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Clinical Summary

The uvea is the middle layer of the eye. Inflammation of the anterior portion (iris and ciliary body) is called anterior uveitis or iritis. The posterior portion includes the choroid. Approximately half of cases of iritis are associated with systemic disease. These include inflammatory disorders (rheumatoid arthritis, Behçet disease, sarcoid), HLA-B27–associated conditions (ankylosing spondylitis, inflammatory bowel disease, Reiter syndrome), and infectious causes (zoster, tuberculosis, toxoplasmosis, AIDS).

Clinical features include conjunctival hyperemia, hyperemic perilimbal vessels (“ciliary flush”), miosis, decreased visual acuity, photophobia, tearing, and pain. Leukocytes in the anterior chamber are characteristic. The slit lamp may demonstrate a hypopyon, cells, flare, and keratic precipitates (agglutinated inflammatory cells adherent to the posterior corneal endothelium). These appear either as fine gray-white deposits or as a large, flat, greasy-looking ones (“mutton fat”). The IOP may be decreased due to decreased aqueous production by the inflamed ciliary body or increased secondary to inflammatory debris within the trabeculae of the anterior chamber angle obstructing outflow.

Management and Disposition

The patient’s history forms the basis for the evaluation and laboratory testing and should focus on rheumatic illness, dermatologic problems, bowel disease, infectious exposures, and sexual history. Treatment is nonspecific. Topical cycloplegics and corticosteroids may be prescribed in conjunction with the ophthalmologist. Antibiotics are not usually prescribed.

FIGURE 2.43

Uveitis. Conjunctival injection, miosis, and cloudy anterior chamber with discoloration of iris compared to other eye in patient with anterior uveitis four days after intraocular injection. (Photo contributor: Kevin J. Knoop, MD, MS.)

FIGURE 2.44

Anterior Uveitis. Atraumatic left eye pain, photophobia, and limbal injection, in a middle-aged male with inflammatory bowel disease. Miosis is also present, a hallmark of uveitis. (Photo contributor: Lawrence B. Stack, MD.)

Pearls

  1. Iritis is usually associated with a miotic pupil.

  2. When uveitis is associated with a systemic disorder, the associated condition is usually evident. Common exceptions include sarcoidosis and syphilis. A chest x-ray looking for sarcoidosis and serologic testing for syphilis are reasonable.

  3. Patients with recurrent uveitis should undergo workup for systemic inflammatory disease.

  4. Topical analgesics do not significantly ameliorate the pain of anterior uveitis.

  5. Consider sympathetic ophthalmia with unexplained uveitis and a history of eye trauma.

FIGURE 2.45

Anterior Uveitis. Marked conjunctival injection and perilimbal hyperemia (“ciliary flush”) are seen in this patient with recurrent iritis. (Photo contributor: Frank Birinyi, MD.)

FIGURE 2.46

Hypopyon. A thin layering of white blood cells is present in the inferior anterior chamber. (Used with permission from Brice Critser, CRA, The University of Iowa and EyeRounds.org.)

FIGURE 2.47
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