Uveitis

Context

Uveitis refers to inflammation of the uveal tract, which encompasses the iris, ciliary body and choroid. Uveitis and its complications are a significant contributor to UK and global sight impairment and blindness, particularly in the working age population.1 Anterior uveitis is the most common form of uveitis. It is frequently associated with systemic autoimmune or infectious causes, requiring a multi-disciplinary team approach. Early recognition and management are crucial to prevent complications and sight impairment.

Definition

The Standardisation of Uveitis Nomenclature (SUN) Working Group2 classifies uveitis based on anatomical location:

Fig. 1 – Human Eye Anatomy via Shutterstock 

 

The Standardisation of Uveitis Nomenclature (SUN) Working Group 2 classifies uveitis based on anatomical location:

Type of uveitis	Site of inflammation	Clinical features	Common associations
Anterior uveitis	Anterior chamber (iris and/or ciliary body)	Ocular pain, redness (ciliary flush), photophobia, anterior chamber cells and flare	Idiopathic, HLA-B27 diseases, JIA, herpes viruses
Intermediate uveitis	Vitreous chamber, pars plana	Floaters, blurry vision associated with vitritis, mild or absent pain and redness	Idiopathic, sarcoidosis, multiple sclerosis
Posterior uveitis	Retina and/or choroid	Blurry vision/ visual loss, floaters	Toxoplasmosis, CMV, sarcoidosis, Behçet’s disease
Panuveitis	Inflammation of significant components of the anterior chamber, vitreous and retina/choroid	Combination of the above symptoms: pain, redness, photophobia, floaters, blurring/ visual loss	Sarcoidosis, Behçet’s disease, Vogt–Koyanagi–Harada (VKH)

Fig. 2 Keratic precipitates in anterior uveitis [Image By Jonathan Trobe, M.D via Wikimedia Commons]

Fig. 3 – Vitreous cells in intermediate uveitis [Image by By Imrankabirhossain via Wikimedia Commons]

Fig. 4 – Retinal whitening and intraretinal haemorrhages associated with posterior uveitis [This image was originally published in the Retina Image Bank. From the Collections of Thomas M. et al. © American Society of Retina Specialists.]

Learning bite

Anterior uveitis is inflammation of the anterior segment of the uveal tract, primarily involving the iris and anterior ciliary body. It can be acute or chronic. It accounts for the majority of uveitis cases.

Intraocular inflammation may be triggered by infectious agents, autoimmune mechanisms, or be idiopathic in origin.1 Immune dysregulation – driven by genetic predisposition (e.g., HLA-B27), molecular mimicry, or innate immunity activation – disrupts ocular immune privilege, leading to T-cell and macrophage infiltration. This results in blood-ocular barrier breakdown (BAB anteriorly, BRB posteriorly).

Recurrent/bilateral uveitis is strongly associated with HLA-B27 in anterior disease. Chronic inflammation promotes fibrosis via TGF-β and causes structural damage (posterior synechiae, cataracts, glaucoma, CME).

Learning bite

The cause of uveitis is idiopathic, autoimmune or infectious in origin.1

History and Risk Factors

• Onset and duration: acute (within days), recurrent (episodes without treatment for >3months), chronic (persistent inflammation >3 months)
• Laterality and recurrence- Unilateral acute episodes are associated with HLA-B27-related disorders. Bilateral chronic presentations may suggest autoimmune conditions like juvenile idiopathic arthritis and sarcoidosis
• Ocular symptoms- Ocular pain, photophobia, blurred vision, redness, floaters, lacrimation
• Systemic symptoms and co-morbidities- symptoms such as inflammatory back pain, oral/genital ulcers and GI disturbances may indicate associated systemic disease like spondyloarthropathies, Behcet’s disease or inflammatory bowel disease.
• Infections and medication history- history of infections like TB, syphilis, herpes simplex, etc and medication use like bisphosphonates, immune checkpoint inhibitors and sulphonamides may reveal underlying cause.

Learning bite

Detailed systemic history-taking and appropriate steroid use is crucial in patients with uveitis.

Fig. 1 – Close up of the anterior uveitis during eye examination [ Image via Shutterstock]

Examination

Examination findings include ciliary flush, miosis, abnormally shaped pupil (due to posterior synechiae) and hypopyon.2

Criteria for Urgent Referral – refer to an ophthalmologist within 24 hours when

• There is severe pain/photophobia or visual loss (≥2 Snellen lines)
• Anterior chamber cells with inflammation
• Diagnosis is uncertain or posterior segment involvement is suspected
• There is risk of complications (hypopyon, posterior synechiae, raised IOP (>30mmHg or symptomatic)

Learning Bite

Onset, duration, laterality, recurrence, ocular symptoms, systemic symptoms, and infection and medication history are crucial aspects to ask a patient with suspected uveitis.

