CHRONIC, USUALLY GRANULOMATOUS:
Sarcoidosis [Usually African-American, usually bilateral; may have dense posterior synechiae, conjunctival nodules, or signs of posterior uveitis (see Section 13.2, Posterior Uveitis). Mild-to-moderate anergy, an abnormal chest radiograph, positive gallium scan, and increased serum angiotensin-converting enzyme (ACE) are common. See Section 13.4, Sarcoidosis.]
Herpes simplex/herpes zoster/varicella (Look for corneal scars, history of past unilateral recurrent red eye, occasionally history of skin vesicles, associated with increased IOP, followed by iris atrophy.)
Syphilis [May have a maculopapular rash (often on the palms and soles), iris roseola (vascular papules on the iris), and interstitial keratitis with ghost vessels in late stages. Usually seen with uveitis in acquired syphilis versus interstitial keratitis in congenital syphilis. A positive VDRL or rapid plasma reagin (RPR) and positive fluorescent treponemal antibody, absorbed (FTA-ABS) are usually present. See Section 14.2, Acquired Syphilis.]
Tuberculosis [Positive purified protein derivative (PPD), typical chest x-ray, occasionally phlyctenular keratitis, sometimes signs of posterior uveitis (see Section 13.2, Posterior Uveitis).]
Others [Rare (e.g., leprosy, brucellosis).]
Differential Diagnosis
The following may be associated with an anterior-chamber reaction.
Rhegmatogenous retinal detachment (RRD) (Elevated retina with a retinal break, pigment cells in the vitreous or anterior chamber. See Section 12.19, Retinal Detachment.)
Posterior segment tumor (e.g., retinoblastoma or leukemia in children, malignant melanoma in adults. See Section 8.3, Malignant Melanoma of the Choroid.)
Juvenile xanthogranuloma (Age younger than 15 years, often with a spontaneous hyphema, yellow–gray poorly demarcated iris nodule or nodules, and slightly raised orange skin lesions.)
Intraocular foreign body
Sclerouveitis (Uveitis secondary to scleritis.)
Endophthalmitis (See Section 13.9, Postoperative Uveitis, Section 13.10, Postoperative Endophthalmitis, Section 13.11, Traumatic Endophthalmitis, Section 13.12, Endogenous Bacterial Endophthalmitis.)
Workup
1.Obtain a history, attempting to define the etiology.
2.Complete ocular examination, including an IOP check and a dilated fundus examination. The vitreous should be evaluated for cells (see Appendix 8).
If a unilateral, nongranulomatous uveitis develops for the first time and the history and examination are unremarkable, then no further workup is pursued.
If the uveitis is bilateral, granulomatous, or recurrent, and the history and examination are unremarkable, then a nonspecific initial workup is conducted:
3.Complete blood count (CBC).
4.ESR.
5.HLA-B27.
6.ACE level, ANA.
7.RPR or VDRL.
8.FTA-ABS or MHA-TP.
9.PPD and anergy panel.
10.Chest radiograph, especially to rule out sarcoidosis and tuberculosis.
11.In endemic areas, a Lyme titer is recommended (see the following).
If the history, symptoms, or signs, or a combination of these point strongly to a certain etiology, then the workup should be tailored accordingly:
Syphilis: RPR or VDRL, FTA-ABS or MHA-TP.
Ankylosing spondylitis: Sacroiliac spine radiographs show sclerosis and narrowing of the joint spaces, ESR, HLA-B27.
Inflammatory bowel disease: Medical or gastrointestinal consult, HLA-B27.
Reiter's syndrome: Conjunctival, urethral, and prostatic cultures (for chlamydia) if indicated; joint radiographs if arthritis is present; a medical or rheumatology consult; consider an HLA-B27.
Psoriatic arthritis: A rheumatology or dermatology consult, HLA-B27.
Glaucomatocyclitic crisis: Diagnosed clinically.
Lens-induced uveitis: Diagnosed clinically. See Phacolytic Glaucoma, Section 10.8; Lens-Particle Glaucoma, Section 10.9; and Phacoanaphylactic Endophthalmitis, Section 13.14.
Herpes: Diagnosed clinically.
UGH: Diagnosed clinically.
Behçet's disease: Behçet's skin-puncture test (if a blister develops minutes to hours after puncturing the skin intradermally with a sterile 25- to 30-gauge needle, a positive test is noted), a medical or rheumatology consult, consider an HLA-B27 or HLA-B5.
