Anterior Uveitis

Question 1

Aetiology

Answer 1

Inflammation of all or part of the uveal tract.
Iritis - inflammation of the iris.
Iridocyclitis - inflammation of the iris and ciliary body.

Exogenous aetiology
- Trauma
- Surgery
- Rarely, drug induced e.g. biphosphonates

Endogenous aetiology
- Autoimmune conditions such as: RA, ankylosing spondylitis, juvenile arthritis, psoriatic arthritis, Behçet’s disease, sarcoidosis, IBS, lupus
- Infectious conditions such as HSK, HZO.
- Fuch’s heterochromic iridocyclitis - low grade uveitis, heterochromia, cataract
- Posner - Schlossman syndrome - recurrent spikes in IOP with AC inflammation.

Question 2

Symptoms

Answer 2

Pain - dull ache which is worsened with pupillary constriction.
Photophobia
Redness
Watering
Blurred vision

Question 3

Signs

Answer 3

Always conduct dilated exmaination of both eyes to rule out posterior involvement e.g. vitreous cells, snow banking, macular oedema

Hyperaemia - circumcorneal flush
KPs - non-granulomatous are fine and less likely to be associated with systemic disease, granulomatous are large mutton fat KPs likely associated with systemic disease
Iris nodules - Koeppe (small, near pupil), Busacca ( large, far from pupil)
AC cells and flare
Posterior synechiae - causing pupil block, raised IOP, iris bombe
Hypopyon / fibrin in more severe cases
Anterior vitreous cells - indicating int/post involvement
Pupil is small, constricted, non-reactive in some cases

Question 4

Non-pharmacological management

Answer 4

Sunglasses for photophobia
Spectacle near addition for cycloplegia

Thorough history taking
Dilated fundoscopy of both eyes
Check IOP

Question 5

Pharmacological management

Answer 5

First episode if non-granulomatous, unilateral, no post/int involvement, no systemic associations:

HOURLY steroid (Dexamethasone / Prednisolone) until eye is white.
CYCLOPENTOLATE tds for 1 week.

Review within 3 days.
If getting better, reduce steroid to every 2 hours for 5 days and then TAPER over no less than 6 weeks.

If no better after 1 week, refer urgently to HES.

Subsequent / second episode: As above but refer urgently to HES.

Question 6

Referral criteria?

Answer 6

First episode if non-granulomatous, unilateral, no post/int involvement, no systemic associations - manage with pharmacological treatment, if no better after 1 week, then refer urgently.

First episode - initiate pharmacological treatment and refer urgently if the following is present:
- no improvement after 1 week
- granulomatous features from outset
- hypopyon or fibrin in AC
- failure to break PS, inadequate pupil dilation
- bilateral
- systemic associations
- post/int involvement

SAME DAY if severe pain, raised IOP, significant loss of vision - NO INTERVENTION

If Fuchs heterochromic iridocyclitis or Posner Schlossman syndrome - refer urgently with no intervention

Question 7

What can be done at hospital?

Answer 7

Investigate cause of uveitis and refer to immunology, rheumatology

Anti microbial treatment if infectious in origin

treat secondary glaucoma

Sub conjunctival injection of mydriatic

sub tenon steroid injection

systemic immunosuppression / immunomodulatory therapies