Acute anterior uveitisBMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b2986 (Published 25 August 2009) Cite this as: BMJ 2009;339:b2986
- Ashraf A Khan, senior house officer1,
- Ross J Kelly, general practitioner with special interest in ophthalmology2,
- Zia I Carrim, specialist registrar in ophthalmology3
- 1Department of Medicine, Northern General Hospital, Sheffield S5 7AU
- 2Spencer Street Practice, Carlisle CA1 1BP
- 3Department of Ophthalmology, St James’s University Hospital, Leeds LS9 7TF
- Correspondence to: Z I Carrim
- Accepted 1 December 2008
A 37 year old man presents with a five day history of progressively painful red right eye. He is photophobic and has blurred vision. For the past two days he has been using chloramphenicol eye drops, but his symptoms have not improved.
What issues you should cover
The iris, ciliary body, and choroid constitute the uveal tract of the eye. Inflammation of these structures is termed uveitis. Anterior uveitis, in which inflammation is confined to the anterior portion of the uveal tract, is a common cause of acute red eye and has an incidence of 1 in 10 000.
Onset—usually acute with progressive symptoms.
Pain—usually throbbing and aggravated by accommodative effort or change in lighting conditions.
Discharge—absent, but lacrimation may be excessive.
Vision—ranges from normal in early and mild presentations to greatly reduced in severe cases.
Systemic inflammatory conditions—a coexisting inflammatory condition, such as inflammatory bowel disease or connective tissue disorder, increases likelihood of anterior uveitis.
Differential diagnoses—Consider acute angle closure (more likely in older, long sighted patients); herpetic keratitis or microbial keratitis (associated with contact lens wear); episcleritis or scleritis; corneal abrasion or recurrent erosion; viral conjunctivitis.
Considerations—Be aware that:
Treatment with dilating drops can alter depth perception (the Pulfrich phenomenon), making it unsafe for patients to operate machinery or drive a car.
Acute anterior uveitis is an unpredictably recurrent condition. When patients have known recurrent disease and are familiar with their symptoms, start them on treatment and arrange follow-up by an ophthalmologist.
Inflammation and steroid treatment can predispose to premature cataract formation and raised pressure, so give appropriate counselling.
What you should do
Do a basic ophthalmic examination to establish the severity of the condition and the urgency of referral. Using a Snellen chart and a direct ophthalmoscope:
Record monocular visual acuity. Use the pinhole to compensate for refractive error and assess the reduction of vision.
Set the lens dial on your direct ophthalmoscope to +10D. Holding the ophthalmoscope about10 cm (4 inches) from the patient’s eye, compare the red reflex on either side in dim lighting. Look for unequal pupils. The affected eye is likely to have a smaller, irregular pupil as a result of posterior synechiae. Severe inflammation may cause a dull reflex and make iris detail appear misty. Sometimes clumps of cells are visible on the inside of the cornea as opaque spots (keratic precipitates). A predominantly circumcorneal pattern of injection suggests intraocular inflammation. Notice how the patient reacts to bright light.
Look out for severe corneal oedema (associated with greatly reduced vision and caused by raised pressure or severe inflammation), the presence of a hypopyon (indicating intraocular infection, or inflammation, or both) and a fixed mid-dilated pupil (typical of acute angle closure) as important signs indicating immediate referral.
Instil a small amount of fluorescein dye into the red eye and examine under blue light. A break in the cornea, caused by an ulcer or abrasion, will fluoresce.
Distinguish mild acute anterior uveitis (will worsen without treatment) from viral conjunctivitis (self limiting) (table⇓).
If you suspect acute anterior uveitis, refer the patient to an ophthalmologist. Treat with dilating drops (cyclopentolate or atropine) and steroids. Consider prescribing dilating drops for pain relief (except for acute angle closure) if referral is likely to be delayed. Give the steroids topically, as an injection in the subconjunctival space, or orally, depending on the severity of inflammation. Most patients will get better after a month of treatment. A minority of patients will have a chronic form of uveitis. Reserve investigations for patients with recurrent, bilateral, and chronic inflammation.
Diaper CJM. Pulfrich revisited. Surv Ophthalmol 1997;41:493-9 (doi:10.1016/S0039-6257(97)00014-3)
Royal National Institute of Blind People. Eye info—uveitis. www.rnib.org.uk/xpedio/groups/public/documents/PublicWebsite/public_rnib003667.hcsp
Uveitis Information Group (www.uveitis.net)—Patient support
Cite this as: BMJ 2009;339:b2986
This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs
Contributors: ZIC had the idea for the article and is the guarantor. AAK conducted a literature search. All authors contributed equally to writing the article.
Funding: None declared.
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally reviewed.