Anterior Uveitis

Eliza Hoskins



• Non-granulomatous anterior uveitis (NGAU) is a broad classification for various inflammatory conditions localized to the iris (iritis), ciliary body (cyclitis), or both (iridocyclitis) that typically present with pain, redness, and photophobia.

– Etiologies can be infectious or immune-mediated

– Systemic involvement or isolated to the eye

– NGAU is characterized by small punctate or stellate keratic precipitates (KP) versus granulomatous anterior uveitis with large greasy mutton fat KP with iris nodules or choroidal granulomas.



• 8–17 cases per 100,000 population (1,2)

• HLA-B27 more common in Caucasian males

• Behçet’s disease is more common in Asian and Middle- Eastern males

• Juvenile idiopathic arthritis (JIA) more common in females.


• Trauma

• Genetic predisposition (HLA-B27, HLA-B51)

• Smoking (3)


• HLA-B27 (ankylosing spondylitis (AS)), reactive arthritis (formerly Reiter’s syndrome), inflammatory bowel disease (IBD), psoriatic arthropathy

• HLA-B51 (Behçet’s disease)


No prevention of idiopathic NGAU.


• Idiopathic (50%)

• 30% AS patients have NGAU


See Review of Systems (ROS).



Targeted history onset, duration, location, quality of symptoms, and associated conditions. Clinical course (acute, chronic, or recurrent) laterality and previous treatments/trauma.

• Standardization of uveitis nomenclature (SUN) (4)

– Acute: Sudden onset with limited duration.

– Recurrent: Repeat episodes separated by periods of inactivity without treatment >3 months in duration

– Chronic: Persistent uveitis with relapse <3 months after discontinuing treatment

• Past medical, social, and family history

– Infectious disease exposure

– Autoimmune/Rheumatologic disease


– Medications: Rifabutin, Cidofovir, Prostaglandins

– Pets: Cats-Toxoplasmosis, puppies-Toxocariasis

– Family history: HLA-B27

• Review of systems (ROS):

– Constitutional: Fever, night sweats, chills (Infectious-endogenous endophthalmitis, tuberculosis), weight loss (malignancy)

– Skin/mucocutaneous: Erythema nodosum (IBD, Behçet’s, sarcoid) erythema chronicum migrans (Lyme), polyarteritis nodosa (PAN), aphthous/oral ulcers (Behçet’s, herpetic), scaling lesions (psoriasis, reactive arthritis), vitiligo, (Vogt Koyanagi Harada (VKH))

– Musculoskeletal: Sacroiliitis (ankylosing spondylitis, reactive arthritis, IBD); Monoarticular/pauciarticular arthritis (JIA), fasciitis/tendonitis (reactive arthritis)

– Respiratory: Asthma, wheezing, shortness of breath, cough (sarcoid, TB, coccidioidomycosis), sinus, and pulmonary disease (Wegener’s granulomatosis)

– Cardiovascular: Pericarditis (reactive arthritis, Lyme), thrombophlebitis (Behçet’s), AV block (Lyme)

– Gastrointestinal: Diarrhea (IBD, reactive arthritis)

– Genitourinary: Urethritis/circinate balanitis (reactive arthritis, syphilis), epididymitis (reactive arthritis, Behçet’s), genital sores/ulcers (syphilis, reactive arthritis, HSV, Behçet), urinary incontinence (Multiple sclerosis (MS)), elevated creatinine, abnormal urinalysis (Tubulointerstitial nephritis and uveitis syndrome (TINU))

– Hematological: anemia/elevated ESR (TINU)

– Neurologic: Meningitis (Behçet’s, Lyme, sarcoid, VKH), cranial nerve palsies (sarcoid, lyme, lymphoma, MS)


• External: Skin, joints, oral cavity, lymph nodes, neurologic, genitourinary

• Pupils: Irregular/secluded pupil (posterior synechiae), miotic and/or accommodate but don’t react to light (syphilis-Argyll Robertson pupil)

