Doctors Revision

Ophthalmology (Eye Conditions)

Uveitis

Inflammation of the uvea, the middle layer of the eye, which includes the iris, ciliary body, and choroid. Can be anterior, intermediate, posterior, or panuveitis.

Also known as: Iritis, Iridocyclitis, Choroiditis

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Referral and warning signs

When to refer

IMMEDIATE URGENT REFERRAL to Eye Specialist/Hospital (HC4/H/RR) for ALL suspected cases of uveitis. DO NOT treat with topical steroids at primary level without definite diagnosis by specialist.

Red flags

  • Eye pain with photophobia and blurred vision.
  • Ciliary flush (redness around cornea).
  • Small or irregular pupil.
  • Floaters or sudden decrease in vision (posterior uveitis).

Signs and symptoms

  • Anterior Uveitis (Iritis/Iridocyclitis - Most Common):
  • - Eye pain (often aching, deep).
  • - Photophobia (light sensitivity).
  • - Redness (often ciliary flush - redness concentrated around the cornea).
  • - Blurred or decreased vision.
  • - Pupil may be small (miotic) and/or irregular (due to posterior synechiae - adhesions).
  • - Tearing.
  • - Slit lamp findings: Cells and flare in anterior chamber, keratic precipitates (KPs) on corneal endothelium.
  • Intermediate Uveitis (Pars Planitis):
  • - Floaters.
  • - Blurred vision.
  • - Usually painless, minimal redness.
  • Posterior Uveitis (Choroiditis/Retinitis):
  • - Blurred vision.
  • - Floaters.
  • - Scotomas (blind spots).
  • - Usually painless unless associated anterior inflammation.
  • - Slit lamp/Fundoscopy: Vitreous cells/haze, choroidal/retinal inflammatory lesions.
  • Panuveitis: Inflammation involves anterior, intermediate, and posterior segments.

Risk factors

  • Systemic Inflammatory/Autoimmune Diseases: Ankylosing spondylitis (HLA-B27 associated), Reactive arthritis, Inflammatory bowel disease (Crohn's, UC), Psoriatic arthritis, Sarcoidosis, Behçet's disease, Juvenile Idiopathic Arthritis (JIA).
  • Infections: Tuberculosis (TB), Syphilis, Herpes Simplex Virus (HSV), Varicella Zoster Virus (VZV), Cytomegalovirus (CMV - esp. in HIV), Toxoplasmosis, Leprosy.
  • Trauma (can trigger anterior uveitis).
  • Idiopathic (no identifiable cause found in many cases).
  • Certain malignancies (masquerade syndromes, e.g., lymphoma).

Diagnosis

Clinical assessment

Suspect based on symptoms (pain, photophobia, blurred vision, floaters) and signs (redness pattern, pupil changes). Requires ophthalmic examination.

Investigations

  • Ophthalmic Examination (Specialist):
  • - Visual Acuity.
  • - Slit Lamp Biomicroscopy: Essential to assess anterior chamber (cells, flare), iris, lens, anterior vitreous. Look for KPs.
  • - Intraocular Pressure (IOP) measurement (can be low, normal, or high).
  • - Dilated Fundus Examination: Assess vitreous, retina, choroid, optic nerve.
  • Systemic Workup (Guided by clinical suspicion):
  • - Chest X-ray (Sarcoidosis, TB).
  • - Blood tests: FBC, ESR/CRP, ACE level (Sarcoidosis), HLA-B27 typing, Syphilis serology (RPR/VDRL, TPPA), TB testing (Quantiferon/TST, sputum AFB), HIV test, Toxoplasma serology.
  • - Imaging (Sacroiliac joints if AS suspected).

Diagnostic criteria

Diagnosis confirmed by ophthalmic examination findings (cells/flare in AC, vitreous cells, retinal/choroidal lesions). Classification based on anatomical location (anterior, intermediate, posterior, panuveitis).

Management

Non-pharmacological management

  • Identify and treat underlying systemic disease or infection.
  • Dark glasses for photophobia.

Pharmacological treatment

  • Requires Specialist Management (Ophthalmologist). Treatment aims to control inflammation, relieve pain, prevent vision loss, and manage complications.
  • Topical Corticosteroids: Mainstay for Anterior Uveitis. Intensive dosing initially (e.g., Prednisolone acetate 1% or Dexamethasone 0.1% hourly), then tapered slowly based on response. (LOC: HC4/H/RR)
  • Cycloplegics/Mydriatics: Dilate pupil to relieve pain (ciliary spasm) and prevent/break posterior synechiae. E.g., Atropine 1% drops/ointment BID-TID (long-acting) OR Homatropine/Cyclopentolate (shorter acting). (LOC: HC4/H/RR)
  • Periocular Steroid Injections: For severe anterior uveitis or intermediate/posterior uveitis. (Specialist procedure).
  • Systemic Corticosteroids: For bilateral, severe, posterior, or refractory uveitis. Requires careful monitoring. (Specialist management).
  • Immunosuppressants / Biologics: For chronic, non-infectious uveitis unresponsive to steroids or requiring long-term control (e.g., Methotrexate, Azathioprine, Mycophenolate, Adalimumab). (Specialist management).
  • Antimicrobials: Specific treatment directed at underlying infection if identified (e.g., anti-TB drugs, anti-syphilis treatment, anti-toxoplasma therapy, antivirals).

Monitoring

Requires close follow-up with ophthalmologist to monitor inflammation (cell/flare grade), visual acuity, IOP (steroids can raise IOP), and taper treatment appropriately. Monitor for systemic side effects if on systemic therapy.

Complications

  • Posterior Synechiae (iris adhesions to lens).
  • Cataract formation (due to inflammation or steroids).
  • Glaucoma (secondary, due to inflammation or steroids).
  • Cystoid Macular Oedema (CME - swelling in central retina).
  • Vitreous opacities/haze.
  • Retinal detachment.
  • Optic nerve damage.
  • Permanent vision loss / Blindness.

Prevention

  • Prompt treatment of underlying systemic diseases/infections.
  • Protective eyewear to prevent trauma.

Patient education

  • Explanation of uveitis as inflammation inside the eye.
  • Importance of adhering to treatment schedule (especially steroid tapering).
  • Potential side effects of steroids (IOP rise, cataract).
  • Need for regular follow-up.
  • Symptoms of recurrence or worsening to report.
  • Importance of investigating/managing underlying systemic conditions if present.

Uganda-specific notes

Important to consider infectious causes like TB, Syphilis, HIV, Toxoplasmosis. Diagnosis requires slit lamp examination, limiting confirmation at lower levels. Referral is key. Misdiagnosis and inappropriate steroid use can lead to severe complications (e.g., worsening herpetic keratitis mistaken for uveitis).

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 20, Section 20.1.6

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