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Uveitis
Aka: Uveitis, Iritis, Anterior Uveitis, Iridocyclitis, Intermediate Uveitis, Posterior Uveitis, Neuroretinitis, Panuveitis, Corneal Keratic Precipitate, Keratic Precipitate, Traumatic Iritis
- See Also
- See Medication Causes of Uveitis
- Defintions
- Uvea
- Contains three pigmented and continuous structures: Choroid, Ciliary Body and Iris
- Uveitis
- Uveal tract inflammation
- Defined as chronic if duration more than 3 months
- Epidemiology
- Incidence: 17 to 52 per 100,000 per year in North America
- Prevalence: 58 to 115 per 100,000 per year in North America
- Peak ages: 20-59 years old
- Pathophysiology
- Autoimmune reaction (similar to Episcleritis and Scleritis)
- Uveitis may occur in isolation or as part of a systemic inflammatory condition (see causes below)
- Diagnosis is as a result of spillover inflammation into the aqueous and vitreous resulting in cells and flare
- Types
- Anterior Uveitis (Iritis or Iridocyclitis)
- Inflammation of iris of the uveal tract (and the ciliary Muscle) in the anterior chamber
- When the ciliary Muscle/body is involved it is known as Iridocyclitis
- May occur from spillover inflammation from the Cornea (keratouveitis) or Sclera (sclerouveitis)
- Intermediate Uveitis
- Inflammation of the vitreous chamber (vitritis)
- Posterior Uveitis
- Inflammation of the Retina (retinitis) or Choroid (Choroiditis or chorioretinitis)
- May extend to the Optic Nerve head (Neuroretinitis)
- Panuveitis
- Generalized ocular inflammation
- Causes
- See Medication Causes of Uveitis
- Traumatic Iritis
- Blunt Eye Trauma causes intraocular inflammation and blood barrier breakdown
- Onset may be delayed 2-3 days after injury
- Traumatic Iritis duration is typically 7-10 days
- Bacterial Infection
- See Endophthalmitis under differential diagnosis below
- Bloodbourne infection
- Involves any uveal location
- Cat-Scratch Disease
- Involves Posterior Uveitis, specifically Neuroretinitis
- Lyme Disease
- Involves any uveal location
- Mycobacterium tuberculosis
- Involves any uveal location
- Affects <1% of Tb cases
- Syphilis
- Involves any uveal location
- Affects <5% of Syphilis cases
- Toxocariasis
- Involves posterior uveal location (Posterior Uveitis)
- Leprosy
- Other infectious causes
- Local infection from perforating wound or Corneal Ulcer
- Viral Exanthem
- HIV Infection
- Rheumatologic Conditions
- Rheumatoid Arthritis
- Occurs in up to 50% of pauciarticular Juvenile Rheumatoid Arthritis
- Accounts for 80% of Uveitis cases in children
- Occurs in <5% of adult Rheumatoid Arthritis
- Typically a result of Scleritis or Keratitis spill-over
- Spondyloarthropathy (often seronegative, affects Anterior Uveitis)
- Ankylosing Spondylitis
- Reiter's Syndrome (Reactive Arthritis)
- Psoriatic Arthritis
- Behcet's Disease
- May affect any uveal location
- Occurs in >60% of cases
- Relapsing Polychondritis
- Involves anterior chamber (Anterior Uveitis)
- Sarcoidosis
- Involves any uveal location
- Systemic Lupus Erythematosus (SLE)
- Involves any uveal location
- Affects <1% of SLE cases
- Vogt-Koyanagi-Harada Syndrome
- Involves Posterior Uveitis
- Uveitis occurs in 100% of cases
- Kawasaki's Disease
- Inflammatory Bowel Disease (Anterior Uveitis, affecting >15% of IBD cases)
- Ulcerative Colitis
- Crohn's Disease
- Neurologic disorders
- Multiple Sclerosis (Intermediate Uveitis, affecting 30% of MS cases)
- Renal disorders
- Tubular Interstitial Nephritis
- Involves anterior chamber (Anterior Uveitis)
- Symptoms
- Eye Pain
- Moderate deep aching Sensation
- May radiate into periocular structures (e.g. brow pain or temporal pain)
- Eye Pain is often absent in Intermediate Uveitis and Posterior Uveitis
- Not relieved with Topical Anesthetic (e.g. tetracaine)
- Photophobia
- Vision decreased or blurred
- Visual Floaters
- Eye tearing
- Signs
- Pupil constricted and poorly reactive (due to iris spasm)
- Other acute eye conditions typically cause Mydriasis
- Pain on direct light exposure
- Pain also occurs on Consensual Light Reflex when light is shone into opposite eye
- Conjunctival injection
- Present in most cases of Anterior Uveitis
- Injection is localized around the iris, in contrast with Conjunctivitis in which the the injection is more widespread
- Ciliary Flush (or blush)
- Injection of bulbar Conjunctiva around limbus (circumcorneal hyperemia)
- Anterior flare
- Flare is an increased turbidness or cloudiness of the Aqueous Humor
- Anterior chamber "cells" slough
- Anterior cells seen on Slit Lamp exam
- Often in combination with flare (known as "cells and flare")
- Corneal Keratic Precipitates
- Yellow or white deposits of aggregated cells on the posterior surface of the Cornea (endothelial surface)
- Results from the anterior chamber cells
- Sterile Hypopyon
- White Blood Cells in severe inflammatory response may settle and accumulate at the anterior chamber floor
- Irregular pupil shape
- Iris may adhere to adjacent structures (anterior lens or posterior Cornea)
- Intraocular Pressure abnormal
- May be either increased or decreased
- Labs
- First-line labs to consider if systemic cause is suspected
- Complete Blood Count
- Basic metabolic panel
- Urinalysis
- Erythrocyte Sedimentation Rate (ESR)
- C-Reactive Protein (CRP)
- Other tests to consider
- Rapid Plasma Reagin (RPR)
- Tuberculin Skin Test or Quantiferon-TB
- HLA-B27 (if Spondyloarthropathy suspected)
- Other rheumatologic of infectious disease tests as indicated based on history and exam
- Imaging
- Chest XRay
- Consider if Sarcoidosis, Tuberculosis suspected
- Differential Diagnosis
- See Acute Red Eye
- Acute Glaucoma
- Primary ocular Lymphoma
- Consider in age over 50 years old with intermediate or Posterior Uveitis
- Endophthalmitis
- Bloodborne infection with intraocular infection
- Patients typically present appearing toxic or septic
- Some cases may develop more insidiously
- KlebsiellaPneumoniae in diabetic patients
- Systemic Fungal infections
- Less virulent Bacterial Infections (e.g. Central Line infection, IV Drug Abuse)
- Complications
- Decreased Visual Acuity
- Severe Visual Impairment: 35%
- Legally blind: 10%
- Iris scarring
- Impaired pupillary movement
- Secondary Glaucoma
- Precautions
- Children be asymptomatic with minimal exam findings despite significant inflammation (e.g. juvenile RA)
- Intermediate and Posterior Uveitis may have relatively normal anterior chambers
- Most Uveitis findings require the magnification of a Slit Lamp exam
- Management
- Urgent referral all cases to Ophthalmology
- Risk of serious complications if delayed management
- Timely Pupillary dilatation
- Topical Corticosteroids may be indicated (based on ophthalmology evaluation)
- References
- Rosenbaum in Yanoff (1999) Ophthalmology, p. 4.1
- Trobe (2012) Physician's Guide to Eye Care, AAO, p. 67-8
- Harman (2014) Am Fam Physician 90(10): 711-6 [PubMed]