3.1.8 Uses a slit lamp to assess anterior chamber signs of ocular inflammation

Question 1

What is acute vs chronic anterior uveitis?

Answer 1

• Acute - <6 weeks duration – may be recurrent
• Chronic - > 6 weeks duration - white eye, mild signs, mild or asymptomatic

Question 2

What are the symptoms of uveitis?

Answer 2

Red eye (unilateral),
* Pain,
* Blurred Vision,
* Photophobia,
* Lacrimation
* VA Reduced to;
o 6/9 in mild disease,
o 6/30 in moderate disease,
o <6/30 in severe disease

Question 3

Describe the slit lamp techniques required to view anterior uveitis?

Answer 3

• Conical Beam – Looking for cells and flare floating in AC Aqueous.
  Room completely pitch black for maximum pupil dilation.
  o Cells can be physically counted
  o Flare looks like smoke
• Specular Reflection – Looking for Keratic Precipitates on corneal endothelium
  Bring SL in set up position
  o Angle: 60°
  o Position: illumination arm 30°; Position of observation arm 30°
  o Slit: width maximum 4mm
  o Magnification: 16-40x
  o Illumination: medium to maximum
• Parallelepiped – Will also show Keratic precipitates, as well as iris nodules,
  posterior synechiae/anterior lens
• Optic Section – Anterior lens surface and Iris can be visualized to look for:
  Posterior Synechiae, Koeppe, Bussaca.

Question 4

What are the causes of uveitis?

Answer 4

• Idiopathic
• IBS, Lupus Erythematosus, Rheumatoid Arthritis, Juvenile Idiopathic Arthritis
• HLA-B27 gene linked to increased risk of developing uveitis

Question 5

Describe IOP in anterior uveitis?

Answer 5

Reduced (Aqueous humour production reduced), Normal/Elevated IOP (Inflammation affect outflow
pathway)

Question 6

What are the signs of anterior uveitis?

Answer 6

• Circumlimbal injection,
• AC flare and cells,
• Keratic Precipitates,
• Pupil Miosis,
• Hypopyon,
• Band Keratopathy,
• Fibrin in the AC,
• Cells in aqueous,
• Peripheral anterior synechiae (PAS),
• Posterior Synechiae,
• Rubeosis Iridis,
• Mutton fat KP,
• Iris nodules.

Question 7

How do you grade anterior uveitis?

Answer 7

• Grade 0 - No Flare/No Cells
• Grade 0.5+ - 1-5 cells
• Grade 1+ - Faint Flare (Barely detectable)/6-15 Cells in view
• Grade 2+ - Moderate Flare (Iris and Lens still clear) / 16 - 25 Cells in view
• Grade 3+ - Marked Flare (Iris and Lens Hazy) / 26 – 50 Cells in view
• Grade 4+ - Intense flare (coagulated aqueous, fibrin visible) / 50+ Cells in view

Question 8

What are the features of mild anterior uveitis?

Answer 8

• VA 6/6 -6/9,
• Superficial circumcorneal flush
• No KPs,
• Grade 0 -1+,
• Normal pupil,
• no posterior synechiae,
• IOP reduced <4mmHg.

Question 9

What are the features of moderate anterior uveitis?

Answer 9

• VA 6/9 – 6/30
• Deep circumcorneal flush
• KPs
• Grade 1+- 3+
• Miotic or sluggish pupil
• Mild posterior synechiae
• Mild iris bombe
• IOP reduced 3-6 mmHg
• Anterior vitreous cells

Question 10

What are the features of severe anterior uveitis?

Answer 10

• VA<6/30
• Deep circumcorneal flush
• KPs
• Grade 3+-4+
• sluggish or fixed pupil
• Fibrous posterior synechiae
• IOP increased
• Moderate to Severe anterior vitreous cells.
• Koeppe or Bussaca

Question 11

What is the management of anterior uveitis?

Answer 11

• Cycloplegia (relieves pain, prevent posterior synechiae, stabilise blood-aqueous
  barrier),
  o Ciliary spasm causes pain, cyclopentolate relaxes the cilary muscle and
  therefore relieves the pain
• Sunglasses for light sensitivity
• Systemic steroid therapy – prednisolone to relieve inflammation
• Systemic NSAID therapy – Diclofenac
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