>A Case of Uveitis

Medical Student Clinical Pearl (RCP) October 2020

Ben McMullin, Clinical Clerk III

Dalhousie Medicine New Brunswick, Saint John

Reviewed by Dr. Mandy Peach

 

Case Presentation

A 40 year old female presented to the Emergency Department with a 5 day history of right sided eye pain. The pain came on insidiously and had gradually been worsening. She had gone to a walk in clinic 3 days prior to presenting to the ED, and was prescribed antibiotics. Her symptoms continued to worsen despite treatment.

In the emergency department, she denied any discharge, and claimed that her eye was not pruritic. She stated that her eye pain was photophobic, but denied any visual disturbances or changes. She did not have fever or chills.

On exam, she did not have any periorbital erythema or conjunctival injection. She did not have any discharge. Normal ocular movements were noted. Her pupils were equal and reactive to light. Her visual acuity was 20/20 in both eyes. Peripheral vision was normal bilaterally. On slit lamp exam, no foreign body or corneal abrasion was identified.

Ophthalmology was consulted emergently, and agreed to assess this patient the same day.

 

Differential Diagnosis

  • Conjunctivitis
  • Acute closed-angle glaucoma
  • Scleritis
  • Keratitis
  • Uveitis
  • Foreign body1

 

Definition

Uveitis refers to inflammation in the uvea, which is the middle portion of the eye. The uvea is made up of the iris and the ciliary body anteriorly, and the choroid posteriorly. Inflammation can be localized anteriorly, posteriorly, or can be generalized.1

Figure 1 : Anatomy of the eye. Rosenbaum, James. “Uveitis: etiology, clinical manifestations, and diagnosis” last modified August 31, 2020

Anterior uveitis can be acute or chronic, and the acute form is the most common form of uveitis. Posterior uveitis, affecting the retina and choroid, and intermediate uveitis, affecting the vitreous body, are less common.2 Uveitis can be classified by location, clinical course or side affected.

Table 1: Classification of uveitis. Muñoz-Fernández S, & Martín-Mola E. (2006). Uveitis. Best Practice & Research Clinical Rheumatology 2006; 20(3), 487-505.

 

Etiology

Approximately 30% of uveitis cases are idiopathic.1 However uveitis can be associated with many rheumatologic conditions such as spondylarthritis, juvenile idiopathic arthritis, psoriatic arthritis, as well as inflammatory bowel disease, multiple sclerosis, and sarcoidosis3. It can also arise from infectious sources such as cytomegalovirus, HSV, varicella zoster virus, lyme disease, syphilis, and tuberculosis, among others. Uveitis can also occur after trauma to the eye.1

 

Clinical Presentation

Anterior and posterior uveitis typically have different presentations.

In anterior inflammation, pain, photophobia, and redness are more commonly seen with a variation in the degree of vision loss (if any). On exam, one can see a ciliary flush where inflammation of the limbus results in redness next to the iris, but not in the periphery of the eye.

Figure 2:  Ciliary flush. https://commons.wikimedia.org/wiki/File:Ciliary-flush.jpg

Photophobia is consensual meaning shining a light in the unaffected eye causes pain in the affected eye due to pupillary constriction.7 On slit lamp examination one may see ‘cells and flare’ when looking at the anterior chamber  in the oblique view – the stereotypical ‘snowflakes in headlights’ appearance.

Figure 3: Cells and flare.http://blog.clinicalmonster.com/2017/08/22/bored-review-anterior-uveitis/cell-flare/

Precipitates or a hypopyon may also be seen.

 

Posterior inflammation is more subtle and can present with non specific vision changes such as flashers/floaters or decreased visual acuity, while pain is less frequently present.1

Visual loss is an important complication of uveitis and can be caused by cataracts, macular edema, epiretinal membrane, and glaucoma.4

 

 

Red Flags for Painful Red Eye

 The following signs and symptoms should prompt urgent referral to ophthalmology:

  • Severe eye pain
  • Vision loss or deficits
  • Loss of pupil reactivity
  • Corneal ulceration
  • Extraocular eye movement stiffness5

 

 

Management

 Uveitis is an ophthalmologic emergency which is vision threatening. Ophthalmological follow up within 24 hours is vital. Without prompt referral to an ophthalmologist for slit lamp examination and treatment, vision loss can be permanent.1

Topical corticosteroids such as prednisolone are often used in the initial management of uveitis. Immunomodulatory agents can also be used6 – both should be used in discussion with an ophthalmologist as inappropriate steroid use could lead to worsening infection or corneal ulceration7.

To help control pain from excessive constriction of the pupil, cycloplegic drops – like Homatropine (1 drop TID of 2‐5% solution) – can be used. Be aware the effects can last a few days.7

A workup for associated conditions is also reasonable, such as chest XR and serologic testing for commonly associated autoimmune and rheumatologic conditions. Screening for associated infections should also be considered.4

 

 

 References

  1. Rosenbaum, James. “Uveitis: etiology, clinical manifestations, and diagnosis” last modified August 31, 2020, https://www.uptodate.com/contents/uveitis-etiology-clinical-manifestations-and-diagnosis?search=uveitis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H4
  2. Muñoz-Fernández S, & Martín-Mola E. (2006). Uveitis. Best Practice & Research Clinical Rheumatology 2006; 20(3), 487-505.
  3. Brown, H. (2010). Uveitis.Gp, , 34-35. Retrieved from http://ezproxy.library.dal.ca/login?url=https://www-proquest-com.ezproxy.library.dal.ca/docview/744242835?accountid=10406
  4. Dunn, James. Uveitis. Prim Care Clin Office Pract 2015; 42: 305-323.
  5. Dunlop AL, Wells JR. Approach to red eye for primary care practitioners. Prim Care Clin Office Pract 2015; 42: 267-284.
  6. Dupre AA & Wightman JM. (2018). Red and painful eye. In R. M. Walls (Ed.), Rosen’s Emergency Medicine: Concepts and Clinical Practice (9th, pp. 169-183). Philadelphia, PA: Elsevier Inc.
  7. Emergency Medicine Cases (2010). Nontraumatic Eye Emergencies. Retrieved from https://emergencymedicinecases.com/episode-9-nontraumatic-eye-emergencies/

 

Copyedited by Dr. Mandy Peach

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