Uveitis, Anterior, Granulomatous Workup

  • Author: Abdullah Al-Fawaz, MD, FRCS; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Feb 25, 2010
 

Laboratory Studies

  • Findings from the physical examination, a comprehensive review of the patient's medical history, and the review of systems should guide the laboratory evaluation. The workup should be tailored accordingly.
  • All patients who present with a granulomatous iritis should receive a diagnostic evaluation, even if it is their first episode of uveitis.
  • Laboratory tests that may be requested are outlined below. At the least, chest radiography and fluorescent treponemal antibody absorption (FTA-ABS) or other specific antitreponemal syphilis serology should be ordered.
    • Purified protein derivative (PPD) test or Quantiferon testing for TB
    • Chest radiograph for sarcoidosis and TB should be obtained. However, the chest radiograph is not very sensitive or specific for sarcoidosis and a high-resolution chest CT should be considered if sarcoidosis is strongly suspected. Gallium scan can also be considered for sarcoidosis.
    • Venereal Disease Research Laboratory (VDRL) test, FTA-ABS (or similar treponemal specific serology) test for syphilis A specific antitreponemal test must be obtained, as RPR or VDRL can provide false-negative results on RPR or VDRL.
    • CBC with differential
    • Angiotensin-converting enzyme (ACE) test for sarcoidosis may be obtained but is not very sensitive or specific, especially in children.
    • Anergy evaluation for sarcoidosis (rarely done)
    • Lyme serology if Lyme disease is suspected (eg, endemic area, tick bite, systemic manifestations)
    • Toxoplasmosis enzyme-linked immunosorbent assay (ELISA) if posterior uveitis associated
    • Antineutrophil cytoplasmic autoantibodies: c-ANCA with PR3 specificity is most specific for Wegener granulomatosis. c-ANCA is found in 80-95% of active cases.
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Imaging Studies

  • MRI of the head may help in suspected cases of intraocular (CNS) lymphoma or in cases of multiple sclerosis; however, this is a rare cause of granulomatous anterior uveitis (multiple sclerosis is more commonly associated with intermediate uveitis and lymphoma with vitritis or subretinal lesions).
  • In patients in whom sarcoidosis is suspected and in whom chest radiographs are negative for disease, consider chest CT to look for hilar adenopathy. Up to 10% of patients with sarcoidosis who have negative chest radiographs may exhibit hilar pathology on chest CT.
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Procedures

  • Biopsy of any conjunctival nodules or the lacrimal gland may help in diagnosing sarcoidosis.
  • Vitreous biopsy may be indicated if the diagnosis of intraocular (CNS) lymphoma is seriously considered or if a diagnostic dilemma exists in which a specific tissue diagnosis may alter or direct therapy.
  • Lumbar puncture may be required to help rule out intraocular (CNS) lymphoma.
  • If the patient presents with a secluded pupil from extensive posterior synechiae, iris bombe with angle-closure glaucoma may be present. Perform iridotomy as soon as possible (after quieting the eye with anti-inflammatory medications).
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Histologic Findings

Mutton fat KPs: These consist of accumulation of macrophages.

Iris nodules: Histopathologic examination of the iris nodule has revealed abundant lymphocytes and plasma cells with areas of chronic granulomatous inflammation.[5]

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Contributor Information and Disclosures
Author

Abdullah Al-Fawaz, MD, FRCS  Assistant Professor, Cornea and Uveitis Department, King Abdulaziz University Hospital, Department of Ophthalmology, King Saud University, Riyadh, Saudi Arabia

Abdullah Al-Fawaz, MD, FRCS is a member of the following medical societies: American Academy of Ophthalmology and Royal College of Physicians and Surgeons of Glasgow

Disclosure: Nothing to disclose.

