathy. Fluorescein
angiography is very helpful in making the diagnosis of CME, stereo photographs of the macula
coupled with a good clinical examination may be a better way to follow a patient's response to
treatment.
32
1.5.4 Hypotony:

Hypotony can result from many etiologies reducing intraocular pressure [50]. It is commonly
seen in patients with a history of ocular trauma, previous vitreoretinal surgery and in cases
of long-standing uveitis. IOP below 4–6 mmHg can have deleterious effects on ocular
[51].
function and if sustained can lead to phthisis The complications of hypotony include
keratopathy with Descemet's folds optic disc edema, maculopathy and eventually, phthisis
bulbi.

Figure. 14 Patient with chronic iridocyclitis and hypotony.

33
Management of Hypotony.

Hypotony secondary to inflammation usually responds to steroid treatment. In these cases,

the IOP may be increased because of an increased aqueous production by the ciliary body and
because of a decreased outflow facility as a result of the steroids. Hypotony due to ciliary
body detachment by cyclitic membranes may respond to pars plana vitrectomy with
membranectomy and reattachment of the ciliary body. This process involves the removal of
[52].
all traction and membranes on the ciliary processes Unfortunately, the hypotony caused
by ciliary body fibrosis or atrophy has no specific treatment. Pars plana vitrectomy with
silicone oil injection has been used in a number of patients with intractable hypotony, with
improvement in both IOP and visual acuity. Repeated intravitreal injection of viscoelastic
material has also been reported in one patient with chronic hypotony in whom visual acuity
and IOP were maintained over a period of 6 years. The patient received injections through the
limbus under general anesthesia every 4 to 5 months, as the viscoelastic cleared from the eye.
Viscoelastic injection through the pars plana under local anesthesia has also been used
successfully in two patients with chronic hypotony, again maintaining IOP and visual acuity.
The use of viscoelastic material instead of silicone oil eliminates the corneal decompensation
seen with oil but has the disadvantage of requiring repeated injections, with each injection
carrying the risk of infection and retinal detachment.

Band Keratopathy:
Band keratopathy is a type of degenerative disease, which is characterized by the deposition of gray
or white opacities in the superficial layers of cornea in chronic uveitis and complicate the situation
[53].

Band keratopathy usually occurs in the interpalpebral area. It typically begins at the periphery as
grayish white opacities. The opacification may spread centrally and in time may form a complete
band in the interpalpebral zone. The presence of these holes imparts a “Swiss cheese” appearance
to band keratopathy when examined at the slit lamp.

34
Management of Band Keratopathy:

Band keratopathy does not need to be treated unless there is a decrease in visual acuity or significant
foreign body sensation or discomfort. Treatment includes removal of calcium deposits with
ethylenediaminetetraacetic (EDTA), superficial keratectomy or phototherapeutic keratectomy
(PTK) that are indicated for improvement of visual acuity and ocular discomfort caused by band
keratopathy [54]. The corneal epithelium must first be removed with a blade or a spatula. A 2% to 3%
solution of EDTA is then applied to the area of band keratopathy. This is most easily accomplished
by rubbing the affected corneal surface with a cellulose sponge dipped in the EDTA solution. The
cornea is repetitively wiped in this fashion, removing the abnormal deposits. Care must be taken to
avoid application to uninvolved areas of cornea or to the conjunctiva, because EDTA is very
irritating to the ocular surface. This procedure can be repeated as often as is necessary to maintain
vision and prevent discomfort. At the end of this procedure, we put a bandage soft contact lens for
7 days and prescribe eye drops of antibiotic and corticosteroid [55].

35
 1.8 Literature Review:

1. This study was done by P Neri and Arapi in 2011.It showed that the most common
complications included cataract, glaucoma and Cystoid macular oedema.An early
recognition as well as timely management are mandatory for proper outcome.
2. This study was done by Rachel Jorg and Martha Skup.It concluded optimal treatment
initiatives remain imperative to reduce the ocular complications related to chronic
uveitis.Hazard ratios indicated greater risks of ocular complications in cases versus controls
during the overall observation period.(HR 5.2 for any ocular complication,HR 4.8 for any
visual disturbance,HR 3.2 for cataract,HR 2.7 for glaucoma, all P<0.001)
3. This Study was done by Fritts Treffers, NussenBlatt RB. And Bloke’s in 2004.This study
showed that complications from chronic uveitis are common. Among these macular edema
can complicate any type of uveitis while glaucoma is the most overlooked complication.
Some patients need oral medication while surgery is reserved for those who have
progressive visual loss or uncontrollable IOP.
4. This study was done by Miserocchi, ElisabettaFogliato, GiovanniModorati, Giulio
Bandello, Francesco PURPOSE: We describe the worldwide epidemiology of uveitis
through a systematic literature review. METHODs: Data obtained from the most relevant
studies published until November 2012 were reported. RESULTs: Results of our research
were structured in sections about the epidemiology of uveitis by anatomical location of
inflammation (anterior, intermediate, posterior, and panuveitis), type of inflammation
(infectious and noninfectious), and by age (children and elderly). Difficulties encountered
analyzing the different epidemiologic studies available regarding the epidemiology of
uveitis. Worldwide epidemiologic studies may help the clinician in the management of
patients with inflammatory ocular diseases, enabling the comparison of different uveitis
entities.