Ophthalmic investigations

Fig. 1 – Eye test using slit lamp [Image via Shutterstock]

• Slit-lamp biomicroscopy- anterior chamber cells and flare, keratic precipitates (granulomatous vs non-granulomatous), iris nodules and posterior synechiae are associated with anterior uveitis. The SUN Working Group 2 recommends grading anterior chamber cells and flare to quantify disease activity.
• Tonometry- Measurement of IOP is important as uveitis can cause hypotony due to ciliary body dysfunction, and it can cause secondary ocular hypertension due to trabeculitis or steroid response
• Dilated fundus examination- to detect intermediate or posterior uveitis, and complications like cystoid macular oedema, epiretinal membrane and retinal detachment
• Ancillary imaging (OCT, FFA, B-scan) may be indicated to further investigate findings or in the presence of ocular symptoms not explained by the above.

Systemic investigations

• HLA-B27 typing
• Syphilis serology
• Tuberculosis screen
• ACE and CXR
• ANCA
• Serum lysozyme and calcium levels
• Ocular fluid sampling

Learning bite

Investigations in uveitis are guided by clinical suspicion and include slit-lamp examination, intraocular pressure measurement, and targeted systemic testing to identify infectious or autoimmune causes.3

Initial ED management3

Immediate assessment

• Assess and document visual acuity (VA)
• Assess pupils (size, shape, reactivity)
• Check for consensual photophobia
• Perform slit-lamp examination and measure intraocular pressure (IOP) if possible

Exclude alternate pathology

• Perform fluorescein staining to exclude corneal epithelial defect and infectious keratitis
• Assess for features suggesting serious pathology like acute angle-closure glaucoma, endophthalmitis, panuveitis, etc.

Initial management

• Provide systemic analgesia as required
• Avoid initiating topical steroids in ED due to risk of exacerbating herpetic keratitis, worsening fungal infection, or causing steroid-induced glaucoma
• Arrange eye casualty follow-up within 24 hours
• If anterior uveitis is confirmed and in line with local guidelines, consider cycloplegic therapy after discussion with ophthalmology to relieve pain and to prevent posterior synechiae.

Urgent review required if there is reduced VA, moderate-severe pain, raised IOP, hypopyon, bilateral involvement, suspected posterior uveitis or panuveitis, immunocompromised patient, paediatric patient,or first presentation with atypical features.

ED discharge criteria

• Mild anterior uveitis only
• Normal VA
• Normal IOP
• No corneal involvement
• Patient is reliable to administer drops
• Ophthalmology follow-up arranged and documented
• Safety netting provided- Return urgently if worsening pain, reduced vision, increasing redness, new floaters or photophobia

Treatment summary

Learning bite

The cornerstone of initial management of anterior uveitis is prompt initiation of cyclopegics and topical corticosteroids.

• Children with JIA may present with non-specific symptoms like redness and blurred vision and lack of photophobia or pain, leading to misdiagnosis or late diagnosis of chronic uveitis.
• No taking a detailed medical and rheumatological history can lead to missed diagnosis of associated conditions like HLA-B27 associated spondyloarthropathies, sarcoidosis, TB and Behçet’s disease and delayed treatment.
• Initiating corticosteroids alone in infectious uveitis without concurrent antimicrobial therapy exacerbates symptoms.
• Delayed initiation of topical corticosteroids increases risk of posterior synechiae and vision loss. Prolonged use of steroids without tapering can lead to steroid-induced glaucoma and posterior subcapsular cataracts.

1. Tsirouki T, Dastiridou A, Symeonidis C, Tounakaki O, et al. A Focus on the Epidemiology of Uveitis. Ocul Immunol Inflamm. 2018 Jan 2;26(1):2–16. [cited 2025 Jun 19]
2. Jabs DA, Nussenblatt RB, Rosenbaum JT, et al. Standardization of uveitis nomenclature for reporting clinical data. Results of the First International Workshop. Am J Ophthalmol. 2005 Sep 1;140(3):509–16. [cited 2025 Jun 4]
3. Royal College of Ophthalmologists (RCOphth). Emergency eye care in hospital eye units and secondary care. London: Royal College of Ophthalmologists; 2024.