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:
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.”
Attention should always be given to the wording of the question as this will direct you to the primary pathology:
Uveitis patients can have pathology in any part of the eye and the question will not give away the presence of uveitis.
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
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
Cells and flare are the primary finding. Grade the number of cells with a 1x1mm slit beam at 45 degrees
< 1 cell
1 – 5 cells
6 – 15 cells
16 – 25 cells
26 - 50 cells
Moderate (iris and lens detail clear)
Marked (iris and lens detail hazy)
Intense (plasmoid or fibrinous aqueous)
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.
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.
Grade vitreous opacity:
Clear posterior segment details
Trace (disc margin blurry or RNFL not visible)
Mild (retinal details just visible)
Moderate (retinal vessels just visible)
Severe (disc just visible – “headlight in the fog”)
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)
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.
Assess for glaucomatous findings and neovascularisation.
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.
Look for scars or atrophy and neovascularisation
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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