Watch Those Eyes

figure 3: Large concretions of leukocytes adhere to the corneal endothelium (keratic precipitates) in a patient with granulomatous uveitis.

figure 4: Patient with unilateral acute anterior uveitis associated with positive HLA-B27. Right eye shows ciliary injection with irregular pupil, compared to normal left eye.

Ocular involvement is common in rheumatologic disease and varies among different diagnoses. The major ophthalmic manifestations of rheumatic diseases include uveitis, conjunctivitis, scleritis, retinal vasculitis, dry eye syndrome, orbital inflammation, and neuro-ophthalmic lesions. The patterns of common involvement are listed in Table 1 (TK). Among the listed ocular manifestations, uveitis is the most common vision-threatening inflammation associated with rheumatic diseases.¹

The etiologies of uveitis include infection, trauma, tumor, or immune-mediated processes. Uveitis is commonly classified by anatomical location of inflammation into anterior, intermediate, posterior, and panuveitis.²

• Anterior uveitis: When the primary site of inflammation is in the anterior chamber, a synonym for iritis or iridocyclitis.
• Intermediate uveitis: When the vitreous is the major site of inflammation.
• Pars planitis: The subset of intermediate uveitis characterized by leukocytic exudates called a snowbank or snowball at the peripheral retina or pars plana.
• Posterior uveitis: When the retina and/or choroid are the primary site of involvement. Includes including retinitis, choroiditis, chorioretinitis, and retinochoroiditis. The abnormalities can usually be observed by fundoscopic examination.
• Panuveitis: Reserved for situations in which inflammation is observed in the anterior chamber, vitreous, retina, and/or choroid.
• Retinal vasculitis: Indicates inflammation in retinal vessels and occasionally occurs without a concomitant uveitis.

Uveitis subsets can also be characterized the following features: onset (sudden versus insidious), laterality (unilateral versus bilateral), duration (limited versus chronic), continuity (recurrent versus persistent), and presence of complications such as the iris sticking to the lens (a phenomenon known as posterior synechiae). Uveitis is termed granulomatous if large concretions of leukocytes adhere to the corneal endothelium (see Figure 3) and non-granulomatous if these concretions are small.