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Key Features

Essentials of Diagnosis

  • Usually immunologic but possibly infective or neoplastic

  • Acute nongranulomatous anterior uveitis: pain, redness, photophobia, and visual loss

  • Granulomatous anterior uveitis: blurred vision in a mildly inflamed eye

  • Posterior uveitis: gradual loss of vision in a minimally inflamed eye

General Considerations

  • Intraocular inflammation (uveitis) is classified

    • By its clinical presentation: acute or chronic and nongranulomatous or granulomatous

    • By its distribution: anterior, intermediate, posterior, or panuveitis

  • Most common types are

    • Acute nongranulomatous anterior uveitis

    • Granulomatous anterior uveitis

    • Posterior uveitis

Pathogenesis

  • Systemic disorders associated with acute nongranulomatous anterior uveitis include

    • Ankylosing spondylitis

    • Reactive arthritis

    • Psoriasis

    • Ulcerative colitis

    • Crohn disease

  • Chronic nongranulomatous anterior uveitis occurs in juvenile idiopathic arthritis

  • Behçet syndrome produces

    • Anterior uveitis, with recurrent hypopyon but little discomfort

    • Posterior uveitis, characteristically with branch retinal vein occlusions

  • Both herpes simplex and herpes zoster infections may cause nongranulomatous anterior uveitis as well as retinitis

  • Diseases that produce granulomatous anterior uveitis also tend to be causes of posterior uveitis, including

    • Sarcoidosis

    • Toxoplasmosis

    • Tuberculosis

    • Syphilis

    • Vogt-Koyanagi-Harada disease

    • Sympathetic ophthalmia following penetrating ocular trauma

  • In toxoplasmosis, there may be evidence of previous episodes of retinochoroiditis

  • In HIV infection, other principal pathogens responsible for ocular inflammation are

    • Cytomegalovirus (CMV)

    • Herpes simplex and herpes zoster viruses

    • Mycobacteria

    • Cryptococcus

    • Toxoplasma

    • Candida

  • Retinal vasculitis and intermediate uveitis

    • Predominantly manifest as posterior uveitis with central or peripheral retinal abnormalities in retinal vasculitis and far peripheral retinal abnormalities (pars planitis) in intermediate uveitis

    • Retinal vasculitis can be caused by a wide variety of infectious agents and noninfectious systemic conditions but also may be idiopathic

    • Intermediate uveitis is often idiopathic but can be due to multiple sclerosis or sarcoidosis

Clinical Findings

Symptoms and Signs

  • Anterior uveitis

    • Characterized by inflammatory cells and flare within the aqueous humor

    • In severe cases, there may be hypopyon and fibrin within the anterior chamber

    • Cells may also be seen on the corneal endothelium as keratic precipitates (KPs)

  • In granulomatous uveitis, the KPs are large, and iris nodules may be seen

  • In nongranulomatous uveitis,

    • The KPs are smaller and iris nodules are not seen

    • The pupil is usually small, and with the development of posterior synechiae, it also becomes irregular

  • Nongranulomatous anterior uveitis tends to present acutely with unilateral pain, redness, photophobia, and visual loss

  • In juvenile idiopathic arthritis, there tends to be an indolent, often initially asymptomatic, process with a high risk of sight-threatening complications

  • Granulomatous anterior uveitis is usually indolent, causing blurred vision in a mildly inflamed eye

  • Posterior uveitis

    • Tends to present with gradual visual loss in a minimally inflamed eye

    • Bilateral involvement is common

    • Inflammatory lesions may be present in the retina or choroid

    • Fresh retinal lesions are yellow, with indistinct margins, and with retinal hemorrhages

    • Older lesions have more definite margins and are commonly pigmented

    • Visual loss may be due to

      • Vitreous haze and ...

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