Quick Answer
Uveitis delivers 2 to 3 NEET PG questions per year across ophthalmology and rheumatology. Lock these:
- SUN 2005 — anterior / intermediate / posterior / panuveitis.
- India — TB is the leading cause (10 to 20 percent of tertiary series).
- Granulomatous — mutton-fat KPs, Koeppe/Busacca nodules — TB, sarcoid, syphilis, VKH.
- Non-granulomatous — fine KPs, no nodules — HLA-B27, JIA, idiopathic.
- VKH triad — dermatologic (poliosis, vitiligo) + auditory (dysacusis) + neurologic (meningismus) + serous retinal detachment.
- Anterior treatment — topical prednisolone acetate 1 percent + cycloplegic (atropine/homatropine).
- Ocular TB — 6 to 9 month ATT trial + concurrent oral steroids.
Uveitis is the ophthalmology examiner's favourite systems-integration topic — it forces you to pair a slit-lamp finding with a spondyloarthropathy, a chest X-ray, a Mantoux and (in India) an ATT trial. The SUN 2005 classification (still current, minor revisions in 2021) is the anatomical spine of the workup, and the etiological framework of infection versus autoimmune versus masquerade is the exam's core testable dichotomy. In India, TB dominates the differential in a way that Western textbooks under-emphasise.
This NEETPGAI deep dive walks through the anatomy of the uveal tract, SUN classification, granulomatous versus non-granulomatous distinction, a systematic etiology framework, the treatment ladder from topical steroids to biologics, and the ATT-plus-steroid regimen that is unique to Indian ophthalmology practice.
Anatomy of the uveal tract
The uveal tract is the pigmented vascular middle coat of the eye — iris (anterior), ciliary body (middle) and choroid (posterior). Uveitis is inflammation of any part of this coat, but the SUN classification uses the primary anatomic site of inflammation (not the primary structure inflamed) to name the disease.
SUN 2005 anatomic classification
| Class | Primary site | Named conditions |
|---|
| Anterior | Iris, ciliary body | Iritis, iridocyclitis, anterior cyclitis |
| Intermediate | Vitreous, pars plana, peripheral retina | Pars planitis, posterior cyclitis, hyalitis |
| Posterior | Retina, choroid | Retinitis, choroiditis, chorioretinitis, neuroretinitis |
| Panuveitis | All three (anterior + intermediate + posterior) | VKH, sympathetic ophthalmia, Behçet |
Duration — limited (under 3 months) versus persistent (over 3 months).
Onset — sudden versus insidious.
Course — acute (one episode, resolves), recurrent (multiple episodes with off-treatment quiet periods), chronic (persistent, relapses within 3 months of stopping treatment).
Anterior uveitis
Symptoms — pain, photophobia, redness, blurred vision, lacrimation. Usually unilateral (HLA-B27 alternating unilateral) or bilateral (JIA-associated, sarcoid).
Slit-lamp signs
- Ciliary flush (circumcorneal congestion).
- Keratic precipitates (KPs) — cellular deposits on corneal endothelium. Mutton-fat KPs (large greasy, granulomatous — TB, sarcoid, VKH) vs small punctate KPs (non-granulomatous — HLA-B27).
- Anterior chamber cells and flare — SUN grading 0 to 4+ in a 1×1 mm slit-beam.
- Hypopyon — layered pus at inferior AC angle — HLA-B27, Behçet, endophthalmitis.
- Posterior synechiae — adhesions of iris to lens capsule; seclusio pupillae if 360 degrees; iris bombé from aqueous trapping.
- Iris nodules — Koeppe (pupillary border) and Busacca (mid-iris) — granulomatous.
- Complicated cataract — usually posterior subcapsular from chronic inflammation and steroid use.
- Band keratopathy — calcium deposition in Bowman layer, especially in JIA.
Common causes
- HLA-B27 — ankylosing spondylitis, reactive arthritis, psoriatic arthritis, IBD — sudden, unilateral, alternating, hypopyon, non-granulomatous.
- JIA-associated — young girls, oligoarticular, ANA+, chronic asymptomatic — screen every 3 months.
- Herpes (HSV/VZV) — unilateral granulomatous with sectoral iris atrophy and raised IOP.
- TB — granulomatous, chronic.
- Sarcoidosis — bilateral granulomatous, mutton-fat KPs, ACE and lysozyme elevated, chest X-ray hilar lymphadenopathy.
