Ophthalmology · Uveitis
The facts most likely to be tested
Anterior uveitis presents with unilateral eye pain, photophobia, blurred vision, and a ciliary flush (limbal injection).
The pathognomonic finding on slit-lamp examination is cells and flare in the anterior chamber.
HLA-B27 positivity is the strongest genetic association, linking anterior uveitis to ankylosing spondylitis, reactive arthritis, and psoriatic arthritis.
Physical examination reveals a constricted, non-reactive pupil (miosis) due to ciliary muscle spasm.
Keratic precipitates (white blood cell clumps on the corneal endothelium) are a hallmark finding of granulomatous anterior uveitis.
First-line treatment for non-infectious anterior uveitis is topical corticosteroids to reduce inflammation and prevent synechiae formation.
Cycloplegic agents (e.g., homatropine or cyclopentolate) are essential to relieve pain from ciliary spasm and prevent posterior synechiae.
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A 28-year-old male presents with 3 days of unilateral left eye pain, tearing, and photophobia. He reports a history of chronic low back pain that is worse in the morning. On physical exam, there is a ciliary flush and a constricted pupil. Slit-lamp examination reveals cells and flare in the anterior chamber.
What is the most appropriate initial management to prevent long-term ocular complications?
Topical corticosteroids and cycloplegic agents
The patient has anterior uveitis associated with HLA-B27 spondyloarthropathy; topical steroids treat the inflammation, while cycloplegics prevent the formation of synechiae.
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Etiology / Epidemiology
Associated with HLA-B27 positive conditions like ankylosing spondylitis. Often idiopathic or autoimmune.
Clinical Manifestations
Unilateral ocular pain, ciliary flush, and photophobia. Miosis is common.
Diagnosis
Slit-lamp examination showing cells and flare in the anterior chamber.
Treatment
Topical corticosteroids are first-line. Do not use steroids if herpes simplex is suspected.
Prognosis
Risk of synechiae formation. Requires urgent ophthalmology referral to prevent vision loss.
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Epidemiology & Etiology
Most cases are idiopathic, but a significant subset is linked to systemic inflammatory diseases. HLA-B27 positivity is the strongest genetic association, seen in ankylosing spondylitis, reactive arthritis, and psoriatic arthritis. Other causes include sarcoidosis, Behçet disease, and infections like syphilis or tuberculosis.
Pertinent Anatomy
Involves inflammation of the iris (iritis) or the iris and ciliary body (iridocyclitis). The ciliary flush (limbal injection) occurs due to dilation of deep conjunctival vessels near the limbus.
Pathophysiology
Breakdown of the blood-aqueous barrier allows protein and inflammatory cells to enter the aqueous humor. This results in the classic cells and flare appearance on slit-lamp exam. Persistent inflammation leads to the formation of synechiae (adhesions between the iris and lens or cornea).
Clinical Manifestations
Patients present with acute unilateral eye pain, redness, and intense photophobia. Physical exam reveals ciliary flush, a constricted pupil (miosis), and decreased visual acuity. Red flags include severe pain, vision loss, or elevated intraocular pressure, which may indicate secondary glaucoma.
Diagnosis
The slit-lamp examination is the gold standard for diagnosis. Findings include cells and flare (leukocytes and protein in the anterior chamber). A hypopyon (layering of white blood cells) may be present in severe cases.
Treatment
Management centers on topical corticosteroids (e.g., prednisolone acetate) to reduce inflammation. Cycloplegics (e.g., homatropine) are used to relieve pain and prevent synechiae. Contraindication: Topical steroids can worsen herpes simplex keratitis, which must be ruled out first.
Prognosis
Complications include secondary glaucoma, cataracts, and cystoid macular edema. Patients require prompt ophthalmology referral for monitoring and to prevent permanent vision impairment.
Differential Diagnosis
Acute Angle-Closure Glaucoma: Mid-dilated fixed pupil and steamy cornea
Conjunctivitis: Purulent or watery discharge without ciliary flush
Keratitis: Corneal ulceration or epithelial defect on fluorescein staining
Scleritis: Deep, boring pain and blue-violet hue of the sclera
Trauma: History of injury and potential hyphema