At the completion of this article, the reader should be able to improve their management of patients requiring treatment for uveitis, including:
• Know the various signs and symptoms of uveitis in clinical presentation
• Review the essential components of a comprehensive uveitis eye exam
• Review a list of patient questions to ask to ascertain potential underlying causes and associated symptoms of uveitis
• Review recommended dosage guidelines of topical steroid eye drops
Hannah Peltzer
B.Optom, therapeutically endorsed
Professional services manager & optometrist
The Optical Company
Uveitis is a complex eye condition characterised by inflammation that can lead to serious complications if not managed promptly. HANNAH PELTZER delves into the essentials of the condition, equipping optometrists with the knowledge to recognise its signs, conduct effective examinations and collaborate with specialists.
Uveitis is a potentially sight-threatening condition characterised by inflammation of the uveal tract and classified by its anatomical location1 which includes the iris (anterior), ciliary body (intermediate) and choroid (posterior). When all areas are affected, it’s called ‘panuveitis’.
Uveitis can be acute or chronic and, as primary eyecare providers, optometrists play a crucial role in the early recognition, diagnosis and management. This article aims to provide optometrists in Australia with a comprehensive guide to understanding uveitis, recognising its signs, conducting a thorough uveitis eye exam, providing tailored management, educating patients about the condition and fostering quality collaboration with ophthalmologists.
Prevalence and context
Uveitis is an umbrella term for a group of conditions that cause inflammation in the eye (the word ‘uveitis’ comes from the Latin word ‘uva’, meaning grape, and the suffix ‘-itis,’ which indicates inflammation). In Australia, it is most often caused by an autoimmune response, but it can occasionally be due to infections. In the case of autoimmune conditions, the immune system is attacking perfectly healthy tissues.
There is a reported uveitis incidence of 20 in 100,000 people in Australia per year. Across the world, however, uveitis is the third leading cause of irreversible blindness.2 Although it is still relatively uncommon, uveitis needs to be diagnosed and treated quickly and correctly. Anterior uveitis, or inflammation of the iris, is the most common form, and represents 70-90% of all cases.
Recognising the signs
Acute uveitis appears suddenly, shows symptoms and typically resolves completely within three months with treatment. In contrast, chronic uveitis tends to develop slowly, may have no symptoms or mild symptoms and can last for several months or longer. Since acute anterior uveitis is the most common type that optometrists encounter, this article will mainly discuss this form.
Uveitis presents with various signs and symptoms that optometrists should be vigilant in identifying during routine eye examinations. These may include:
• Redness and pain: Patients with uveitis often experience redness, discomfort, or pain in the affected eye. The severity of pain can vary from mild discomfort to severe, debilitating pain.
• Photophobia: Sensitivity to light is another common symptom of uveitis. Patients may report increased discomfort in bright environments or when exposed to light.
• Blurred vision: Blurred vision may occur due to inflammation-induced changes in the structures of the eye, such as the cornea or vitreous.
• Decreased visual acuity: Uveitis can lead to a decrease in visual acuity, which may be mild to severe depending on the extent of inflammation and involvement of ocular structures.
Essentials for a comprehensive uveitis eye exam
A comprehensive examination of uveitis is crucial for accurate diagnosis and effective management. It involves several key components; each plays a vital role in evaluating the extent and severity of uveitis and guiding appropriate treatment strategies.
• History taking: obtain a detailed medical and ocular history, including the onset and duration of symptoms, past ocular conditions, systemic health, medications and any recent infections or injuries.
• Visual acuity assessment: evaluate visual acuity and document any changes compared to previous visits.
• Pupil assessment: check for pupil size differences; uveitis often gives a miotic pupil
• Slit lamp examination: Use a slit lamp to examine the anterior segment of the eye, including the conjunctiva, cornea, anterior chamber, iris and lens.
• Intraocular pressure measurement: Measure intraocular pressure (IOP) to rule out elevated IOP from blockage of the trabecular meshwork with cells or steroid use. Or low IOP from ciliary body shutdown.
• Dilated fundus examination: perform a dilated fundus examination to assess the posterior segment, including the vitreous, retina and optic nerve head. Look for signs of posterior uveitis such as vitreous cells, retinal vasculitis and optic disc swelling.
Slit lamp
Slit lamp examination is invaluable for detecting acute anterior uveitis due to its ability to provide detailed magnification and illumination of the structures in the front of the eye. The typical acute anterior uveitis signs that are often seen on slit lamp examination are:
• Anterior chamber reaction – cells and flare
• Circumlimbal flush due to the ciliary body being inflamed
• Corneal oedema
• Keratic precipitates – if they’re small, it’s likely acute. Large, waxy ‘mutton fat’ precipitates are an indicator that the uveitis is more likely chronic
• Posterior synechiae (Figure 1)
• Hypopyon, which is suggestive of an infective cause
Grading cells and flare
Grading cells and flare is crucial for tailoring appropriate management and monitoring treatment effectiveness. The best way to do this is to count the number of cells in a 1x1mm beam.
Due to the convection currents in the anterior chamber, the cells at the front of the eye, closer to the cornea will be moving up and the ones at the back, closer to the iris, will be moving down. I count all of the cells moving up and then double this to get the total.
Underlying conditions associated with anterior uveitis
Optometrists should also be aware of systemic signs and symptoms, such as joint pain, fatigue, or skin rashes, which may indicate an underlying systemic condition associated with uveitis.