Intermediate uveitis
Vitreous is the primary site — snowballs (vitreous cellular aggregates) and snowbanks (exudate over pars plana on scleral depression). Pars planitis is the idiopathic form (60 to 80 percent).
Causes — pars planitis (idiopathic), multiple sclerosis (10 to 20 percent), sarcoidosis, TB, Lyme disease.
Complications — cystoid macular oedema (leading cause of vision loss), cataract, epiretinal membrane.
Posterior uveitis
- Chorioretinitis — pathogens that infect retinal pigment epithelium and choroid — Toxoplasma (most common posterior uveitis worldwide, focal necrotising chorioretinitis with satellite lesion beside old scar), CMV (in HIV, "pizza-pie" retinitis with haemorrhage and perivenous exudate), Toxocara (peripheral granuloma).
- Retinitis — Herpes acute retinal necrosis (ARN — HSV/VZV), progressive outer retinal necrosis (PORN — in HIV).
- Choroiditis — TB (serpiginous-like choroiditis, choroidal tubercles), sarcoid (multifocal choroiditis), sympathetic ophthalmia (Dalen-Fuchs nodules).
- Retinal vasculitis — Behçet, SLE, Eales disease (peripheral retinal vasculitis, obliterative in young Indian males, TB-hypersensitivity likely).
Panuveitis
- VKH — bilateral granulomatous panuveitis + poliosis + vitiligo + dysacusis + meningismus + serous retinal detachment. Multiple pinpoint leaks on FFA (starry-sky).
- Sympathetic ophthalmia — mirror-image of VKH — bilateral granulomatous panuveitis after penetrating trauma or surgery to fellow eye. Enucleate blind traumatised eye within 2 weeks if visual recovery impossible.
- Behçet disease — hypopyon + oral and genital ulcers + skin lesions + retinal vasculitis; HLA-B51.
- Endophthalmitis — infective panuveitis (bacterial/fungal); vitritis, hypopyon, pain, rapid vision loss — emergency vitreous tap and intravitreal antibiotics.
Etiology framework
| Category | Examples |
|---|
| Infectious | TB (India-dominant), syphilis, HSV/VZV, CMV, HIV, Lyme, Whipple, Toxoplasma, Toxocara |
| Autoimmune | HLA-B27 spondyloarthropathy, JIA, sarcoidosis, Behçet, VKH, sympathetic ophthalmia, SLE |
| Masquerade | Primary intraocular lymphoma (PCNSL), retinoblastoma (children), leukemia, retinal detachment |
Investigations
All uveitis workup starts with a stepwise approach — do not order everything at first presentation of a unilateral non-granulomatous anterior uveitis, but do a full workup for bilateral, recurrent, granulomatous, intermediate or posterior disease.
- Slit-lamp — cells, flare, KPs, nodules.
- Indirect ophthalmoscopy with scleral depression — vitreous cells, snowbanks, retinal/choroidal lesions.
- Fundus fluorescein angiography (FFA) — vasculitis, VKH pinpoint leaks, CME.
- OCT — CME, epiretinal membrane, serous retinal detachment.
- USG B-scan — dense vitritis, exudative RD, PIOL.
- Workup panel — CBC, ESR, CRP, VDRL/RPR, HIV, Mantoux + IGRA (QuantiFERON), chest X-ray or CT thorax (TB, sarcoid), HLA-B27, ANA, ACE and lysozyme (sarcoid), ANCA, complement, autoimmune panel.
- Vitreous PCR — for HSV, VZV, CMV, Toxoplasma, Mycobacterium tuberculosis in select cases.
Treatment ladder
First line — topical
- Prednisolone acetate 1 percent — hourly initially, taper over 6 to 8 weeks based on cell count. Difluprednate 0.05 percent for refractory anterior disease.
- Cycloplegic — atropine 1 percent tds (long duration) or homatropine 2 percent qid — prevents synechiae, relieves ciliary spasm.
Second line — regional and systemic
- Periocular triamcinolone (40 mg subtenon) — anterior/intermediate.
- Intravitreal steroids — dexamethasone implant (Ozurdex, 0.7 mg, 3-4 months duration), fluocinolone implant (Iluvien, 2-3 years).
- Systemic prednisolone — 1 mg/kg/day for severe posterior or panuveitis; taper over 6 months.
Third line — steroid-sparing immunosuppressants
- Methotrexate 15 to 25 mg/week — most used first-line steroid-sparer.
- Mycophenolate mofetil 1 to 3 g/day.
- Azathioprine 2 mg/kg/day.
