Aetiology

Uveitis (anterior)

Anterior uveitis (the most common form of uveitis, accounting for approx. 75% of all cases of uveitis). Annual incidence 15-52 per 100,000 population 

• iritis: inflammation predominantly affects iris
• iridocyclitis (more common): inflammation predominantly affects iris and anterior part of ciliary body (pars plicata)

The Standardisation of Uveitis Nomenclature (SUN) working group has developed an international standard for classifying uveitis:

• Onset: sudden or insidious
• Duration: limited, if it is ≤3 months, or persistent, i.e. >3 months in duration
• Recurrent: describes repeated episodes of uveitis separated by periods of inactivity without treatment of ≥3 months in duration
• Chronic: describes persistent uveitis characterized by prompt relapse (in <3 months) after discontinuation of therapy

Endogenous aetiology

• Majority of cases assumed to be autoimmune in origin and may be associated with systemic disease:
  • Spondyloparthropodies (e.g. ankylosing spondylitis, reactive arthritis (also known as Reiter’s syndrome), psoriatic arthropathy, juvenile idiopathic arthritis
  • Behçet’s disease 
  • Inflammatory bowel disease 
  • Sarcoidosis
• prior infections (e.g. Herpes simplex, Herpes zoster, Mycobacterium tuberculosis, Treponema pallidum [the agent of syphilis], Toxoplasma)
• idiopathic (not associated with an underlying systemic disease)
• specific uveitis entities with distinct characteristics, e.g.:
  • Fuchs heterochromic iridocyclitis (also known as Fuchs uveitis syndrome)
  • Posner-Schlossman syndrome

Exogenous aetiology

• external injury or infection
• intraocular surgery
  • following cataract surgery, post-op inflammation is typically mild and transitory. However a small number of patients may develop a persistent anterior uveitis. Risk factors include previous history of uveitis and black ethnicity
• rarely, drug-induced

Anterior uveitis is traditionally classified as ‘non-granulomatous’ or ‘granulomatous’, based on the nature of the keratic precipitates

• non-granulomatous uveitis typically has an acute onset and shows fine KP. It is more likely to be idiopathic
• granulomatous uveitis typically presents as a chronic condition showing large, ‘mutton fat’ KP and iris nodules. It is more likely to be associated with systemic conditions

Predisposing factors

Age over 20 years in 90% of cases (mean age at onset = 40 years)
Major histocompatibility complex antigen HLA-B27 is positive in 8% of the general population, but in approximately 50% of all patients with acute anterior uveitis.
Systemic disease as above.

Symptoms of anterior uveitis

Onset usually sudden at first episode, gradual at subsequent episodes
Usually unilateral (if bilateral, more likely to be associated with systemic disease and more likely to become chronic)

• pain (dull/ache)
  • exacerbated on induced pupillary constriction (direct, near or consensual)
• photophobia
• redness
• decreased vision
• lacrimation

NB If condition recurrent, eye may be asymptomatic and white despite presence of inflammation

Signs of anterior uveitis

• hyperaemia: circumcorneal (‘ciliary injection’)
• keratic precipitates (KP) – fine, stellate or ‘mutton fat’
• aqueous cells
• aqueous flare
• hypopyon/fibrin (severe cases)
• intraocular pressure commonly normal but raised in some cases
• posterior synechiae possibly causing pupil block and iris bombé
• iris nodules: Koeppe (small, near pupil), Bussaca (large, far from pupil)

Anterior vitreous cells may be seen in iridocyclitis but often will indicate intermediate ±  posterior uveitis
Other signs include constricted or non-reactive pupil, iris atrophy, heterochromia, cataract, chronic corneal oedema including bullous keratopathy
NB If condition recurrent, signs may be less apparent, and will vary according to severity and the specific underlying disease

Differential diagnosis

Glaucoma (acute angle closure)
Other causes of acute red eye, e.g. endophthalmitis
Lens-induced uveitis, intraocular foreign body

Other forms of uveitis:

• intermediate uveitis: involves posterior ciliary body (pars plana), anterior choroid
• posterior uveitis: involves choroid ± retina, optic disc or retinal vasculature
• panuveitis: inflammation of the entire uveal tract

Management by optometrist

Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere

It is important to take a comprehensive medical history, including features of inflammatory back pain (e.g. chronic lower back pain beginning <45 years, duration > 3 months, early morning stiffness). In one study 40% of patients presenting with idiopathic acute anterior uveitis had undiagnosed spondyloarthritis.

