Uveitis (OP)

Question 1

Define uveitis.

Answer 1

Inflammation of one or all parts of the uvea (middle vascular layer between retina and sclera)

Question 2

What are the different types of uveitis, and what parts of the uvea do they affect? (4)

Answer 2

• anterior uveitis (most common) - iris (iritis) and ciliary body
• posterior uveitis - choroid, retina, retinal vasculature
• intermediate uveitis - posterior ciliary body and pars plana
• panuveitis - inflammation in all three segments (iris, ciliary body, choroid)

Question 3

What is anterior uveitis associated with?

Answer 3

HLA-B27 gene

Question 4

What are the causes of anterior uveitis? (2)

Answer 4

• idiopathic
• non-infectious (autoimmune systemic disease) - reactive arthritis, ankylosing spondylitis, IBD, sarcoidosis

Question 5

What are the causes of posterior uveitis? (1 + 5)

Answer 5

Infections:

• HSV
• Varicella zoster virus
• HIV
• Lyme disease
• TB

Question 6

How can uveitis be classified by duration? (3)

Answer 6

• acute - sudden onset (hours-days), limited duration (<3 months)
• recurrent - repeated episodes separated by disease inactivity >3 months
• chronic - persistent uveitis >3 months, characterised by relapse within 3 months of therapy termination

Question 7

What are the clinical features of anterior uveitis? (10)

Answer 7

• pain (acute, progressive, dull pain in orbital region)
• red eye with no discharge
• photophobia
• decreased visual activity (blurred)
• lacrimation
• flare (inflammation and leukocytes floating in aqueous humour of anterior chamber)
• hypopyon (pus accumulation in anterior chamber)
• synechiae (constricted and fixed oval pupil)
• keratic precipitates (leukocyte deposits on corneal endothelium)
• no pain on eye movement (as with scleritis, orbital cellulitis, optic neuritis)

Question 8

What are the clinical features of posterior uveitis? (3)

Answer 8

• painless visual disturbances
• floaters
• decreased visual acuity (blurred)

Question 9

What might you see on examination in uveitis? (8)

Answer 9

• reduced visual acuity
• hyperaemia
• ciliary flush
• flare (inflammation and leukocytes floating in aqueous humour of anterior chamber)
• hypopyon (pus accumulation in anterior chamber)
• synechiae (constricted and fixed oval pupil)
• keratic precipitates (leukocyte deposits on corneal endothelium)
• no pain on eye movement (as with scleritis, orbital cellulitis, optic neuritis)

Question 10

What are some risk factors for uveitis? (5)

Answer 10

• inflammatory diseases (of joints, bowel or skin)
• HLA-B27 positive
• ocular trauma
• immunosuppression
• 30-40y

Question 11

How is uveitis usually diagnosed?

Answer 11

Clinical diagnosis

Important to do Ix for associated systemic conditions e.g. ACE (sarcoidosis), ANA (collagen vascular disease)

Question 12

What are some differential diagnoses for uveitis? (8)

Answer 12

• ocular lymphoma
• intra-ocular solid tumour/foreign body
• ocular ischaemia syndrome
• retinal detachment
• glaucoma (may see ‘halos’ around lights)
• scleritis (severe ocular pain and redness, no discharge)
• episcleritis (acute onset of redness, normal visual acuity and papillary reactions)
• conjunctivitis (discharge without significant pain, photophobia or change in vision)

Question 13

What is 1st-line management for non-infectious uveitis at initial presentation?

Answer 13

• corticosteroid eye drops (prednisolone) to reduce inflammation
• cycloplegic (mydriatic) eye drops (e.g. atropine) - dilates pupil = helps with photophobia and pain
• consider: peri-ocular/intra-ocular/oral corticosteroid (not in pregnancy)

Question 14

What do we do if a patient has infectious uveitis?

Answer 14

Specialty consultation - Abx or antiviral

Question 15

How do we manage chronic uveitis? (2)

Answer 15

• long-term local corticosteroid therapy (triamcinolone acetonide or intravitreal implants)
• immunomodulatory drugs (methotrexate)

Question 16

What should all patients with anterior uveitis do?

Answer 16

Emergency - if suspected, the patient should be referred immediately to ophthalmologist for treatment

Question 17

What are some complications of uveitis? (8)

Answer 17

• synechia
• retinal scarring
• cataract
• band keratopathy
• macular oedema
• glaucoma
• choroidal neovascularisation
• retinal detachment

Question 18

Describe the prognosis of uveitis.

Answer 18

• variable and depends on aetiology, location and severity
• 35% visual loss of >20/60 in 1+ eye
• 22% unilaterally/bilaterally blind