[Emergency] ATLAS OF ANTERIOR UVEITIS (IRITIS)

ANTERIOR UVEITIS (IRITIS), ATLAS OF ANTERIOR UVEITIS (IRITIS), [Emergency] ATLAS OF ANTERIOR UVEITIS (IRITIS), OPHTHALMIC CONDITIONS

Clinical Summary

The uvea is the middle layer of the eye. Its anterior portion includes the iris and ciliary body; the posterior portion includes the choroid. Inflammation of the anterior portion is called anterior uveitis or iritis. It is often idiopathic, but approximately half of cases are associated with systemic disease. These include inflammatory disorders (rheumatoid arthritis, Behçet disease, sarcoid), HLA-B27-associated conditions (ankylosing spondylitis, inflammatory bowel disease, Reiter syndrome), and infectious causes (zoster, tuberculosis, toxoplasmosis, AIDS).

Clinical features include conjunctival hyperemia, hyperemic perilimbal vessels (“ciliary flush”), miosis, decreased visual acuity, photophobia, tearing, and pain. The slit-lamp may demonstrate a hypopyon, cells, flare, and keratic precipitates. Keratic precipitates are agglutinated inflammatory cells adherent to the posterior corneal endothelium. These precipitates appear either as fine gray-white deposits or as a large, flat, greasy-looking area (“mutton fat”). The IOP may be decreased due to decreased aqueous production by the inflamed ciliary body, or increased secondary to inflammatory debris within the trabeculae of the anterior chamber angle obstructing outflow. 

FIGURE 2.33 ■ Anterior Uveitis. Atraumatic left eye pain, photophobia, 

and limbal injection, in a middle-aged male with inflammatory

bowel disease. Miosis is also present, a hallmark of uveitis.  

FIGURE 2.34 ■ Anterior Uveitis. Marked conjunctival injection

and perilimbal hyperemia (“ciliary flush”) are seen in this patient

with recurrent iritis.  

FIGURE 2.35 ■ Hypopyon. A thin layering of white blood cells is

present in the inferior anterior chamber.

FIGURE 2.36 ■ Anterior Chamber Cells. Cells in the anterior

chamber are a sign of inflammation or bleeding and appear similar to particles of dust in a sunbeam. They are best seen with a narrow slit-lamp beam directed obliquely across the anterior chamber.  

FIGURE 2.37 ■ Anterior Chamber Flare. Flare in the anterior

chamber represents an elevated concentration of plasma proteins

from inflamed, leaking intraocular blood vessels. Flare seen in a slitlamp 

beam appears similar to a car headlight cutting through the fog.

FIGURE 2.38 ■ Keratic Precipitates. Deposits of cells on the endothelial layer of the cornea are seen in these photographs with a slit-lamp

beam (A), and under diffuse light (B).  

Management and Disposition

The patient’s history forms the basis for the evaluation and laboratory testing. The history should focus on rheumatic illness, dermatologic problems, bowel disease, infectious exposures, and sexual history. Treatment of the uveitis is nonspecific. Topical cycloplegics and corticosteroids may be prescribed in conjunction with the ophthalmologist. Antibiotics are not usually prescribed.

Pearls

1. Iritis is usually associated with a miotic pupil, pain, and redness primarily at the limbus (“ciliary flush”).

2. When uveitis is associated with a systemic disorder, the associated condition is usually evident. Common exceptions include sarcoidosis and syphilis.

3. In patients with uveitis of unknown etiology, a chest x-ray looking for sarcoidosis and serologic testing for syphilis are reasonable.

4. Visual loss may occur with uveitis.

5. Topical analgesics do not significantly ameliorate the pain of anterior uveitis.

6. Consider sympathetic ophthalmia with unexplained uveitis and a history of eye trauma. 

REFERENCES
The Atlas of Emergency Medicine, Fourth Edition, 2016.