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OP6.1-4 | Iris, Uvea and Anterior Chamber — Graded Quiz
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The SUN Working Group classification of uveitis is based primarily on:
Correct. The SUN classification is anatomical. Anterior uveitis = iridocyclitis; intermediate = pars planitis; posterior = chorioretinitis; panuveitis = involvement of all uveal layers. Anatomical classification directs the workup and guides prognosis.
The SUN (Standardization of Uveitis Nomenclature) Working Group classification is anatomical: anterior (iris/ciliary body), intermediate (vitreous/pars plana), posterior (choroid/retina), and panuveitis (all layers). This anatomical classification guides the investigative and therapeutic approach.
The SUN Working Group classification is anatomical: anterior (iris and ciliary body), intermediate (vitreous and pars plana), posterior (choroid and retina), and panuveitis (all layers). Aetiology, duration, and treatment response inform management but are not the basis of this classification system.
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Which combination of findings on slit-lamp examination most specifically differentiates granulomatous from non-granulomatous anterior uveitis?
Correct. Mutton-fat KPs and iris nodules (Koeppe/Busacca) are the distinguishing features of granulomatous iridocyclitis. Causes include sarcoidosis, tuberculosis, VKH syndrome, and sympathetic ophthalmitis. Non-granulomatous disease has fine/stellate KPs and no iris nodules.
Mutton-fat KPs (large, greasy deposits of epithelioid cells and macrophages on the corneal endothelium) and iris nodules (Koeppe at the pupillary margin; Busacca on the iris stroma) are specific to granulomatous iridocyclitis. Cells, flare, synechiae, and ciliary flush occur in both types.
Mutton-fat KPs and Koeppe/Busacca iris nodules are the features that distinguish granulomatous from non-granulomatous iridocyclitis. Cells and flare, synechiae, ciliary flush, and photophobia occur in both types and do not differentiate between them.
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A patient with long-standing iridocyclitis develops 360-degree posterior synechiae (seclusio pupillae). The iris is bowed forward and the IOP has risen acutely to 45 mmHg. The immediate treatment of choice is:
Correct. Iris bombe with acute IOP of 45 mmHg requires urgent laser peripheral iridectomy (LPI) to relieve the pupil block. Systemic acetazolamide lowers IOP as a temporising measure while preparing for the procedure. Cycloplegics cannot dilate a pupil held by 360-degree synechiae.
Iris bombe from seclusio pupillae is an ophthalmic emergency. The pupil block must be relieved by a laser peripheral iridectomy (LPI), which creates an alternative aqueous pathway from the posterior to anterior chamber, bypassing the blocked pupil. While arranging LPI, IOP is lowered medically with systemic acetazolamide plus topical agents.
Seclusio pupillae causing iris bombe and acute angle-closure is an emergency. The definitive treatment is laser peripheral iridectomy (LPI) to bypass the pupil block. Systemic acetazolamide is used as a bridge to lower IOP urgently. Cycloplegics cannot break 360-degree synechiae; steroids alone do not relieve the mechanical block.
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A patient with uveitis develops a posterior subcapsular cataract. Which is the most likely cause?
Correct. PSC in uveitis is caused by the combined effect of chronic inflammation on the lens epithelium and the cataractogenic effect of long-term corticosteroids. Steroid-induced cataract characteristically affects the posterior subcapsular region.
Posterior subcapsular cataract (PSC) in uveitis arises from two mechanisms: (1) direct toxic effect of chronic intraocular inflammation on the lens epithelium, and (2) corticosteroid-induced cataract (classic PSC). Both mechanisms act together in patients on long-term steroid therapy for uveitis, making cataract a common complication.
Posterior subcapsular cataract in a uveitis patient arises from chronic intraocular inflammation damaging the lens epithelium and from the cataractogenic effect of prolonged corticosteroid use. Both mechanisms produce PSC. Raised IOP and synechiae do not cause cataract directly.
