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Anterior Uveitis

URGENT — Uveitis

Symptoms

  • acute pain: a deep, aching "boring" pain in the eye
  • redness: localized mostly around the iris (ciliary flush)
  • photophobia: sensitivity to light; often "consensual" (light in the healthy eye hurts the sick eye)
  • blurred vision: from inflammatory debris or secondary swelling (CME)
  • chronic floaters: more common in long-standing or recurrent cases

Clinical Findings

Slit lamp findings

  • ciliary flush: circumlimbal injection (redness concentrated in a ring around the cornea)
  • ac cells & flare: "dust motes" in a sunbeam; 0 to 4+ grading of white cells and protein leakage
  • keratic precipitates (kp): inflammatory dots on the corneal back surface; "mutton-fat" (large/greasy) suggests granulomatous disease
  • hypopyon: a layered "level" of white blood cells at the bottom of the anterior chamber

Structural changes

  • posterior synechiae: the iris "sticks" to the lens, causing an irregular, non-reactive pupil
  • iris nodules: koeppe (pupil margin) or busacca (iris stroma) nodules in granulomatous disease
  • band keratopathy: calcium deposits on the cornea from chronic inflammation

Etiology

Non-infectious (common)

  • idiopathic: 30–50% of cases have no identifiable cause
  • hla-b27 associated: linked to Ankylosing Spondylitis, IBD, Psoriatic Arthritis, or Reactive Arthritis
  • sarcoidosis: often presents with bilateral "mutton-fat" KPs and iris nodules
  • jia: chronic, often asymptomatic iritis in children; can lead to blindness if not screened

Infectious

  • herpetic (hsv/vzv): typically unilateral with high eye pressure and iris atrophy
  • syphilis/tb: the "great imitators"; can cause any pattern of inflammation

Special syndromes

  • fuchs heterochromic iridocyclitis (fhic): chronic, low-grade, non-responsive to steroids; different colored eyes

Red Flags

  • mutton-fat kps: strongly suggests sarcoid, TB, or syphilis—requires systemic workup
  • hypopyon: classic for HLA-B27 or Behçet disease; also rules out endophthalmitis
  • high iop: common in herpetic uveitis (trabeculitis) or synechial angle closure
  • chronic pediatric uveitis: may be completely white and painless (JIA) while still causing damage

Investigations

Clinical workup

  • review of systems: check for back pain, rashes, cough, diarrhea, or ulcers
  • dilated fundus exam: essential to ensure there is no posterior involvement (Panuveitis)

Targeted labs

  • hla-b27: if acute/recurrent and unilateral
  • syphilis/tb/sarcoid screen: RPR/FTA-ABS, QuantiFERON, and Chest X-ray/ACE
  • pcr: of aqueous fluid if viral (HSV/CMV) or toxo is suspected

Treatment

Topical therapy

  • steroids: Prednisolone Acetate 1% or Difluprednate 0.05% with a slow, careful taper
  • cycloplegics: Cyclopentolate 1% or Atropine 1% for comfort and pupil management

Systemic/advanced

  • immunomodulators: Methotrexate or Biologics (e.g., Adalimumab) for JIA or chronic steroid-requiring cases
  • iop control: standard glaucoma drops (avoiding prostaglandins if they worsen inflammation)

Clinical Pearl

Granulomatous KPs (large, "mutton fat") suggest sarcoidosis, TB, or syphilis. Non-granulomatous (small, fine) KPs suggest HLA-B27 associated disease or herpes.

Differential Diagnosis

  • • scleritis (presents with much more severe, "boring" pain and a deeper red hue)
  • • endophthalmitis (post-surgical or traumatic; severe vision loss and vitritis)
  • • pigment dispersion syndrome (pigment in the AC can mimic cells; look for iris transillumination)
  • • masquerade syndromes (lymphoma or leukemia in older or high-risk patients)

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