Crystal's MCW Coder HubUveitis and Iridocyclitis - Clinical Overview
What Is Uveitis?
Uveitis is inflammation of the uvea — the pigmented, vascular middle layer of the eye — encompassing the iris, ciliary body, and choroid. Depending on which anatomic segment is predominantly involved, it is classified as anterior, intermediate, posterior, or panuveitis. Symptoms can range from mild discomfort and photophobia to complete vision loss if untreated. It is one of the most common causes of preventable blindness in working-age adults worldwide.
Anatomic Classification
| Type | Location | Structures Involved | Typical Laterality |
|---|---|---|---|
| Anterior uveitis | Anterior segment | Iris (iritis), iris + ciliary body (iridocyclitis), ciliary body only (anterior cyclitis) | Usually unilateral |
| Intermediate uveitis | Vitreous / pars plana | Vitreous cavity, pars plana of ciliary body | Usually bilateral |
| Posterior uveitis | Posterior segment | Retina (retinitis), choroid (choroiditis), retina + choroid (chorioretinitis) | Usually bilateral |
| Panuveitis | All segments | Iris, ciliary body, choroid, retina simultaneously | Usually bilateral |
Prevalence by type:
- Anterior uveitis: 41-60% of all uveitis.
- Posterior uveitis: 17-23%.
- Intermediate uveitis: 9-15%.
- Panuveitis: 7-32%.
Clinical Features by Type
Anterior Uveitis (Iritis / Iridocyclitis)
Most common form of uveitis. Presents acutely in many cases with:
- Symptoms: Unilateral red eye, acute ocular pain, photophobia, blurred vision, tearing.
- Signs:
- Circumlimbal (ciliary) injection.
- Anterior chamber cells and flare (graded 0-4+).
- Keratic precipitates (KPs) on corneal endothelium.
- Posterior synechiae (adhesions between iris and anterior lens capsule).
- Hypopyon (layered WBCs in inferior anterior chamber — indicates severe inflammation).
- IOP may be elevated (steroid-induced or trabecular inflammation) or low (ciliary body shutdown).
- Associated ICD-10-CM codes: H20.011-H20.013 (primary iridocyclitis), H20.051-H20.053 (hypopyon), H20.021-H20.023 (recurrent acute iridocyclitis).
Intermediate Uveitis (Pars Planitis)
- Symptoms: Floaters, blurred vision, often minimal pain/redness.
- Signs: Vitreous cells and haze, “snowbank” exudate over pars plana, macular edema (most common cause of visual loss in intermediate uveitis).
- Often idiopathic; associated with MS, sarcoidosis, Lyme disease.
Posterior Uveitis
- Symptoms: Floaters, visual field defect, reduced visual acuity.
- Signs: Retinal/choroidal lesions, vasculitis, vitritis.
- Etiologies include toxoplasmosis (most common worldwide), CMV retinitis (immunocompromised), syphilis, TB, sarcoidosis.
Panuveitis
- Involves all segments simultaneously.
- Associated with Behcet disease, VKH (Vogt-Koyanagi-Harada), sarcoidosis, syphilis, TB.
- Most severe form — highest risk of permanent vision loss.
Onset and Course Classification
| Classification | Definition |
|---|---|
| Acute | Sudden onset, limited duration (less than 3 months) |
| Recurrent | Repeated episodes with disease-free intervals of 3+ months without treatment |
| Chronic | Persistent inflammation lasting 3+ months, or relapse within 3 months of stopping treatment |
Common Etiologies and Associations
Non-Infectious (Most Common Overall)
- HLA-B27-associated:
- Ankylosing spondylitis (most common HLA-B27-associated condition).
- Reactive arthritis (Reiter syndrome).
- Psoriatic arthritis.
- IBD-associated uveitis (Crohn disease, ulcerative colitis).
- Behcet disease — classic cause of recurrent, hypopyon-forming bilateral uveitis.
- Sarcoidosis — can cause anterior, posterior, or panuveitis; granulomatous KPs.
- Juvenile idiopathic arthritis (JIA) — risk of chronic anterior uveitis, especially oligoarticular type.
- Vogt-Koyanagi-Harada (VKH) — bilateral granulomatous panuveitis with systemic features.
- Multiple sclerosis — intermediate uveitis association.
- Drug-induced uveitis — rifabutin, cidofovir, bisphosphonates, checkpoint inhibitors.
Infectious
| Organism | Uveitis Type | Key Features |
|---|---|---|
| Toxoplasma gondii | Posterior | Focal chorioretinitis, “headlight in fog” lesion |
| Herpes simplex virus | Anterior | Sectoral iris atrophy, keratouveitis |
| Herpes zoster virus | Anterior | Dermatome distribution rash + iridocyclitis |
| CMV | Posterior | Retinitis in immunocompromised (HIV) |
| Syphilis (Treponema) | Any segment | Great mimicker; test all unexplained uveitis |
| Mycobacterium tuberculosis | Posterior/pan | Granulomatous; endemic regions |
| Borrelia (Lyme) | Intermediate/ant | Bilateral, endemic region history |
Diagnostic Workup
Always perform for a new uveitis patient:
- Complete slit-lamp examination with anterior segment grading.
- Dilated fundus exam.
- IOP measurement (both eyes).
- Visual acuity.
Systemic workup for undifferentiated uveitis (directed by clinical picture):
- HLA-B27 typing.
- RPR/VDRL + FTA-ABS (syphilis).