• Acute: Rheumatoid arthritis, reactive arthritis syndrome (formally known as Reiter’s), psoriatic arthritis, inflammatory bowel conditions (ulcerative colitis, Crohn’s disease), Behcet’s disease, ankylosing spondylitis
• Chronic: Juvenile idiopathic arthritis, Fuchs heterochromic iridocyclitis, sarcoidosis
Recognising these systemic signs and symptoms can help optometrists identify the underlying systemic condition and guide appropriate management, which is crucial for preventing recurrences of uveitis and managing the overall health of the patient.
Questions to ask any patient with uveitis
It’s important for an optometrist to ask specific questions of their uveitis patients to understand the potential underlying causes and associated symptoms.
• Lungs/chest: do you ever have difficulty breathing, a chronic cough or recent fever?
• Back/joints: Do you have any joint pain, if so, which joints and how many? Do you have any arthritis diagnoses? Do you have back pain or stiffness, especially in the morning or limited motion of your hips?
• Tummy/bowel: Do you experience recurrent diarrhoea, abdominal cramps or pain?
• Groin/mouth: Do you get ulcers or painful lesions in your mouth or on your groin?
• Skin: Do you have any psoriasis or other skin lesions?
Managing uveitis
The management for acute anterior uveitis is different depending on the severity and presentation. It’s vital to treat the inflammation as well as prevent posterior synechiae and manage ocular pain.
Inflammation
• Corticosteroids
Optometrists need to consider the location that they are trying to reach if using topical steroid eye drops. In acute anterior uveitis, the drop needs to reach the anterior chamber/ciliary body and so good penetration is required. The strength and dose used is based on the severity of the inflammation.
In the eye, prednisolone acetate 1% is approximately equal to dexamethasone 0.1% in its inflammatory response, however dexamethosone has a higher risk of IOP response. The goal is rapid control of the inflammation and there are some patients that respond better to one than the other.
Dosage Guidelines
• Grade 3-4+ inflammation: one drop every hour. Depending on severity this may include overnight or a loading dose of one drop every five minutes over 15 minutes (four drops total) before bed and upon waking.
• Grade 2 inflammation: one drop every two hours during waking hours
• Grade 1 inflammation: one drop every four hours
Once the inflammation has recovered to grade 1 or less, a taper of the drops is necessary to both avoid rebound as well as help stop recurrence. A guide for a taper is four times a day for one week, three times a day for one week, twice a day for one week and finally once a day for one week. Once the patient has finished their drops completely, it is important to review the patient’s condition five to seven days later to ensure there is no return of inflammation and that their IOP is normal.
Pupil dilation
In uveitis, there is an increase in Substance-P, an inflammatory cytokin, which induces sphincter contraction (the miotic pupil) as well as fibrin making the aqueous ‘sticky’. Both of these contribute to posterior synechiae development increasing the risk of pupil block.
By dilating the pupil, we lessen the chance of this as well as helping to control the pain from spasm of the ciliary muscle and iris sphincter.
Cycloplegic such as atropine 1% two to three times a day while there is active inflammation should be prescribed. If there is posterior synechiae, an attempt to break it in the consulting room can be done with Tropicamide 1%, one drop every five minutes for three drops.5
Conclusion
When presented with a patient with uveitis always ask yourself: ‘Why does this patient have uveitis?’.
Treat the underlying cause if identifiable. Remember, not all uveitis is the same, be sure to tailor your treatment to the individual case and always check IOP at each visit to monitor for any steroid response.
Uveitis is a sight-threatening condition that requires prompt recognition, thorough evaluation and appropriate management to prevent vision loss and complications. Optometrists in Australia play a crucial role in the early detection and management of uveitis by recognising its signs, conducting comprehensive eye exams, educating patients about the condition and collaborating effectively with ophthalmologists.
By staying informed, communicating effectively, and working collaboratively, optometrists can make a significant difference in the lives of patients with uveitis, ensuring they receive the best possible care and outcomes.
More reading
Ménière’s disease: a primer for optometrists
Accommodation disorders: Recognising, assessing and managing
Dry eye: Patient identification, product formulation and therapy escalation
References
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2.CERA https://www.cera.org.au/conditions/uveitis/
3.Jabs DA, Nussenblatt RB, Rosenbaum JT; Standardization of Uveitis Nomenclature (SUN) Working Group. Standardization of uveitis nomenclature for reporting clinical data. Results of the First International Workshop. Am J Ophthalmol. 2005 Sep;140(3):509-16. doi: 10.1016/j.ajo.2005.03.057. PMID: 16196117; PMCID: PMC8935739.
4.Agrawal RV, Murthy S, Sangwan V, Biswas J. Current approach in diagnosis and management of anterior uveitis. Indian J Ophthalmol. 2010 Jan-Feb;58(1):11-9. doi: 10.4103/0301-4738.58468. PMID: 20029142; PMCID: PMC2841369
5.RVEEH CLINICAL PRACTICE GUIDELINE: Emergency Department Anterior Uveitis (AU)
6.Herbort CP. Appraisal, work-up and diagnosis of anterior uveitis: a practical approach. Middle East Afr J Ophthalmol. 2009 Oct;16(4):159-67. doi: 10.4103/0974-9233.58416. PMID: 20404984; PMCID: PMC2855658.
7.CERA. Is there a link between vitamin D deficiency and uveitis? 2019 Sept 24
8.Optometry Australia Clinical Practice Guide for the Diagnosis, Treatment and Management of Anterior Eye Conditions April 2018
