Anterior Uveitis

11/12/2024

Anterior Uveitis

Anterior uveitis is defined as inflammation of the iris and the ciliary body. This could affect one or both eyes. Anterior uveitis is part of a larger group of uveitis, which also includes intermediate, posterior, and panuveitis

Symptoms:

  1. Pain: A common and early symptom, typically described as a deep, aching pain that worsens with eye movement or light exposure.

  2. Redness: secondary to the inflammation occurring.

  3. Photophobia: Sensitivity to light due to irritation of the iris and the ciliary body.

  4. Blurred vision: This can occur because of the accumulation of inflammatory cells and proteins in the anterior chamber.

  5. Watering: Increased lacrimation is often seen due to irritation of the eye.

  6. Decreased visual acuity

Examination Findings:

  1. Conjunctival injection: The eye will appear red, especially around the corneal limbus (limbal injection is a classic feature).

  2. Cells and flare in the anterior chamber: The presence of white blood cells (cells) and proteinaceous material (flare) in the aqueous humor is characteristic of inflammation. (Tip: when examining for cells, it is best done in a dim environment and using the brightest configuration of your slit lamp, in addition to using a shorter beam of light)

  3. Keratic precipitates: These are inflammatory cells that deposit on the corneal endothelium and can be seen under slit-lamp examination (Tip: also known as mutton fat, these are found on the cornea and not the lens!)

  4. Iris abnormalities: In more severe cases, the iris may be swollen or irregular, with possible formation of posterior synechiae (It is important to release synechiae in patients to avoid long term iris abnormalities)

  5. Hypopyon: This is a collection of white blood cells in the lower part of the anterior chamber, and although it's more common in acute uveitis, it indicates a more severe inflammatory response.

Investigations:

  1. Slit-lamp examination: As mentioned, this is essential for detecting cells and flare in the anterior chamber, keratic precipitates, and other ocular signs of inflammation.

  2. Blood tests: Common investigations include:

    • Full blood count (FBC): To assess for systemic inflammation or infection.

    • Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP): These markers of systemic inflammation can help in diagnosing autoimmune conditions.

    • HLA-B27 testing: Useful for identifying associated systemic conditions such as ankylosing spondylitis, psoriatic arthritis, or reactive arthritis.

  3. Ocular imaging:

    • Optical coherence tomography (OCT): Can be used to evaluate the retina and optic nerve, particularly for detecting macular edema.

    • Fundus fluorescein angiography: This can help rule out posterior segment involvement, particularly in the case of panuveitis.

Treatment: The treatment of anterior uveitis aims to control inflammation, alleviate symptoms, and prevent long-term complications. The specific treatment plan depends on the severity and underlying cause of the disease.

  1. Topical corticosteroids: This is the mainstay of treatment for anterior uveitis is the use of topical corticosteroids (e.g Maxidex, PredForte), which help reduce inflammation. (Tip: At the start of the attack it is important to council the patients to use their drops hourly/2-hourly before slowly tapering down the dose to control the inflammation).

  2. Mydriatics (cycloplegics): Agents like atropine or cyclopentolate are used to relieve pain by dilating the pupil and preventing the formation of posterior synechiae.

  3. Oral corticosteroids: Only considered in severe or recurrent anterior uveitis, oral corticosteroids - topical is preferred due to their localised action.

  4. Other: immunosuppressive agents, antibiotics, surgery.

Complications: If untreated or poorly controlled, anterior uveitis can lead to several serious complications:

  1. Cataract formation: Prolonged inflammation can lead to the development of cataracts, particularly with the use of corticosteroids.

  2. Glaucoma: Increased intraocular pressure can occur, either due to steroid use or as a direct result of the inflammation.

  3. Macular edema: Swelling of the macula can lead to decreased vision and is particularly concerning for central vision loss.

  4. Posterior synechiae: Adhesions between the iris and lens can result in pupil irregularity and, in severe cases, may impair vision.

  5. Retinal involvement: In some cases, inflammation may extend posteriorly, leading to complications such as retinal vasculitis or choroiditis.

  6. Vision loss: Chronic, untreated anterior uveitis can lead to significant, permanent vision loss if complications like macular edema or retinal detachment occur.

Conclusion: Anterior uveitis is a potentially serious ocular condition that requires prompt diagnosis and treatment to prevent complications and preserve vision. The condition can be idiopathic or associated with systemic diseases such as autoimmune disorders or infections. A detailed clinical examination, appropriate investigations, and timely initiation of therapy are essential for successful management. Regular follow-up is crucial to monitor for recurrence and potential long-term complications.

References:

  1. Foster, C. S., & Vitale, A. T. (2019). Uveitis: Fundamentals and Clinical Practice (5th ed.). Elsevier.

  2. Jain, A. V., & Gritz, D. C. (2011). Epidemiology of uveitis. Seminars in Ophthalmology, 26(3), 137-146.

  3. Baghaie, M., & Asgarian, S. (2021). Current trends in the management of anterior uveitis. Ocular Immunology and Inflammation, 29(4), 777-785.

  4. McCluskey, P., & Wakefield, D. (2012). Inflammatory Eye Diseases. Springer Science & Business Media.

  5. Sika, P. A., & Guner, O. M. (2018). Diagnosis and management of anterior uveitis: A review. Current Opinion in Ophthalmology, 29(6), 505-514.

Author: Dr James Ng (5 mins read) 


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