Uveitis
Exam Tips
- Pain with consensual photophobia plus ciliary flush is a classic clue for anterior uveitis in OSCE stations.
- Intermediate/posterior uveitis often presents with floaters and blurred vision without a very red painful eye, so do not exclude uveitis because redness is mild.
- In primary care, key management mark is same-day ophthalmology referral and no empiric steroid initiation unless directed by ophthalmology.
- High-yield complication triad for visual loss: cystoid macular oedema, cataract, and glaucoma.
- If globe perforation is possible after trauma, avoid palpation and arrange emergency specialist review.
- Image anchor: review slit-lamp photos of keratic precipitates/cells-flare and fundus images of chorioretinitis in the uveitis chapter of Yanoff and Duker (clinical ophthalmology textbook figures).
Definition
Uveitis is intraocular inflammation involving the uveal tract (iris, ciliary body, and choroid), and it may extend to adjacent structures such as the retina, vitreous, and optic nerve. It is classified anatomically into anterior, intermediate, posterior, or panuveitis, and clinically by onset/course (acute, recurrent, or chronic), which predicts both complications and visual outcome.
Pathophysiology
The core mechanism is disruption of ocular immune privilege with breakdown of the blood-aqueous and/or blood-retinal barriers, causing leukocyte influx, protein leakage ("flare"), and cytokine-driven tissue injury (including TNF-alpha, IL-6, and other inflammatory mediators). In non-infectious disease this is commonly autoimmune (for example HLA-B27-associated disease, sarcoid, Behcet disease), while in infectious uveitis direct pathogen-triggered inflammation (for example herpes viruses, TB, syphilis, toxoplasma) drives damage. Persistent or recurrent inflammation leads to structural complications such as posterior synechiae, cataract, glaucoma, and cystoid macular oedema.
Risk Factors
- Previous episode of uveitis
- HLA-B27 positivity
- Personal or family history of autoimmune disease (for example spondyloarthropathy, inflammatory bowel disease, psoriasis)
- Smoking
- Age over 20 years (peak 30-40 years)
- Immunotherapy or other trigger medications (for example rifabutin, bisphosphonates)
- Recent ocular trauma or intraocular surgery
- Risk factors for infection (for example TB exposure, STI risk, immunosuppression, HIV)
Clinical Features
Symptoms
- Anterior uveitis: dull aching eye pain, photophobia (including consensual photophobia), red eye, blurred vision, epiphora
- Chronic anterior uveitis: milder pain/redness with progressive blurred vision
- Intermediate/posterior uveitis: floaters and blurred vision with little or no pain/redness
- Panuveitis: mixed anterior and posterior symptoms
- May be unilateral (often acute/idiopathic or infectious) or bilateral (more often chronic/systemic)
Signs
- Perilimbal (ciliary) injection, most marked near the limbus
- Small or irregular pupil (miosis), possible posterior synechiae
- Reduced visual acuity in affected eye
- Direct and consensual photophobia on pupillary testing
- IOP may be low early, then rise later (including steroid-related elevation)
- Extraocular movements usually normal
- Slit-lamp confirmation: anterior chamber cells and flare; keratic precipitates may be present
- Dilated fundus findings in posterior disease: vitreous haze/cells, chorioretinal lesions, vasculitis, optic disc swelling
Investigations
Management
Lifestyle Modifications
- Same-day ophthalmology referral for any suspected new or recurrent uveitis; do not start treatment in primary care unless advised by ophthalmology
- Stop contact lens wear until specialist review if red painful eye
- Smoking cessation support (reduced inflammatory burden and recurrence risk)
- Safety-net urgently for worsening pain, photophobia, reduced vision, headache/nausea, or new floaters/flashes
Pharmacological Treatment
Topical corticosteroids (specialist-initiated first-line for anterior non-infectious uveitis)
- Prednisolone acetate 1% eye drops: typically 1 drop every 1-2 hours initially, then taper according to inflammation
- Dexamethasone 0.1% eye drops: typically 1 drop every 1-2 hours in severe disease, then taper
Check IOP and lens status regularly; prolonged/intensive steroid use can cause ocular hypertension/glaucoma, cataract, and secondary infection. Avoid unsupervised steroid use if herpetic epithelial keratitis is possible.
Cycloplegic/mydriatic agents (pain relief and synechiae prevention)
- Cyclopentolate 1% eye drops: 1 drop up to three times daily
- Atropine 1% eye drops: 1 drop once or twice daily in severe inflammation
Reduces ciliary spasm and helps prevent posterior synechiae. Warn about blurred near vision and photophobia; caution in angle-closure risk.
Systemic corticosteroids (for severe bilateral, intermediate/posterior, or refractory inflammation)
- Prednisolone oral: usually 0.5-1 mg/kg once daily (often max 60 mg/day), then gradual taper
Used under specialist supervision after excluding infection where possible. Monitor blood pressure, glucose, mood, bone protection needs, and infection risk.
Steroid-sparing immunomodulatory therapy (non-infectious chronic/recurrent disease)
- Methotrexate 10-25 mg once weekly oral/subcutaneous with folic acid supplementation
- Mycophenolate mofetil 1-1.5 g twice daily
- Adalimumab 40 mg subcutaneously every 2 weeks (selected non-infectious intermediate/posterior/panuveitis)
Screen for TB/hepatitis before biologics; monitor FBC, LFT, renal function as appropriate. Teratogenicity and infection risks must be discussed; specialist/shared-care protocols required.
Cause-directed anti-infective therapy (when infectious uveitis identified)
- Valaciclovir oral 1 g three times daily for herpes zoster ophthalmic disease (dose-adjust in renal impairment)
- Aciclovir oral 800 mg five times daily for herpes simplex/zoster patterns (specialist regimen-dependent)
- Anti-tuberculous therapy or penicillin for syphilis according to infection specialist advice
Do not treat presumed infectious uveitis with steroids alone. Coordinate with ophthalmology and microbiology/infectious diseases.
Surgical / Interventional
- Periocular or intravitreal corticosteroid injection/implant (for selected refractory or posterior disease)
- Cataract surgery once inflammation is adequately controlled
- Glaucoma procedures if medical therapy fails
- Pars plana vitrectomy in selected complications (for example non-clearing vitreous opacity/haemorrhage, tractional pathology)
Complications
- Cystoid macular oedema (commonest cause of visual impairment)
- Secondary cataract (disease- and steroid-related)
- Secondary glaucoma/ocular hypertension
- Posterior synechiae
- Band keratopathy
- Hypotony
- Macular hole/pucker/ischaemia
- Retinal detachment and retinal scarring
- Choroidal/retinal neovascularization
- Optic neuropathy/optic atrophy
- Vitreous opacities or haemorrhage
- Phthisis bulbi
- Permanent visual loss/legal blindness
Prognosis
Outcome depends on anatomical site, cause (infectious vs non-infectious), chronicity, severity, and treatment speed. Acute anterior uveitis generally has the best visual prognosis, while chronic, recurrent, bilateral, intermediate/posterior, and panuveitis carry higher risk of irreversible complications and visual disability. Delayed diagnosis, poor inflammatory control, and paediatric-onset disease are associated with worse long-term vision.
Sources & References
🏥BMJ Best Practice(1)
💊BNF Drug References(3)
- Cyclopentolate hydrochloride[management.pharmacological]
- Ponesimod[cautions]
- Safinamide[contraindications]
✅NICE Guidelines(1)
- Uveitis[overview]
📖Textbook References(2)
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1097, 1098)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1098)[context]