Uveitis (anterior, acute and recurrent)

The CMGs are guidelines on the diagnosis and management of a range of common and rare, but important, eye conditions that present with varying frequency in primary and first contact care.

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Aetiology

Uveitis (anterior)

Anterior uveitis (the most common form of uveitis; annual incidence 12 per 100,000)

  • 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 (e.g. Ankylosing Spondylitis, Behçet’s Disease, Juvenile Idiopathic Arthritis, Reactive Arthritis (also known as Reiter’s Syndrome), inflammatory bowel disease, Psoriatic Arthropathy, 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
    • Posner-Schlossman syndrome
    • anterior segment ischaemia

Exogenous aetiology

  • external injury or infection

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 population, but in 50% of all patients with this condition
Systemic disease as above: it is important to take a comprehensive medical history

Symptoms

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

  • pain (dull/ache)
  • photophobia
  • redness
  • decreased vision
  • lacrimation

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

Signs

  • hyperaemia: circumcorneal (‘ciliary injection’)
  • keratic precipitates (KP) – fine or ‘mutton fat’
  • aqueous cells
  • aqueous flare
  • 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 sluggish pupil reactions, cataract, chronic corneal oedema including bullous keratopathy
Dilated posterior segment examination is essential: check for cystoid macular oedema & posterior uveitis in both eyes
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
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

GRADE* Level of evidence and strength of recommendation always relates to the statement(s) immediately above

Non pharmacological

Check intraocular pressure
Dilated fundus examination (both eyes) to exclude intermediate and/or posterior uveitis

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

Pharmacological

First episode:
Topical steroid (first exclude herpes): e.g. gutt. prednisolone acetate 1% hourly until eye is white or inflammation controlled
Topical cycloplegic (NB first check for possibility of angle closure): gutt. cyclopentolate 1% tds
Review frequently, tapering off treatment as possible; 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 posterior segment involvement

A3: 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
  • posterior segment involvement
  • inadequate pupil dilation (to exclude posterior uveitis)
  • history suggestive of an underlying systemic aetiology

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 of second or third episolde followed by routine referral at third episode

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

Cycloplegia (gutt. cyclopentolate 1%)
Topical steroid (e.g. gutt. dexamethasone 0.1% or gutt. prednisolone acetate 1%)
Treat secondary glaucoma
Sub-Tenon’s steroid injection may be required
Possible sub-conjunctival injection of mydriatic
Possible systemic immunosuppression
May investigate aetiology of uveitis and possibly refer appropriately for further medical investigation

Evidence base

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

Sources of evidence

Islam N, Pavesio C: Uveitis (acute anterior). Clin Evid (Online). 2010

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

Lay Summary

The uvea is the coloured part of the eye, lying beneath the white part of the eye (the sclera) and comprising the iris (which gives the eye its blue, brown or other colour), the ciliary body (which controls focussing and secretes the clear fluid that fills the front of the eye) and the choroid (which nourishes the outer layers of the retina). Inflammation of the uvea is called uveitis.  When this inflammation affects the iris and the ciliary body only, it is known as anterior uveitis.  It is the most common form of uveitis and occurs in around 12 per 100,000 people per year.

If someone develops anterior uveitis for the first time, it is known as acute anterior uveitis. If this recurs within 12 weeks, the second episode is called recurrent anterior uveitis.  The third (and any subsequent) episodes are called recurrent uveitis and are the signal for the patient to have a comprehensive medical investigation to establish the cause.

Anterior uveitis may be caused by injury or infection, but the most common cause is inflammation elsewhere in the body.

Most patients are over the age of 20 years. Approximately half of them are born with an antigen known as Human Leucocyte Antigen (HLA) B27 and, as well as uveitis, this makes them more likely to develop inflammation elsewhere such as:

  • psoriatic arthropathy (joint inflammation associated with an abnormal skin condition)
  • ankylosing spondylitis (which affects the spine and its joints with the pelvis)
  • inflammatory bowel disease (such as Crohn’s disease and ulcerative colitis), and
  • reactive arthritis (joint inflammation as a reaction to infection of another part of the body)

The HLA-B27 antigen is found in only 8% of the general population.

Acute anterior uveitis usually comes on suddenly, producing a dull ache, redness, light intolerance and blurred vision in one eye.  The optometrist sees evidence of inflammation in the anterior chamber (the front part of the eye).  Using the slit lamp biomicroscope, he or she will see that the aqueous fluid, which fills the anterior chamber, contains tiny cells and protein, making it cloudy.  There may be nodules on the iris.  Provided that there is no serious effect on vision, severe pain or raised eye pressure, or inflammation affecting other parts of the eye, the optometrist will usually prescribe steroid drops to control the inflammation, plus other drops to relax the pupil by widening it.  If there is no improvement within one week, he or she will refer the patient urgently to the ophthalmologist.  The ophthalmologist will prescribe other drugs as necessary to suppress the inflammation and to deal with other problems such as raised eye pressure.

If the uveitis recurs twice, investigations including blood tests and X-rays will usually be ordered to look for underlying inflammation elsewhere in the body.  Controlling that inflammation may help to prevent further attacks of uveitis.

Uveitis (anterior, acute, and recurrent) Version 4
Date of search 18.03.16
Date of revision 22.12.16
Date of publication 01.06.17
Date for review 17.03.18
© College of Optometrists

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