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Definition
Uveitis is a condition that involves inflammation of
the uveal tract (iris, ciliary body, choroid) or adjacent ocular structures (retina, optic nerve, vitreous, sclera).
Anatomical Classification
Type
Anterior uveitis
Intermediate uveitis Posterior uveitis
Includes
Iritis/iridocyclitis/anterior cyclitis Pars planitis/posterior cyclitis/hyalitis Focal, multifocal, or diffuse choroiditis/chorioretinitis/ retinochoroiditis/retinitis/ Neuroretinitis
Panuveitis
Further Classification
Onset (sudden or insidious) Duration (limited less than 3 months duration, or
persistent more than 3 months duration) Course (acute, recurrent, or chronic) Laterality (unilateral or bilateral)
Etiology
The most common etiology of uveitis is idiopathic.
Herpes simplex/zoster
Syphilis Toxoplasmosis
Brucellosis
HIV infection
Epidemiology
Age The majority of patients are aged 20-50 years. Race Racial predisposition to uveitis is related to the patient's underlying systemic disease.
Caucasian: HLA-B27 related diseases, multiple sclerosis African American: Sarcoidosis, SLE Mediterranean/Middle Eastern: Behet's disease (HLA-B5)
Sex In general, uveitis does not have a gender predisposition except in cases secondary to systemic disease, such as JRA and SLE
The most common type of uveitis presented to the emergency department is Acute Anterior Uveitis.
Clinical Presentation
Symptoms:
Red eye Pain Blurred vision Photophobia Excessive tearing
Clinical Presentation
Signs:
Perilimbal injection Direct and consensual photophobia Pupillary miosis (common but not always present) Keratic precipitates on corneal endothelium (granulomatous
or non-granulomatous)
Marked cell and flare reaction in the anterior chamber (WBC,
RBC, protein)
Hypopyon (seen in Behets disease & endophthalmitis) Various degrees of posterior synechiae (Iris bomb
pupillary
block glaucoma)
Differential Diagnosis
Consider all other causes of a red eye before uveitis is diagnosed. Acute conjunctivitis Corneal abrasion or ulceration Ultraviolet keratitis Foreign body Acute angle-closure glaucoma Scleritis
Lab studies
CBC, ESR (non-specific) ANA (autoimmune disorders)
Imaging studies
Chest X-ray is indicated if tuberculosis or sarcoidosis is
considered. Sacroiliac X-ray is indicated if HLA-B27 related diseases are suspected. Brain MRI may be needed if multiple sclerosis is a possibility.(intermediate uveitis) Fluorescein angiography or ocular sonography may be needed in certain types of posterior uveitis
Medical management
Corticosteroids (topical, periocular and/or systemic use) Reduces active inflammation in the eye Prevents and treats uveitis complications Beware of drug complications (cataract, glaucoma, HSV keratitis) Cycloplegics (Homatropine, cyclopentolate,...) Relief of pain and photophobia Breaking posterior synechiae/ pupillary block Immunosuppressive therapy (methotrexate, cyclophosphamide,) Severe uveitis Unresponsive to corticosteroids Severe corticosteroid induced complications
Follow up
Refer the patient to an ophthalmologist within 24
hours Cases of uveitis should be monitored every 1-7 days in the acute phase Steroids and cycloplegics should be tapered and not discontinued suddenly When the condition is stable, patients are monitored every 1-6 months