Fig. 6.101 Hyphema with large iris disinsertion (dialysis) from its root.

the damaging effect of the pressure on the corneal endothelium.

One type of juvenile glaucoma occurs in Sturge-Weber syndrome (Fig. 4.46) in which there are angiomatosis of the face and meninges with cerebral calcifications and seizures.

Uvea (Figs 6.105 and 6.106)

The uvea is composed of the iris, ciliary body and choroid. All three are contiguous, and pigmented with melanocytes.

The iris is a diaphragm that changes the size of the pupil by the action of the sympatheic dilator m. and the cholinergic constrictor m.

The ciliary body (Figs 6.106–6.108) is made up of the four clinically significant parts.

1.The anterior region serves as the site for insertion of the iris.

2.The ciliary processes secrete the aqueous.

Fig. 6.105 Uvea. Courtesy of

Stephen McCormick.

Fig. 6.102 Angle recessed posteriorly following traumatic hyphema. The recessed angle is seen as a wide dark band between the cornea and the iris (≠).

Fig. 6.103 Glaucoma causing a cloudy, edematous cornea.

Fig. 6.104 Congenital glaucoma in an 8 month old causing squinting, an enlarged globe, and subtle corneal edema causing an obscured view of the iris. Courtesy of Karen Joos, MD, PhD, Vanderbilt Eye Instit., Nashville, TN.

Fig. 6.107 Ciliary body. Courtesy of Pfizer Pharmaceuticals.

Fig. 6.108 Ciliary muscle focusing lens. Courtesy of Pfizer Pharmaceuticals.

Fig. 6.109 Tigroid fundus with clearly visible choroidal vasculature. Courtesy of Elliot Davidoff, M.D.

Malignant melanoma

A melanocyte tumor is the most common primary intraocular malignancy. It is unilateral and develops from the choroid in 85% of cases, the ciliary body in 9%, and the iris in 6%. Choroidal lesions are elevated and usually slate gray, but may be white to black with yel- low–gold and uneven pigmentation (Fig. 6.111) unlike a benign nevus, which is usually a more uniform gray color and flat (Fig. 6.110). This must be distinguished from metastatic carcinoma to the eye, which is also most common in the choroid but is usually lighter in color. The primary site is most often the breast or lung. Small intraocular malignancies are usually treated with a radioactive plaque (Fig. 6.112) which may preserve some vision. For larger tumors, the eye is sometimes removed (Figs 6.113, 6.114 and 6.151). If the tumor extends beyond the globe and is life threatening, an exenteration of the orbit is required. This rarely performed surgery is disfiguring and destructive. It could necessitate removal of the orbital contents, the eyelids, orbital walls, and periorbital structures (Fig. 6.115).

Patients with melanoma of the skin and elsewhere are often referred to eye physicians to rule out the eye as a primary site or a site of metastasis.

Fig. 6.110 Flat benign choroidal nevus.

Fig. 6.111 Elevated malignant choroidal melanoma. Note change in direction as artery rises over tumor (≠).

Fig. 6.112 Radioactive plaque sewn or glued to the episclera of the eye is usually left in place for about

4 days and is used to treat smaller intraocular tumors. Courtesy of Dr. Santosh G. Honor and Dr. Surbhi Joshi, Prasad Eye Institute, Hyderabad, India.

Sclera

Vitreous

Choroidal Melanoma

Fig. 6.114 B-scan ultrasound of a malignant choroidal melanoma showing typical domeshaped growth which helps to confirm the diagnosis. The scan also shows its size and whether it extends beyond the sclera which will determine the type of treatment. This eye, with this massive tumor, was enucleated.

Fig. 6.116 Benign iris freckle.

Fig. 6.115 Exenteration of the orbit for malignant melanoma extending beyond the sclera. Reproduced from Brit. J. Ophthal. Vol. 94, Issue 5, May 2010, Massive orbital recurrence or uveal melanoma without metastases after 28 years. Jonathan J. Ross, Simon J. Dean, David A. Koppel, Fiona Roberts, Ewan G. Kemp with permission from BMJ Publishing Group, Ltd.

Fig. 6.117 Malignant iris melanoma with elevated lesions and distorted pupil.

