Diagnosing acute anterior uveitis in practice

The question:

A 40-year old woman with an achy left eye presents in practice. She reports that she has had a ‘deep ache’ in her eye for three days, as well as blurred vision. On inspection, you notice that the eye is also red. The right eye is normal, and the patient is not a contact lens wearer. How would you manage?

OT’s panel says...

Ceri Smith Jaynes: My first thought is iritis – unilateral ache, redness, and blur all fit the profile. However, there are a few differential diagnoses to consider, for example episcleritis, primary angle closure, keratitis, and foreign body. I like to keep an open mind as I gather the evidence, but let’s assume for this discussion that it is acute anterior uveitis.

Careful history taking might give us a few clues: has she has iritis or uveitis before? General health and family history questions will include autoimmune conditions, skin, bowel, lower back pain, tattoos (have they gone red and lumpy?), travel, and infections. Matthew Chan has written an excellent and comprehensive CPD article on this very topic, entitled Uveitis: know what to ask and why.

In my area, these patients usually present under the community urgent eye care service enhanced service, which means I can view their summary care record for an overview of established diagnoses, medications and any adverse drug reactions.

Let’s think about the slit lamp exam: first, I’ll grade the hyperaemia, and check pressures and angles. On the cornea, there may be fine keratic precipitates or mutton fat – if the latter, I’ll suspect granulomatous and more likely a systemic cause. I’ll be looking carefully for cells and flare, not forgetting that the other eye might get it a few days after the first eye, especially with HLA-B27-associated uveitis. Once I’ve done that, I’ll look again: room very dark, bright(ish) beam, high magnification, and sit, wait and watch. The SUN classification is a standard way of recording cells or flare so you or another clinician can tell if it has improved or worsened next time.

Next, are there any iris nodules or posterior synechiae? I might use cyclopentolate for dilation, to help break synechiae and to ease the pain. I’ll check for vitritis and macular oedema. I have an optical coherence tomography and Optomap with autofluorescence, so this will assist in looking for and/or ruling out posterior inflammation.

In my area, the hospital like us to send in all cases of iritis, but I’ll usually chat to the on-call ophthalmologist, start the patient off on treatment and they will pick them up in a few days’ time. Prednisolone acetate seems to be available in local pharmacies, so that would be the steroid drop I would likely choose (hourly) and cyclopentolate (three times a day). The patient will need to use sunglasses and maybe some ready-readers.

“Iritis would be top of my list of suspects. Patients who have had it before are often very good at recognising the symptoms when they recur, even years later”

Kevin Wallace: I’m with Ceri – iritis would be top of my list of suspects. Patients who have had it before are often very good at recognising the symptoms when they recur, even years later. My standard questions for a patient with a red eye continue with asking about discharge and photophobia. Photophobia is particularly helpful because it can indicate something significant – and because a number of the differentials would not be expected to present with that, so it probably rules them out.

I don’t have the same access to medical records as in Ceri’s area, but in Scotland the General Ophthalmic Services Specialist Supplementary service pays an enhanced fee for treatment and review of patients with anterior uveitis, so I would usually treat these to completion in the community.

If the signs do not indicate iritis, then I would want to assess the intraocular pressure (IOP), the lids, and the cornea, looking for something else to explain it.

It’s important to ask if the patient has been doing anything to treat it too – a few years ago I had a patient with a significant red eye and I could not understand why it wasn’t very painful – until he showed me the anaesthetic drops that he had been using regularly since getting them from a pharmacy overseas.

Ankur Trivedi: I concur with Ceri and Kevin that acute anterior uveitis (AAU) or iritis would be at the top of my working diagnoses. They have covered in detail the aspects of questioning and examining the patient. I find that utilising the signs and symptoms to modify the most likely diagnosis as I carry out the examination is a useful approach for me.

A few points I would add:

• The type of hyperaemia may point towards AAU – textbooks and guidance suggest a circumcorneal (‘ciliary injection’) type appearance, but I have not found this is always the case
• As outlined in the excellent article that Ceri has mentioned – a comprehensive history and symptoms is invaluable to developing the clinical picture. Ask about any previous ophthalmic history – any trauma – and about any previous similar occurrences, drilling down on how the previous episode or episodes were managed. Was there the need for concurrent IOP control, either due to the uveitis or a subsequent steroid response? Was there any rebound to the condition, or was a particularly slow taper of the steroid required? I find it useful to consider the “pitfalls” that may arise and try to pre-empt them where possible. I appreciate this can be tricky in a busy clinical practice
• If this a reoccurrence of uveitis, then it is important to make sure that the patient has had a full systemic investigation carried out to rule out any systemic cause, with possible involvement of rheumatology if warranted.

For advice in any situation where you are unsure how to manage a patient, contact the AOP’s clinical and regulatory team via email or phone on 0207 549 2020, extension 1.