Recent approach in diagnosis and management of anterior uveitis

Sushil Kumar Bajoria; Jyotirmay Biswas

doi:10.4103/jcor.jcor_92_16

COMMISSIONED ARTICLE

Year : 2018 | Volume : 6 | Issue : 1 | Page : 36-41

Recent approach in diagnosis and management of anterior uveitis

Sushil Kumar Bajoria¹, Jyotirmay Biswas²
¹ Department of Ophthalmology, Tata Main Hospital, Jamshedpur, Jharkhand, India
² Department of Uveitis and Ocular Pathology, Medical Research Foundation, Sankara Nethralaya, Chennai, Tamil Nadu, India

Date of Web Publication

18-Jan-2018

Correspondence Address:
Sushil Kumar Bajoria
Department of Ophthalmology, Room No 138, Tata Main Hospital, Bistupur, Jamshedpur - 831 001, Jharkhand
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jcor.jcor_92_16

Abstract

This article aims to review the current literature to find the various current concepts in the diagnosis and management of anterior uveitis. It is important to go into the detailed history of the complaints. It will help in finding any systemic cause in most of the cases, if any. A thorough and detailed extraocular and ocular examination should be done. It will bring us closer as to which part of the uveal tissue is involved, i.e. anterior, intermediate, or posterior. It also highlights the various investigative and laboratory tests to be done, which will help in arriving at a diagnosis. Further aiding in diagnosis is radiological investigations such as computerized tomography of the chest which help in the diagnosis and management of systemic disorders such as tuberculosis or sarcoidosis. The primary modality of treatment in such cases is topical in the form of topical steroid and cycloplegics. The use of systemic steroids and immunosuppressants for treatment is reserved only for recalcitrant cases. The aim of the treatment is to preserve the vision of the patient and reduce the subsequent morbidity. To write this article, detailed search was carried out in the MEDLINE search. Published articles from various journals and national library of medicines MEDLINE were reviewed. Electronic database was also searched.

Keywords: Anterior uveitis, corticosteroids, cycloplegia, human leukocyte antigen-B27, immunosuppressants

How to cite this article:
Bajoria SK, Biswas J. Recent approach in diagnosis and management of anterior uveitis. J Clin Ophthalmol Res 2018;6:36-41

How to cite this URL:
Bajoria SK, Biswas J. Recent approach in diagnosis and management of anterior uveitis. J Clin Ophthalmol Res [serial online] 2018 [cited 2020 Oct 28];6:36-41. Available from: https://www.jcor.in/text.asp?2018/6/1/36/223573

It is an inflammatory process that affects the tissue structure of anterior uvea, i.e., iris and ciliary body. Anterior uveitis consists of 30%–73%^{[1],[2],[3],[4]} of all cases of uveitis. Anterior uveitis, if treated early and adequately, does not cause much visual disability. However, delayed and inadequate treatment can have devastating visual outcome. This article will discuss the recent trends in the diagnosis and management of anterior uveitis.

To write this article, detailed search was carried out in the MEDLINE search. Published articles from various journals and national library of medicines MEDLINE were reviewed. Electronic database was also searched. There are several classifications based on anatomy, clinical course, etiology, and histopathology. In 2005, Standardization of Uveitis Nomenclature Working Group ^[5] developed a classification based on anatomy, descriptors, standardized grading system, and terminology used for following the activity of uveitis [Table 1], [Table 2], [Table 3].

Table 1: The Standardization of Uveitis Nomenclature Working Group anatomical classification of uveitis

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Table 2: The Standardization of Uveitis Nomenclature Working Group descriptors in uveitis

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Table 3: The Standardization of Uveitis Nomenclature Working Group activity of uveitis terminology

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Workup in a Case of Anterior Uveitis

A careful history and systemic examination is very important in a patient who comes with complaints suggestive of anterior uveitis. It also tells us the course of the disease. A meticulous history helps us to come to a differential diagnosis.

The following points should be considered in history:

Age and sex of the patient

Different types of anterior uveitis affect different age groups. Some types of anterior uveitis show sex predilection also, for example, juvenile idiopathic arthritis affects children and females more.^[6],[7]

Human leukocyte antigen (HLA)-B27-related anterior uveitis, juvenile idiopathic arthritis-related anterior uveitis, granulomatous anterior uveitis associated with tuberculosis, and sarcoidosis are more common in young adults.^[6]

Middle age has preponderance of anterior uveitis associated with sarcoidosis and HLA-B27-related anterior uveitis.

Infectious uveitis, masquerade syndromes, and postoperative and drug-induced anterior uveitis are more common in elderly.

Anterior uveitis caused by infection, posttrauma, and following surgery can occur at any age.^[6]

Symptoms

The patients can present with various symptoms:

Most common of them are ocular pain, photophobia, redness, watering, and diminished vision.^[8],[9] It is important to find if any of these is present or not and the severity of each. Type of onset is also necessary to find in terms of whether it is sudden or gradual. The presence of absence of other symptoms, either ocular or systemic, should be elucidated, for example, watering, joint pains, fever, cough, etc.