Coauthor(s)

Ralph D Levinson, MD  Associate Professor of Ophthalmology, Jules Stein Eye Institute at the David Geffen School of Medicine at UCLA

Ralph D Levinson, MD is a member of the following medical societies: American Academy of Ophthalmology, American Uveitis Society, Association for Research in Vision and Ophthalmology, and International Ocular Inflammation Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Andrew A Dahl, MD  Director of Ophthalmology Teaching, Mid-Hudson Family Practice Institute, The Institute for Family Health; Assistant Professor of Surgery (Ophthalmology), New York College of Medicine

Andrew A Dahl, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American College of Surgeons, American Medical Association, American Society of Cataract and Refractive Surgery, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Simon K Law, MD, PharmD  Associate Professor of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

R Christopher Walton, MD  Professor, Director of Uveitis and Ocular Inflammatory Disease Service, Department of Ophthalmology, Assistant Dean for Graduate Medical Education, University of Tennessee College of Medicine; Consulting Staff, Regional Medical Center, Memphis Veterans Affairs Medical Center, St Jude Children's Research Hospital

R Christopher Walton, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Healthcare Executives, American Uveitis Society, Association for Research in Vision and Ophthalmology, and Retina Society

Disclosure: Nothing to disclose.

Lance L Brown, OD, MD  Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Roger K George, MD, to the development and writing of this article.

References

  1. McCannel CA, Holland GN, Helm CJ, Cornell PJ, Winston JV, Rimmer TG. Causes of uveitis in the general practice of ophthalmology. UCLA Community-Based Uveitis Study Group. Am J Ophthalmol. Jan 1996;121(1):35-46. [Medline].

  2. Friedman AH, Deutsch-Sokol RH. Sugiura's sign. Perilimbal vitiligo in the Vogt-Koyanagi-Harada syndrome. Ophthalmology. Nov 1981;88(11):1159-65. [Medline].

  3. Suzuki T, Ohashi Y. Corneal endotheliitis. Semin Ophthalmol. Jul-Aug 2008;23(4):235-40. [Medline].

  4. Jabs DA, Nussenblatt RB, Rosenbaum JT,. Standardization of uveitis nomenclature for reporting clinical data. Results of the First International Workshop. Am J Ophthalmol. Sep 2005;140(3):509-16. [Medline].

  5. Ocampo VV Jr, Foster CS, Baltatzis S. Surgical excision of iris nodules in the management of sarcoid uveitis. Ophthalmology. Jul 2001;108(7):1296-9. [Medline].

  6. Theodossiadis PG, Markomichelakis NN, Sfikakis PP. Tumor necrosis factor antagonists: preliminary evidence for an emerging approach in the treatment of ocular inflammation. Retina. Apr-May 2007;27(4):399-413. [Medline].

  7. Lobo A, Barton K, Minassian D, du Bois RM, Lightman S. Visual loss in sarcoid-related uveitis. Clin Experiment Ophthalmol. Aug 2003;31(4):310-6. [Medline].

  8. Nussenblatt RB, Whitcup SM. Uveitis. In: Fundamentals and Clinical Practice. 3rd ed. Mosby-Year Book; 2003.

  9. Pepose JS, Holland GN, Wilhelmus KR. Ocular Infection and Immunity. Mosby-Year Book; 1996.

  10. Rao NA, Cousins S, Forster D. Intraocular Inflammation and Uveitis. In: Basic and Clinical Science Course. 1999.

  11. Rosenbaum JT, George RK. Uveitis. In: Current Ocular Therapy 5. 2000:519-21.

  12. [Guideline] Jabs DA, Rosenbaum JT, Foster CS, et al. Guidelines for the use of immunosuppressive drugs in patients with ocular inflammatory disorders: recommendations of an expert panel. Am J Ophthalmol. Oct 2000;130(4):492-513. [Medline].

  13. Jap A, Chee SP. Immunosuppressive therapy for ocular diseases. Curr Opin Ophthalmol. Nov 2008;19(6):535-40. [Medline].

  14. Rodrigues EB, Farah ME, Maia M, Penha FM, Regatieri C, Melo GB. Therapeutic monoclonal antibodies in ophthalmology. Prog Retin Eye Res. Mar 2009;28(2):117-44. [Medline].

 
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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.
 
 
 
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