Anterior uveitis

75-90% of all cases of uveitis

All patients must have a dilated fundus examination

Idiopathic AAU

• 50% of AAU occurs in isolation
• Biphasic: ages 30 and 60
• M=F
• Typically unilateral

Clinical features

• Pain
• Photophobia
• Circumlimbal injection
• KPs
• AC flare/cells
• Posterior synechiae
• Spillover anterior vitreous cells

Management

• Frequent topical corticosteroids
• Mydriasis: acutely to break PS
• Consideration of oral steroid if not responding within 48 hours

HLA-associated AAU

• 55% of AAU patients are HLA-B27 positive (8% of general population) rising to 70% of those with recurrent episodes

  • However, only 1% of HLA-B27 positive patients develops AAU
  • 84% of HLA-B27 positive patients with AAU have other systemic disease

• M>F

• Peaks age 30

• Associated with positive family history

• Associated with

  • Reiter’s disease
  • Ankylosing spondylitis
  • Psoriatic arthritis
  • IBD:
    • IBD patients with sclerouveitis are more likely to be HLA-B27 negative and more likely to have RA-pattern arthritis rather than sacroilitis

• Anterior segment inflammation typically more severe than idiopathic AAU

  • Fibrin is a more common feature
  • Hypopyon and PS more common
  • Late CMO may develop
  • Recurrence is more likely

• Management is as for AAU

Seronegative spondyloarthropathies

• Inflammatory arthritides affecting the synovium and extra-articular sites
• Typically an asymmetrical arthritis
• Strongly associated with HLA-B27
• Ankylosing spondylitis
  • Affects the spine and sacro-iliac joints
  • M>F
  • 25% develop anterior uveitis
  • anti-TNF drugs may reduce recurrences
  • 9% develop intractable uveitis
  • Alternating/’flip-flopping’ uveitis

Psoriatic arthritis

• 10% develop ophthalmic disease: conjunctivitis (self-limiting), keratitis (peripheral corneal infiltrates), uveitis (which is atypical in that it may present bilaterally)
• Psoriatic arthritis is usually benign mut a minority develop arthritis mutilans which is destructive
• IBD-related: 5% develop anterior uveitis. Rarely epi/scleritis or retinal vasculitis
• Reiter’s syndrome: reactive arthritis, urethritis and conjunctivitis
  • Associated with non-gonococcal STI: chlamydia, yersinia, salmonella, shigella
  • 70% are HLA-B27 positive
  • Bilateral mucopurulent conjunctivitis (self-limiting)
  • Punctate corneal epitheliopathy
  • AAU (12%)
  • Aortic incompetence is a rare life-threatening complication

Anterior uveitis syndromes

Fuch’s heterochromic cyclitis

• Chronic non-granulomatous anterior uveitis
• Unknown cause: may be associated with rubella
• F=M
• Unilateral in 90%
• Clinical features
  • White eye
  • Floaters
  • Glare
  • Asymptomatic
  • Iris atrophy: moth-eaten, transillumination defects, abnormal iris vessels, iris heterochromia, iris nodules (Koeppe > Busacca)
  • No PS
  • PSCO
  • Vitreous opacities
  • Raised IOP: rarely secondary glaucoma
  • Gonioscopy: open angles, twig-like vessels in the angle (occasionally cause hyphaema on paracentesis)

Tubulo-interstitial nephritis and uveitis (TINU)

• Typically affects young females

• Bilateral nongranulomatous anterior uveitis

• Associated with HLA-DQ and HLA-DR14

• Idiopathic or associated with medication or infection

  • NSAIDs, penicillin, furosemide
  • Strep and staph infections

• Acute renal failure: typically recovers but occasionally some chronic impairment

• Associated systemic illness

  • Creatinine and ESR are raised
  • Increased beta-2 microglobulin in urine

• Renal biopsy is indicated: oedema in the renal interstitium with mononuclear infiltrate

• Most patients recover normal renal function and VA with treatment (systemic steroid)

IgA-nephropathy

• Micro- or macroscopic haematuria associated with respiratory tract infections

Kawasaki’s disease

• Acute vasculitis in children

• >5 days of fever with

  • Conjunctival injection
  • Rash
  • Desquamation of the extremities
  • Cervical lymphadenopathy
  • Mucosal changes (pharyngeal injection, cracked red lips, strawberry tongue)

• AAU develops in the first week of illness

• Coronary artery aneurysms develop in 20%

Others

• Posner Schlossman syndrome: see also Glaucoma section
• Anterior segment ischaemia
  • May be associated with OIS (look for irregular/attenuated retinal vessels)
• Schwartz-matsuo syndrome: see Glaucoma section
  • Associated with large, mac-off detachments