Anterior uveitis

Typical symptoms in acute anterior uveitis are redness of the eye, pain, and photophobia (sensitivity to light). Vision may or may not be blurry. Acute anterior uveitis is usually a unilateral condition (mostly non-granulomatous inflammation), although different eyes may be affected at different times. The granulomatous kind of inflammation is more severe and usually bilateral.

Please note that patients may experience eye pain in different ways. Some may report no pain, while others may describe it as a foreign body sensation or an abrupt onset of a dull eye ache. The pain may be purely ocular or periorbital/temple pain.

Redness of the eye is not companied by discharge. However, photophobia (sunlight particularly) worsens eye discomfort.

Thoroughly obtaining a comprehensive medical history is crucial, involving the patient’s present and past personal history, surgical procedures, history of trauma, medications, and family medical history. Always ask about arthritis, rashes, shortness of breath, swollen lymph nodes, recent headaches, hearing difficulties, hair loss, pigment changes in the skin, a history of ocular trauma, recent insect bites, sexually transmitted diseases (STDs), TB exposure, blood in stools, and recent travel.(12,13,14)

Various clinical signs indicate the presence of intraocular inflammation. It is important to be familiar with them as the proper diagnosis is vital in uveitis conditions. It may be of sight-saving importance.

Intraocular pressure
Intraocular pressure is usually lower in the affected eye due to decreased production of aqueous secondary to an inflamed ciliary body. Sometimes, the IOP may be increased, and such uveitis is called hypertensive uveitis. It is commonly present in unilateral viral-related anterior uveitis.

Eye redness
Eye redness is present in the form of ciliary injection/flush. However, diffuse redness of conjunctiva may be present. Carefully examine conjunctiva for small nodules.

Keratitic precipitates
Keratitic precipitates are white blood cells present on the corneal endothelium. Small, white KPs are a sign of the non-granulomatous type of inflammation, while large, yellowish to brown KPs are significant for the granulomatous type of uveitis.

The presentation of corneal oedema and corneal decompensation may indicate viral aetiology.

Competence in examining the anterior chamber is crucial in recognising and monitoring anterior uveitis. Flares and cells in the anterior chamber are signs of intraocular inflammation. Therefore, the cells in the AC should be graded by severity under high-magnification slit lamp examination in a 1 X 1-mm field of light, as described by The SUN Working Group Grading Scheme for Anterior Chamber Cells, as follows(15):

• 0 < 1 cell
• 0.5 = 1-5 cells
• 1+ = 6-15 cells
• 2+ = 16-25 cells
• 3+ = 26-50 cells
• 4+ = More than 50 cells

Flare is the presence of proteins in the anterior chamber, and the SUN Working Group proposed the below classification(15):

• 0 = None
• 1+ = Faint
• 2+ = Moderate (iris and lens details clear)
• 3+ = Marked (iris and lens details hazy)
• 4+ = Intense (fibrin or plastic aqueous)

Examining the iris is very important in evaluating patients with uveitis. Chronic inflammation can develop anterior peripheral synechiae (adhesions between the iris and iridocorneal angle) or posterior synechiae (adhesions between the pupil margin and intraocular lens). Moreover, nodules on the iris may be observed, indicating inflammatory cell accumulation. These nodules are categorised into two types: Koeppe nodules, situated at the pupillary border, and Busacca nodules, located on the iris surface.

Patients with chronic uveitis may develop posterior subcapsular cataracts as a complication of the condition, taking steroids or both. Anterior vitreous cells are present in cases of cyclitis. Usually, the vitreous cells are signs of more extensive intraocular inflammation.

Slit lamp examination is crucial in examining patients with anterior uveitis.

Colour fundus photos are useful in checking posterior eye segments and recognising signs of posterior uveitis.

Optical coherence tomography is a golden standard in diagnosing uveitis macular oedema. Anterior uveitis may be complicated with macular oedema, and OCT scans are essential in overall workup with uveitis patients.

As highlighted in the section above, a thorough medical history is vital in evaluating uveitis patients.

During the first episode of patients with granulomatous inflammation, it is advisable to conduct laboratory and imaging workups. The recommended laboratory and imaging tests for such cases are as follows:(16)

• Purified protein derivative (PPD) test or Quantiferon testing for tuberculosis.
• A chest radiograph for sarcoidosis and TB should be obtained. In addition, a high-resolution chest CT should be considered if sarcoidosis is strongly suspected.
• Sacroiliac, lumbar, or thoracolumbar spine radiographs may be ordered if ankylosing spondylitis is suspected.
• Venereal Disease Research Laboratory (VDRL) test, FTA-ABS (or similar treponemal specific serology) test for syphilis.
• CBC with differential.
• Angiotensin-converting enzyme (ACE) test for sarcoidosis.
• Lyme serology if Lyme disease is suspected.

An experienced eye care specialist should prescribe treatment of uveitis.
Topical corticosteroids are the mainstay of therapy and should be used aggressively during the initial phases of therapy. A long-acting cycloplegic agent (cyclopentolate) is used to relieve pain. However, it is recommended for the acute form of the condition rather than for chronic forms. Systemic immunosuppression therapy may be indicated for recurrent or chronic diseases and flares that are vision-threatening despite local therapy.

Remember that infectious causes primarily require treatment for the specific infectious agent.
Surgery (i.e., cataract surgery) is performed when the eye is quiescent for at least three months.