Anterior Uveitis - Pearls and Pitfalls

A patient presents with anterior uveitis. You have so many questions.

What is the uvea?
The uvea is the term for the iris, ciliary body and choroid. The anterior uvea consists of the iris and ciliary body, while the posterior uvea is the choroid. Hence, anterior uveitis is also called iritis, (or iridocyclitis if it involves the ciliary body).

Uvea anatomy

What causes anterior uveitis?

Most causes of anterior uveitis are from systemic infections or systemic inflammatory diseases (ankylosing spondylitis, sarcoidosis or other rheumatic disorders). Direct eye trauma can also cause anterior uveitis, called traumatic iritis. This can present days after the trauma. About 30% of cases are idiopathic.

What are the symptoms?

Anterior uveitis typically presents as a unilateral, painful red eye. Patients may have tearing and photophobia. Slightly decreased visual acuity may be present as well.

What does anterior uveitis look like on exam?

The eye exam will show conjunctival injection, worse around the limbus, which is the area of the conjunctiva adjacent to the iris. This is called perilimbal injection or ciliary flush.

Perilimbal injection aka ciliary flush

The affected eye will likely have a constricted pupil, and patient will likely have pain with both direct and consensual light reflex. On slit lamp exam you will see cells and flare in the anterior chamber. This represents leukocytes that appear as little sparkles (cells) and proteins that appear as a general haze (flare).

Cells and flare

In severe inflammation there can be a layer of pus in the anterior chamber, called a hypopyon.

Hypopyon

Importantly, patients rarely have increased intra-ocular pressure (IOP), so acute angle-closure glaucoma should be ruled out with IOP measurement.

What should we do in the ED for anterior uveitis?

Ophthalmology consultation is warranted for suspected anterior uveitis. Treatment is topical corticosteroids, typically prednisolone acetate 1%, and re-evaluation in ophthalmology clinic in 2-3 days.

Alteveer, Janet and Kathryn McCans. The Red Eye, The Swollen Eye and Acute Vision Loss: Handling Nontraumatic Eye Disorders in the ED. Emergency Medicine Practice 2002, 4:6.
Dahl, Andrew. Nongranulomatous Iritis (Anterior Uveitis). Medscape 2017. Accessed August 20, 2017 http://emedicine.medscape.com/article/1209595-overview
Dupre, Alan and John Wightman. Red and Painful Eye. Rosen’s Emergency Medicine: Concepts and Clinical Practice 9th Ed. Philadelphia, PA: Elsevier.
Rosenbaum, James. Uveitis: Etiology, clinical manifestations and diagnosis. UptoDate 2017. Accessed August 20, 2017 https://www.uptodate.com/contents/uveitis-etiology-clinical-manifestations-and-diagnosis
Smith WM, Reddy MG, Hutcheson KA, Bishop RJ, Sen HN: Rifabutin-associated hypopyon uveitis and retinal vasculitis with a history of acute myeloid leukemia. J Ophthalmic Inflamm Infect 2012, 2: 149–152. 10.1007/s12348-012-0059-9