Uveitis comes from the Latin word uva,meaning grape
Related Subjects:
Atropine |
About
- Intraocular inflammation of the middle tract of the eye can involve iris and ciliary body and uveal tract
- Causes include trauma or iatrogenic sources, an infectious agent, medications, a systemic autoimmune condition or idiopathic causes
- AAU affects relatively young patients with significant distress and potentially long-lasting sight-threatening complications
Epidemiology
- 50% of cases are
idiopathic
- Uveitis can occur at any age, but the average age at
presentation is about 40
- Anterior uveitis causes 90% of cases of uveitis
Types
- Anterior Uveitis: involves the iris(iritis),anterior ciliary
body(cyclitis),or both (iridocyclitis)
- Posterior uveitis : choroid(choroditis),retina (retinitis),both( chororetinitis),or retinal vessels(retinal vasculitis)
- Intermediate uveitis
- Panuveitis uveitis
Aetiology: 50% of cases are
idiopathic
- Idiopathic: Anterior uveitis with the HLA-B27 haplotype
- Trauma, including penetrating injury and ophthalmic surgery
- Fuchs’
heterochromic cyclitis
- Posner–Schlossman
syndrome
- Rheumatological HLA-B27-associated Ank SPond, Psoriatic, recative
- Juvenile
idiopathic arthritis
- Behçet’s
disease
- Polyarteritis
nodosa
- Granulomatosis
with polyangiitis (Wegener’s)
- Brucellosis
- Herpes
virus infections
(CMV, HSV, VZV)
- Leptospirosis, Lyme
borreliosis, Syphilis
- Toxoplasmosis, Tuberculosis
- Whipple’s
disease, Crohn’s disease, ulcerative colitis)
- Primary
central nervous system lymphoma (rare)
- Multiple
sclerosis, Sarcoidosis
Clinical
- Anterior uveitis: redness and pain tends to start quickly
- Pupil may be constricted. Tearing.
- Limbal flush, posterior synechiae and Anterior chamber cells
- Assess visual acuity which may be reduced
- Flare observed on slit-lamp biomicroscopy see below
Investigations
- Slit lamp biomicroscopy: are cells and “flare” (protein) in the
anterior chamber. The inner surface of the cornea may be speckled with keratic precipitates that either fine (“granular”) or globular (“granulomatous” or “mutton fat” keratic precipitates)
- PCR has proven most helpful in herpetic uveitis cases, such as herpetic anterior uveitis and ARN
- Investigations for systemic disease - TB and other infections and autoimmune diseases etc.
Differentials
- AAU (iritis, iridocyclitis)
- Episcleritis/Scleritis
- Acute angle closure glaucoma
- Endophthalmitis (post operation, endogenous)
- Keratitis (infective, traumatic/toxic, contact lens
acute red eye)
- Lens-related (phacolysis/phacoanaphylaxis)
- Posterior segment disease (tumor, panuveitis)
Complications
- Glaucoma
- Cataracts
- Corneal complications
- Systemic side effects
Management: Dialate pupil and give steroids
- Idiopathic Anterior uveitis: Acutely, dilating
drops prevent the inflamed iris from sticking to the
lens (posterior synechiae) and obstructing the outflow of aqueous
fluid. Given with a reducing dose of topical glucocorticoids, usually
over 4–6 weeks
- Management of AAU is focused on reducing the inflammation and any associated pain, redness, photophobia and visual blur and determining the aetiology.
- Sun protection: avoidance of bright light is to their immediate benefit. Encouragement of sunglasses, a brimmed hat, staying indoors more frequently and lowered lighting levels are good behavioural modifications during the acute symptomatic stage.
- Cycloplegics: Cycloplegic agents are important for relaxing the iris (for comfort), breaking posterior synechiae, and stabilizing the blood-aqueous barrier by decreasing the iris surface area (preventing further cellular and exudative leakage). The most popular agents used in AAU treatment are homatropine 5% or scopolamine 0.25%. Atropine is used in more severe cases. They will enlarge pupils and
temporarily blur vision,
especially when reading
- Mydriatics: Phenylephrine is an adrenergic
(alpha receptor) agonist used for assisting with the dilation of the pupil. It is used in-office with a cycloplegic agent for breaking recalcitrant posterior synechiae. Usually, only one or two drops are instilled in the affected eye to facilitate dilation. The drug also assists in facilitating view of the vitreous and retina, to determine if there is any posterior segment inflammation.
- Corticosteroids: Corticosteroids are critical in the
treatment of uveitides, including
AAU. They reduce pain (including photophobia), inflammation
(of most ocular tissues) and redness
(of conjunctiva, episclera, limbus).
Corticosteroids block the enzyme phospholipase A2 (which converts cell membrane phospholipids into inflammatory mediators such as leukotrienes and prostaglandins).
- Herpetic anterior uveitis is treated primarily with topical corticosteroids. Oral acyclovir should be
started as well because long term prophylactic oral Aciclovir(400 mg twice daily)
References