Uveitis

Background

• Uveitis = inflammation of iris, ciliary body, and/or choroid

Anterior uveitis

Anterior uveitis with hypopyon

Types

• Anterior Uveitis
  • Inflammation of iris and/or ciliary body
  • Types:
    • Iritis
    • Iridocyclitis
• Posterior uveitis = choroiditis

Causes

• Inflammatory
  • Associated with HLA B-27
  • 50% have associated systemic disease
    • Ankylosing spondylitis
    • Psoriatic arthritis
    • Reactive arthritis
    • Inflammatory bowel disease
    • Sarcoidosis
    • Juvenile idiopathic arthritis
    • Behcet disease
    • Kawasaki disease
    • Multiple sclerosis
    • Granulomatosis with polyangiitis
• Environmental
  • Trauma
  • Corneal foreign body
  • UV keratitis
• Infectious (uncommon)
  • Corneal ulcer
  • TB
  • Lyme
  • HSV
  • Toxoplasmosis
  • VZV
  • Syphilis
  • Adenovirus

Complications

• Cataracts
• Glaucoma (from synechia)
• Retinal detachment

Clinical Features

Anterior

• Sudden red/painful eye
• Deep pain; worse with eye movement
  • Due to ciliary muscle spasm which irritates CN V
    • Causes consensual photophobia
• Ciliary flush, marked injection at the limbus (as opposed to perilimbal sparing seen in conjunctivitis)
• Typically small, poorly reactive pupil

Posterior

• Floaters
• Visual changes
• Generally does not cause redness or significant pain
• Blind spots or flashing lights

Slit-lamp exam

• Cell (WBCs from uveal vessels) & flare (proteinaceous transudate from uveal vessels)
• Hypopyon (with severe disease)

Differential Diagnosis

Unilateral red eye

• Nontraumatic
  • Acute angle-closure glaucoma^
  • Anterior uveitis
  • Conjunctivitis
  • Corneal erosion
  • Corneal ulcer^
  • Endophthalmitis^
  • Episcleritis
  • Herpes zoster ophthalmicus
  • Inflamed pinguecula
  • Inflamed pterygium
  • Keratoconjunctivitis
  • Keratoconus
  • Nontraumatic iritis
  • Scleritis^
  • Subconjunctival hemorrhage
• Orbital trauma
  • Caustic keratoconjunctivitis^^
  • Corneal abrasion, Corneal laceration
  • Conjunctival hemorrhage
  • Conjunctival laceration
  • Globe rupture^
  • Hemorrhagic chemosis
  • Lens dislocation
  • Ocular foreign body
  • Posterior vitreous detachment
  • Retinal detachment
  • Retrobulbar hemorrhage
    • Ocular compartment syndrome
  • Traumatic hyphema
  • Traumatic iritis
  • Traumatic mydriasis
  • Traumatic optic neuropathy
  • Vitreous detachment
  • Vitreous hemorrhage
  • Ultraviolet keratitis

^Emergent diagnoses ^^Critical diagnoses

Acute onset flashers and floaters

• Ocular causes
  • Floaters and/or flashes
    • Posterior vitreous detachment
    • Retinal tear or retinal detachment
    • Posterior uveitis
  • Predominantly floaters
    • Vitreous hemorrhage secondary to proliferative retinopathy
    • Sympathetic ophthalmia
  • Predominantly flashes
    • Oculodigital stimulation
    • Rapid eye movements
    • Neovascular age-related macular degeneration
• Nonocular causes
  • Migraine aura (classic)
  • Migraine aura (acephalgicmigraine)
  • Occipital lobe disorders
  • Postural hypotension

Evaluation

• Clinical
• Consider CXR (uveitis often associated with sarcoidosis, TB)

Management

Infectious

• Treat the underlying infection

Noninfectious

Anterior uveitis

• • Topical steroid (anterior only; typically in consultation with ophthalmology)
    • Prednisolone 1%
  • Mydriatics (sympathomimetics)
    • Dilate the iris
    • Prevents the formation of synechiae
    • Cyclopentolate, homatropine or phenylephrine HCl
  • Cycloplegics
    • Relieves pain
    • Scopolamine 0.25% OR cyclopentolate 1%
• Posterior Uveitis
  • Generally not responsive to topical treatment
  • Consult ophtho for observation vs intraocular steroid injection

Disposition

• Generally may be discharged with urgent ophthalmology follow-up within 24-48 hours

See Also

• Acute onset flashers and floaters
• Red Eye (Unilateral)