Anterior uveitis

Introduction – epidemiology and causes/risk factors:

Uveitis is a condition that describes the inflammation of the iris, ciliary body, and choroid. Anterior uveitis, more specifically, is inflammation of the anterior segment, which includes iritis (anterior chamber inflammation alone), iridocyclitis (anterior chamber and anterior vitreous inflammation) and anterior cyclitis.

Anterior uveitis is the common type of uveitis, accounting for 90% of all cases of uveitis in primary care (in Western countries). There is no difference in prevalence by sex, while the most common age group of presentation is 20-50 years.

Anterior uveitis is more common in people with a previous history of uveitis, people over the age of 20, and HLA-B27 positive individuals (lifetime risk of 1%). HLA-B27 associated uveitis is typically more pronounced when first presenting and needs more intensive topical therapy.

Causes

  • Anterior uveitis is most commonly idiopathic (38-88% of cases).
  • Systemic autoimmune disorders are a common cause of anterior uveitis, including Behçet’s disease, sarcoidosis, multiple sclerosis, seronegative spondyloarthropathies (Reiter’s syndrome, IBD, juvenile inflammatory arthritis and ankylosing spondylitis) and psoriatic arthropathy.
  • Infections can also cause anterior uveitis – most commonly CMV, toxoplasmosis, HSV and VZV. More rarely, it can be caused by syphilis, toxocariasis, Lyme disease, TB, histoplasmosis, Aspergillus spp. and Candida spp.
  • Trauma and neoplasia are also potential causes.

Clinical features

  • History:
    • Symptoms arising over hours to days (acute) or more gradual (chronic)
    • Can be unilateral or bilateral
    • Worsening vision with flashes/floaters, dull pain, difficulty with bright lights
    • Increasingly red eye(s)
  • Examination findings:
    • Pain or dull ache worse when the ciliary muscle is contracted (e.g. reading), pain on palpation/extension to the surrounding orbit
    • Red eye with watering, photophobia, flashes and floaters (in chronic or recurrent uveitis the sclera can be white)
    • Diminished/blurred vision, unreactive/distorted pupil (iris-lens adhesion)
    • Can be accompanied with clinical signs of ocular trauma.
    • Increased intraocular pressure (most typically associated with herpetic keratouveitis)
    • Large yellow (“mutton-fat”) keratic precipitates  signs of granulomatous uveitis, typically chronic in nature and associated with microbial infection (e.g. syphilis, TB, herpes or toxoplasmosis) or autoimmune conditions (e.g. sarcoidosis)

Differentials to exclude

  • Acute glaucoma, endophthalmitis, keratitis, scleritis, ocular trauma, ocular ischaemia syndrome  all of these are sight-threatening differentials.
  • Benign differentials: dry eyes, episcleritis, conjunctivitis, superficial corneal injury, subconjunctival haemorrhage
  • Also keep in mind there are neoplastic syndromes that can mimic intraocular inflammation, such as lymphoma, leukaemia, ocular melanoma and metastases.

Investigations

  • Basic bloods (U&Es, LFTs, FBC, CRP/ESR, bone profile)
  • Autoimmune screens: HLA-B27 testing, ANA, serum ACE, rheumatoid factor
  • Faecal calprotectin (if suspecting IBD)
  • Infectious screen (TB, Lyme, CMV, HSV/VZV, HIV, syphilis, toxoplasmosis)
  • Imaging/other investigations: OCT (to assess for cystoid macular oedema), X-rays (chest if suspecting sarcoid/TB, spinal if suspecting ankylosing spondylitis), colonoscopy/sigmoidoscopy if concerned about IBD (not first-line)

Management

  • Patients with suspected new presentation of uveitis should be referred for assessment by secondary care within 24 hours – if there is severe eye pain and significant loss of vision, assessment should take place the same day.
  • Treatment should be initiated only in secondary care.
    • For non-infectious uveitis, the mainstay of treatment is corticosteroids to help reduce inflammation, typically as eye drops (though oral, IM or intravitreous steroids can also be used). Corticosteroids should be tapered over time to prevent rebound inflammation. Cycloplegic agents (e.g. cyclopentolate 1%) can be used to help relieve pain and prevent adhesions between the lens and iris.
    • If one eye is more affected than the other, periocular steroid injection (such as triamcinolone) can be considered.
    • For infectious uveitis, appropriate antimicrobials are added to the treatment with cycloplegics and corticosteroids.
      • Particularly for herpetic keratouveitis, treatment must include oral antivirals and intraocular pressure-lowering agents.
    • For severe or chronic uveitis, immunosuppression (e.g. TNFα inhibitors, methotrexate or mycophenolate) can be given, or procedures such as photo- or cryotherapy (or vitrectomy) can be pursued.

Prognosis and Complications

Anterior uveitis tends to resolve rapidly with appropriate treatment (and specifically acute anterior uveitis has the best visual outcomes post-treatment), though there is a proportion of people who develop chronic inflammation, which causes significant visual impairment and ocular complications. Permanent visual loss may be a complication of late detection and treatment, poor inflammatory control and recurrent episodes.

Bibliography/Acknowledgements

This guide was developed with information based on the CKS NICE Guidelines for uveitis (https://cks.nice.org.uk/topics/uveitis/) and BMJ Best Practice guide for uveitis (https://bestpractice.bmj.com/topics/en-gb/407).

Written by Dr Emmanuel Tasos (FY3) & reviewed by Mr Pavel Sharma (ST3 Ophthalmology)

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