Anterior Uveitis

Anterior uveitis is inflammation of the iris and ciliary body (iritis and iridocyclitis). It is the most common form of uveitis (about 75%), with incidence of 8 to 12 in 100,000 a year and peak onset between 20 and 50 years. HLA-B27 is positive in about half of acute cases.

Associations: ankylosing spondylitis and other spondyloarthropathies, reactive arthritis, inflammatory bowel disease, psoriatic arthritis, juvenile idiopathic arthritis (chronic, painless, usually antinuclear antibody positive), sarcoidosis, Behçet disease, herpes simplex and zoster, syphilis, tuberculosis, Fuchs heterochromic cyclitis and trauma. Roughly half remain idiopathic.

Complications: posterior synechiae with iris bombé, secondary glaucoma, cataract, band keratopathy, cystoid macular edema and hypotony. Recurrence is common, particularly with HLA-B27 disease.

• Pain, photophobia, tearing and blurred vision, usually over hours to days
• Circumcorneal injection, small irregular pupil, cells and flare in the anterior chamber
• Keratic precipitates: fine in nongranulomatous disease, large "mutton fat" in granulomatous disease. Iris nodules (Koeppe and Busacca) in granulomatous disease
• Hypopyon in HLA-B27 disease and Behçet disease
• Herpetic: sectoral iris atrophy, raised intraocular pressure and reduced corneal sensation
• Fuchs: white quiet eye, stellate precipitates and cataract without synechiae
• Juvenile idiopathic arthritis: white eye and no symptoms until complications
• Red flags: hypopyon, intraocular pressure over 30 mmHg, corneal involvement, vitreous cells, bilateral involvement

• Slit lamp examination with cell and flare grading, intraocular pressure, and corneal and iris examination. Perform a dilated fundus examination to exclude posterior involvement.
• Investigations for first severe, recurrent, bilateral or granulomatous episodes: HLA-B27, treponemal serology and RPR, interferon gamma release assay, chest radiograph, serum ACE, urinalysis.
• MRI of sacroiliac joints for inflammatory back pain. Anterior segment optical coherence tomography and aqueous PCR for herpetic disease with an atypical course.

Differentials: acute angle closure, conjunctivitis, keratitis, scleritis, endophthalmitis, intraocular lymphoma, retinoblastoma in a child.

• Prednisolone acetate 1% hourly while awake for 2 to 3 days, then every 2 hours, then four times daily, reducing by one drop weekly over 4 to 6 weeks. Do not stop abruptly (rebound).
• Cycloplegia: cyclopentolate 1% three times daily, or atropine 1% once or twice daily in severe disease. A single phenylephrine 2.5% drop helps break fresh synechiae.
• Severe inflammation or hypopyon: subconjunctival dexamethasone 2 mg in 0.5 mL, or sub-Tenon triamcinolone 40 mg.
• Raised pressure: timolol 0.5% twice daily, dorzolamide 2% three times daily, acetazolamide 250 mg orally four times daily short term. Avoid prostaglandin analogues and pilocarpine.
• Herpetic disease: aciclovir 400 mg orally five times daily (or valaciclovir 500 mg twice daily) with topical steroid under antiviral cover. Prophylaxis aciclovir 400 mg twice daily for 6 to 12 months after recurrences.
• Recurrent HLA-B27 uveitis (over 2 episodes in a year): sulfasalazine 500 mg daily, increasing weekly to 1 g twice daily with monitoring of full blood count and liver enzymes. Adalimumab 40 mg subcutaneously every 2 weeks for refractory cases.
• Juvenile idiopathic arthritis: methotrexate 10 to 15 mg/m2 weekly and adalimumab 24 mg/m2 (maximum 40 mg) every 2 weeks.

Surgery: laser or surgical peripheral iridotomy for iris bombé. Cataract surgery after 3 months of quiescence.

Review at 1 week, then 3 to 4 weeks, with intraocular pressure each visit. Counsel patients to present within 24 hours of recurrent symptoms.