Definition
A.Uveitis, also known as iritis, is inflammation of the uveal tract (iris, ciliary body, and choroid) and is usually accompanied by a dull ache and photophobia due to the irritative spasm of the pupillary sphincter.
Incidence
A.The true incidence is unknown. Approximately 15% of patients with sarcoidosis present with uveitis.
Pathogenesis
A.The cause is unknown. Underlying causes include infections, viruses, and arthritis.
Predisposing Factors
A.Collagen disorders.
B.Autoimmune disorders.
C.Ankylosing spondylitis.
D.Sarcoidosis.
E.Juvenile rheumatoid arthritis.
F.Lupus.
G.Reiter’s syndrome.
H.Behcet’s syndrome.
I.Syphilis.
J.Tuberculosis.
K.AIDS.
L.Crohn’s disease.
M.Lyme disease.
N.Cerebral vasculitis.
Common Complaints
A.Eye pain: Painless to deep-seated ache.
B.Photophobia.
C.Blurred vision with decreased visual acuity.
D.Black spots.
Other Signs and Symptoms
A.Unilateral or bilateral symptoms:
1.Unilateral: The pupil is smaller than that of the other eye because of spasm.
B.Ciliary flush.
C.Pupillary contraction.
D.Nausea and vomiting with vagal stimulation.
E.Halos around lights.
F.Hypopyon (pus in anterior chamber).
G.Limbal flush with small pupil.
Subjective Data
A.Elicit the onset, course, duration, and frequency of symptoms. Are symptoms bilateral or unilateral?
B.Identify the possible causal activity or agent (chemical, traumatic, or infectious etiologies).
C.Review the patient’s history of previous uveitis and other ophthalmologic disorders.
D.Review any associated fever, rash, headache, weight loss, joint pain, back pain, oral ulcers, or genital ulcers.
E.Review full medical history for comorbid conditions.
Physical Examination
A.Check temperature, pulse, respirations, and blood pressure.
B.Inspect:
1.Assess both eyes for visual acuity and peripheral fields of vision.
2.Check sclera and conjunctiva.
C.Other physical and mental health assessments need to be completed related to comorbid conditions.
Diagnostic Tests
A.Slit-lamp test: Slit-lamp examination reveals cells in the anterior chamber and flare,
representing increased aqueous humor protein. Inflammatory cells, called keratic precipitates, can collect in clusters on the posterior cornea.
B.Penlight examination: Flashlight examination shows a slightly cloudy anterior chamber in the uveitic eye.
Differential Diagnoses
A.Uveitis: Usually idiopathic, but it may be associated with many systemic and ocular diseases.
B.Acute angle-closure glaucoma.
C.Retinal detachment.
D.Central retinal artery occlusion.
E.Endophthalmitis.
Plan
A.General interventions:
1.Treat underlying cause as indicated.
2.Provide immediate referral to an ophthalmologist due to possible complications of cataracts and blindness.
B.Patient teaching:
1.Inform the patient that recurrent attacks are common and also require immediate attention.
2.Advise the patient to notify the provider if eye pain, change of vision, or other new symptoms occur.
C.Pharmaceutical therapy:
1.Medications are given by an ophthalmologist.
2.Uveitis and colitis often flare simultaneously; oral steroids are effective for both.
Follow-Up
A.A patient with uveitis needs a follow-up with an ophthalmologist.
Consultation/Referral
A.The patient should be referred immediately to an ophthalmologist for evaluation and intervention.
Individual Considerations
A.Adults:
1.Recurrent uveitis may be a sign of another systemic condition. Other conditions include infections (bacterial, spirochetal, viral, fungal, and parasitic infections); inflammatory diseases, including spondyloarthropathies (ankylosing spondylitis, psoriatic arthritis, reactive arthritis); inflammatory bowel disease; multiple sclerosis; and the use of new medications. Further workup should be performed for recurrent uveitis.
B.Geriatrics:
1.Research has indicated that uveitis is strongly associated with immunosuppression and autoimmunity disorders such as ankylosing spondylitis, gout, psoriasis, and rheumatic diseases, which are prevalent among the geriatric population.
2.with noninfectious/treatment resistant uveitis, refer to ophthalmologist/rheumatologist for collaborative management. Monoclonal tumor necrosis factor inhibitors (TNFi) such as adalimumb (Humira®) and infliximab (Remicade®) are demonstrating safety and efficacy with
no statistical significant differences.