Anterior uveitis on one page

Anterior uveitis shows up across all three exams: the immunology behind it in Part I, the case in Part II and the conversation with the patient in Part III. Here is the core in one place.

Recognize it

• Symptoms: pain, photophobia, redness and blurred vision, usually in one eye in acute disease.
• Signs: circumlimbal (ciliary) flush, anterior chamber cells and flare, keratic precipitates, posterior synechiae, and sometimes a low pressure from reduced aqueous production.
• Grading: the SUN scheme counts cells in a 1 mm by 1 mm beam. Fewer than 1 cell is grade 0, 1 to 5 is 0.5+, 6 to 15 is 1+, 16 to 25 is 2+, 26 to 50 is 3+ and more than 50 is 4+.

Classify it

Granulomatous inflammation, with large mutton-fat precipitates or iris nodules, points toward sarcoidosis, tuberculosis, syphilis or herpetic disease. Non-granulomatous inflammation with fine precipitates is typical of HLA-B27-associated disease. Note whether it is acute, recurrent or chronic, and whether one or both eyes are involved.

Work it up

A first, mild, unilateral, non-granulomatous episode with an unremarkable history often needs little testing beyond what the history suggests, though many clinicians test for syphilis in every case because it can mimic any uveitis. Granulomatous, bilateral, recurrent or atypical disease usually calls for a workup guided by the history, often including:

• HLA-B27, especially with inflammatory back pain.
• Syphilis serology.
• A chest X-ray and serum ACE or lysozyme for sarcoidosis.
• A tuberculosis test such as an interferon-gamma release assay.

Treat it

• Topical steroid: prednisolone acetate 1%, shaken well, dosed from every hour or two for severe inflammation down to four times daily for mild disease, then tapered slowly as the cells clear. Difluprednate is a potent alternative.
• Cycloplegic: homatropine 5% or cyclopentolate 1% two or three times daily to ease pain and prevent or break posterior synechiae, or atropine for severe inflammation.
• Pressure: check it at every visit. Inflammation can raise or lower it, and steroids can raise it. Treat a raised pressure with aqueous suppressants, and generally avoid prostaglandin analogs while the eye is inflamed.

Follow it

Recheck in about a week, then taper the steroid according to the response. Never stop a steroid abruptly in active disease, and make sure the patient knows to come back quickly if the pain, redness or blur returns.