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ESSENTIALS OF DIAGNOSIS

ESSENTIALS OF DIAGNOSIS

  • Usually immunologic but possibly infectious or neoplastic.

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

  • Acute anterior uveitis: sudden redness and blurry vision often with photophobia.

  • Posterior uveitis: gradual loss of vision, commonly with floaters, in a variably inflamed eye.

GENERAL CONSIDERATIONS

Intraocular inflammation (uveitis) is clinically classified as acute or chronic, as nongranulomatous or granulomatous, and by which ocular anatomic locations are involved (anterior, intermediate, posterior, or all [panuveitis]).

In most cases the pathogenesis of uveitis is primarily immunologic, but infection may be the cause, particularly in immunodeficiency states.

1. Nongranulomatous anterior uveitis

The systemic disorders associated with acute nongranulomatous anterior uveitis are the HLA-B27-related conditions (ankylosing spondylitis, reactive arthritis, psoriasis, ulcerative colitis, and Crohn disease). The initial presentation of Behçet syndrome, a chronic recurrent disease, is usually acute anterior uveitis, with recurrent hypopyon, and posterior uveitis, characteristically with branch retinal vein occlusions. Both herpes simplex and herpes zoster infections may cause acute nongranulomatous and granulomatous anterior uveitis as well as retinitis (acute retinal necrosis). Chronic nongranulomatous anterior uveitis occurs in juvenile idiopathic arthritis.

2. Granulomatous anterior uveitis

Diseases producing granulomatous anterior uveitis also tend to be causes of posterior uveitis. These include sarcoidosis, toxoplasmosis, tuberculosis, syphilis, Vogt-Koyanagi-Harada disease (bilateral uveitis associated with alopecia, poliosis [depigmented eyelashes, eyebrows, or hair], vitiligo, and hearing loss) (eFigure 7–32), and sympathetic ophthalmia that occurs after penetrating ocular trauma. In toxoplasmosis, there may be evidence of previous episodes of retinochoroiditis. Syphilis characteristically produces a “salt and pepper” fundus but may present with a wide variety of clinical manifestations. The principal pathogens responsible for ocular inflammation in HIV infection are cytomegalovirus (CMV), herpes simplex and herpes zoster viruses, mycobacteria, Cryptococcus, Toxoplasma, and Candida.

eFigure 7–32.

Vogt–Koyanagi–Harada (VKH) disease. A: Poliosis of the eyelashes. B: Alopecia, vitiligo, and poliosis of the hair. (Reproduced, with permission, from A: Lueder GT. Pediatric Practice: Ophthalmology. McGraw-Hill, 2011; B: Riordan-Eva P, Augsburger JJ. Vaughan & Asbury's General Ophthalmology, 19th ed. McGraw-Hill, 2018.)

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

Anterior uveitis is characterized by inflammatory cells and flare, best visualized with a slit lamp within the aqueous humor. In severe cases, there may be ...

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