- Cyclosporine 3 to 5 mg/kg/day — favoured in Behçet.
Fourth line — biologics
- Adalimumab (anti-TNF) — FDA-approved for non-infectious intermediate, posterior and panuveitis (2016).
- Infliximab — Behçet.
- Rituximab — refractory VKH, IgG4.
Ocular TB — ATT plus steroids
- India-specific — Indian ophthalmologists routinely start empirical 6 to 9 month ATT for presumed ocular TB in patients with positive Mantoux/IGRA, chest imaging or high-risk exposure and compatible ocular findings.
- Concurrent oral prednisolone 1 mg/kg for 6 to 8 weeks to prevent paradoxical worsening (Herxheimer-like) from mycobacterial death.
NEET PG MCQ traps
- SUN 2005 — anatomic classification (anterior/intermediate/posterior/pan).
- Anterior uveitis = iris + ciliary body (iritis, iridocyclitis).
- Intermediate uveitis = vitreous + pars plana (pars planitis) — snowballs + snowbanks.
- Posterior uveitis = retina + choroid (retinitis, choroiditis).
- Panuveitis = all three — VKH, sympathetic ophthalmia, Behçet.
- Mutton-fat KPs = granulomatous (TB, sarcoid, syphilis, VKH).
- Fine punctate KPs = non-granulomatous (HLA-B27, JIA, idiopathic).
- HLA-B27 anterior uveitis — young male, acute, unilateral, alternating, hypopyon.
- JIA-associated — young girl, oligoarticular, ANA+, chronic asymptomatic — 3-monthly slit-lamp screening.
- VKH triad — dermatologic (poliosis, vitiligo) + auditory (dysacusis) + neurologic (meningismus).
- VKH FFA — starry-sky pinpoint hyperfluorescent leaks.
- Sympathetic ophthalmia — bilateral granulomatous panuveitis; enucleate blind eye within 2 weeks of injury.
- Behçet disease — hypopyon + oral/genital ulcers + HLA-B51.
- Eales disease — peripheral retinal vasculitis in young Indian males; TB hypersensitivity.
- Toxoplasma — focal necrotising chorioretinitis with satellite scar; most common posterior uveitis.
- CMV retinitis — "pizza-pie" haemorrhagic retinitis in HIV/CD4 under 50.
- Herpes ARN — full-thickness retinal necrosis, arteritis, vitritis; IV acyclovir.
- India — TB is the most common uveitis in tertiary series (10 to 20 percent).
- Ocular TB — presumptive diagnosis (Mantoux, IGRA, chest imaging) plus 6 to 9 months ATT with concurrent steroids.
- First-line topical — prednisolone acetate 1 percent + cycloplegic (atropine/homatropine).
- Adalimumab — FDA-approved biologic for non-infectious intermediate/posterior/panuveitis (2016).
- Sarcoid workup — ACE, lysozyme, chest X-ray hilar lymphadenopathy, gallium scan (panda + lambda signs).
- Complicated cataract — posterior subcapsular from chronic inflammation and steroid use.
Recent updates and India context
- SUN 2021 revision — updated criteria for individual uveitis entities (Behçet, VKH, sarcoid, HLA-B27) but the 2005 anatomic classification remains the framework.
- Adalimumab in India — biosimilars (Exemptia, Zydus; Adfrar, Torrent) at about 15,000 to 20,000 INR/month have made anti-TNF therapy more accessible.
- Indian Uveitis Society (IUvS) and Uveitis Society of India — publish consensus guidelines on ocular TB workup and ATT trial.
- National TB Elimination Programme (NTEP, formerly RNTCP) — provides free 6-month ATT under DOTS for confirmed and presumptive ocular TB.
- Aravind Eye Care System, LV Prasad Eye Institute (LVPEI), Sankara Nethralaya — major Indian uveitis referral centres with dedicated uveitis clinics.
- PMJAY — panels intravitreal dexamethasone implant (Ozurdex) and Adalimumab biosimilars at select empanelled hospitals.
- HIV-related uveitis — CMV retinitis at CD4 under 50 remains a major cause; ART rollout under NACO has reduced incidence significantly.
- Serpiginous-like choroiditis — the Indian variant of ocular TB is now recognised as a distinct entity requiring long ATT plus immunosuppressives to prevent recurrence.
Frequently asked questions
What is the SUN 2005 anatomic classification of uveitis?