Sarcoidosis [Usually African-American, usually bilateral; may have dense posterior synechiae, conjunctival nodules, or signs of posterior uveitis (see Section 13.2, Posterior Uveitis). Mild-to-moderate anergy, an abnormal chest radiograph, positive gallium scan, and increased serum angiotensin-converting enzyme (ACE) are common. See Section 13.4, Sarcoidosis.]
Herpes simplex/herpes zoster/varicella (Look for corneal scars, history of past unilateral recurrent red eye, occasionally history of skin vesicles, associated with increased IOP, followed by iris atrophy.)
Syphilis [May have a maculopapular rash (often on the palms and soles), iris roseola (vascular papules on the iris), and interstitial keratitis with ghost vessels in late stages. Usually seen with uveitis in acquired syphilis versus interstitial keratitis in congenital syphilis. A positive VDRL or rapid plasma reagin (RPR) and positive fluorescent treponemal antibody, absorbed (FTA-ABS) are usually present. See Section 14.2, Acquired Syphilis.]
Tuberculosis [Positive purified protein derivative (PPD), typical chest x-ray, occasionally phlyctenular keratitis, sometimes signs of posterior uveitis (see Section 13.2, Posterior Uveitis).]
Others [Rare (e.g., leprosy, brucellosis).]
Differential Diagnosis
The following may be associated with an anterior-chamber reaction.
Rhegmatogenous retinal detachment (RRD) (Elevated retina with a retinal break, pigment cells in the vitreous or anterior chamber. See Section 12.19, Retinal Detachment.)
Posterior segment tumor (e.g., retinoblastoma or leukemia in children, malignant melanoma in adults. See Section 8.3, Malignant Melanoma of the Choroid.)
Juvenile xanthogranuloma (Age younger than 15 years, often with a spontaneous hyphema, yellow–gray poorly demarcated iris nodule or nodules, and slightly raised orange skin lesions.)
Intraocular foreign body
Sclerouveitis (Uveitis secondary to scleritis.)
Endophthalmitis (See Section 13.9, Postoperative Uveitis, Section 13.10, Postoperative Endophthalmitis, Section 13.11, Traumatic Endophthalmitis, Section 13.12, Endogenous Bacterial Endophthalmitis.)
Workup
1.Obtain a history, attempting to define the etiology.
2.Complete ocular examination, including an IOP check and a dilated fundus examination. The vitreous should be evaluated for cells (see Appendix 8).
If a unilateral, nongranulomatous uveitis develops for the first time and the history and examination are unremarkable, then no further workup is pursued.
If the uveitis is bilateral, granulomatous, or recurrent, and the history and examination are unremarkable, then a nonspecific initial workup is conducted:
3.Complete blood count (CBC).
4.ESR.
5.HLA-B27.
6.ACE level, ANA.
7.RPR or VDRL.
8.FTA-ABS or MHA-TP.
9.PPD and anergy panel.
10.Chest radiograph, especially to rule out sarcoidosis and tuberculosis.
11.In endemic areas, a Lyme titer is recommended (see the following).
If the history, symptoms, or signs, or a combination of these point strongly to a certain etiology, then the workup should be tailored accordingly:
Syphilis: RPR or VDRL, FTA-ABS or MHA-TP.
Ankylosing spondylitis: Sacroiliac spine radiographs show sclerosis and narrowing of the joint spaces, ESR, HLA-B27.
Inflammatory bowel disease: Medical or gastrointestinal consult, HLA-B27.
Reiter's syndrome: Conjunctival, urethral, and prostatic cultures (for chlamydia) if indicated; joint radiographs if arthritis is present; a medical or rheumatology consult; consider an HLA-B27.
Psoriatic arthritis: A rheumatology or dermatology consult, HLA-B27.
Glaucomatocyclitic crisis: Diagnosed clinically.
Lens-induced uveitis: Diagnosed clinically. See Phacolytic Glaucoma, Section 10.8; Lens-Particle Glaucoma, Section 10.9; and Phacoanaphylactic Endophthalmitis, Section 13.14.
Herpes: Diagnosed clinically.
UGH: Diagnosed clinically.
Behçet's disease: Behçet's skin-puncture test (if a blister develops minutes to hours after puncturing the skin intradermally with a sterile 25- to 30-gauge needle, a positive test is noted), a medical or rheumatology consult, consider an HLA-B27 or HLA-B5.