5. This study was done by Jancevski, MariaFoster, Charles S. To describe recent evidence
from the literature regarding cataract surgery and lens implantation in patients with uveitis.
FINDINGS: Most uveitic patients enjoy good vision despite potentially sight-threatening
complications, including cataract development. In those patients who develop cataracts,
successful surgery stems from educated patient selection, careful surgical technique, and
aggressive preoperative and postoperative control of inflammation.

36
6. This study was done by Malalis, Julia F.Escott, Sarah M.Goldstein, Debra A. Infectious
uveitis is one of the most common and visually devastating causes of uveitis in the US and
worldwide. This review provides a summary of the identification, treatment, and
complications associated with certain forms of viral, bacterial, fungal, helminthic, and
parasitic uveitis. In particular, this article reviews the literature on identification and
treatment of acute retinal necrosis due to herpes simplex virus, varicella virus, and
cytomegalovirus. While no agreed-upon treatment has been identified, the characteristics of
Ebola virus pan uveitis is also reviewed.

37
1.9 RATIONALE OF STUDY:

Uveitis is a major cause of complications as well as monocular blindness in many developed

countries. It is caused by various endogenous and exogenous factors as well as trauma. If not treated
it causes complications which lead to blindness. My study was designed to find out complications
of uveitis among all age groups. The data was collected from holy family hospital in a selected
period of time.

1.10 AIM:

To find out the comparison of rates of acute and chronic uveitis and its complications, presenting in
Ophthalmology OPD of Holy family Hospital Rawalpindi.

1.11 OBJECTIVE:

• To compare the rates of acute and chronic uveitis.

• To evaluate the frequency of patients exposed to diagnostic criteria of complication of
uveitis.
• To check the management of each complication.

38
CHAPTER 2:

MATERIALS AND METHODOLOGY:

2.1 Subject:

Patients with acute and chronic uveitis.

2.2 Study design:

Descriptive hospital-based study.

2.3 Study location:

Holy Family Hospital, Rawalpindi.

2.4 Study Duration:

6 months after the approval of synopsis.

2.5 Sample size:

25 sample size.

2.6 Sampling technique:

Consecutive sampling.

2.7 Sample selection:

2.8 Inclusion criteria:

1. Patients of both genders.

39
 2. Patients of any age.
3. Patients suffering from acute and chronic uveitis.
4. Patients having any history of ocular surgery.

2.9 Exclusion criteria:

1. Non-cooperative patients.
2. Patients who are not willing to be the part of research.

2.10 Study Methodology:

This study is going to be conducted at Holy Family Hospital, Rawalpindi. My study will start
soon after the approval of synopsis. The data collection process will commence afterwards.
Patients fulfilling the inclusion criteria and reporting to the Out-patient department of both
hospitals will be enrolled. These patients will be the sample size of my study. The data of the
patients exposed to diagnostic criteria of comparative study of acute and chronic uveitis and of
complications of chronic uveitis will be recorded on especially designed proforma.

2.11 Method of data collection:

By especially designed proforma.

2.12 Data collection tools and procedure:

1. Visual acuity charts (Snellen chart).

2. Pinhole vision.
3. Auto refractor for objective refraction.
4. Trial box and trial frame for subjective refraction.
5. Slit-lamp examination with Gonio lens.
6. Ophthalmoscopy (dilated eye exam for fundus).
7. Tonometer for measuring IOP.
8. B. scan

40
2.13 INFORMED CONSENT:

Proper informed consent will be taken from the patients & in case of children to their parents,
that their ocular examination will not cause any harm to them and there are no ethical issues
regarding it.

2.14 STATISTICAL ANALYSIS;

MS-Word and MS-Excel used to enter and analyze the data for all the categorical variables like
frequencies and percentages calculation.

41
CHAPTER 3:

3.1Results:

3.2 Gender Wise distribution:

I collected 25 patient’s data having the history of acute and chronic uveitis from all age
groups. Fifteen among them were females and ten were males.

