Uveitis
Background
- Uveitis = inflammation of iris, ciliary body, and/or choroid
Anterior uveitis
Anterior uveitis with hypopyon
Types
- Anterior Uveitis
- Inflammation of iris and/or ciliary body
- Types:
- Iritis
- Iridocyclitis
- Posterior uveitis = choroiditis
Causes
- Inflammatory
- Associated with HLA B-27
- 50% have associated systemic disease
- Environmental
- Trauma
- Corneal foreign body
- UV keratitis
- Infectious (uncommon)
Complications
- Cataracts
- Glaucoma (from synechia)
- Retinal detachment
Clinical Features
Anterior
- Sudden red/painful eye
- Deep pain; worse with eye movement
- Due to ciliary muscle spasm which irritates CN V
- Causes consensual photophobia
- Due to ciliary muscle spasm which irritates CN V
- Ciliary flush, marked injection at the limbus (as opposed to perilimbal sparing seen in conjunctivitis)
- Typically small, poorly reactive pupil
Posterior
- Floaters
- Visual changes
- Generally does not cause redness or significant pain
- Blind spots or flashing lights
Slit-lamp exam
- Cell (WBCs from uveal vessels) & flare (proteinaceous transudate from uveal vessels)
- Hypopyon (with severe disease)
Differential Diagnosis
Unilateral red eye
- Nontraumatic
- Acute angle-closure glaucoma^
- Anterior uveitis
- Conjunctivitis
- Corneal erosion
- Corneal ulcer^
- Endophthalmitis^
- Episcleritis
- Herpes zoster ophthalmicus
- Inflamed pinguecula
- Inflamed pterygium
- Keratoconjunctivitis
- Keratoconus
- Nontraumatic iritis
- Scleritis^
- Subconjunctival hemorrhage
- Orbital trauma
- Caustic keratoconjunctivitis^^
- Corneal abrasion, Corneal laceration
- Conjunctival hemorrhage
- Conjunctival laceration
- Globe rupture^
- Lens dislocation
- Ocular foreign body
- Posterior vitreous detachment
- Retinal detachment
- Retrobulbar hemorrhage
- Ocular compartment syndrome
- Traumatic hyphema
- Traumatic iritis
- Traumatic mydriasis
- Traumatic optic neuropathy
- Vitreous detachment
- Vitreous hemorrhage
- Ultraviolet keratitis
^Emergent diagnoses ^^Critical diagnoses
Acute onset flashers and floaters
- Ocular causes
- Floaters and/or flashes
- Posterior vitreous detachment
- Retinal tear or retinal detachment
- Posterior uveitis
- Predominantly floaters
- Vitreous hemorrhage secondary to proliferative retinopathy
- Sympathetic ophthalmia
- Predominantly flashes
- Oculodigital stimulation
- Rapid eye movements
- Neovascular age-related macular degeneration
- Floaters and/or flashes
- Nonocular causes
- Migraine aura (classic)
- Migraine aura (acephalgicmigraine)
- Occipital lobe disorders
- Postural hypotension
Evaluation
- Clinical
- Consider CXR (uveitis often associated with sarcoidosis, TB)
Management
Infectious
- Treat the underlying infection
Noninfectious
Anterior uveitis
- Topical steroid (anterior only; typically in consultation with ophthalmology)
- Prednisolone 1%
- Mydriatics (sympathomimetics)
- Dilate the iris
- Prevents the formation of synechiae
- Cyclopentolate, homatropine or phenylephrine HCl
- Cycloplegics
- Relieves pain
- Scopolamine 0.25% OR cyclopentolate 1%
- Topical steroid (anterior only; typically in consultation with ophthalmology)
- Posterior Uveitis
- Generally not responsive to topical treatment
- Consult ophtho for observation vs intraocular steroid injection
Disposition
- Generally may be discharged with urgent ophthalmology follow-up within 24-48 hours
References
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