eMedicine Specialties > Ophthalmology > Iris & Ciliary Body

Uveitis, Anterior, Granulomatous

Author: Roger K George, MD, Director of Uveitis Service, Madigan Army Medical Center; Clinical Instructor, Department of Ophthalmology, Oregon Health and Sciences University
Contributor Information and Disclosures

Updated: Sep 5, 2007

Introduction

Background

Iritis, also known as anterior uveitis, is the most common form of ocular inflammation and often causes a painful red eye.

Inflammation of the iris appropriately may be termed iritis. Inflammation of the iris and the ciliary body is called iridocyclitis. Iritis may be subdivided into 2 broad categories: granulomatous and nongranulomatous.

A granulomatous iritis has an increased likelihood of being part of a systemic disease process or a component of certain ocular syndromes. However, the diagnosis of granulomatous iritis does not definitively indicate that an underlying systemic granulomatous process is present.

Patients with a granulomatous iritis may present with an acutely painful eye or with chronic subclinical inflammation that is discovered only as part of a routine ocular examination.

Pathophysiology

The exact pathophysiology of granulomatous iritis is unknown. It may result from an autoimmune reaction or from the host's immune response to a systemic infectious process, such as syphilis, Lyme disease, tuberculosis (TB), or local reactivation of herpetic viral infection.

Frequency

United States

Iritis, granulomatous and nongranulomatous, is the most frequent form of uveitis that ophthalmologists encounter. In one community-based study, anterior uveitis accounted for more than 90% of all cases of uveitis seen. The annual incidence is about 8 cases per 100,000 population.

International

No particular geographic distribution has been noted for granulomatous iritis.

Mortality/Morbidity

Morbidity may arise from both the iritis and any associated systemic disease if present.

• Patients may have anterior and posterior synechiae. Extensive posterior synechiae can lead to a secluded pupil that can result in angle-closure glaucoma. In addition, trabecular obstruction can lead to secondary glaucoma.
• The eye with a granulomatous iritis is likely to have uveitis involving other structures of the eye, including the posterior segment. This may result in an increased risk of substantial visual impairment.
• Associated ocular complications (eg, cataracts, corneal decompensation, glaucoma, chronic cystoid macular edema) may result in severe vision loss.

Race

Racial differences may exist, depending on the underlying cause of the iritis. For example, sarcoidosis is more likely to be diagnosed in the African American population than in other groups.  Vogt-Koyanagi-Harada disease, although a rare cause of uveitis in the United States, is much more prevalent in persons of Asian or American Indian ancestry.

Sex

No significant sex differences are reported.

Age

Granulomatous iritis may develop in individuals of any age.

Clinical

History

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.
• 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.

Physical

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.
• External findings: Examine the patient for enlarged lacrimal glands, 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.
• 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.
• Anterior chamber: Flares and cells are usually present.
  • A flare, resulting from extra protein in the aqueous, is usually present and can be graded as follows:
    • 0 = Completely absent
    • 1+ = Barely present
    • 2+ = Moderate
    • 3+ = Marked (iris and lens detail hazy)
    • 4+ = Intense (formed fibrin in 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 3-mm field of light, as follows:
    • Trace = 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.
• 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.

Causes

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
• Coccidioidomycosis
• Leprosy
• Toxoplasmosis
• Brucellosis
• Idiopathic

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