• Intraocular pressure:

– Acute increased IOP: Herpetic (trabeculitis), Fuchs’ heterochromic iridocyclitis, Glaucomatocyclitic crisis

• Gonioscopy: Peripheral anterior synechiae (PAS), KP, abnormal angle vessels-”Amsler sign” (Fuchs’)

• Eyelids/lashes: Vesicles (HSV), vitiligo (VKH), poliosis (white eyelashes) (VKH)

• Conjunctiva/Sclera: Circumferential ciliary flush, granulomas (sarcoid, TB), papillo-follicular conjunctivitis (reactive arthritis or Reiter’s Syndrome) conjunctival dendrites (herpetic), episcleritis/scleritis (IBD, RA, SLE, Wegener’s)

• Cornea: Decreased corneal sensation (herpetic), diffuse-stellate KP (Fuchs’, herpetic), band keratopathy (JIA, chronic uveitis), stromal edema (herpetic), peripheral ulcerative keratitis (Rheumatoid arthritis (RA), IBD, systemic lupus erythematosus (SLE), Wegener’s, PAN)

• Iris/anterior chamber/angle: Posterior synechiae, pupillary membranes, iris nodules (sarcoid- Koeppe-pupillary margin, Busacca-throughout iris), transilluminatory defects (TID’s)/atrophic iris (herpetic, UGH), heterochromia (Fuchs’), hypopyon (HLA-B27, Behçet’s, Retinoblastoma (Rb), infectious), hyphema (Herpetic, Fuchs’, juvenile xanthogranuloma (JXG), Rb, neovascularization of the iris/angle, leukemia)

• Anterior chamber reaction: Grading cell/flare: SUN (1 x1 mm2 slit beam) (4)

– Grade 0 (<1 cells)/complete absence

– Grade 0.5+ (1 – 5 cells)/n/a

– Grade 1+ (6–15 cells)/Faint

– Grade 2+ (16–25 cells)/Moderate (iris & lens clear)

– Grade 3+ (26–50 cells)/Marked (iris & lens hazy)

– Grade 4+ (>50 cells)/Intense (fibrin, plastic aqueous

• Lens/anterior vitreous: Lenticular precipitates, posterior subcapsular cataracts (chronic inflammation and topical/oral steroids), haptic induced TID’s (UGH), retained lens fragment, cyclitic membrane

• Dilated fundus examination: Vitreitis, snowballs, snowbanking (MS), cystoid macular edema (CME), vasculitis (Behçet’s), Toxoplasmosis scars, retinal necrosis/whitening (herpetic, acute retinal necrosis (ARN)), choroidal infiltrates (sarcoid, Birdshot, VKH, Dalen-Fuchs’ nodules), intraocular foreign body



Initial lab tests

Workup indicated if bilateral, severe, recurrent/nonresponsive to treatment or guided by History/ROS:

• RPR, FTA-ABS, CXR, ACE, HLA-B27, PPD (or quantiferon if vaccinated), Lyme Ab

– Target labs according to ROS and anatomic location of inflammation (anterior, intermediate, posterior, panuveitis)

– Consider ANA, rheumatoid factor if JIA is suspected: Girls: ANA +, RF- and pauciarticular; Boys: HLA-B27+, ANA-, RF-

– Consider ANCAs, ESR, CRP if associated scleritis and/or peripheral ulcerative keratitis Wegener’s/polyarteritis nodosa (PAN), rash (PAN), pulmonary/sinus disease (Wegener’s)

– Consider urinalysis for β2 microglobulin level, renal biopsy if suspect TINU

Follow-Up & Special Considerations

• Glaucoma

– Angle closure glaucoma (PAS)

– Pupillary Block glaucoma (Secluded pupil)

– Elevated IOP: Steroid induced glaucoma

• Posterior subcapsular cataract

• Cystoid macular edema (CME)


• CXR (Sarcoid, TB)

– Consider CT-chest, pulmonary function tests

• X-ray-sacroiliac joints (HLA-B27, ankylosing spondylitis)

