eMedicine Specialties > Ophthalmology > Iris & Ciliary Body

Uveitis, Anterior, Nongranulomatous

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, or anterior uveitis, is the most common form of ocular inflammation encountered. It is a common cause of a painful red eye. Inflammation of the iris may appropriately be termed iritis, whereas inflammation of the iris and the ciliary body is called iridocyclitis. Iritis may be subdivided into 2 broad categories: granulomatous and nongranulomatous.

This article addresses nongranulomatous iritis, although iritis due to a granulomatous disease process may have a nongranulomatous appearance. For information about granulomatous disease, see Uveitis, Anterior, Granulomatous.

Pathophysiology

The exact pathophysiology is not known. Inflammation of the iris and the ciliary body causes a breakdown of the blood ocular barrier. This condition allows both protein and WBCs to extravasate into the aqueous, resulting in the typical iritis signs of cell and flare. Frequently, the cause is idiopathic, but certain ocular and systemic diseases may be the underlying cause of the iritis.

Frequency

United States

Iritis is the most frequent form of uveitis that is encountered by ophthalmologists. In one community-based study, anterior uveitis accounted for more than 90% of all cases of uveitis. The annual incidence rate is approximately 8 cases per 100,000 population.

International

No particular geographic distribution for iritis has been noted.

Mortality/Morbidity

  • Morbidity arises from iritis and any associated disease process, if present.
  • Patients may develop posterior synechiae, and, if severe, a secluded pupil and subsequent angle-closure glaucoma may result.
  • Associated ocular complications (eg, cataract, glaucoma) may result in severe vision loss.

Race

No significant racial differences exist.

Sex

No significant sexual differences exist.

Age

Iritis may develop in patients of any age. The mean patient age is approximately 45 years.

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 recent ocular trauma, back stiffness, arthritis, rashes, shortness of breath, 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 are unilateral.

Physical

  • Vision: Visual acuity is usually normal or only slightly decreased.
  • 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.
  • Conjunctiva: Typically, the eye has a perilimbal injection termed ciliary flush. Less commonly, generalized redness of the bulbar conjunctiva may be present.
  • 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. Stellate-shaped KPs, uniformly spread over the endothelium, are typical of Fuchs heterochromic iridocyclitis. Corneal stromal edema may be present.
  • Anterior chamber: Flares, cells, and/or hypopyon may be 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
    • Hypopyon, if present, is highly suggestive of diseases associated with HLA-B27; with Behcet disease; or, less commonly, with an infection-associated iritis.
  • Iris: Posterior synechiae may be present. Inflammatory nodules are usually not present in nongranulomatous iritis. Sector atrophy of the iris, if present, suggests herpes zoster as the etiology of the inflammation. Heterochromia and loss of iris detail (eg, blurring of stroma) are suggestive of Fuchs heterochromic iridocyclitis.
  • 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.
    • Occasionally, patients with HLA-B27 disease have an intense vitritis, papillitis, and cystoid macular edema.

Causes

  • Idiopathic causes
  • Diseases associated with HLA-B27
    • Ankylosing spondylitis
    • Reactive arthritis
    • Inflammatory bowel disease
    • Psoriasis
  • Sarcoidosis
  • Trauma
  • Infections
    • Herpes zoster and/or herpes simplex
    • Syphilis
    • Lyme disease
  • Juvenile idiopathic arthritis
  • Tubulointerstitial nephritis and uveitis syndrome (TINU)
  • Fuchs heterochromic iridocyclitis

More on Uveitis, Anterior, Nongranulomatous

Overview: Uveitis, Anterior, Nongranulomatous
Differential Diagnoses & Workup: Uveitis, Anterior, Nongranulomatous
Treatment & Medication: Uveitis, Anterior, Nongranulomatous
Follow-up: Uveitis, Anterior, Nongranulomatous
Multimedia: Uveitis, Anterior, Nongranulomatous
References

References

  1. Kump LI, Cervantes-Castaneda RA, Androudi SN, Foster CS. Analysis of pediatric uveitis cases at a tertiary referral center. Ophthalmology. Jul 2005;112(7):1287-92. [Medline].

  2. Mackensen F, Smith JR, Rosenbaum JT. Enhanced recognition, treatment, and prognosis of tubulointerstitial nephritis and uveitis syndrome. Ophthalmology. May 2007;114(5):995-9. [Medline].

  3. 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].

  4. Menezo V, Lightman S. The development of complications in patients with chronic anterior uveitis. Am J Ophthalmol. Jun 2005;139(6):988-92. [Medline].

  5. Nussenblatt RB, Whitcup SM. Uveitis: Fundamentals and Clinical Practice. 3rd ed. 2003.

  6. Pepose JS, Holland GN, Wilhelmus KR. Ocular Infection and Immunity. 1996.

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

Further Reading

Keywords

iritis, iridocyclitis, iris, ciliary body, iritis flare, cell and flare, anterior uveitis

Contributor Information and Disclosures

Author

Roger K George, MD, Director of Uveitis Service, Madigan Army Medical Center; Clinical Instructor, Department of Ophthalmology, Oregon Health and Sciences University
Roger K George, MD is a member of the following medical societies: American Uveitis Society
Disclosure: Nothing to disclose.

Medical Editor

Andrew A Dahl, MD, Residency Director, Ophthalmology, Kingston Hospital, Department of Ophthalmology, Assistant Professor of Surgery (Ophthalmology), Mid Hudson Family Practice Institute
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.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
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.

Managing Editor

R Christopher Walton, MD, Director of Uveitis and Ocular Inflammatory Diseases Service, Associate Professor, Department of Ophthalmology, University of Tennessee College of Medicine
R Christopher Walton, MD is a member of the following medical societies: American Academy of Ophthalmology and American Medical Association
Disclosure: Nothing to disclose.

CME Editor

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.

 
 
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