Uveitis, Posterior

Key Features

• The terms choroiditis, retinitis, and retinochoroiditis denote the tissue layers primarily involved in posterior uveitis

• Infectious agents are the most common cause of posterior uveitis in the pediatric population

Clinical Findings

• Children with posterior uveitis often present with systemic manifestations of a congenital infection

• Congenital rubella presents with deafness, developmental delay, cataracts, "salt and pepper" retinopathy, and hearing and cardiac disorders

• Active toxoplasmosis

  • Produces a white lesion appearing as a "headlight in the fog" owing to the overlying vitreitis

  • Inactive lesions have a hyperpigmented border

  • Contiguous white satellite lesions suggest reactivation of disease

• Ocular candidiasis/endogenous endophthalmitis typically occurs in an immune compromised host or a premature infant in the intensive care nursery receiving hyperalimentation

• Candidal chorioretinitis appears as multifocal, whitish yellow, fluffy retinal lesions that may spread into the vitreous and produce a so-called cotton or fungus ball vitritis

• Acute retinal necrosis syndrome

  • Caused most often by varicella-zoster virus and occasionally by HSV

  • May present with vision loss and a red and painful eye

• CMV infection is the most common cause of retinitis in immunocompromised children, especially those with hematopoietic stem cell transplantation or HIV infection

  • CMV retinitis appears as a white retinal lesion, typically but not always associated with hemorrhage, or as a granular, indolent-appearing lesion with hemorrhage and a white periphery

  • Cotton-wool spots (nerve fiber layer infarcts) also commonly occur in HIV-positive patients

• In toddlers and young children, Toxocara canis or Toxocara cati infections (ocular larva migrans) occur from ingesting soil contaminated with parasite eggs

  • Disease is usually unilateral

  • Red injected eye, leukocoria, and decreased vision are common

Diagnosis

• Serologic analysis and retinal examination by an ophthalmologist are used to identify the cause of posterior uveitis

• Acute retinal necrosis syndrome

  • Ophthalmoscopy may show

    • Unilateral or bilateral patchy white areas of retina

    • Arterial sheathing

    • Vitreous haze

    • Atrophic retinal scars

    • Retinal detachment

    • Optic nerve involvement

• In toddlers and young children, Toxocara canis or Toxocara cati infections

  • Funduscopic examination may show endophthalmitis (vitreous abscess) or localized granuloma

  • Diagnosis is based on the appearance of the lesion and serologic testing using ELISA for T canis and T cati

Treatment

• Congenital toxoplasmosis infections must be treated with systemic antimicrobials

• Other infectious agents such as Candida, varicella, and CMV require systemic and/or intraocular injections of antimicrobial agents and may require retinal surgery

• Treatment of toxocariasis includes periocular corticosteroid injections and vitrectomy