• B scan if there is no view to posterior pole

• Fluorescein angiogram (CME, vasculitis, retinal/choroidal infiltrates)

• OCT for CME monitoring

Diagnostic Procedures/Other

• Anterior chamber/vitreous tap: PCR: herpetic or toxoplasmosis-correlate with serology, Cytology: lymphoma or leukemia

• Conjunctival biopsy (caseating vs. non-caseating granulomas)

Pathological Findings

• Small/medium KP: Neutrophils and lymphocytes

• Large (mutton fat) KP: Macrophages granulomatous

– Note: Granulomatous disease can present with small/medium KP.


• HLA-B27

– Ankylosing spondylitis

– Psoriatic arthropathy

– Inflammatory bowel disease (IBD)

– Postinfectious, or reactive arthritis (formerly Reiter’s syndrome)

• Juvenile idiopathic (rheumatoid) arthritis (JIA)

• Herpetic disease

– Herpes Simplex virus

– Varicella Zoster virus

– Cytomegalovirus

• Glaucomatocyclitic crisis (Posner-Schlossman syndrome)

• Fuchs’ heterochromic iridocyclitis

• Behçet’s disease

• Tubulointerstitial nephritis and uveitis syndrome (TINU)

• Traumatic iritis

• Lens-associated uveitis

– Phacolytic

• IOL-associated uveitis: Uveitis, glaucoma, hyphema (UGH)

• Drug induced uveitis

• Lymphoma

• Idiopathic uveitis

NOTE: Syphilis, sarcoidosis, tuberculosis (TB), VKH, and Lyme disease are in the differential diagnosis, but are classified as granulomatous.



First Line

• Topical steroids

– Prednisolone acetate 1% q 1–2 hour during first week and slowly taper over 4–6 weeks.

– Difluprednate 0.05% (Durezol) q.i.d = Prednisolone acetate 1% q2h

• Topical cycloplegics (ciliary spasm, prevention of posterior synechiae)

– Homatropine 5% b.i.d–t.i.d

• Sub-tenons steroid injection for chronic uveitis and/or CME. Consider short-acting prep such as dexamethasone phosphate if steroid response is a concern.

• Oral antiviral if herpetic disease suspected

Second Line

• Oral prednisone (1 mg/kg/d) (max 60–80 mg) do not continue at high dose >1 month. If there is no response after 2–4 weeks or fails a slow taper, steroid sparing immunosuppressive should be considered.

• Calcium 1500 mg and Vitamin D 800 IU (bone density prophylaxis)

• H2 Blockers (GI prophylaxis)


Counsel patients about 1) Cushingoid changes with oral prednisone >5–10 mg/d. 2) Dangers of abrupt discontinuation after adrenal glands have been suppressed. 3) Blood pressure, blood glucose, and cholesterol monitoring every 3 months. 4) Bone mineral density testing if on oral steroids >3 months, then annually. Risk of aseptic necrosis of bone 10–15% if on 60 mg in first month and >20 mg for first 6 months. 5) Children <15 years may have delayed pubertal growth (5).

• Steroid-sparing immunosuppressives if chronic and cannot taper systemic prednisone <10 mg without flare. Rheumatology consult.

– Antimetabolites: Azathioprine (Imuran), Methotrexate, Mycophenolate mofetil (CellCept)

– T cell inhibitor: Cyclosporine

– Biologics (TNF-alpha inhibitors) particularly useful in Ankylosing spondylitis, Behçet’s, JIA, or recalcitrant disease

Patients on antimetabolites should be monitored for bone marrow suppression, liver function, and pulmonary function q 3–6 weeks. Patients on cyclosporine should be monitored for nephrotoxicity and hypertension q 3–6 weeks (5). Patients on biologics should be monitored for malignancy, auto-antibodies, sepsis, and infection q 3–6 weeks.

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Nov 9, 2016 | Posted by in OPHTHALMOLOGY | Comments Off on Anterior Uveitis

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