Systemic Examination

Various systemic diseases can cause uveitis. History pertaining to those systems is to be asked. History of joint pain and swelling suggestive of arthritis, central nervous system symptoms, and symptoms related to gastrointestinal tract, genitourinary tract should be asked.^[6] Similarly, history of skin diseases or recent dental procedure should be enquired.^[6]

Past Ocular History

It should pertain to the number of attacks the patient had. When was the first attack, the date of last attack and the interval between the attacks should be looked into.

We should also find if one or both eyes were involved.

Any history of trauma or ocular surgery should always be considered.^[6]

Treatment History

It should include the various treatments the patient has taken previously. Ask for the use of steroids whether topical, systemic, or periocular and the duration. How often the treatment was given? When was the last periocular injection given? Was the patient given any type of immunosuppressives? The dosage and duration should be noted. Was the treatment stopped or dosage reduced due to complications such as cataract/glaucoma or Cushingoid syndrome? Has the cataract been operated or put on therapy for glaucoma. What are the current medications the patient on. Can any of them cause/aggravate uveitis such as prostaglandins.

History of Ocular Surgery

Has the patient undergone any ocular surgery such as cataract surgery, vitreoretinal surgery, or surgery for glaucoma? For cataract, the type of surgery, intraocular lens (IOL) implanted history of previous uveitis, any postoperative complications, postoperative steroid cover, or any complication should be enquired about.

Examination of a Case of Anterior Uveitis

Extraocular examination

Face

In facial examination, we should look for any scars caused by herpes zoster ophthalmicus or Hansen's disease. We should look for any vitiligo also.

Hands

In the examination of hands, see if any deformity such as swan neck deformity is present which is seen in rheumatoid arthritis.^[8] Any deformity suggestive of Hansen's disease should be looked for.

Posture

We should examine for change in posture in ankylosing spondylitis or juvenile idiopathic arthritis.^[8]

Ocular Examination

Torchlight examination is done for type, color, and extent of congestion. Whether the congestion is localized or diffuse suggestive of scleritis or anterior uveitis (circumciliary).^[8]

Pupillary reaction should be examined.

Slit-lamp examination

Conjunctiva

We should look for the type of congestion,^[6],[8] is there a presence or absence of nodules or any necrosis.

Sclera

While examining sclera, type of congestion, presence or absence of nodules, or any necrosis should be looked for.

Cornea

During corneal examination, look for clarity of the cornea, and presence of band-shaped keratopathy,^[6] any scars of viral keratitis are the corneal lesions active or healed? Is there any corneal edema or folds in the Descemet's membrane? We should look for any keratic precipitates – whether fresh (round and whitish)/old (pigmented and crenated edges), size – fine distributed over whole of endothelium, small, medium, or large mutton-fat type [Figure 1].^[6],[8],[10] What is the distribution pattern – along Arlt's triangle, diffuse, or localized.

Figure 1: Mutton-fat keratic precipitates in a case of granulomatous anterior uveitis

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Anterior chamber

While examining anterior chamber, look for depth, both central and peripheral. For anterior chamber reaction – look for cells and flare and grade them according to severity. If hypopyon is present note the type, color and extent. Also look for presence or absence of exudates/fibrin/hyphema ^{[8],[11],[12]} [Figure 2] and [Figure 3] and [Table 4], [Table 5].

Figure 2: Hypopyon anterior uveitis

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Figure 3: Fibrinous anterior uveitis

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Table 4: The Standardization of Uveitis Nomenclature Working Group grading scheme for anterior chamber flare

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Table 5: The Standardization of Uveitis Nomenclature Working Group grading scheme for anterior chamber cells

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Pupils

Pupillary examination is important and includes reaction of the pupils, their size, and shape (festooned) [Figure 4]. We should look for the presence of broad posterior synechiae or peripheral anterior synechiae.^[8]

Figure 4: Festooned pupil

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Iris

We should look for nodules– Koeppes nodules are seen at the pupillary edge. [Figure 5], busaccas nodules are seen in the iris stroma. [Figure 6]. Look for any atrophic patch in the iris, whether it is diffuse or sectoral [Figure 7],^{[8],[12],[13]} If posterior synechiae are present, whether they are localised and how many clock hours. If they are broad, it is suggestive of tuberculosis. It may be plastered to the anterior surface of the lens, 360°, giving rise to iris bombe. Look for peripheral anterior synechiae and mark their extent.

Figure 5: Koeppe's nodules

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Figure 6: Busacca nodules

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Figure 7: Iris atrophy in viral uveitis

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Lens

We should examine for lenticular changes and type of cataract – posterior subcapsular,^[6] nuclear, or total.

