K. Kazemi Zand

Ophthalmologist

Semnan University of Medical Sciences

Definition Uveitis is a condition that involves inflammation of

the uveal tract (iris, ciliary body, choroid) or adjacent ocular structures (retina, optic nerve, vitreous, sclera).

Anatomical Classification Type Primary Site of

Inflammation Includes

Anterior uveitis Anterior chamber Iritis/iridocyclitis/anterior cyclitis

Intermediate uveitis Vitreous Pars planitis/posterior cyclitis/hyalitis

Posterior uveitis Choroid Focal, multifocal, or diffuse choroiditis/chorioretinitis/retinochoroiditis/retinitis/Neuroretinitis

Panuveitis Anterior chamber, vitreous, and/or choroid

Further Classification Onset (sudden or insidious)

Duration (limited — less than 3 months duration, or persistent — more than 3 months duration)

Course (acute, recurrent, or chronic)

Laterality (unilateral or bilateral)

Etiology

The most common etiology of uveitis is idiopathic.

A wide variety of infectious, traumatic, autoimmune

or neoplastic mechanisms are known to promote or

trigger uveitis.

Systemic disorders associated with uveitis Seronegative spondylarthropathies (Ankylosing spondylitis, Reiter’s

syndrome, Inflammatory bowel disease, psoriatic arthropathy)

Behçet’s disease

Systemic lupus erythematosus

Juvenile rheumatoid arthritis

Multiple sclerosis

Chronic granulomatous disorders (tuberculosis, sarcoidosis)

Herpes simplex/zoster

Syphilis

Toxoplasmosis

Brucellosis

HIV infection

……

Epidemiology • Age

• The majority of patients are aged 20-50 years.

• Race • Racial predisposition to uveitis is related to the patient's

underlying systemic disease. • Caucasian: HLA-B27 related diseases, multiple sclerosis

• African American: Sarcoidosis, SLE

• Mediterranean/Middle Eastern: Behçet's disease (HLA-B5)

• Sex • In general, uveitis does not have a gender predisposition

except in cases secondary to systemic disease, such as JRA and SLE

The most common type of uveitis presented to the emergency department is “Acute Anterior Uveitis”.

Clinical Presentation

Symptoms:

Red eye

Pain

Blurred vision

Photophobia

Excessive tearing

Clinical Presentation

Signs: Perilimbal injection

Direct and consensual photophobia

Pupillary miosis (common but not always present)

Keratic precipitates on corneal endothelium (granulomatous or non-granulomatous)

Marked cell and flare reaction in the anterior chamber (WBC,

RBC, protein)

Hypopyon (seen in Behçet’s disease & endophthalmitis)

Various degrees of posterior synechiae (Iris bombé pupillary block glaucoma)

Differential Diagnosis

Consider all other causes of a red eye before uveitis is diagnosed.

Acute conjunctivitis

Corneal abrasion or ulceration

Ultraviolet keratitis

Foreign body

Acute angle-closure glaucoma

Scleritis

Workup & evaluation Lab studies are not part of the emergency management of uveitis.

Lab workup is not necessary in all cases. (e.g. a mild, unilateral non-

granulomatous uveitis or a known predisposing systemic disease)

Indications for requesting lab studies:

Unremarkable history and physical examination

Bilateral uveitis

Granulomatous uveitis

Recurrent uveitis

Lab studies should be individualized according to clinical suspicion. Not all workups are necessary for all patients.

Lab studies CBC, ESR (non-specific)

ANA (autoimmune disorders)

Serum ACE, lysosyme (Sarcoidosis)

HLA-B27 (seronegative spondyloarthropathies)

HLA-B5 (Behçet’s disease)

VDRL, RPR, FTA-ABS (Syphilis)

PPD (Tuberculosis, Sarcoidosis)

HIV antibody (AIDS)

Imaging studies Chest X-ray is indicated if tuberculosis or sarcoidosis is

considered.

Sacroiliac X-ray is indicated if HLA-B27 related diseases are suspected.

Brain MRI may be needed if multiple sclerosis is a

possibility.(intermediate uveitis)

Fluorescein angiography or ocular sonography may be needed in certain types of posterior uveitis

Medical management Corticosteroids (topical, periocular and/or systemic use)

Reduces active inflammation in the eye

Prevents and treats uveitis complications

Beware of drug complications (cataract, glaucoma, HSV keratitis)

Cycloplegics (Homatropine, cyclopentolate,...)

Relief of pain and photophobia

Breaking posterior synechiae/ pupillary block

Immunosuppressive therapy (methotrexate, cyclophosphamide,…)

Severe uveitis

Unresponsive to corticosteroids

Severe corticosteroid induced complications

Follow up Refer the patient to an ophthalmologist within 24

hours

Cases of uveitis should be monitored every 1-7 days in the acute phase

Steroids and cycloplegics should be tapered and not discontinued suddenly

When the condition is stable, patients are monitored every 1-6 months