eMedicine Specialties > Emergency Medicine > Ophthalmology

Iritis and Uveitis

Author: Kilbourn Gordon III, MD, FACEP, Urgent Care Physician
Contributor Information and Disclosures

Updated: Aug 13, 2009

Introduction

Background

Uveitis is defined as inflammation of one or all parts of the uveal tract. Components of the uveal tract include the iris, the ciliary body, and the choroid. Uveitis may involve all areas of the uveal tract; however, involvement most often is (1) anterior, (2) confined to the iris and the anterior chamber (iritis), or (3) confined to the iris, the anterior chamber, and the ciliary body (iridocyclitis). Posterior uveitis, also known as choroiditis and chorioretinitis, is uncommon, with the exception of cytomegalovirus (CMV) retinitis in patients with AIDS. Uveitis can be acute or chronic. The acute form is observed most commonly in the ED and is the main focus of this article.

Pathophysiology

The exact pathophysiology of uveitis is unknown. In general, uveitis is caused by an immune reaction. Uveitis often is associated with infections, such as herpes, toxoplasmosis, and syphilis; therefore, the postulated immune reaction directed against foreign molecules or antigens also may injure the uveal tract vessels and cells.

Uveitis also is found in association with autoimmune disorders, such as systemic lupus erythematosus and rheumatoid arthritis. In these cases, uveitis may be caused by a hypersensitivity reaction involving immune complex deposition within the uveal tract.

Frequency

United States

The estimated incidence is approximately 15 cases per 100,000 persons.

International

Same as that in the United States.

Mortality/Morbidity

  • No deaths have been reported.
  • Morbidity results from posterior synechiae formation (adhesions between the iris and the lens) that may lead to high intraocular pressure and subsequent optic nerve loss.
  • Additional morbidity may include cataract formation, an adverse effect of topical steroid use.

Sex

Uveitis occurs equally in males and females.

Age

The majority of patients are aged 20-50 years.

Clinical

History

  • Anterior uveitis1
    • Acute - Unilateral, painful red eye, blurred vision, photophobia, and tearing
    • Chronic - Recurrent episodes, few or no acute symptoms
  • Posterior uveitis1
    • Blurred vision
    • Floaters
    • Occasional pain
    • Occasional photophobia

Physical

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

  • Findings of the examination of the lids, lashes, and lacrimal ducts are normal.
  • The conjunctival exam reveals 360-degree 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 generally is normal.
  • On the pupillary exam, the patient may have 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 exam
    • Examine the cornea by direct illumination with a broad beam at a 30- to 40-degree 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. 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+.
      • 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 due to decreased aqueous humor production; however, pressure may become elevated as the inflammation subsides.

Causes

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

More on Iritis and Uveitis

Overview: Iritis and Uveitis
Differential Diagnoses & Workup: Iritis and Uveitis
Treatment & Medication: Iritis and Uveitis
Follow-up: Iritis and Uveitis
References
Further Reading

References

  1. Wills Eye Hospital. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. 5th ed. Philadelphia, Pa: Lippincott; 2008.

  2. Abad S, Seve P, Dhote R, Brezin AP. [Guidelines for the management of uveitis in internal medicine]. Rev Med Interne. Jun 2009;30(6):492-500. [Medline].

  3. Lyon F, Gale RP, Lightman S. Recent developments in the treatment of uveitis: an update. Expert Opin Investig Drugs. May 2009;18(5):609-16. [Medline].

  4. Lim LL, Smith JR, Rosenbaum JT. Retisert (Bausch & Lomb/Control Delivery Systems). Curr Opin Investig Drugs. Nov 2005;6(11):1159-67. [Medline].

  5. Mohammad DA, Sweet BV, Elner SG. Retisert: is the new advance in treatment of uveitis a good one?. Ann Pharmacother. Mar 2007;41(3):449-54. [Medline].

  6. Wirbelauer C. Management of the red eye for the primary care physician. Am J Med. Apr 2006;119(4):302-6. [Medline].

  7. Nishimoto JY. Iritis. How to recognize and manage a potentially sight-threatening disease. Postgrad Med. Feb 1996;99(2):255-7, 261-2. [Medline].

  8. Nussenblatt R, Whitcup S, Palestine A. Uveitis: Fundamentals and Clinical Practice. 2nd ed. St. Louis, Mo: Mosby; 1996.

  9. Tessler H. Classification and symptoms and signs of uveitis. In: Duane T, ed. Clinical Ophthalmology. New York, NY: Harper and Row; 1987:1-10.

Keywords

iritis, uveitis, inflammation of the uveal tract, inflammation of the iris, inflammation of the ciliary body, inflammation of the choroid, iridocyclitis, anterior uveitis, posterior uveitis, choroiditis, chorioretinitis, retinitis

Contributor Information and Disclosures

Author

Kilbourn Gordon III, MD, FACEP, Urgent Care Physician
Kilbourn Gordon III, MD, FACEP is a member of the following medical societies: American Academy of Ophthalmology and Wilderness Medical Society
Disclosure: Nothing to disclose.

Medical Editor

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
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

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.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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