|
|
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  | Check |
DOI: 10.4103/jcor.jcor_92_16
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 2023 Jan 31];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
Click here to view |
 | Table 2: The Standardization of Uveitis Nomenclature Working Group descriptors in uveitis
Click here to view |
 | Table 3: The Standardization of Uveitis Nomenclature Working Group activity of uveitis terminology
Click here to view |
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
Click here to view |
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]. | Table 4: The Standardization of Uveitis Nomenclature Working Group grading scheme for anterior chamber flare
Click here to view |
 | Table 5: The Standardization of Uveitis Nomenclature Working Group grading scheme for anterior chamber cells
Click here to view |
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]
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.
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.
References | |  |
1. | Dernouchapms JP. Epidemiology of uveitis in Belgium: A preliminary Study. In: Proceedings of the Third International Symposium of Uveitis. Kugler Publications, Amsterdam; 1993. p. 157-9. |
2. | Sugita M, Enomoto Y, Nakaura S. Epidemiological study on endogenous uveitis in Japan. In: Proceedingsof the Third International Symposium of Uveitis. Kugler Publications, Amsterdam; 1993. p. 161-3. |
3. | Couto C, Merlo JL. Epidemiological Study of patients with uveitis in Buenos Aires, Argentina. In: Proceedings of the Third International Symposium of Uveitis. Kugler Publications, Amsterdam; 1993. p. 171-4. |
4. | Weiner A, BenEzra D. Clinical patterns and associated conditions in chronic uveitis. Am J Ophthalmol 1991;112:151-8. |
5. | Jabs DA, Nussenblatt RB, Rosenbaum JT, Standardization of Uveitis Nomenclature (SUN) Working Group. Standardization of uveitis nomenclature for reporting clinical data. Results of the first international workshop. Am J Ophthalmol 2005;140:509-16. |
6. | Cullom RD, Chang B. The Wills Eye Manual. Philadelphia: J.B. Lippincott; 1994. p. 353-4. |
7. | Kanski JJ. Screening for uveitis in juvenile chronic arthritis. Br J Ophthalmol 1989;73:225-8. |
8. | Agrawal RV, Murthy S, Sangwan V, Biswas J. Current approach in diagnosis and management of anterior uveitis. Indian J Ophthalmol 2010;58:11-9.  [ PUBMED] [Full text] |
9. | Rothova A, van Veenedaal WG, Linssen A, Glasius E, Kijlstra A, de Jong PT, et al. Clinical features of acute anterior uveitis. Am J Ophthalmol 1987;103:137-45. |
10. | Benezra D, Ohno S, Seechi AG, Alio JL. Anterior Segment Intraocular Inflammation Guidelines. Dunitz M; 2000. p. 3-21. |
11. | Dua HS, Dick AD, Watson NJ, Forrester JV. A spectrum of clinical signs in anterior uveitis. Eye (Lond) 1993;7(Pt 1):68-73. |
12. | Schlaegel TF Jr., O'Connor GR. Current aspects of uveitis. General considerations. Int Ophthalmol Clin 1977;17:1-42. |
13. | Das D, Biswas J, Ganesh SK. Pattern of uveitis in a referral uveitis clinic in India. Indian J Ophthalmol 1995;43:117-21.  [ PUBMED] [Full text] |
14. | Hogan MJ, Kimura SJ, Thygeson P. Signs and symptoms of uveitis. I. Anterior uveitis. Am J Ophthalmol 1959;47:155-70. |
15. | Pavesio CE, Nozik RA. Anterior and intermediate uveitis. Int Ophthalmol Clin 1990;30:244-51. |
16. | Sinha R, Naithani P, Garg S. Newer investigations and guidelines in uveitis. Indian J Ophthalmol 2010;58:88-91. [Full text] |
17. | Rosenbaum JT, Nozik RA. Uveitis: Many diseases, one diagnosis. Am J Med 1985;79:545-7. |
18. | Forooghian F, Gupta R, Wong DT, Derzko-Dzulynsky L. Anterior uveitis investigation by Canadian ophthalmologists: Insights from the Canadian National Uveitis Survey. Can J Ophthalmol 2006;41:576-83. |
19. | Wakefield D, Montanaro A, McCluskey P. Acute anterior uveitis and HLA-B27. Surv Ophthalmol 1991;36:223-32. |
20. | Brewerton DA, Caffrey M, Nicholls A, Walters D, James DC. Acute anterior uveitis and HL-A 27. Lancet 1973;302:994-6. |
21. | Narayana KM, Bora A, Biswas J. Patterns of uveitis in children presenting at a tertiary eye care centre in South India. Indian J Ophthalmol 2003;51:129-32.  [ PUBMED] [Full text] |
22. | Mackensen F, Becker MD, Wiehler U, Max R, Dalpke A, Zimmermann S, et al. QuantiFERON TB-gold – A new test strengthening long-suspected tuberculous involvement in serpiginous-like choroiditis. Am J Ophthalmol 2008;146:761-6. |
23. | Ang M, Htoon HM, Chee SP. Diagnosis of tuberculous uveitis: Clinical application of an interferon-gamma release assay. Ophthalmology 2009;116:1391-6. |
24. | Weinreb RN, O'Donnell JJ, Sandman R, Char DH, Kimura SJ. Angiotensin-converting enzyme in sarcoid uveitis. Invest Ophthalmol Vis Sci 1979;18:1285-7. |
25. | Shulman JP, Latkany P, Chin KJ, Finger PT. Whole-body 18FDG PET-CT imaging of systemic sarcoidosis: Ophthalmic oncology and uveitis. Ocul Immunol Inflamm 2009;17:95-100. |
26. | Biswas J. Practical concepts in the management of uveitis. Indian J Ophthalmol 1993;41:133-41.  [ PUBMED] [Full text] |
27. | Bartlett JD, Jaanus SD. Anti-inflammatory drugs. Clinical Ocular Pharmacology. 2 nd ed. Boston: Butterworths; 1989. p. 172. |
28. | Foster CS, Alter G, DeBarge LR, Raizman MB, Crabb JL, Santos CI, et al. Efficacy and safety of rimexolone 1% ophthalmic suspension vs. 1% prednisolone acetate in the treatment of uveitis. Am J Ophthalmol 1996;122:171-82. |
29. | Havener WH. Ocular Pharmacology. St. Louis: CV. Mosby; 1983. p. 383-5. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
|