The Aching Red Photophobic Eye

aka Ophthalmology Befuddler 016

A 60 year-old man presents to the emergency department with a painful and red right eye. The pain started yesterday, and has progressed to a deep ache radiating to his right temporal region. His eye pain is exacerbated by eye movements, reading and bright lights.

Anterior Uveitis EYE CASES 1

He has normal visual acuity but has  direct and consensual photophobia in his right eye.

When you look more closely, you see this:

Anterior Uveitis EYE CASES 2

Questions

Q1. What is the likely diagnosis and what are the different types/ terms used to describe this condition?
Answer and interpretation

Uveitis, which unsurprisingly means inflammation of the uveal tract. Note the typical history and important findings of a constricted slightly irregular pupil with ciliary flush (i.e. circumcorneal involvement of the diffusely injected conjunctiva).

Different terms may be used for uveitis depending which components of the uveal tractare involved, such as:

  • iritis — inflammation of the iris
  • cyclitis — ciliary body
  • choroiditis — choroid

Alternatively uveitis may be referred to as:

  • Anterior uveitis — aka iridocyclitis, which involves inflammation of the anterior portion of the uveal tract and usually affects young or middle-aged persons.
  • Posterior uveitis — which includes vitritis, choroiditis, retinitis, chorioretinitis, or retinochoroiditis.
  • Panuveitis — aka diffuse uveitis, which refers to both anterior and posterior involvement.

Uveitis can be acute or chronic/ recurrent.


Q2. What are the underlying causes of this condition?
Answer and interpretation

There are many, many causes of uveitis!

There are 4 broad categories:

  • inflammatory
  • traumatic
  • infectious
  • drug-induced

Inflammatory causes

HLA B-27 associated: HLA antigen is present in 30—70% of patients with anterior uveitis, half of whom have an associated systemic disease such as:

  • ankylosing spondylitis
  • psoriatic arthritis
  • reactive arthritis
  • inflammatory bowel disease

Non-HLA-B27 associated uveitis may result from numerous underlying systemic conditions such as:

Infectious causes:

  • Parasitic — e.g. toxoplasmosis (accounts for 25% of retinochoroiditis in the US)
  • Viral — e.g. cytomegalovirus (CMV), herpes viruses, adenovirus, measles, mumps, influenza
  • bacterial — e.g. tuberculosis, leptospirosis, syphilis
  • ricketsial disease — e.g. Lyme disease

Traumatic causes:

  • Traumatic iritis, usually secondary to a direct blow from a blunt object

Drug-induced:

  • e.g. rifabutin, cidofovir, sulfonamides, pamidronate

NOTE: Uveitis can also occur secondary to other ocular conditions (e.g. lens-induced, post-operative, anterior segment ischemia, tumour).



Q3. What features of this condition should be consider on taking a history?
Answer and interpretation

History:

Anterior uveitis: 

  • Painful red eye — deep ache radiating to periorbital or temple area, worse with movement and accommodation.
  • photophobia. 
  • +/- blurred vision

Posterior uveitis

  • “floaters” and visual changes: blind spots or flashes may be present with retinal involvement.
  • Redness or significant pain are usually absent

Features of an underlying cause (see Q2) — inflammatory (HLA-B27 vs non-HLA-B27 associated conditions), infectious traumatic, or drugs.

Duration and previous episodes?


Q4. What are the features of this condition on examination?
Answer and interpretation

Examination:

  • Visual acuity: often normal, but may be reduced in posterior uveitis
  • Pupils: constricted, may be irregular, and is sluggish in response to light in comparison with the uninvolved eye. Direct and consensual photophobia (the latter may help differentiate anterior uveitis from from superficial causes of photophobia).
  • Red reflex — may be normal or altered, e.g. secondary cataract.
  • Tonometry — check for secondary glaucoma
    Fundoscopy — look for evidence of chorioditis and retiinits, or complications such as retinal detachment.