Table: 1 Showing Gender Distribution

Gender No of Patents

Male 10

Female 15

Total 25

42
 No of Patents

Male Female Total

Pie Chart. 1 Gender Wise Distribution Pie Chart

43
3.3 Age wise distribution of uveitis Patients:

The highest frequency of uveitis patients lied in the age group of 20-40 years i.e. 64%.

Age No. of Patients

0-20 04

21-40 16

41-60 05

Above 60 00

Total 25

44
 No . Of Patient
30

25

20

15

10

0
0-20 21-40 41-60 Above 60 Total

No . Of Patient

Chart. 2 Frequency of uveitis among different age Group

45
3.4-Complications of Uveitis table:

Among the 25 patients having history of uveitis developed complications. 56% of the patients
had developed Cataract followed by 04% of the patients Glaucoma. Other complications are
not common. Mostly uveitis complicated patients developed cataract.

Table 3: showing frequency of Uveitis complications.

Complications Frequency

56%
Cataract

04%
glaucoma

C.M. E 00%

Hypotony 00%

Band Keratopathy 00%

46
 Frequency
60%

50%

40%

30%

20%

10%

0%
Cataract Glaucoma CME Hypotony Band keratopathy

Frequency

Chart. 3 Complications of Uveitis

47
 Distribution of uveitis laterally:

Table: 4 showing percentage of uveitis laterally

Unilateral uveitis 60%

Bilateral uveitis 40%

48
 Frequency

Unilateral Bilateral

Graph: 4 Distribution of uveitis laterally 3-D Pie Chart

49
 Distribution of uveitis according to range:

Acute Uveitis 44%

Chronic Uveitis 56%

Total 100%

Table No. 5: Showing %age according to Acute and Chronic

50
 %age
60%

50%

40%

30%

20%

10%

0%
Acute Uveitis Chronic Uveitis

%age

Graph 5. Distribution of Uveitis according to Acute/Chronic

51
3.5 Discussion:

Uveitis continues to be one of the most important complications of eye and one of the main
causes of ocular morbidity and blindness in developing countries. My study is a retrospective
analysis of data of patients who were presented with Uveitis eyes in outpatient department of
Holy Family Hospital, Rawalpindi from 01 August 2018 to 31th January 2019.

In this study females clearly had higher incidence of uveitis and so also the highest incidence
of complications than males. This is in conformity with several studies conducted elsewhere
that females are more affective from uveitis.

With respect to the overall complications of uveitis in my study, Cataract was most
predominant (56%) and it was followed by Glaucoma (04%).

With regards to age in this study, majority of all the patients with uveitic eyes lied in the age
group of 21-40 years (64%). Among them, most patients with complications also lied in the
same age group i.e. 21-60 years (84%).

3.6 Conclusion:

 Overall frequency of Uveitis was 60% females and 40% in males.

 Age group 21-40 years had highest frequency of uveitic patients i.e. 64%.
 The overall prevalence of cataract in Uveitic patients was 56%.
 Non-surgical management was used in 90% of the patients with Uveitis.

3.7 Limitations:

Limitations of this study are due to:

 Small sample size.
 Short duration of study.

52
 3.8 Recommendation

The present study shows that age group 20-60 are an important group suffering from
Uveitis. Urgent treatment for uveitis should be emphasized, for all ages to avoid complications.
Further such studies should be carried out in other hospitals with large sample size.

53
Chapter 4:

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57
 4.2 :PATIENT PROFORMA

Eye OPD Reg. No: ___

Personal Info:

Name: _____________________ Age: ______________________

Gender: _____________________ _ Residence_________________

Chief Complain: _________________________________________________________

Patient History:

Ocular History: __________________________________________________________

Medical History: _________________________________________________________

Family History: __________________________________________________________

Visual Status:

V.A: __________________ Pinhole V.A: _______________

A.R Reading: ____________ Sub Refraction: ______________

IOP: _________________ EOM: ____________________

Slit Lamp Exam:

Adnexa: __________________ Conjunctiva: _________________

Sclera: ____________________ Cornea: _____________________

A.C: ______________________ Pupil: _____________________

58
Iris: ___________________ Lens: _____________________

Vitreous: ______________ Fundus: ____________________

LAB INVESTIGATIONS:

Lab Tests: _____________________________________________________

X-Ray: ________________________________________________________

Diagnosis:

_______________________________________________________________

Complications:

________________________________________________________________

Treatment:

Medical:

Surgical:

Date: ……………..

Supervisor Sign:

59
 CONSENT

I hereby agree to participate in this study. I have been informed by the researcher about the
purpose of this study in my native language and he also assured that my personal information
and responses will not be highlighted or used for any unfair purposes.

Signature:

Date:

60