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Uveitis

Basics

Uveitis is inflammation of the uveal tract, comprising the iris, ciliary body, and choroid. Types: - Anterior uveitis: Inflammation of the iris and ciliary body (iritis/iridocyclitis) - Intermediate uveitis: Pars planitis - Posterior uveitis: Involves choroid, retina, and optic nerve - Panuveitis: Inflammation of the entire uveal tract Pediatric considerations: Infections, trauma, and psychogenic factors (e.g., stress, depression) are more common.

Epidemiology

  • Equal sex distribution except:
    • HLA-B27 anterior uveitis: More common in males
    • Autoimmune uveitis: More common in females
  • Incidence: 17–52 per 100,000/year in developed nations
  • Prevalence: 38–714 per 100,000
  • Anterior uveitis: 80% of cases (iritis 4× more common than posterior uveitis)

Etiology and Pathophysiology

  • Infectious causes: Viral, bacterial, fungal, parasitic
  • Immune-mediated: Often linked to systemic autoimmune diseases
  • Drug-induced: e.g., rifabutin, bisphosphonates, sulfonamides, immune checkpoint inhibitors
  • Masquerade syndromes: Malignancies mimicking inflammation
  • Genetic:
    • HLA-B27: 50–70% of anterior uveitis cases
    • HLA-B51: Behçet disease

Risk Factors

  • No specific universal risk factor

Associated Conditions

  • Infectious: HSV, HZV, TB, toxoplasmosis, syphilis, CMV, histoplasmosis
  • Autoimmune: JIA, AS, Reiter, SLE, sarcoidosis, Behçet, Crohn, UC
  • Masquerade syndromes: Lymphoma, leukemia, retinoblastoma

Diagnosis

History

  • Symptoms:
    • Anterior: acute onset, pain, photophobia, blurred vision
    • Intermediate/posterior: bilateral, chronic, floaters, visual loss

Physical Exam

  • Requires slit-lamp and indirect ophthalmoscopy
  • Anterior:
    • Conjunctival/ciliary flush
    • Keratic precipitates, hypopyon
    • Posterior synechiae
  • Posterior:
    • Macular edema, retinal vasculitis, vitritis

Differential Diagnosis

  • Acute angle-closure glaucoma
  • Scleritis, conjunctivitis, keratitis

Diagnostic Workup

  • Initial labs: CBC, ESR, CRP, ANA, HLA-B27, VDRL, FTA-ABS, Lyme serology, TB screening
  • Imaging: Chest X-ray (sarcoidosis, TB), SI joint X-ray (AS)

Treatment

General Measures

  • Urgent ophthalmology referral
  • Identify and treat underlying cause

Medications

First-line: - Topical corticosteroids: Prednisolone acetate 1% most common - Taper gradually - Avoid in infectious uveitis unless co-treated - Cycloplegics: Atropine 1%, homatropine 5% to reduce pain, prevent synechiae Second-line: - Systemic corticosteroids: Posterior or severe non-infectious uveitis - Intravitreal corticosteroids: Retisert, Yutiq, Ozurdex - Immunosuppressives: - Antimetabolites: Methotrexate, azathioprine - T-cell inhibitors: Cyclosporine, tacrolimus - Alkylators: Cyclophosphamide - Biologics: Adalimumab (FDA-approved); other TNF inhibitors being studied - NSAIDs: Adjunct symptom relief

Referral

  • Ophthalmology consult is essential in most cases

Surgery

  • Reserved for complications (e.g., glaucoma, cataract, retinal detachment)

Ongoing Care

  • Regular follow-up with ophthalmology
  • Monitor for systemic disease
  • Patient education: eye drop administration, use of sunglasses

Prognosis

  • Infectious uveitis: Resolves with pathogen eradication
  • Autoimmune uveitis: Often recurrent, needs long-term management

Complications

  • Vision loss
  • Cataracts
  • Glaucoma
  • Retinal damage
  • Synechiae
  • Macular edema
  • Optic nerve atrophy

References

  1. Harthan JS, Opitz DL, Fromstein SR, et al. Clin Optom. 2016;8:23–35.
  2. Burkholder BM, Jabs DA. BMJ. 2021;372:m4979.
  3. Pleyer U, Neri P, Deuter C. Int Ophthalmol. 2021;41(6):2265–2281.
  4. Dick AD et al. Ophthalmology. 2018;125(5):757–773.

Clinical Pearls - Suspect uveitis with eye pain and visual changes - Posterior or recurrent uveitis needs systemic treatment - Always exclude masquerade syndromes and infectious etiologies before corticosteroid therapy