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Uveitis is caused by disorders of diverse etiologies including wide spectrum of infectious and non-infectious Access this article online
causes. Often clinical signs are less specific and shared by different diseases. On several occasions, uveitis Website:
represents diseases that are developing elsewhere in the body and ocular signs may be the first evidence of www.ijo.in
such systemic diseases. Uveitis specialists need to have a thorough knowledge of all entities and their work DOI:
up has to be systematic and complete including systemic and ocular examinations. Creating an algorithmic 10.4103/0301-4738.114092
approach on critical steps to be taken would help the ophthalmologist in arriving at the etiological diagnosis. PMID:
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Key words: Algorithmic approach, differential diagnosis, naming and meshing, uveitis Quick Response Code:
Uveitis is caused by disorders of diverse etiologies including Etiological diagnosis of uveitis starts with the first step
wide spectrum of infectious and non-infectious causes. The of elaborate history followed by systemic examination and
inflammatory process primarily affects the uveal tissues with ocular examination to reach a clinical conclusion. Subsequently
subsequent damage to the retina, optic nerve and vitreous. list of differential diagnosis is created in order to decide on
On several occasions, it reflects diseases that are developing laboratory investigations to rule out or rule in the possible
elsewhere in the body and uveitis may be the first evidence etiology. Sometimes other sub specialty consultation may be
of such systemic diseases, generating a challenge to the required such as rheumatologist, infectious disease specialist,
ophthalmologist in reaching the etiological diagnosis. Besides, pulmonologist or dermatologist.
because several entities share common clinical symptoms and
signs, the etiological diagnosis may prove to be a difficult History Taking
task.[1] Uveitis specialists need to have a thorough knowledge Uveitis work up starts with an elaborate history-taking.[1,3-6]
of all entities and their work up has to be complete including Subsequently meticulous systemic and ocular examination
systemic and ocular examinations. In addition to the above will offer a clinical conclusion. It is estimated that over 70%
mentioned challenges, India presents unique problems of diagnosis can be made on the basis of detailed medical
because of varying socio-economic, demographic and history and thorough clinical work up alone. Systemic
morbidity patterns. The prevalence and severity of diseases history offer possible systemic disease association with
in economically deprived population differ from those in rest ocular involvement. It is often the clinical acumen of the
of the world[2] because of lack of good primary health care, ophthalmologist that points out the diagnosis, that is further
poor affordability and poor compliance. Our ophthalmologist confirmed or ruled out by a tailored laboratory approach.[1]
may also have to meet the added challenge of handling these Table 1 shows the details that need to be collected for a
problems in addition to managing uveitis per se The present thorough history taking. Description of each variable is given
chapter is to define an algorithmic approach in the diagnosis in detail below.
of uveitis. Algorithms solve problem by showing the critical
Age
pathways to be taken. Steps in building an Algorithm include
the following: Several conditions have a predilection for certain age groups.
Defining the problem and deriving a clinical diagnosis by Juvenile arthopaties and parasitic uveitis are the most common
entities in patients younger than 16 years of age.[7] In general
naming technique given by Nozik.[1]
uveitis secondary to infections is common in extremes of age
Reviewing all possible causes of the condition and
and immunological diseases are common in middle age.[2] Some
comparing with existing known uveitis patterns also known
of the examples are:
as meshing technique.
Children: Juvenile Rheumatoid Arthritis, Toxocariasis.
Proving the diagnosis by presenting diagnostic modalities
Young adults: Behcets, Human Leukocyte Associated
in a logical manner. antigen B27 associated uveitis, Fuchs uveitis.
Old age: Vogt Koyanagi Haradas (VKH) syndrome, Herpes
Uveitis Service, Aravind Eye Hospital & PG Institute of Ophthalmology, Zoster Ophthalmicus, Tuberculosis and Leprosy.
Madurai, 1Uveitis Service, Aravind Eye Hospital, Salem, India Gender
Correspondence to: Dr. S. R. Rathinam, Aravind Eye Hospital & PG. Several conditions have a predilection for specific gender as
Institute of Ophthalmology, 1, Anna Nagar, Madurai - 625 020, Tamil given below.[2]
Nadu, India. E-mail: rathinam@aravind.org Males-Ankylosing spondylitis, Reiters, Behcets, Sympathetic
Manuscript received: 23.07.12; Revision accepted: 17.12.12 ophthalmia.
256 IndianJournalofOphthalmology Vol. 61 No. 6
Table 1: History in uveitis factors include HIV related ocular disorders, leptospirosis and
trematode granuloma in children.[9-12]
Demography
Age Systemic conditions
Gender Collagen vascular disorders are best examples for non-infectious
Race
systemic disease which can cause severe ocular morbidity.
Other examples include sarcoidosis, Behcets syndrome,
Residence
Reiters syndrome and VKH syndrome. Tuberculosis, leprosy,
Occupation
syphilis are common systemic infections that can cause
Ocular history uveitis.[11] Other recently reported systemic infections such
Laterality as Chikungunya and West Nile Virus diseases can also cause
Primary symptom ocular inflammation.[13,14] Endogenous endophthalmitis is more
Duration common in diabetics, renal failure and immuno suppressed
Onset patients. In addition patients who received intravenous fluid
Severity prior to onset of uveitis may also suffer from endogenous
Course
endophthalmitis.
Associated findings Ocular symptoms
Systemic history Pain, redness and photophobia are the important symptoms
All systemic problem for anterior uveitis, while floaters with or without decrease
Associated other diseases in vision is important for intermediate and posterior uveitis.
Treatment history Pain on ocular movement is seen in posterior scleritis or
A detail history on dosage of drugs that patient is already taking in orbital inflammatory diseases. Sudden bilateral loss of
vision would indicate either VKHs syndrome or Sympathetic
Response to treatment
ophthalmia.[2-5]
Treatment complications
Compliance of the patient Extraocular Examination
Miscellaneous
The physical signs of extra ocular disease can add evidence
Injury
to support the etiological diagnosis. Frequently, the
Surgery
findings may have escaped recognition by the patient or, if
Migration recognized, may have been deemed insignificant. Thus, it
Exposure to risk factors specific to the diagnosis, e.g.: Syphilis, HIV, is important for the ophthalmologist to routinely evaluate
leptospirosis, trematode eye disease patients for evidence of extra ocular disease. Table 2 gives
some examples of systemic clinical signs one may see in
Females-Rheumatoid arthritis, Juvenile Rheumatoid specific uveitis cases.
Arthritis.
Ocular Examination
Race
A comprehensive eye examination is a requirement for
Demographic characteristics, such as race and ancestry, can
all patients with uveitis, beginning with an assessment of
be predispositions to the development of specific conditions, the patients best-corrected visual acuity. A good day light
for example: examination and external examination with torch light is
Ankylosing spondylitis, Reiters Caucausians.[1] essential in every patient. Often clues on infectious diseases
Sarcoid-Pigmented race. like Hansens disease or Herpes can be obtained on adnexal
VKH syndrome, Behcets syndrome Orientals. examination. Common ocular signs that help in the diagnosis
Socio economic history are given in Table 3.
Recreational activities such as swimming in open water Conjunctiva, episclera, sclera and pupillary examination
reservoirs may expose the individuals to water borne diseases Examination of the anterior surface of the eye should first be
that may eventually result in uveitis. The best example is performed in ambient illumination for subtle color differences.
leptospirosis and trematode granulomas. Patients who own Inflammation of the conjunctiva and episclera appear bright
dogs or cats or are handlers of these animals may be exposed to red in daylight and more in the fornix. In cases of uveitis, the
the intestinal parasites. Toxoplasma gondii and Toxocara canii congestion of the perilimbal area is more than the palpebral and
occur after ingestion of contaminated food sources or contact forniceal conjunctiva. Scleritis will present with dilation of deep
with soil. Plumbers and sewer workers are at an increased risk vascular plexus which is better seen with red free illumination
of leptospirosis, which is transmitted by a spirochete in sewage with tenderness on palpation. Examination of pupil gives clue
water and urine of rats, cattle or other animals.[8] Some of the regarding some of the etiological conditions and structural
examples of zoonotic diseases are: alterations as a result of inflammation.[1]
Cat-Toxoplasmosis.
