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:
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History of autoimmune disease such as inflammatory bowel disease, SLE, and sarcoidosis
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Sexually transmitted diseases, particularly syphilis and chlamydia
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Tuberculosis
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HIV/AIDS
Anterior uveitis may have the following history findings [2] :
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Acute - Pain, redness, photophobia, excessive tearing, and decreased vision; pain generally develops over a few hours or days except in cases of trauma
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Chronic - Primarily blurred vision, mild redness; little pain or photophobia except during an acute episode
Posterior uveitis may have the following history findings [2] :
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Blurred vision, floaters
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Absence of symptoms of anterior uveitis (pain, redness, and photophobia)
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Symptoms of posterior uveitis and pain suggest anterior chamber involvement, bacterial endophthalmitis, or posterior scleritis
Intermediate uveitis may have the following history findings [2] :
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Similar to posterior uveitis; painless floaters and decreased vision
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Minimal photophobia or external inflammation
Panuveitis may present with any or all these symptoms.
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:
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Examine the cornea by direct illumination with a broad beam at a 30°-40° angle between the viewing microscope and the light source.
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Examine the epithelium for abrasions, edema, ulcers, or foreign bodies.
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Inspect the stroma for deep ulcers and edema.
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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.
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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.
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Though the vitreous humor is not considered part of the uveal tract, inflammatory cells in the vitreous humor are characteristic of intermediate uveitis.
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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)
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White blood cells that layer in the anterior chamber are called hypopyon.
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A special lens is needed to focus the beam posterior to the lens to examine the posterior segment of the eye.
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.
Small stellate keratic precipitates with fine filaments in a patient with Fuchs heterochromic iridocyclitis.
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, [17] 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.
Physical Examination
See Physical
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 eye [18] before uveitis is diagnosed.
An acute rise in intraocular pressure can lead to optic nerve atrophy and permanent vision loss.
Depending on the etiology, uveitis can cause blindness or significant visual defects. Such cases include keratouveitis, an inflammation of the cornea and uveal tract, which can be caused by viruses such as "HSV", "VSV" and "EBV". Viral keratouevitis can lead to acute retinal necrosis, a rare complication with guarded visual prognosis despite treatment. [19, 20]
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Anatomy of the eye.
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Small stellate keratic precipitates with fine filaments in a patient with Fuchs heterochromic iridocyclitis.
Tables
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 |
