Uveitis, Anterior, Granulomatous Clinical Presentation

Inquire about the patient's complete medical history, to include all medical conditions, surgeries, medications, and ocular history (eg, history of iritis). Perform a detailed review of systems. This is critical, as the history and the review of systems in many cases will suggest a diagnosis.

Critical review questions include, but are not limited to, asking about arthritis, rashes, shortness of breath, swollen lymph nodes, recent headaches, hearing difficulties, hair loss, pigment changes in the skin, a history of ocular trauma, recent insect bites, sexually transmitted diseases (STDs), TB exposure, blood in stools, and recent travel.

Inquire about the following symptoms:

• Pain: Some patients have no ocular pain, or they may describe a foreign body sensation. Other patients describe an abrupt onset of dull, aching eye pain. This pain may be ocular, or it may be referred to the periorbital region or temple.
• Photosensitivity: Light, especially sunlight, worsens the discomfort, particularly with exacerbations.
• Redness: Patients may describe having an injected eye. A discharge is usually not present.
• Vision: If the posterior segment of the eye is involved, the patient may have reduced visual acuity and may complain of floaters.
• Granulomatous iritis is more likely to be a bilateral process (except in herpetic iridocyclitis), whereas nongranulomatous iritis is typically unilateral.

A complete ocular examination is indicated.

• Vision: Visual acuity may range from normal to significantly reduced, depending on the extent of the ocular inflammation.
• Intraocular pressure (IOP): IOP is usually reduced in the eye with iritis due to decreased aqueous production by the inflamed ciliary body. Occasionally, IOP is elevated as a result of altered or obstructed aqueous outflow. Increased intraocular pressure at the onset may suggest a viral etiology, particularly in unilateral disease.
• External findings: Examine the patient for enlarged lacrimal glands and parotid glands and seventh cranial nerve palsy, as this may suggest sarcoidosis.
• Conjunctiva: Generalized redness of the bulbar conjunctiva may be present. The eye may have a perilimbal injection termed ciliary flush. Carefully examine the patient for small nodules that, if sampled during biopsy, may help in determining the underlying cause of the iritis. Perilimbal vitiligo (Sugiura's sign) is a sign of chronic Vogt-Koyanagi-Harada disease, occurring within a month of disease onset.^[2] It can be found in up to 85% of Japanese patients but is rarely seen in Caucasians.^[2]
• Cornea: Keratic precipitates (KPs) are found on the endothelium. KPs are clusters of WBCs. Mutton-fat KPs are large and have a greasy appearance. They are usually located over the lower half of the cornea. Corneal edema may be present. Corneal endotheliitis is a clinical entity manifested by corneal edema, keratic precipitates, and mild anterior chamber reaction, and can be defined as a spectrum of the disorder in which the corneal endothelium is the primary site of the inflammation. The disease etiology consists of accumulating evidence of various viral infections including herpes simplex virus, varicella zoster virus, and cytomegalovirus.^[3]
• Anterior chamber: Flare and cells are usually present.
• A flare, resulting from extra protein in the aqueous, is usually present and can be graded using the SUN Working Group Grading Scheme for Anterior Chamber Flare:^[4]

  • 0 = None
  • 1+ = Faint
  • 2+ = Moderate (iris and lens details clear)
  • 3+ = Marked (iris and lens details hazy)
  • 4+ = Intense (fibrin or plastic aqueous)
• Cells, the hallmark of iritis, are present in the aqueous. They should be graded by severity under high-magnification slit lamp examination in a 1 X 1-mm field of light, as described by The SUN Working Group Grading Scheme for Anterior Chamber Cells.

  • 0 < 1
  • 0.5 = 1-5 cells
  • 1+ = 6-15 cells
  • 2+ = 16-25 cells
  • 3+ = 26-50 cells
  • 4+ = More than 50 cells
• Iris

  • Peripheral anterior synechiae and posterior synechiae may be present. Inflammatory nodules (Koeppe and Busacca) are usually tan in color and represent accumulations of inflammatory cells. Koeppe nodules are found at the pupillary border. Busacca nodules are located on the surface of the iris. If Busacca nodules are present, then the underlying etiology is almost always a granulomatous process. These nodules are shown in the images below. Granulomatous anterior uveitis with mutton-fat keratic precipitates and Koeppe and Busacca nodules. Granulomatous anterior uveitis with numerous Busacca nodules on the iris surface and a few mutton-fat keratic precipitates on the inferior aspect.
• Lens and vitreous: Lenticular precipitates may be present on the anterior lens capsule. Posterior subcapsular cataracts may be present if the patient has had repeated episodes of iritis or ongoing chronic inflammation. Carefully examine the vitreous for inflammatory cells; if present, they imply a more extensive uveitic syndrome.
• Posterior segment: Carefully examine the posterior segment for evidence of optic nerve edema, for vasculitis, and for focal retinal and/or choroidal lesions. A patient with a granulomatous-appearing iritis is likely to have a more extensive uveitis.

Not all patients with a granulomatous-appearing iritis have a systemic granulomatous disease process. A differential for a patient who has either bilateral granulomatous iritis or unilateral granulomatous iritis is outlined below.

• Sarcoidosis
• Syphilis
• Vogt-Koyanagi-Harada disease
• Sympathetic ophthalmia
• Multiple sclerosis
• Lyme disease
• Tuberculosis
• Herpes zoster, HSV, CMV
• Coccidioidomycosis
• Leprosy
• Toxoplasmosis
• Brucellosis
• Idiopathic