OcuLearning › Uveitis

Posterior and Panuveitis

URGENT — Uveitis

Symptoms

  • blurred vision and floaters (most common presentation)
  • scotomas (blind spots) and metamorphopsia (distorted vision)
  • photopsias (flashing lights) frequently present
  • dull ache or redness if associated anterior chamber inflammation is present
  • severe pain: suggests posterior scleritis or endophthalmitis

Clinical Findings

Core posterior signs

  • vitritis: vitreous cells, haze, "snowballs," or "snowbanking"
  • retinitis: focal or confluent retinal whitening (e.g., "headlight in fog" for toxo)
  • choroiditis: creamy yellow-white placoid or punched-out lesions
  • vasculitis: perivascular sheathing ("candle-wax drippings" in sarcoid) or hemorrhages

Pattern recognition

  • behçet: shifting hypopyon, occlusive vasculitis, and oral/genital ulcers
  • vkh: bilateral serous detachments, "sunset glow" fundus, and hearing/skin changes
  • birdshot: bilateral creamy oval choroidal spots in middle-aged caucasians (hla-a29+)
  • arn (acute retinal necrosis): peripheral confluent whitening and rapid progression
  • multifocal choroiditis: punched-out scars WITH vitritis (unlike pohs)

Complications

  • cystoid macular edema (cme): the leading cause of permanent vision loss
  • optic disc edema, epiretinal membranes, and secondary glaucoma

Etiology

Infectious (must rule out first)

  • toxoplasmosis: most common infectious cause; typically adjacent to an old scar
  • syphilis ("the great masquerader") and tuberculosis (tb)
  • viral: hsv/vzv (arn/porn) and cmv (suspect hiv/immunocompromised)

Non-infectious (autoimmune)

  • sarcoidosis: granulomatous inflammation; often involves lungs
  • vkh syndrome: targets melanocytes (pigmented populations)
  • birdshot chorioretinopathy and behçet disease

Masquerade

  • primary vitreoretinal lymphoma: suspect in older patients with refractory vitritis

Red Flags

  • confluent retinal whitening: suspect arn; emergency antivirals needed to save the eye
  • hypopyon in young patient: suspect behçet; high risk of occlusive retinal vasculitis
  • bilateral serous detachments: suspect vkh; requires immediate high-dose steroids
  • chronic "vitritis" in elderly: must rule out lymphoma before starting steroids

Investigations

Mandatory screening (pre-steroids)

  • syphilis: rpr/vdrl plus treponemal-specific assay (fta-abs)
  • tuberculosis: quantiferon-gold/t-spot plus chest x-ray or ct
  • sarcoidosis: serum ace, lysozyme, and chest imaging
  • hiv testing: mandatory for all patients with opportunistic infections (cmv/porn)

Imaging

  • oct macula: monitor for cme and subretinal fluid
  • wide-field fa: assess for retinal vasculitis, ischemia, and disc leakage
  • icg angiography: superior for choroidal disease (birdshot/vkh/serpiginous)

Specialized

  • hla typing: a29 (birdshot), b51 (behçet), dr4 (vkh)
  • aqueous/vitreous tap: pcr for hsv, vzv, cmv, and toxoplasma

Treatment

Infectious

  • toxoplasmosis: tmp-smx or pyrimethamine/sulfadiazine + folinic acid
  • viral (arn): iv acyclovir or oral valacyclovir + intravitreal foscarnet
  • syphilis/tb: specific iv/quadruple antibiotic protocols

Non-infectious

  • systemic steroids: prednisone 1mg/kg/day with a slow taper
  • steroid-sparing agents: methotrexate, mycophenolate, or anti-tnf (adalimumab)

Local/adjunct

  • periocular or intravitreal steroid implants (ozurdex/yutiq) for refractory/unilateral disease

Clinical Pearl

in posterior uveitis, the patient's ancestry often points to the diagnosis: hla-a29 (birdshot, northern european), hla-b51 (behçet, silk road), hla-dr4 (vkh, pigmented populations).

Differential Diagnosis

  • • white dot syndromes (apmppe, mewds, pic)
  • • primary vitreoretinal lymphoma (older, non-responsive to steroids)
  • • eales disease and multiple sclerosis (intermediate uveitis pattern)
  • • endogenous endophthalmitis

Related Uveitis Conditions