Rubeosis iridis is a serious condition in which abnormal vessels grow on the surface of the iris (Figs 6.119 and 6.120) in response to ischemia associated with central retinal vein occlusion, proliferative diabetic retinopathy, or carotid artery occlusive disease. Laser photocoagulation of the retina may cause regression of iris vessels. Untreated, the neovascularization could cause severe glaucoma.

An iris coloboma (Fig. 6.121) is due to failure of embryonic tissue to fuse inferiorly. It may also involve the choroid, lens, and optic nerve.

Inflammations of the uvea are categorized by location. A. anterior (iritis), B. intermediate (ciliary body-cyclitis), C. posterior (chorioretinitis), and D. panuveitis involving all uveal structures. In 50% of cases, no cause is found. Most are treated with steriods and, less often, with non-steroidal anti-inflammato- ries (NSAID). An immunomodulator, most often, methotrexate is sometimes required.

A. Iritis, inflammation of the iris, accounts for 92% of cases of uveitis. It causes pain, tearing, and photophobia. Signs include miosis (small pupil), perilimbal conjunctival injection (Figs 6.122 and 6.125), and anterior chamber flare and cells (Fig. 6.123). Flare refers to the beam’s milky appearance due to elevated protein. With the slit lamp on high magnification and a short, bright beam shone across the dark pupil, inflammatory cells are graded from trace to very many (4+).

Fig. 6.120 Rubeosis iridis. These abnormal iris blood vessels scar the angle of the eye. They most often result from ischemic retinal diseases such as proliferative diabetic retinopathy and central retinal artery or vein occlusion.

Fig. 6.118 Gonioscopic view of elevated iris melanoma. Courtesy of Michael P. Kelly.

Fig. 6.119 Rubeosis iridis.

Fig. 6.121 Iris coloboma.

Fig. 6.122 Iritis (see Fig. 6.125).

Deposits of inflammatory cells and protein on the corneal endothelium (Figs 6.124, 6.125 and 6.128) are called keratitic precipitates (KPs) and are often a sign of chronicity. Iritis usually reduces eye pressure due to depressed secretion of aqueous and increased uveoscleral outflow. Eye pressure may become elevated if cellular debris obstructs the trabecular meshwork, or from the steroid used to treat the uveitis.

Another complication of iritis is posterior synechiae. These are adhesions between the iris and the lens capsule (Fig. 6.124a). To prevent this, drops are used to keep the pupil dilated and steroids are given to prevent a fibrinous sticky aqueous.

Treatment for iritis includes a topical cycloplegic such as cyclogel 1% and a steroid such as Pred Forte 1%. Frequency and strength of medication depends on the severity of the condition. Besides dilating the pupil, the cycloplegic also relieves the pain due to ciliary muscle spasm spasm.

Fig. 6.123 Slit-beam view of flare and cells in anterior chamber.

Fig. 6.124a Keratitic precipitates and posterior synechiae.

Fig. 6.124b Patient with Behcet’s disease with ulcers and fissures on her tongue. She complained of constant burning in mouth.

4.Inflammatory bowel disease

5.Psoriatic arthritis.

Causes that are not related to HLA-B27 levels are toxoplasmosis, sarcoidosis, Lyme disease, influenza, lymphoma, AIDS, herpes simplex and zoster (shingles), and Behcet’s disease (ulcers in the mouth [Fig 6.124b] and genitals). There are other even rarer etiologies. Therefore, careful clinical judgement is needed in determining the timing and extent of the work-up, taking into consideration cost, severity, chronicity, and associated medical history. (See p. 114 and 115 for basic work-up)

Patients with juvenile idiopathic arthritis and chronic iritis often develop a band of calcification in Bowman’s membrane known as band keratopathy (Fig. 6.126). It also occurs in sarcoidosis and hypervitaminosis D. It may be removed by using a technique called chelation in which the calcium is dissolved by applying diamine-tetra-acetic (EDTA) to the cornea.

B. Inflammation of the ciliary body (cyclitis), also called intermediate uveitis, is characterized 80% of the time by having cells in the vitreous. It causes pain and decreased eye pressure. Cells in the vitreous reduce vision. Multiple sclerosis, sarcoidosis (Figs 6.127 and 6.128) and cigarette smoking are the commonly associated causes.

Fig. 6.126 Band keratopathy.