Uveitis

Key Features

Essentials of Diagnosis

• Usually immunologic but possibly infective or neoplastic

• Inflammation may be confined to the eye or may be systemic

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

• Granulomatous anterior uveitis: blurred vision in a variably painful and inflamed eye

• Posterior uveitis: gradual loss of vision in a variably 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 irregularly shaped and poorly reactive

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

• However, the ocular inflammation associated with juvenile idiopathic arthritis is

  • Frequently indolent

  • Commonly asymptomatic initially

  • Carries a high risk of sight-threatening complications

• Granulomatous anterior uveitis is also frequently chronic, recurrent, and indolent, causing blurred vision in a variably inflamed eye

• Posterior uveitis

  • Tends to present with floaters and visual loss

  • Symptoms are commonly slower in onset, though acute presentations can ...