Uveitis

  • Medical Author:
    Patricia S. Bainter, MD

    Dr. Bainter is a board-certified ophthalmologist. She received her BA from Pomona College in Claremont, CA, and her MD from the University of Colorado in Denver, CO. She completed an internal medicine internship at St. Joseph Hospital in Denver, CO, followed by an ophthalmology residency and a cornea and external disease fellowship, both at the University of Colorado. She became board certified by the American Board of Ophthalmology in 1998 and recertified in 2008. She is a fellow of the American Academy of Ophthalmology. Dr. Bainter practices general ophthalmology including cataract surgery and management of corneal and anterior segment diseases. She has volunteered in eye clinics in the Dominican Republic and Bosnia. She currently practices at One to One Eye Care in San Diego, CA.

  • Medical Editor: William C. Shiel Jr., MD, FACP, FACR
    William C. Shiel Jr., MD, FACP, FACR

    William C. Shiel Jr., MD, FACP, FACR

    Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.

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What is uveitis?

Uveitis is inflammation of the uvea of the eye. The uvea is made up of three parts. The first part is the iris, which is the colored ring of tissue you can see in the mirror. The dark hole in the middle of the iris is the pupil. The second and third parts, which you cannot see directly when looking in a mirror, are the ciliary body and the choroid. They are located behind the iris. An ophthalmologist can visualize them using special examination equipment.

Inflammation of the iris is called iritis. Inflammation of the ciliary body is called intermediate uveitis or cyclitis. Inflammation of the choroid is called choroiditis (or chorioretinitis if the retina is also involved). Inflammation of all three is called panuveitis.

What causes uveitis?

There are many causes of uveitis, including autoimmune disorders (such as sarcoidosis, rheumatoid arthritis, systemic lupus erythematosus, Behcet's disease, and ankylosing spondylitis), infections (such as syphilis and toxoplasmosis), and trauma. Additionally, some are idiopathic, meaning the cause is unknown.

What are uveitis symptoms?

Symptoms of uveitis include some or all of the following:

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Uveitis Symptom

Photophobia

Sensitivity to light is the inability to tolerate light, medically known as photophobia. In someone who is light sensitive, any type of light source (sunlight, fluorescent light, incandescent light) can cause discomfort. Photophobia typically causes a need to squint or close the eyes, and headache, nausea, or other symptoms may be associated with photophobia. Symptoms may be worse with bright light. Light sensitivity is caused by a number of conditions that affect the eye (such as iritis, uveitis, and keratitis), as well as conditions that affect the entire body.

What are the signs of uveitis?

The eyes are often red and typically a deeper red than that seen in pinkeye (conjunctivitis).

Aside from the redness of the eye(s), the only other visible signs of uveitis are microscopic and can be seen by an ophthalmologist or optometrist using a slit lamp microscope. Inflammatory white blood cells can be visualized in and around the uvea.

What are the different types of uveitis?

The different types of uveitis are classified based on which parts of the uvea are affected: iritis (iris), cyclitis or intermediate uveitis (ciliary body), choroiditis (choroid), or panuveitis (all three parts of the uvea).

Different types are then further classified by cause: autoimmune (when associated with an autoimmune disease in the body), infectious (when caused by a bacteria, virus, fungus, or parasite), traumatic (after trauma to either eye), or idiopathic (no identifiable cause).

What other medical conditions are associated with uveitis?

Several autoimmune diseases can be associated with uveitis: sarcoidosis, lupus, rheumatoid arthritis, and multiple sclerosis, to name a few. Several infections in the body can also be associated: tuberculosis, Lyme disease, syphilis, herpes zoster (shingles), and others.

What specialties treat uveitis?

If an associated medical disease is suspected, your eye doctor (ophthalmologist) may ask you to see other doctors, as well. A primary-care doctor or pediatrician will likely be involved in the work-up, and additional specialists such as a rheumatologist or infectious-disease doctor may be consulted.

How do health-care professionals diagnose uveitis?

An ophthalmologist will ask several questions about the symptoms, both in the eyes and the rest of the body. For example, the presence of painful joints, weight changes, skin rashes, fatigue, and other symptoms may help the doctor diagnose an underlying illness that may be associated with uveitis. The doctor will also need a detailed history of any existing medical conditions and family history of medical disorders.

The vision and eye pressures will be measured and the eyes carefully examined with the slit lamp. The dilated red blood vessels on the eyes' surface can have a characteristic appearance called a ciliary flush of deep red that is typical of uveitis (as opposed to the lighter reddish eyes of conjunctivitis). Though there are several types of uveitis, they all have one thing in common; white blood cells (immune cells of inflammation found in the bloodstream) leak from inside the blood vessels of the uvea to outside the blood vessels. These white cells permeate the uveal tissue and leak out of the uvea into the aqueous (liquid in the front part of the eye) and/or the vitreous (gelatinous material in the back part of the eye). This presence of white blood cells is what an ophthalmologist looks for when making the diagnosis of uveitis. Iritis can appear initially as subclinical with no white blood cells visible. Other times, uveitis is not so subtle, with large numbers of cells visible in the aqueous and/or vitreous. In some cases, clusters of white blood cells accumulate on the back side of the cornea (the clear dome-shaped front cover of the eye). These clusters of cells are referred to as mutton fat deposits. In extreme cases, the cells can also form a large pool in the space between the iris and the cornea. This is referred to as a hypopyon.

