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Anterior Uveitis

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Overview

The uvea is the vascular area between the retina and the sclera of the eye. The uvea is made up of the iris, ciliary body, and choroid. Uveitis describes inflammation of the uvea and it can lead to visual loss. 

Uveitis can be unilateral or bilateral. Unilateral conditions are typically more acute and may be infectious, whereas bilateral conditions are more likely due to chronic systemic conditions. This section focuses primarily on anterior uveitis.

Epidemiology

  • Anterior uveitis is the most common form in the UK
  • Usually seen in 20-50 years of age
  • HLA-B27 positivity is more common in Caucasian people
  • Behçet’s disease is more common in people of Mediterranean origin

Classification

Anterior uveitis

Also known as iritis, anterior uveitis describes inflammation of the iris and is associated with HLA-B27. It may be caused by:

Intermediate uveitis

Intermediate uveitis is the inflammation of the vitreous and posterior part of the ciliary body. It may be caused by:

  • Autoimmune disease:
  • Infectious causes:
    • Syphilis
    • Lyme disease

Posterior uveitis

Posterior uveitis is the inflammation of the choroid. It may be called chorioretinitis if the retina is involved. It may be caused by:

  • Autoimmune disease:
    • Sarcoidosis
    • Behçet’s disease
  • Infectious causes:
    • Toxoplasmosis
    • Cytomegalovirus
    • Syphilis

Panuveitis

Panuveitis is inflammation throughout the uveal tract. It may be caused by:

  • Autoimmune disease:
    • Sarcoidosis
    • Behçet’s disease
    • Systemic lupus erythematosus
    • Granulomatosis with polyangiitis
  • Infectious causes:
    • Syphilis

Risk Factors

  • Autoimmune disease, particularly diseases of the joints, skin, or bowels
  • HLA-B27 positive
  • Ocular trauma

Presentation

Clinical features can help distinguish between anterior and posterior uveitis; however, this can only be confirmed through a thorough examination of the eye. Features of anterior uveitis are:

  • Eye redness without discharge
  • Eye pain – this may be worse with use i.e. reading something close by
  • Photophobia
  • Blurred vision
  • Watery eyes
  • Associated headaches
  • Constricted or unreactive pupil
  • There may be irregular pupil margins
  • Ciliary flush – red/violet spreading out from around the cornea
  • Features of associated autoimmune systemic disease may be present

Features of posterior uveitis are:

  • Usually painless
  • Gradual vision loss
  • Blurred vision
  • Floaters
  • Macular oedema – patients may see distorted shapes or changes in colour vision
  • Optic disc swelling
  • Retinal haemorrhages
  • Features of posterior uveitis with pain may suggest panuveitis or bacterial endophthalmitis.

Differential Diagnoses

Keratitis

  • May have an absence of systemic autoimmune disease
  • Patients may wear contact lenses or have a history of corneal trauma

Episcleritis

  • Classically non-painful red eye but there may be some mild pain
  • Injected vessels are mobile and move with gentle pressure
  • Phenylephrine eye drops improve eye redness

Scleritis

  • Classically painful red eye but the pain may only be mild
  • Watering and/or photophobia may be present
  • Injected vessels are not mobile and do not move with gentle pressure
  • Phenylephrine eye drops do not improve eye redness

Bacterial conjunctivitis

  • Red eye and discharge present
  • There is no significant pain, photophobia, or visual changes
  • The eyes may be “sticky” which is worse in the morning

Investigations

Overview

  • Immediate (within 24 hours) referral to ophthalmology
  • Slit-lamp examination:
    • Shows signs mentioned above
  • Diagnosis is usually based on the history and eye signs

Other investigations

Other investigations to consider if relevant are:

  • FBC:
    • May show leukocytosis in infection
  • ESR and CRP:
    • May be increased suggesting inflammation
  • Syphilis testing:
    • If suspected
  • Lyme titre:
    • If Lyme disease suspected
  • Serum ACE:
    • Increased in sarcoidosis
  • Autoantibodies according to suspected disease e.g. rheumatoid factor (RF) for rheumatoid arthritis

Management

  • Immediate (within 24 hours) referral to ophthalmology
  • 1st-line: corticosteroid eyedrops (e.g. prednisolone) + manage underlying condition
  • Cycloplegic eye drops: atropine/cyclopentolate:
    • These dilate the pupil, provide pain relief, and help with photophobia

Patient Advice

  • Patients should be educated about the risk of abrupt corticosteroid withdrawal, along with the side effects they can carry i.e. cataracts and glaucoma
  • Patients taking immunosuppressants should be safety-netted on signs of infection such as fever and sore throat and should be instructed to seek help as soon as possible.

Complications

  • Macular oedema
  • Cataracts – can be due to inflammation or corticosteroid treatment
  • Increased intraocular pressure and glaucoma – can be due to inflammation or corticosteroid treatment
  • Choroidal neovascularisation
  • Retinal detachment

Prognosis

  • Early diagnosis and treatment give a better prognosis
  • Effective management of underlying disease improves outcomes and reduces recurrence rates

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