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A 19-year-old presents with sudden unilateral vision loss after being hit in the eye by a shuttlecock. Anterior chamber examination reveals a dark-red horizontal level occupying one-third of the anterior chamber. IOP is 22 mmHg. The most important early complication to anticipate in the next 48-72 hours is:
Correct. Rebleeding (secondary haemorrhage) between days 2 and 5 is the major early complication of traumatic hyphema. It occurs when the initial clot retracts. Rebleed is often larger, harder to manage, and more likely to cause complications including elevated IOP and corneal blood staining.
Traumatic hyphema (Grade I here, occupying less than one-third of the anterior chamber) carries a significant risk of secondary haemorrhage (rebleed) on days 2-5 after injury, when the initial clot retracts and the damaged vessel reopens. Rebleed is often more severe than the primary bleed and can cause corneal staining and acute glaucoma.
The most feared early complication of traumatic hyphema is rebleed (secondary haemorrhage), occurring on days 2-5 as the initial clot retracts and the damaged iris vessel reopens. Secondary bleed tends to be more severe, raising IOP acutely and risking corneal blood staining. Sympathetic ophthalmia is a rare late complication of penetrating injury.
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A post-cataract surgery patient develops a hypopyon on day 3. The hypopyon is increasing rapidly, the eye is severely injected, and there is vitreous haze. The most urgent step in management is:
Correct. Post-operative hypopyon with rapid progression and vitreous haze on day 3 is acute bacterial endophthalmitis — a surgical emergency. Immediate vitreous biopsy and intravitreal antibiotics (per ESCRS/EVS guidelines) are mandatory. Increasing steroids alone without microbiological diagnosis and targeted antibiotics is dangerous.
Post-operative hypopyon appearing after the first 24 hours, especially with rapid progression and vitreous involvement, is infectious endophthalmitis until proven otherwise. This is a sight-threatening emergency requiring immediate vitreous tap/biopsy and intravitreal antibiotics (vancomycin + ceftazidime). Delay results in irreversible blindness.
Post-operative hypopyon appearing after 24 hours with rapid worsening and vitreous haze is acute infectious endophthalmitis until proven otherwise. This requires immediate vitreous tap and intravitreal antibiotics as an emergency. Merely increasing topical steroids or anti-inflammatories will miss the infection and result in blindness.
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A 25-year-old man presents with recurrent acute unilateral anterior uveitis. He also reports intermittent low back pain that is worse in the morning and improves with exercise. The most likely underlying systemic disease is:
Correct. Ankylosing spondylitis in a young man with recurrent acute unilateral anterior uveitis and inflammatory back pain (morning stiffness, improves with activity) is the classic presentation. HLA-B27 is positive in about 90% of AS cases.
Ankylosing spondylitis (AS) is the most common systemic association with acute anterior uveitis, especially in young men. AS presents with inflammatory back pain — worse in the morning, improves with activity — distinguishing it from mechanical back pain. It is strongly HLA-B27 positive. Sarcoidosis causes granulomatous uveitis, often bilateral and posterior.
The combination of recurrent acute unilateral anterior uveitis and inflammatory back pain (morning stiffness improving with activity) in a young man is ankylosing spondylitis (HLA-B27 positive). Sarcoidosis causes bilateral granulomatous uveitis. SLE and JIA have different age/sex profiles and joint patterns.
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A child with oligoarticular juvenile idiopathic arthritis (JIA) is referred to the ophthalmologist. She has no eye symptoms. Which statement about uveitis in this context is correct?
Correct. ANA-positive oligoarticular JIA is the subtype with the highest risk of chronic asymptomatic anterior uveitis. The lack of symptoms is the key danger — children do not report a red eye. Regular slit-lamp screening is essential because complications (band keratopathy, cataract, glaucoma) develop without warning.
JIA-associated uveitis, particularly in ANA-positive oligoarticular girls, is characteristically silent — no redness, no pain, no photophobia. This makes routine slit-lamp screening mandatory (not symptom-driven). Band keratopathy, cataract, and glaucoma develop insidiously. The inflammation is non-granulomatous.
JIA-associated uveitis (especially ANA-positive oligoarticular type) is a silent, asymptomatic chronic anterior uveitis — no red eye, no pain. This is why routine slit-lamp screening independent of symptoms is mandatory. The uveitis is non-granulomatous, not granulomatous.
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