Cyclitis (intermediate uveitis) appears as white blood cells floating in the vitreous and collections of cells on the surface of uveal tissues behind the iris. Choroiditis appears as cells in the vitreous and uveal tissue but further posterior (toward the back of the eye). An ophthalmologist will need to dilate the patient's eyes and use special examination techniques to visualize this. Pictures of the back part of the eye using OCT, fluorescein angiography, or other technologies can also be helpful in assessing the extent of a posterior uveitis.

Additional tests might include laboratory evaluation of a small sample of aqueous or vitreous liquid from the eye, blood tests, and/or X-rays. These tests take time. Therefore, a treatment plan is usually initiated based on a clinical judgment before the cause can be definitively identified.

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What is the treatment for uveitis?

In noninfectious uveitis, treatment centers on control of the inflammation. Often this can be achieved with steroids given as eyedrops, injection in or around the eye, orally (by mouth), or intravenously, depending on the extent and severity of the inflammation.

The duration of the treatment may be as short as a week or several months or even years, depending on the cause.

In chronic, relapsing or advanced uveitis, steroid alternatives may be used. Immunomodulatory therapy (IMT) drugs such as methotrexate, azathioprine, mycophenolate, and others are used in certain cases. Biologic response modifier (BRM) drugs, including infliximab, adalimumab, and others, are also sometimes used. If the cause is infectious, an anti-infective medication will also be used (for example antibiotic, antiviral, antiparasitic, or antifungal) to combat the underlying infectious agent.

Dilation drops may also be used in conjunction to uveitis treatment to help relieve some of the ache.

Are there home remedies for uveitis?

There are no known home remedies for uveitis. While waiting for the prescribed medications to take effect, wearing dark sunglasses can help with the light sensitivity. Some types of uveitis are more severe among smokers, so stopping (or at least cutting back as much as possible) is advisable.

What is the prognosis for uveitis?

The prognosis varies tremendously; some types are mild and occur only once, never to recur again. Others recur repeatedly over the years, coming and going at seemingly random and unpredictable intervals. Still other types never completely subside and linger for years, requiring chronic treatment to prevent flare-ups.

What are the complications of uveitis?

Uveitis has many potentially serious complications that can lead to permanent, irreversible vision loss. For this reason, it is imperative that uveitis be treated promptly and to the best extent possible.

If the inflammation continues unchecked, complications may include sudden or chronic rises in eye pressure that can lead to permanent damage of the optic nerves, resulting in irreversible vision loss (glaucoma). The inflammation can also damage delicate cells on the cornea and retina, causing fluid buildup that blurs and damages the vision, sometimes irreversibly.

For these reasons, uveitis should ideally be treated as aggressively as possible. The medications used to treat uveitis have side effects of their own, some of them serious. The ophthalmologist, often together with the patient's other doctor(s), balances the risks and benefits of the drug(s) against the potential damage that can result from undertreated uveitis.

Is it possible to prevent uveitis?

It is not always possible to prevent uveitis, particularly since many cases do not have a known cause. However, one can reduce the chances of acquiring traumatic or infectious uveitis with common-sense precautions against risk factors. Examples include the use of eye protection when engaging in activities such as lawn edging and drilling, using extra caution around opening champagne bottles or firecrackers, keeping vaccinations up to date, practicing good hygiene and hand washing, guarding against sexually transmitted diseases, and getting regular general health checkups with a primary-care doctor.

Autoimmune diseases are often genetic (that is, they run in families), and perhaps gene therapies in the future will be available. Prevention of flare-ups of uveitis requires close monitoring with repeat examinations by an ophthalmologist. The treatment must often be adjusted or modified according to both microscopic and clinical changes for optimal control.

REFERENCES:

Durrani, K., et al. "Systemic therapy with conventional and novel immunomodulatory agents for ocular inflammatory disease." Survey of Ophthalmology 56.6 (2011): 474-510.

Foster, C.S., et al. "The Ocular Immunology and Uveitis Foundation preferred practice patterns of uveitis management." Surv Ophthalmol 61.1 Jan.-Feb. 2016: 1-17.

Last Editorial Review: 12/20/2016

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Reviewed on 12/20/2016
References
REFERENCES:

Durrani, K., et al. "Systemic therapy with conventional and novel immunomodulatory agents for ocular inflammatory disease." Survey of Ophthalmology 56.6 (2011): 474-510.

Foster, C.S., et al. "The Ocular Immunology and Uveitis Foundation preferred practice patterns of uveitis management." Surv Ophthalmol 61.1 Jan.-Feb. 2016: 1-17.

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