Uveitis (Iritis, Cyclitis, Chorioretinitis)

The uveal tract (the inner vascular coat of the eye, consisting of the iris, ciliary body, and choroid) is subject to inflammatory involvement in a number of systemic diseases, both infectious and noninfectious, and in response to exogenous factors, including trauma and toxic agents (Table 621-1). Inflammation may affect any 1 portion of the uveal tract preferentially or all parts together.

Iritis may occur alone or in conjunction with inflammation of the ciliary body as iridocyclitis or in association with pars planitis. Pain, photophobia, and lacrimation are the characteristic symptoms of acute anterior uveitis, but the inflammation may develop insidiously without disturbing symptoms. Signs of anterior uveitis include conjunctival hyperemia, particularly in the perilimbal region (ciliary flush), and cells and protein (“flare”) in the aqueous humor (Fig. 621-1). Inflammatory deposits on the posterior surface of the cornea (keratic precipitates) and congestion of the iris may also be seen. More chronic cases may show degenerative changes of the cornea (band keratopathy), lenticular opacities (cataract), development of glaucoma, and impairment of vision. The cause of anterior uveitis is often obscure; primary considerations in children are rheumatoid disease, particularly pauciarticular rheumatoid arthritis, Kawasaki disease, reactive arthritis (postinfectious), and sarcoidosis. Iritis may be secondary to corneal disease, such as herpetic keratitis or a bacterial or fungal corneal ulcer, or to a corneal abrasion or foreign body. Traumatic iritis and iridocyclitis are especially common in children.

Figure 621-1 Cell and flare in the anterior chamber. The flare represents protein leakage.

(Courtesy of Peter Buch, CRA.)

Iridocyclitis that occurs in children with arthritis deserves special mention. Unlike most forms of anterior uveitis, it rarely creates pain, photophobia, or conjunctival hyperemia. Loss of vision may not be noticed until severe and irreversible damage has occurred. Because of the lack of symptoms and the high incidence of uveitis in these children, routine periodic screening is necessary. Ophthalmic screening guidelines are based on 3 factors that predispose children with arthritis to uveitis: