4.1 Uveitis Examination

Examination Outline

Introductory Comments

Uveitis patients often appear in clinical examinations. Expect to see low-grade chronic intermediate or posterior uveitis, and the after-effects of previous severe uveitis of any subtype. Acute presentations may be presented as data stations. They are also sometimes used in live examinations if the patient is admitted to hospital at the same time as the examination. The structure of a uveitis examination is similar to anterior and posterior segment examinations, but special attention must be paid to certain aspects once the stigmata of inflammation has been discovered. In general, once you have detected inflammation, ask yourself the following questions:

  1. What is the age, gender and ethnicity of the patient?
  2. Is the inflammation acute or chronic?
  3. Is the pathology unilateral or bilateral?
  4. Where is the primary site of the inflammation (anterior, intermediate, posterior, panuveitis)?
  5. Are there idiosyncratic examination features that would narrow the diagnosis?
  6. Is there evidence of complications and why is the vision reduced? i. Anterior segment scarring
    ii. Vitritis
    iii. Glaucoma
    iv. Macular oedema
    v. Retinal ischaemia and neovascularisation

When asked to summarise your findings, present them in this way – “This 67-year-old man has a left sided panuveitis with evidence of both acute and chronic inflammation. The pattern of chorioretinal scarring is suggestive of toxoplasmosis uveitis. His vision is reduced due to vitritis, but there is no macular oedema. He has evidence of previous retinal vessel occlusion and also glaucoma in this eye, both of which are likely due to his uveitis.”

Examination Structure

Attention should always be given to the wording of the question as this will direct you to the primary pathology:
“Examine the…”

  1. Anterior segment
  2. Posterior segment

Uveitis patients can have pathology in any part of the eye and the question will not give away the presence of uveitis.

1. Visual Acuity, IOP, Inspection, ± Refraction

  • Always ask for the VA and IOP. In acute uveitis the IOP is often low, although there are exceptions causing hypertensive uveitis (e.g. herpetic). In chronic uveitis the IOP is often high and can be due to open angle (e.g. the uveitis itself, steroid response) or closed angle mechanisms (e.g. pupil block from peripheral anterior synechiae or posterior synechiae).
  • Always stand back and examine the patient as a whole. Age, gender and ethnicity are extremely important in narrowing the potential differential diagnoses. Does the patient have any skin rashes, vitiligo, poliosis or tattoos? Note the presence of hearing aids (VKH, Cogan’s syndrome) or visual aids. Iris heterochromia is more obvious from a distance. Note if the eyes are macroscopically inflamed (red) before proceeding but resist describing this as “conjunctivital injection” as it may be scleritis or episcleritis.
  • Symblephara, ankyloblepharon, forniceal shortening are often more obvious on gross inspection before beginning the slit lamp examination

2. Anterior Segment & Anterior Vitreous

i. Conjunctiva and Sclera

Comment on any injection and determine the ocular layers involved. Conjunctival injection shows fine, dilated vessels that move freely over the ocular surface, without a particular orientation. Episcleral vessels can be seen below the conjunctival vessels and are oriented radially. Scleral injection is deep red / purple discolouration of the sclera. If any are noted, suggest a phenylephrine test – 2.5% phenylephrine should blanch the conjunctiva only, while 10% should blanch both conjunctival and episcleral vessels. Neither will blanch scleral vessels

Figure 4.1.1 Scleritis

Figure 4.1.1
Scleritis

ii. Cornea

Note the presence of band keratopathy signifying chronic uveitis. Examine carefully for keratitis precipitates (KP). Note their character and distribution (e.g. Arlt’s triangle vs pan-corneal). Pan-corneal KP suggest an infective aetiology (including syndromes newly recognised as having a viral association or aetiology, such as Fuch’s uveitis syndrome and Possner-Schlossman syndrome). Changes may be more visible with retro-illumination

iii. Anterior Chamber (AC)

Cells and flare are the primary finding. Grade the number of cells with a 1x1mm slit beam at 45 degrees

Cells

0

< 1 cell

0.5

1 – 5 cells

1 +

6 – 15 cells

2 +

16 – 25 cells

3 +

26 - 50 cells

4 +

50 cells

Flare

0 +

None

1 +

Faint

2 +

Moderate (iris and lens detail clear)

3 +

Marked (iris and lens detail hazy)

4 +

Intense (plasmoid or fibrinous aqueous)

iv. Iris
  • Look for Koeppe (pupil margin) and Busacca (mid iris) nodules which suggest granulomatous uveitis (e.g.. sarcoidosis, TB, toxoplasmosis)
  • Iris transillumination defects are suggestive of herpetic viral infection
Figure 4.1.2 Koeppe Nodules

Figure 4.1.2
Koeppe Nodules

Nodules on the pupil margin associated with granulomatous uveitis (toxoplasmosis in this case)

Figure 4.1.3 Herpetic Uveitis

Figure 4.1.3
Herpetic Uveitis

Atrophy of the posterior pigment epithelium has led to extensive transillumination defects

v. Lens

Note the presence of cataract and its type. Cataract may be present due to inflammation or its treatment with steroids. Comment on position of any posterior synechiae, e.g. 3-9 oclock. If an intraocular lens (IOL) is present, note capsular adhesions and opacification.

vi. Anterior Vitreous

Grade cells in the anterior vitreous the same as in the AC by pushing the slit lamp beam posterior to the lens. Note the colour of cells – brown pigmented cells suggest old inflammation, whereas white cells are generally acute. These are finer and more uniform than the tobacco dust (Shafer’s sign) from a retinal break or tear and are not the same as red cells from vitreous haemorrhage. Atypical large cells may indicate vitreous lymphoma or chronic endophthalmitis.

3. Vitreous

Grade vitreous opacity:

0

Clear posterior segment details

0.5

Trace (disc margin blurry or RNFL not visible)

1 +

Mild (retinal details just visible)

2 +

Moderate (retinal vessels just visible)

3 +

Severe (disc just visible – “headlight in the fog”)

4 +

Very Severe (optic disc not visible)

Also assess for snowballs, pars planitis (may require scleral indentation) and pre-retinal cells (which can be seen with a thin, bright, angled slit beam focussed just anterior to the retina with high magnification)

4. Macula

Look for the signs of inflammation (cystoid macular oedema (CMO), macular star, retinitis, vasculitis) and complications of inflammation (scars, atrophy, pigment migration, choroidal neovascularisation (CNV). Many patients with chronic posterior segment inflammation will have a degree of CMO contributing to vision loss.

5. Optic Disc

Assess for glaucomatous findings and neovascularisation.

6. Retinal Vessels

Look for active inflammation, stigmata of past inflammation and neovascularisation. Differentiate between arteritis (specific) and phlebitis (non-specific). Note the distribution of any changes (peripheral vs central, focal vs generalised, proximity to scars) to narrow the differential diagnosis.

7. Retinal Periphery

Look for scars or atrophy and neovascularisation

8. Optic Nerve Function

The pupils will almost certainly have been dilated in uveitis patients, therefore request the pupil findings prior to dilation and whether a RAPD was present or not. One can also test for redness and brightness saturation

          

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