eMedicine Specialties > Emergency Medicine > Ophthalmology

Iritis and Uveitis

Kilbourn Gordon III, MD, FACEP, Urgent Care Physician

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.

• 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, 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.

Differential Diagnoses

Other Problems to Be Considered

Retinal detachment
Posterior segment tumor (eg, retinoblastoma, leukemia, malignant melanoma)
Sclerouveitis

Workup

Laboratory Studies

• Tailor the workup according to the history or to the signs and symptoms that point to a certain etiology.
• Obtain a complete history, identifying any underlying systemic causes (eg, in young adult men, conjunctivitis, urethritis, and polyarthritis suggest reactive arthritis).
• No further lab studies are needed if a patient presents with a first occurrence of unilateral nongranulomatous uveitis and the history and the physical exam are unremarkable.
• If the history and the physical exam are unremarkable in the presence of bilateral uveitis, granulomatous uveitis, or recurrent uveitis, a nonspecific workup is indicated. These tests do not need to be conducted in the ED and may be ordered by the consulting ophthalmologist.
  • CBC
  • Erythrocyte sedimentation rate (ESR)
  • Antinuclear antibody (ANA)
  • Rapid plasma reagin (RPR)
  • Venereal disease research laboratory (VDRL)
  • Purified protein derivative (PPD)
  • Chest x-ray (CXR)
  • Lyme titer

Treatment

Emergency Department Care

• The main goals in the ED are to correctly diagnose uveitis and to refer the patient to an ophthalmologist.²
• Although the patient's eye is erythematous and cells are present in the anterior chamber, antibiotics are not indicated.

Consultations

• Patients with possible uveitis should be examined by an ophthalmologist within 24 hours.

Medication

The goals of pharmacotherapy are to reduce pain and inflammation.

Cycloplegics

These agents block nerve impulses to the pupillary sphincter and ciliary muscles, easing pain and photophobia.

Cyclopentolate 0.5-2% (Cyclogyl)

Induces cycloplegia in 25-75 min and mydriasis in 30-60 min. Effects last as long as 1 d; however, duration may be less in setting of severe anterior chamber reaction. For this reason, Cyclogyl less attractive for treating uveitis than homatropine.

Dosing

Adult

1 gtt tid

Pediatric

Administer as in adults

Interactions

Decreases effects of carbachol and cholinesterase inhibitors

Contraindications

Documented hypersensitivity; narrow-angle glaucoma

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Exercise caution in patients (eg, elderly) in whom intraocular pressure may be increased; can cause toxic anticholinergic systemic effects (common in children, especially infants) but rare when used sparingly; compressing lacrimal sac by digital pressure for 1-3 min following application may minimize systemic absorption

Homatropine 2-5% (Isopto)

Induces cycloplegia in 30-90 min and mydriasis in 10-30 min. Effects last 10-48 h for cycloplegia and 6 h to 4 d for mydriasis, but duration may be less in setting of severe anterior chamber reaction. Homatropine is agent of choice for uveitis.

Dosing

Adult

1 gtt tid

Pediatric

Administer as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity; with narrow-angle glaucoma

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in elderly in whom intraocular pressure may be increased; toxic anticholinergic systemic effects can occur, but are rare when used sparingly; adverse effects are more common in children, especially infants; compressing lacrimal sac by digital pressure for 1-3 min following instillation minimizes systemic absorption

Topical steroids

These agents decrease inflammation. Corticosteroid treatment often is initiated only after consultation with an ophthalmologist.

Prednisolone 1% (Pred Forte)

Strongest steroid of its group and best choice for uveitis. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.

Dosing

Adult

1 gtt q1-6h

Pediatric

Administer as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity; viral, fungal, or tubercular infections

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

May cause rise in intraocular pressure; can cause cataract formation with chronic use

Follow-up

Further Outpatient Care

• Follow-up care with an ophthalmologist within 24 hours is imperative.
• In the acute phase, cases of uveitis are followed every 1-7 days with slit-lamp exam and intraocular pressure measurements.
• The ophthalmologist tapers steroids and cycloplegics.³
• When the condition is stable, patients are monitored every 1-6 months.
• A fluocinolone acetonide intravitreal implant, available from Bausch & Lomb, provides continuous therapy for approximately 30 months.^4,5

Complications

• An acute rise in intraocular pressure secondary to pupillary block (posterior synechiae), inflammation, or topical corticosteroid use is the single most important complication.
• Examine all patients presenting with a red eye with a slit lamp to detect the presence of cells or flare.
• Consider all other causes of a red eye⁶ before uveitis is diagnosed.
• An acute rise in intraocular pressure can lead to optic nerve atrophy and permanent vision loss.

Prognosis

• Generally, the prognosis is good with appropriate treatment.

Patient Education

• For excellent patient education resources, visit eMedicine's Eye and Vision Center. Also, see eMedicine's patient education articles Anatomy of the Eye and Iritis.

Miscellaneous

Medicolegal Pitfalls

• Failure to diagnose uveitis correctly may lead to permanent vision loss.
  • Uveitis is a diagnosis of exclusion; consider all other causes of a red eye first.
  • Use the slit lamp to examine all red eyes.
  • ED physicians must be trained in the proper use of slit lamps to detect cells and flare.
• Prescription of topical corticosteroid medication in the ED is problematic.
  • Accurate intraocular pressure must be obtained, and herpes keratitis must be ruled out before considering topical steroid application.
  • Steroid treatment usually is initiated only in consultation with an ophthalmologist.

References

1. Wills Eye Hospital. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. 5^th 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. 2^nd 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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