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Iritis and Uveitis Clinical Presentation

  • Author: Monalisa N Muchatuta , MD, MS; Chief Editor: Robert E O'Connor, MD, MPH  more...
 
Updated: Dec 14, 2015
 

History

While most cases of uveitis are idiopathic, a history focused on identifying a potential underlying systemic cause (eg, in young adult men, conjunctivitis, urethritis, and polyarthritis suggest reactive arthritis) is necessary in order to determine if workup is needed.

Important elements of the medical history that should suggest uveitis as the cause of ocular pain include the following:

  • History of autoimmune disease such as inflammatory bowel disease, SLE, and sarcoidosis
  • Sexually transmitted diseases, particularly syphilis and chlamydia
  • Tuberculosis
  • AIDS

Anterior uveitis may have the following history findings:[2]

  • Acute - Pain, redness, photophobia, excessive tearing, and decreased vision; pain generally develops over a few hours or days except in cases of trauma
  • Chronic - Primarily blurred vision, mild redness; little pain or photophobia except during an acute episode

Posterior uveitis may have the following history findings:[2]

  • Blurred vision, floaters
  • Absence of symptoms of anterior uveitis (pain, redness, and photophobia)
  • Symptoms of posterior uveitis and pain suggest anterior chamber involvement, bacterial endophthalmitis, or posterior scleritis

Intermediate uveitis may have the following history findings:[2]

  • Similar to posterior uveitis; painless floaters and decreased vision
  • Minimal photophobia or external inflammation

Panuveitis may present with any or all these symptoms.

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Physical

Evaluate vital signs and check visual acuity and extraocular movement. Perform a funduscopic examination and measure intraocular pressure. Most importantly, perform a slit-lamp examination.

Findings of the examination of the lids, lashes, and lacrimal ducts are normal.

The conjunctival examination reveals 360° perilimbal injection, which increases in intensity as it approaches the limbus. Differentiate this condition from conjunctivitis, in which the pattern is reversed, with the most severe inflammation at a distance from the limbus.

Visual acuity may be decreased in the affected eye.

Extraocular movement is generally normal.

On the pupillary examination, the patient may experience direct photophobia when the light is directed into the affected eye, as well as consensual photophobia when light is directed into the uninvolved eye. Consensual photophobia is helpful in distinguishing between iritis and more superficial causes of photophobia, such as conjunctivitis. In the latter, direct, but not consensual, photophobia is noted. Pupillary miosis is common.

Slit-lamp examination is performed as follows:

  • Examine the cornea by direct illumination with a broad beam at a 30°-40° angle between the viewing microscope and the light source.
  • Examine the epithelium for abrasions, edema, ulcers, or foreign bodies.
  • Inspect the stroma for deep ulcers and edema.
  • Scan the endothelium for keratitic precipitates (white blood cells on the endothelium), a hallmark of iritis (see the image below). Small to medium keratitic precipitates are classified as nongranulomatous, whereas granulomatous keratitic precipitates are large and have a greasy or "mutton-fat" granular appearance.
  • The most important structure to examine is the anterior chamber, which is bound by the cornea and the iris and is filled with aqueous humor. Examine the anterior chamber using a vertically and horizontally short beam. Normally, the aqueous humor is optically clear. In uveitis, however, an increase in the protein content of the aqueous causes an effect upon examination known as flare, which is similar to that produced by a moving projector beam in a dark smoky room.
  • White or red blood cells may be observed in the anterior chamber and are graded on a scale of 1+ to 4+, as follows:
    • 0 - None
    • 1+ - Faint (barely detectable)
    • 2+ - Moderate (clear iris and lens details)
    • 3+ - Moderate (hazy iris and lens details)
    • 4+ - Intense (fibrin deposits, coagulated aqueous)
  • White blood cells that layer in the anterior chamber are called hypopyon.

Opacities of the lens (cataracts) may be present but are not specific for uveitis.

Intraocular pressure may be normal or slightly decreased in the acute phase owing to decreased aqueous humor production; however, pressure may become elevated as the inflammation subsides. See the image below.

Small stellate keratic precipitates with fine fila Small stellate keratic precipitates with fine filaments in a patient with Fuchs heterochromic iridocyclitis.
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Causes

Although uveitis is often associated with an underlying systemic disease, approximately 50% of patients have idiopathic uveitis that is not associated with any other clinical syndrome.

Acute nongranulomatous uveitis is associated with diseases related to human leukocyte antigen B27 (HLA B27), including ankylosing spondylitis, inflammatory bowel disease, reactive arthritis, psoriatic arthritis, and Behçet disease. Herpes simplex, herpes zoster,[14] Lyme disease, and trauma also are associated with acute nongranulomatous uveitis.

Chronic nongranulomatous uveitis is associated with juvenile rheumatoid arthritis, chronic iridocyclitis of children, and Fuchs heterochromic iridocyclitis.

Chronic granulomatous uveitis is observed with sarcoidosis, syphilis, and tuberculosis.

Posterior uveitis is found in such diseases as toxoplasmosis, ocular histoplasmosis, syphilis, sarcoidosis, and in immunocompromised hosts with CMV or candidal or herpetic infection. Embolic retinitis also may cause posterior uveitis.

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Contributor Information and Disclosures
Author

Monalisa N Muchatuta , MD, MS Resident Physician, Clinical Assistant Instructor, Department of Emergency Medicine, Kings County Hospital, State University of New York Downstate Medical Center

Monalisa N Muchatuta , MD, MS is a member of the following medical societies: African Federation for Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Society for Clinical Pathology, Emergency Medicine Residents' Association, Global Humanitarian Health Association, International Federation for Emergency Medicine, National Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Richard H Sinert, DO Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Vice-Chair in Charge of Research, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Douglas Lavenburg, MD Clinical Professor, Department of Emergency Medicine, Christiana Care Health Systems

Douglas Lavenburg, MD is a member of the following medical societies: American Society of Cataract and Refractive Surgery

Disclosure: Nothing to disclose.

Chief Editor

Robert E O'Connor, MD, MPH Professor and Chair, Department of Emergency Medicine, University of Virginia Health System

Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Association for Physician Leadership, American Heart Association, Medical Society of Delaware, Society for Academic Emergency Medicine, Wilderness Medical Society, American Medical Association, National Association of EMS Physicians

Disclosure: Nothing to disclose.

Additional Contributors

Eric M Kardon, MD, FACEP Attending Emergency Physician, Georgia Emergency Medicine Specialists; Physician, Division of Emergency Medicine, Athens Regional Medical Center

Eric M Kardon, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Medical Association of Georgia

Disclosure: Nothing to disclose.

Keith Tsang, MD Resident Physician, Clinical Assistant Instructor, Department of Emergency Medicine, State University of New York Downstate, Kings County Hospital

Keith Tsang, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Kilbourn Gordon III, MD, to the development and writing of this article.

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Anatomy of the eye.
Small stellate keratic precipitates with fine filaments in a patient with Fuchs heterochromic iridocyclitis.
Table 1. Classification of Uveitis
Type Primary Site of Inflammation Manifestation
Anterior uveitis Anterior chamber Iritis/iridocyclitis/anterior cyclitis
Intermediate uveitis Vitreous Vitreitis/hyalitis/pars planitis
Posterior uveitis Choroid Choroiditis/chorioretinitis/retinochoroiditis/retinitis/neuroretinitis
Panuveitis Anterior chamber, vitreous, and/or choroid All of the above
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