The Standardisation of Uveitis Nomenclature (SUN 2005) working group classifies uveitis by primary anatomic site of inflammation — anterior (iris and ciliary body — iritis, iridocyclitis, anterior cyclitis), intermediate (vitreous plus peripheral retina and pars plana — pars planitis), posterior (retina and choroid — retinitis, choroiditis, chorioretinitis) and panuveitis (all three chambers involved). Duration is limited (under 3 months) or persistent (over 3 months); onset is sudden or insidious; course is acute, recurrent or chronic. Cell and flare grading uses a 0 to 4+ scale in a standard 1×1 mm slit-beam field. The SUN classification replaces the older duration-based Woods classification and drives both diagnostic workup and therapy.
Why is tuberculosis the leading cause of uveitis in India?
India carries about 27 percent of the global TB burden, and ocular TB accounts for 10 to 20 percent of uveitis cases in Indian tertiary referral centres — the highest in any single etiology. Ocular TB can be primary (direct organism) or secondary (immune hypersensitivity to distant infection), presenting as serpiginous-like choroiditis, choroidal tubercles, anterior granulomatous uveitis with mutton-fat KPs, or retinal vasculitis (Eales disease). Diagnosis is largely presumptive — Mantoux (over 15 mm), IGRA (QuantiFERON), chest X-ray or CT, and vitreous PCR for Mycobacterium tuberculosis, since ocular tissue is rarely biopsied. Treatment is a full six to nine month ATT trial plus concurrent oral steroids to suppress paradoxical worsening from mycobacterial death.
What is the difference between granulomatous and non-granulomatous uveitis?
Granulomatous uveitis has large greasy mutton-fat keratic precipitates (KPs) on the corneal endothelium, iris nodules (Koeppe at pupillary border, Busacca in mid-iris) and a chronic, indolent course. Causes — TB, sarcoidosis, syphilis, VKH, sympathetic ophthalmia, herpetic (HSV, VZV), lens-induced. Non-granulomatous uveitis has small fine punctate KPs, no iris nodules and a more acute, often self-limiting course. Causes — HLA-B27-associated spondyloarthropathy, JIA-associated (paradoxically chronic despite being non-granulomatous), post-traumatic, idiopathic (about 50 percent). The distinction guides workup — a granulomatous appearance mandates a TB and sarcoid workup, while non-granulomatous with acute alternating hypopyon in a young male shouts HLA-B27.
What triad defines Vogt-Koyanagi-Harada syndrome?
VKH is an autoimmune panuveitis directed against melanocytes, presenting with the triad of dermatologic (poliosis of eyelashes and eyebrows, vitiligo, alopecia), auditory (dysacusis, tinnitus, sensorineural hearing loss) and neurologic (meningismus, headache, CSF pleocytosis) findings on top of bilateral granulomatous panuveitis with serous retinal detachment. Fluorescein angiography shows multiple pinpoint hyperfluorescent leaks (starry-sky pattern). Common in pigmented races — Asian, Indian, Hispanic, native American. Treatment is high-dose oral or IV pulse methylprednisolone followed by long taper plus early steroid-sparing (methotrexate, MMF, azathioprine, cyclosporine). Sympathetic ophthalmia is the mirror-image diagnosis — bilateral granulomatous panuveitis triggered by penetrating trauma or surgery to the fellow eye.
How is anterior uveitis treated at first presentation?
First-line therapy for anterior uveitis is topical prednisolone acetate 1 percent — one drop hourly initially, tapering over 6 to 8 weeks based on cell count response — plus a topical cycloplegic (atropine 1 percent or homatropine 2 percent) to prevent posterior synechiae, relieve ciliary spasm pain and stabilise the blood-aqueous barrier. Systemic workup is triggered by bilateral disease, recurrence, granulomatous features, chronic course over 3 months or intermediate/posterior involvement — includes CBC, ESR/CRP, VDRL, HIV, Mantoux/IGRA, chest X-ray, HLA-B27, ANA, ACE and lysozyme for sarcoid. Steroid failure or steroid dependence pushes therapy up the ladder — periocular triamcinolone injection, systemic prednisolone, methotrexate or mycophenolate, and biologics (adalimumab is FDA-approved for non-infectious intermediate, posterior and panuveitis).
This content is for educational purposes for NEET PG exam preparation. It is not a substitute for professional medical advice, diagnosis, or treatment. Clinical information has been reviewed by qualified medical professionals.
Written by: NEETPGAI Editorial Team
Reviewed by: Pending SME Review
Last reviewed: July 2026