On slit lamp examination, uveitis can be classified either
Dog-Toxocariasis,
as granulomatous or non-granulomatous [causes mentioned
Cattle-Leptospirosis, cysticercosis.
in Table 4]. Rarely keratic precipitates (KP) may be uniformly
Pigs-Cysticercosis, Leptospirosis.
distributed as seen in Fuchs uveitis, Possner Schlossman
Best examples to be concerned about exposure to risk syndrome, sarcoid uveitis and lens induced uveitis.
June 2013 (Uveitis) Rathinam and Babu: Diagnosis of uveitis 257
Table 6d: Causes of retinal vasculitis according to size of Table 6e: Causes of joint pain in ocular inflammation
vessels
Non-infectious Infectious
Veins Arteries Capillaries
Seronegative arthropathies Leptospirosis
Sarcoidosis Polyarteritis nodosa Whipples disease Juvenile rheumatoid arthritis Syphilis
Behcets syndrome Wegener Crohns disease Collagen vascular diseases Lymes disease
Eales disease granulomatosis Polychondritis Wegeners granulomatosis Tuberculosis
Multiple sclerosis Systemic Lupus Behcets syndrome Behcets syndrome Erethema Nodosum Leprosum
Erythematosus of Lepromatous.leprosy
Toxoplasmosis Syphilis
Syphilis Chikungunya
Tuberculosis Leptospirosis
Leptospirosis West nile virus infection West nile virus infection
General and specific lab testing To evaluate the patient for treatment; to rule in/rule out diagnosis
Specialist consultation To confirm the systemic disease and start the treatment
(Table 8 Continued)
Table 8: Differential diagnosis of various clinical signs in
uveitis Glaucoma in the absence of synechiae
Hypopyon Sarcoidosis
HLA B27 uveitis Toxoplasmosis
Behcets, syndrome Viral uveitis
Leptospirosis Fuchs heterochromic uveitis
Phacolysis Phaco anaphylaxis
Endophthalmitis Lens protein uveitis
Post-operative uveitis Low Tension in uveitis
Leukemia Bilateral exudative retinal detachment
Hyphema Ciliary detachment
Fuchs heterochromic uveitis Retinal detachment induced uveitis
Viral uveitis Ciliary shock in acute uveitis
Syphilis Traumatic and perforated globe
Gonococcal uveitis Post-operative
Leukemia Optic disc edema in uveitis
Irregular Anterior chamber depth Vogt Koyanagi Haradas syndrome
Iris cyst Sympathetic ophthalmia
Sub luxated lens Leptospirosis
Peripheral anterior synechiae Pars planitis
Ruptured lens capsule with released cortex in one side Juxta papillary choroiditis
Ciliary body tumour Multiple sclerosis
Iris atrophy Neuro retinitis
Viral uveitis (Herpes zoster and simplex) HLA: Human Leukocyte Antigen, ICE: Iridocorneal Endothelial Syndrome
Traumatic
Post-laser atrophy work up takes the clinician to the list of differential diagnosis
Post-operative uveitis [Table 8] and then to a laboratory work up before the treatment
Hansens uveitis is finalised.
Fuchs heterochromic uveitis
Anterior segment ischemia Acknowledgements
Essential Iris atrophy We greatly acknowledge Dr. Rathika, Aravind eye hospital, and
ICE syndrome Dr. Tulika Kar, Dehra Dun for their patient assistance in preparation
Vitreous cells and opacities of the manuscript.
Inflammatory cells
References
Red blood cells
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Ophthalmol 2002;133:773-9.
diagnosis of uveitis. Indian J Ophthalmol 2013;61:255-62.
13. Lalitha P, Rathinam S, Banushree K, Maheshkumar S, Vijayakumar
Source of Support: Nil. Conflict of Interest: None declared.
R, Sathe P. Ocular involvement associated with an epidemic
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