Slit lamp:

  • Conjunctiva — diffusely injected conjunctiva with circumcorneal involvement aka ‘ciliary flush’ (no perlimbal sparing as occurs in conjunctivitis). Tearing, but no purulent discharge.
  • Cornea —keratitic precipitates (deposits of white blood cells on the endothelium) may be visualized and are a hallmark of iritis. There are two types: nongranulomatous (small-medium) and granulomatous (large — e.g. sarcoidosis).
  • Anterior chamber — cloudy anterior chamber due to inflammatory cells and proteinaceous flare. Synechieae (adhesions of the iris to the cornea or lens) may be present. Look for a hypopyon.
  • Posterior chamber — cells and flare may be present in posterior uveitis.

RootAtlas has nice brief videos of nongranulmatous and granulomatous KPs, as well as an excellent ‘must see’ video demonstrating ‘cells and flare’ in the anterior chamber.


Q5. What investigations are required?
Answer and interpretation

Investigations are rarely required as part of the emergency management of uveitis, however they may expedite subsequent treatment.

Investigations may not be required if:

  • known underlying cause (e.g. sarcoidosis or drugs)
  • mild unilateral nongranulomatous disease with no evidence of systemic disease

Infectious uveitis, although rare, must be ruled out before treatment with immunosuppressive agents. Sometimes it is only suspected after a failure of treatment.

Investigations may include:

  • identification of specific findings on ophthalmologic and general examination
  • infectious work up — specific serology testing (e.g. syphilis), PCR, and cultures (e.g. STD screen), HIV tests
  • HLA-B27 typing
  • CXR and/or CT chest if pulmonary symptoms — e.g. sarcoidosis, tuberculosis
  • Imaging of the sacroiliac joints if suspected spondyloarthropathy as a diagnosis.
  • Colonoscopy if gastrointestinal symptoms or heme-positive stools — e.g. inflammatory bowel disease

Q6. What severe sight-threatening complications may occur as a result of this condition?
Answer and interpretation

Important complications include:

  • cataracts
  • glaucoma (e.g. due to synechiae)
  • retinal detachment
  • ophthalmitis

Q7. Describe the management of this condition.
Answer and interpretation
  • Urgent referral to ophthalmology.
  • Seek and treat underlying causes.
  • Treat complications e.g. glaucoma
  • Mydriatics (eg, sympathomimetics like phenylephrine HCl) —  prevent the formation of synechiae by pupillary dilation.
  • Parasympatholytic agents (eg, atropine, cyclopentolate) — produce both mydriasis and cycloplegia  reducing pain and photophobia

Treat with corticosteroids after consultation with an ophthalmologist and consideration of a possible infectious etiology:

  • Topical corticosteroids (eg, prednisolone acetate 1%) — useful for anterior uveitis, but due to poor penetration are less effective for posterior uveitis
  • Systemic corticosteroid therapy — usually reserved for bilateral disease that is refractory to local medication or for patients with significant ocular disability or retinitis

Other immunosuppressants — may be used in steroid-dependent or refractory uveitis.


Q8. What is the appropriate disposition of a patient with this condition?
Answer and interpretation

All cases of uveitis should be discussed with an ophthalmologist.

  • Uncomplicated noninfectious uveitis — outpatient management with ophthalmology follow up within 24 hours.
  • Refractory or infectious uveitis — usually require admission and further work up

Q9. What is the classic pattern of this condition when it is associated with HLA-B27?
Answer and interpretation

Bilateral recurrent alternating anterior uveitis


red-eye-hypopyon EYE CASES
Q10. What can be seen in the anterior chamber in the above image?
Answer and interpretation

Hypopyon

With severe inflammation leukocytes can settle in the anterior chamber and form a hypopyon, which is a white or yellowish accumulation of purulent material.


References

Ophthalmology Befuddler 700

CLINICAL CASES

Ophthalmology Befuddler

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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