Intraocular lens

Examination of the IOL should include the type of lens, any pigments on it, and fixation of the haptics.^[14]

Intraocular pressure

It should be recorded in all cases of anterior uveitis. If it is high, it indicates blockage of the drainage or trabeculitis;^[9] if low, it indicates ciliary shutdown or membrane over ciliary body. High intraocular pressure is often associated with viral anterior uveitis.^[15]

Gonioscopy

Gonioscopic examination includes looking for peripheral anterior synechiae, their type, and extent.^[6] Nodules can also be seen in the angle in sarcoidosis.

Anterior vitreous

The presence of cells and grading, if present, should be recorded.^[6]

Fundus examination

It is done by slit-lamp biomicroscopy or indirect ophthalmoscopy and looks for posterior segment pathology such as cystoid macular edema, intermediate uveitis, or any other lesions.^[6]

Investigations in a Case of Anterior Uveitis

Since approximately 26% of anterior uveitis cases are associated with a systemic disease, a complete and thorough evaluation of all patients with anterior uveitis is necessary.^{[8],[16],[17]}

The investigations can be carried out in the following manner:^[18]

Nongranulomatous anterior uveitis in an adult

HLA-B27,^[19],[20] should be done routinely. In recurrent or chronic cases chest X-ray, X-ray sacroiliac joint are done. Other tests include venereal disease research laboratory (VDRL) and fluorescent treponemal antibody absorption (FTA-ABS)test.

Granulomatous anterior uveitis in an adult

Baseline complete blood count is to be done. It will show leucocytosis in infectious etiology. Other investigations that should be done are Mantoux test, Erythrocyte sedimentation rate, Chest X-ray, purified protein derivative tuberculin testing, serum angiotensin converting enzyme (ACE) levels,[21] serum lysozyme, Serum calcium and phosphorus, Quantiferon test for tuberculosis,^[22],[23] VDRL and FTA-ABS test. Anterior chamber paracentesis can be done in suspected tubercular uveitis.

Granulomatous anterior uveitis, suspected sarcoidosis, in an adult or child

Chest X-ray, serum ACE levels;[24] should be done. If the clinical suspicion is high despite these tests being normal then High-resolution computerized tomography scans of the chest or whole body gallium scan with or without biopsy should be undertaken. Equivocal cases can be further investigated and a possible diagnosis can be achieved[25] by Gallium scan and whole body 18-fluorodeoxyglucose positron emission tomography-computed radiographic tomography.

Anterior uveitis in a child

Anti-nuclear antibody, HLA-B27 and rheumatoid factor should be done in a chlid with anterior uveitis.

Treatment of Anterior Uveitis

The mainstay of treatment of anterior uveitis is topical steroids and cycloplegics.^[8] They help in controlling inflammation and give relief from pain and photophobia. They also help in the prevention of complications such as synechiae formation and development of secondary glaucoma. The ultimate aim is to preserve good visual function.

The preferred topical steroid is prednisolone acetate 1% eye drops. The frequency may vary according to the severity of the disease. The frequency needs to be gradually tapered depending on the response. If the response is inadequate, periocular or systemic steroids should be considered and started. The systemic steroids should be started at the dosage of 1.0 mg/kg body weight as a single dose in the morning after/with breakfast.^[26] Due to the risk of gastrointestinal problems, oral antacids should also be prescribed. Calcium supplements should also be prescribed, especially women due to the risk of osteoporosis. Intraocular pressure should be monitored at regular intervals.

Other topical corticosteroid drops available are:^{[27],[28],[29]}

Prednisolone acetate 0.125% and 1%
Betamethasone 1%
Dexamethasone sodium phosphate 0.1% (also available in 0.05% ointment form)
Fluorometholone 0.1% and 0.25% (also available in 0.1% ointment form)
Loteprednol
Rimexolone 1%.

The commonly used cycloplegic agents in treating anterior uveitis are atropine eye drops, 0.5%, 1%, 2%, homatropine eye drops, 2%, 5%, cyclopentolate eye drops, 0.5%, 1%, 2%, or phenylephrine eye drops, 2.5%. In severe cases of uveitis, atropine can be started twice or thrice daily for a few days and then switch to homatropine which is a short-acting cycloplegic. It keeps the pupil mobile preventing the formation of posterior synechiae. Prolonged use of atropine is not recommended as it may lead to posterior synechiae formation in dilated position.

Nonsteroidal anti-inflammatory drugs

These work by inhibition of arachidonic acid metabolism and include drugs such as indomethacin, flurbiprofen, and diclofenac sodium. However, when used alone, their efficacy in treating acute intraocular inflammation has not been established.

Immunosuppressive agents

In recalcitrant cases of juvenile idiopathic arthritis, not responding to systemic steroids may be considered for immunosuppressive therapy. The commonly used immunosuppressives are methotrexate and azathioprine. The patients should be told about the side effects of the medicines and the need for regular checkup.

One needs to start immunosuppressive in conjunction with the internist. Patients need to be educated about the side effects of immunosuppressives and should be strictly asked for regular blood and systemic examinations as and when required.

Conclusion

A thorough history, meticulous systemic examination, detailed ocular examination, relevant investigations, and sound knowledge of various causes of uveitis will help us in managing the anterior uveitis patients properly.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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