Uveitis, Anterior, Nongranulomatous Clinical Presentation

Inquire about the patient's complete medical history, to include all medical conditions, surgeries, medications, and ocular history (eg, history of iritis, trauma, surgery). 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 recent ocular trauma, back stiffness, arthritis, rashes, shortness of breath, urethral discharge or dysuria, swollen lymph nodes, diarrhea, blood in stools, recent insect bites, sexually transmitted diseases (STDs), and tuberculosis (TB) exposure.

Inquire about the onset of the symptoms. Most cases of acute anterior uveitis begin with the sudden onset of redness, pain, and photophobia.

Family history is important as well. Inquire if there is a family history of uveitis or other symptoms in family members that might suggest associated diseases, such as a spondyloarthropathy or other human leukocyte antigen (HLA)-B27 processes.

Inquire in particular about the following symptoms:

• Dull, aching eye pain occurs and may worsen when one touches the eye through the eyelid. Pain may be referred to the temple or periorbital region.

  • Pain is usually abrupt in onset.
  • Photosensitivity to light, especially sunlight, worsens the patient's discomfort.
• Redness with no mucopurulent discharge is seen. Patients rarely have a watery discharge or tearing.
• Mild blurring of vision may be noted.
• Most cases of AAU are unilateral.

• Vision: Visual acuity is usually normal or only slightly decreased, although in severe episodes the acuity can be very low.
• Intraocular pressure (IOP) is often lower in the eye with iritis when compared to the fellow eye. This is secondary to a decrease in aqueous production by the inflamed ciliary body. However, in some cases, the IOP may be elevated as a result of altered aqueous outflow; this may be more common in viral anterior uveitis.
• Conjunctiva: Typically, the eye has a perilimbal injection termed ciliary flush. Less commonly, generalized redness of the bulbar conjunctiva may be present. This is not found in Fuchs heterochromic iridocyclitis or the anterior uveitis associated with juvenile idiopathic arthritis.
• Cornea

  • Keratic precipitates (KPs) may be present. These clusters of WBCs collect on the endothelium. In nongranulomatous iritis, they tend to be small and are usually located over the inferior half of the cornea. Keratic precipitates in acute anterior uveitis associated with ankylosing spondylitis are shown below. Fine keratic precipitates in a patient with ankylosing spondylitis–associated acute anterior uveitis.
  • Stellate-shaped KPs, uniformly spread over the endothelium, are typical of Fuchs heterochromic iridocyclitis, as shown in the image below, and also may be seen in herpetic viral anterior uveitis. Small stellate keratic precipitates with fine filaments in a patient with Fuchs heterochromic iridocyclitis.
  • Calcific band keratopathy can occur in chronic uveitides as in the uveitis associated with juvenile idiopathic arthritis. Corneal stromal edema may be present secondary to viral endotheliitis or endothelial dysfunction due to uveitic glaucoma or extensive anterior chamber inflammation. Cytomegalovirus infection in nonimmunosuppressed patients can cause corneal edema that may even recur in corneal grafts.^[4]
• Anterior chamber: Flare, cells, and/or hypopyon may be present.

  • Anterior chamber 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:^[5]
    • 0 = None
    • 1+ = Faint
    • 2+ = Moderate (iris and lens detail clear)
    • 3+ = Marked (iris and lens detail 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 3-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
  • Hypopyon, if present, is highly suggestive of diseases associated with HLA-B27; with Behçet disease; or, less commonly, with an infection-associated iritis. Hypopyon is shown in the image below. Acute anterior uveitis with plasmoid aqueous and hypopyon in a patient with ulcerative colitis.
• Iris

  • Posterior synechiae may be present. Inflammatory nodules are usually not present in nongranulomatous iritis, although Koeppe nodules can be present in Fuchs heterochromic iridocyclitis. Sector atrophy of the iris, if present, suggests herpes zoster as the etiology of the inflammation and patchy or generalized iris atrophy suggests herpes simplex uveitis. Iris atrophy is shown in the image below. Iris atrophy in a patient with herpes simplex virus–associated anterior uveitis.
  • Heterochromia and loss of iris stromal detail are suggestive of Fuchs heterochromic iridocyclitis. An example is shown in the image below. Fuchs heterochromic iridocyclitis with cataract and iris heterochromia.
• Lens and anterior 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.

  • Cells are commonly seen in the anterior vitreous. They represent either an iridocyclitis or a spillover of cells from the anterior chamber into the retrolental space. This may happen even in Fuchs iridocyclitis.
  • Occasionally, patients with HLA-B27 disease have an intense vitritis, papillitis, and cystoid macular edema.

It is important to ascertain whether the uveitis is unilateral or bilateral, symptomatic (pain and photophobia), and acute (lasting less than 3 months) or chronic.

Unilateral, sudden onset, acute

• Acute anterior uveitis

  • Idiopathic
  • Diseases associated with HLA-B27 (usually is a unilateral acute anterior uveitis with a high tendency to recur sometimes in the contralateral eye)
    • Ankylosing spondylitis
    • Reactive arthritis
    • Inflammatory bowel disease
    • Psoriasis
  • Behçet's disease
  • Sarcoidosis
  • Trauma
  • Infections
    • Herpes zoster, herpes simplex, cytomegalovirus
    • Syphilis
    • Postoperative or metastatic endophthalmitis

Unilateral, chronic

• Infections

  • Herpes zoster, herpes simplex, cytomegalovirus
  • Syphilis
  • Fuchs heterochromic iridocyclitis (which may be due to rubella, at least in some cases)
• Sarcoidosis
• Chronic postoperative endophthalmitis

Bilateral

• Sarcoidosis
• Lyme disease
• Fuchs heterochromic iridocyclitis, rarely
• Juvenile idiopathic arthritis
• Tubulointerstitial nephritis and uveitis syndrome (TINU)