Uveitis

Last reviewed: June 2019

Last updated: March 2018

Summary

Anterior uveitis involves inflammation of the iris and ciliary body. Intermediate uveitis involves the posterior ciliary body and pars plana. Posterior uveitis involves the posterior vitreous, retina, choroid, retinal vasculature, and optic nerve. Panuveitis involves inflammation in the anterior, intermediate, and posterior segments of the eye.

All types of uveitis are potentially blinding conditions and should be referred to and managed by an experienced ophthalmologist.

Diagnosis is clinical. Acute anterior uveitis may be idiopathic, or associated with HLA-B27-related disease or viral eye disease. Posterior uveitis is associated with localised infections or systemic infection, or systemic inflammatory disease. Diagnosis of underlying disease may require investigation. In the clinical setting of multiple recurrences or strong suspicion based on history and review of systems, a targeted work-up should be undertaken to rule out an underlying infectious cause or co-existent autoimmune disease. Rarely, uveitis can be caused by a previous eye injury or underlying neoplasm.

Even after full laboratory and diagnostic work-up and treatment, aetiology may not be determined.

Treatment for systemic disease causing uveitis must be given in conjunction with uveitis therapy.

Topical corticosteroids are usually adequate for acute non-infectious anterior uveitis, but intermediate and posterior uveitis usually requires injected local corticosteroids or systemic steroids, or other immunosuppression.

Definition

Uveitis is an inflammation of one or all parts of the uvea, or the vascular area between the retina and sclera of the eye. The anterior uvea is composed of the iris and ciliary body; an irritation of this segment, or anterior uveitis, leads to acute painful symptoms and photophobia. Inflammation of the posterior uvea, including the choroid, retina, and retinal vasculature, carries a risk of painless visual loss. Uveitis of all types affects children and adults, and the aetiology is most commonly idiopathic.

History and exam

Key diagnostic factors

presence of risk factors
pain (anterior uveitis)
decreased vision
synechiae
flare
keratic precipitates

Full details

Other diagnostic factors

tearing
photophobia
floaters
eye redness without discharge
constricted or non-reactive pupil
decreased intra-ocular pressure
retinal exudates and oedema, optic nerve oedema
retinal vascular sheathing
macular oedema
optic disc swelling
retinal haemorrhages
ciliary flush
corneal oedema
cataract

Full details

Risk factors

inflammatory diseases of the joints, bowel, or skin
HLA-B27 positive
ocular trauma
age 30 to 40 years

Full details

Diagnostic investigations

1st investigations to order

clinical diagnosis

Full details

Investigations to consider

FBC
ESR
CRP
fluorescent treponemal antibody (FTA-ABS), venereal disease research laboratory (VDRL), and rapid plasma reagin (RPR)
serum ACE
antinuclear antibodies
HLA-B27
Lyme titre
purified protein derivative (PPD) skin test
cytoplasmic antineutrophil cytoplasmic antibodies (c-ANCA)
perinuclear antineutrophil cytoplasmic antibodies (p-ANCA)
C3 and C4
antidouble-stranded DNA antibody (anti-dsDNA)
rheumatoid factor
anticyclic citrullinated peptide (anti-CCP) antibodies
Bartonella henselae titre
toxoplasma serological titre
other HLA antigens
chemistry screen
CXR

Full details

Emerging tests

vitreous biopsy

Full details

Treatment algorithm

ACUTE

non-infectious, initial presentation: not pregnant

non-infectious, initial presentation: pregnant

infectious

ONGOING

non-infectious, after immediate control of inflammation: not pregnant

non-infectious, after immediate control of inflammation: pregnant

Contributors

Authors VIEW ALL 

John J. Huang, MD

President

Connecticut Uveitis Foundation

Associate Clinical Professor

Yale University

New Haven

Eye Disease Consultants

Hartford

Disclosures

JJH declares that he has no competing interests.

Max Elia, MD

Uveitis and Retina Specialist

Medical Eye Center of New Hampshire

Manchester

Disclosures

ME declares that he has no competing interests.

Acknowledgements

Dr John J. Huang and Dr Max Elia would like to gratefully acknowledge Dr Richard Gale, Dr Zsolt Varga, Dr Victor L. Perez, and Dr Carlos A. Medina, the previous contributors to this monograph. RG, ZV, VLP, and CAM declare that they have no competing interests.

Peer reviewers VIEW ALL 

Jessica Ackert, MD

Assistant Professor

Ophthalmology

Mount Sinai Hospital

New York

Disclosures

JA declares that she has no competing interests.

Anthony J. Hall, MD, FRANZCO

Director of Ophthalmology

Alfred Hospital

Melbourne

Australia

Disclosures

AJH has been reimbursed by Novartis, the manufacturer of Lucentis, for lecture fees. AJH's employer, the Alfred Hospital, has received research funding from Novartis, the manufacturer of Lucentis, and from Bayer, the manufacturer of Eylea.

Daniel A. Johnson, MD

Chairman

Department of Ophthalmology

The University of Texas Health Science Center at San Antonio

San Antonio

Disclosures

DAJ declares that he has no competing interests.

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Uveitis

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Emerging tests

Treatment algorithm

non-infectious, initial presentation: not pregnant

non-infectious, initial presentation: pregnant

infectious

non-infectious, after immediate control of inflammation: not pregnant

non-infectious, after immediate control of inflammation: pregnant

Contributors

Authors VIEW ALL 

John J. Huang, MD

Disclosures

Max Elia, MD

Disclosures

Acknowledgements

Peer reviewers VIEW ALL 

Jessica Ackert, MD

Disclosures

Anthony J. Hall, MD, FRANZCO

Disclosures

Daniel A. Johnson, MD

Disclosures

Differentials

Guidelines

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