Uveitis

Consensual photophobia is always a red flag!

Case: Pt presented to PMD earlier in the day, dx: conjunctivitis, sent home on topical abx, came to ED later that day for persistent pain.  L eye red, pt in considerable pain, photosensitive even when light shown in other eye, noticeable perilimbal or ciliary flush, anisocoria c affected eye more miotic, 1+ flare in anterior chamber on slit lamp, no fluorescein uptake, visual acuity wnl b/l, IOP < 20 b/l, no FB detected or mechanism, only some of the engorged vessels moved when brushed c Q-tip.

Dx: Uveitis

1. Consensual photophobia
   1. Definition: severe pain in affected eye when light is shined in unaffected eye
   2. Cellular Flare
      1. Inflammatory cells in anterior chamber (on slit lamp)
      2. May cause blurry vision
      3. Miosis
         1. From ciliary mm spasm, will have anisicora and pain with accomodation (have them follow your finger close then far)
         2. How to evaluate anisicora (http://www.pacificu.edu/optometry/ce/courses/19433/pupilanompg2.cfm)
            1. Basically, note pupil size in the dark and the light, if this difference is constant, it’s physiologic
            2. Scleral Vascular Engorgement
               1. Conjunctival and episclera vessels move when touched with a Q-tip; the deep-seated scleral vessels do NOT
               2. Conjunctival and episcleral vessels blanch c topical phenylephrine gtts, scleral vessels do not
               3. Conjunctivitis: superficial vessel inflammation, Scleritis: deep vessel inflammation, Uveitis: both affected
               4. Ciliary Flush
                  1. 2/2 dilation of radial vessels
                  2. Often perilimbal flushing, whereas conjunctivitis has more peripheral conjunctival injection (uveitis on left below, conjunctivitis on right)

Book Stuff

Uveitis

• Inflammation of the middle portion of the eye.
  • Anterior Uvea consists of iris and ciliary body = iritis (iris only) & iridocyclitis (both)
  • Posterior Uvea consists of the choroid - choroiditis, does not cause red eye but included for completeness purposes

Causes

• Trauma (blunt or penetrating), corneal or scleral injury
• Systemic microbial infection
  • Syphilis, brucelosis, herpes simplex, Lyme dz, TB
  • Immune-mediated
    • HLA-B27-associated diseases, sarcoidosis, JRA
    • Idiopathic in 50% of cases

Presentation

• Red eye, unilateral in most cases
• "Real" photophobia
• Deep boring pain

Treatment

1. Ophthalmologist referral within 24 hours
   • Topical steroids + intermediate-acting cycloplegics (i.e. cyclopentolate) for the ciliary spasm
   • Antibiotics not needed
2. Expectant secondary glaucoma (often due to debris blocking normal drainage). Treat accordingly if IOP > 20.
3. w/u can be performed by the ophthalmologist in an outpatient setting in 24 hrs, and may include a CBC, ESR, ANA, RPR, VDRL, PPD skin testing, lyme titer, etc.