eMedicine Specialties > Ophthalmology > Iris & Ciliary Body
Uveitis, Anterior, Nongranulomatous
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.
- A flare, resulting from extra protein in the aqueous, is usually present and can be graded as follows:
- 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
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References
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].
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].
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].
Menezo V, Lightman S. The development of complications in patients with chronic anterior uveitis. Am J Ophthalmol. Jun 2005;139(6):988-92. [Medline].
Nussenblatt RB, Whitcup SM. Uveitis: Fundamentals and Clinical Practice. 3rd ed. 2003.
Pepose JS, Holland GN, Wilhelmus KR. Ocular Infection and Immunity. 1996.
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