Check intraocular pressure

Dilated posterior segment examination is essential: check for vitreous cells, snow ball/snow banking, cystoid macular oedema & posterior uveitis in both eyes 

Following the initiation of therapy:

Monitor for ocular complications, including raised intraocular pressure
Sunglasses for photophobia
Spectacle near addition for cycloplegia
(GRADE*: Level of evidence=low, Strength of recommendation=strong)

Patients should be instructed to return immediately if they experience deterioration of vision or increased pain

First episode:

Initiate pharmacological therapy with review within 3 days. Topical steroid: e.g. gutt. prednisolone acetate 1% or dexamethasone 0.1% hourly until inflammation controlled.
Topical cycloplegic (NB first check for possibility of angle closure): gutt. cyclopentolate 1% tds for up to 7 days
See within the first 3 days and if the uveitis is responding well to treatment reduce the topical steroid to every 2 hours for 5 days, then start tapering. The topical steroid should be tapered over not less than 6 weeks.
If no improvement at one week, refer to ophthalmologist

Second or subsequent episode:

Reinstate uveitic therapies as above
Refer to an ophthalmologist for systemic review and possible onward referral to rheumatologist
(GRADE*: Level of evidence=low, Strength of recommendation=strong)

NB: do not commence treatment if patient is known to have a history of corticosteroid-induced ocular hypertension or has had an episode of hypertensive uveitis

Management category

First episode:

B2: Alleviation and palliation: normally no referral to ophthalmologist, where there is:

• non-granulomatous inflammation
• unilateral involvement
• no underlying systemic aetiology
• no vitreous or posterior segment involvement

A3: (modified): Initiate pharmacological therapy, followed by urgent (within one week) referral to ophthalmologist if:

• no improvement after one week of pharmacological treatment
• granulomatous features from the outset
• hypopyon or fibrin in anterior chamber
• failure to break posterior synechiae
• bilateral disease
• vitreous or posterior segment involvement
• inadequate pupil dilation (to exclude posterior uveitis)
• history suggestive of an underlying systemic aetiology (including musculoskeletal symptoms)

A1: Emergency (same day) referral to ophthalmologist (no intervention) if:

• significant reduction in vision
• severe pain
• significantly raised IOP

Second or subsequent episode:

B1 (modified): pharmacological management followed by urgent referral (within one week) to an ophthalmologist
Following medical investigation of underlying cause, may be appropriate for the optometrist to manage subsequent episodes in collaboration with the ophthalmologist

Possible management by ophthalmologist

May investigate aetiology of uveitis and possibly refer appropriately for further medical investigation (e.g. rheumatologist, clinical immunologist, infectious disease specialist)
Treat secondary glaucoma
Sub-Tenon’s steroid injection may be required
Possible sub-conjunctival injection of mydriatic
Possible systemic immunosuppression
 

Evidence base

*GRADE: Grading of Recommendations Assessment, Development and Evaluation (www.gradeworkinggroup.org)

Sources of evidence

Haroon M, O'Rourke M, Ramasamy P, Murphy CC, FitzGerald O. A novel evidence-based detection of undiagnosed spondyloarthritis in patients presenting with acute anterior uveitis: the DUET (Dublin Uveitis Evaluation Tool). Ann Rheum Dis. 2015;74(11):1990-5

Huang JJ, Elia M.  BMJ Best Practice: Uveitis. Aug 10; 2021

Jabs DA, Nussenblatt RB, Rosenbaum JT; Standardization of Uveitis Nomenclature (SUN) Working Group. Standardization of uveitis nomenclature for reporting clinical data. Results of the First International Workshop. Am J Ophthalmol. 2005;140(3):509-16

Jabs DA, Busingye J. Approach to the diagnosis of the uveitides. Am J Ophthalmol. 2013;156(2):228-36. 

Reddy AK, Patnaik JL, Miller DC, Lynch AM, Palestine AG, Pantcheva MB. Risk Factors Associated with Persistent Anterior Uveitis after Cataract Surgery. Am J Ophthalmol. 2019;206:82-86

Trusko B, Thorne J, Jabs D, Belfort R, Dick A, Gangaputra S, Nussenblatt R, Okada A, Rosenbaum J. The Standardization of Uveitis Nomenclature (SUN) Project. Development of a clinical evidence base utilizing informatics tools and techniques. Methods Inf Med. 2013;52(3):259-65

Uveitis (anterior) Version 7
Date of search 19.01.23
Date of revision 23.03.23
Date of publication 26.05.23
Date for review 18.01.25
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