- Chest X-ray and/or chest CT (sarcoidosis, TB).
- QuantiFERON-TB Gold (TB).
- ACE level, serum lysozyme (sarcoidosis).
- Lyme serology (endemic region, bilateral intermediate uveitis).
- ANA, RF (JIA in children).
- CBC, metabolic panel, UA (baseline before immunosuppression).
Ocular imaging:
- Fundus photography (92250).
- OCT posterior segment (92134) — for CME, subretinal fluid, choroidal thickening.
- OCT anterior segment (92132) — for anterior chamber assessment.
- Fluorescein angiography (92235) — vasculitis, disc leakage, CME.
- Indocyanine green angiography (92240) — choroidal involvement.
- B-scan ultrasound (76511/76512) — if media opacity limits fundus view.
Treatment Overview
Anterior Uveitis — First-Line
- Topical corticosteroids: Prednisolone acetate 1% q1-6h depending on severity; taper based on response.
- Cycloplegics: Cyclopentolate 1%, scopolamine 0.25%, or atropine 1% — relieve ciliary spasm and prevent posterior synechiae.
- Topical NSAIDs: Adjunctive role in mild cases.
- IOP management: If steroid-induced IOP rise occurs, add IOP-lowering agents; avoid prostaglandins (can worsen inflammation).
Anterior Uveitis — Second-Line
- Periocular corticosteroid injection (posterior sub-Tenon or orbital floor triamcinolone acetonide).
- Oral corticosteroids (short course for severe or bilateral disease).
Intermediate, Posterior, and Panuveitis — Step-Ladder Approach
- First line: Systemic corticosteroids (oral prednisone); periocular or intravitreal steroid injection (triamcinolone acetonide 2-4 mg) for unilateral posterior segment disease.
- Second line (steroid-sparing): Disease-modifying antirheumatic drugs (DMARDs):
- Methotrexate: 52-75% success rate.
- Mycophenolate mofetil: ~71% success for posterior/panuveitis.
- Azathioprine, cyclosporine (less commonly used first).
- Third line / refractory disease: Biologic agents:
- TNF inhibitors (adalimumab — FDA-approved for non-infectious uveitis, infliximab).
- IL-6 inhibitors (tocilizumab).
- Interferons (IFN-alpha 2b, IFN-beta for MS-related uveitis).
Infectious Uveitis
- Always treat the underlying infection first.
- Bacterial: Pathogen-directed antibiotics.
- Herpesvirus: Oral/IV acyclovir or valacyclovir; topical steroids adjunctively.
- Syphilis: IV penicillin G (per CDC/WHO guidelines); adjunct steroids improved outcomes to ~95%.
- Toxoplasmosis: Pyrimethamine + sulfadiazine + leucovorin ± prednisone.
- TB: WHO-recommended 6-month RIPE regimen; 85% success.
Complications of Uveitis
| Complication | Description |
|---|---|
| Posterior synechiae | Iris-lens adhesions; can cause pupil distortion, secondary angle closure |
| Band keratopathy | Calcium deposition in Bowman layer; chronic uveitis, especially JIA |
| Cataract | Steroid-induced or inflammatory lens changes |
| Secondary glaucoma | Steroid-induced or trabecular meshwork inflammation |
| Cystoid macular edema (CME) | Most common cause of vision loss in intermediate uveitis |
| Hypotony | Ciliary body shutdown reducing aqueous production |
| Phthisis bulbi | End-stage, shrunken eye from chronic severe uveitis |
| Choroidal neovascularization | Rare complication of posterior/panuveitis |
Key ICD-10-CM Code Cross-Reference
| Condition | ICD-10-CM | Notes |
|---|---|---|
| Primary iridocyclitis, right eye | H20.011 | Non-specific acute anterior uveitis, right |
| Primary iridocyclitis, left eye | H20.012 | Non-specific acute anterior uveitis, left |
| Primary iridocyclitis, bilateral | H20.013 | Bilateral acute anterior uveitis |
| Recurrent acute iridocyclitis, right | H20.021 | HLA-B27 associated pattern is often recurrent |
| Hypopyon, right eye | H20.051 | Severe anterior uveitis with layered WBCs |
| Hypopyon, left eye | H20.052 | |
| Hypopyon, bilateral | H20.053 | |
| Iridocyclitis in herpes simplex | B00.51 | Excludes1 from H20 category |
| Iridocyclitis in herpes zoster | B02.32 | Excludes1 from H20 category |
| Iridocyclitis in sarcoidosis | D86.83 | Excludes1 from H20 category |
| Iridocyclitis in tuberculosis | A18.54 | Excludes1 from H20 category |
| Iridocyclitis in syphilis | A51.43 | Excludes1 from H20 category |
| Chorioretinitis in toxoplasmosis | B58.01 | Excludes1 from H20 category |
| Sympathetic uveitis, right eye | H44.111 | Panuveitis following trauma to fellow eye |
| Chronic iridocyclitis, right eye | H20.011 | Persistent inflammation 3+ months |
| Pars planitis, right eye | H30.21 | Intermediate uveitis, right eye |
Suggested Obsidian Linkouts
- H20.051 — Hypopyon, right eye (detailed coding note)
- Ophthalmology CPT Codes Reference
- Global Surgical Package MOC
- -22 (modifier for complex uveitis surgical cases)
- Anesthesia Payment Modifiers MOC (for OR-level ocular procedures)