Uveitis

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Uveitis
Overview

Uveitis is diagnosed when there is inflammation of the uvea, which is the middle layer of the eye in between the eye wall called the sclera (outer layer) and the retina (inner layer).

The uvea in the anterior (front) of the eye includes the iris and ciliary body, and the uvea in the posterior (back) of the eye is known as the choroid.

The type of uveitis is determined by the location of the inflammation and type of inflammation within the eye:

  • Anterior Uveitis (Iritis) – The presence of inflammation of the anterior uveal tract, characterized by the presence of white blood cells (leukocytes) in the anterior chamber of the eye. When the adjacent ciliary body is also inflamed, it is called iridocyclitis.
  • Intermediate Uveitis - The presence of inflammation and white blood cells in the anterior segment and posterior segment (vitreous gel but not the retina or choroid) of the eye.
  • Vitritis – The presence of inflammation in the vitreous gel within the center cavity of the eye.
  • Posterior Uveitis – The presence of inflammation in the vitreous, retina and choroid in the posterior segment of the eye.
  • Panuveitis - The presence of inflammation and white blood cells in the anterior segment and posterior segment (vitreous gel, retina & choroid) of the eye.
  • Pars planitis – The accumulation of inflammatory white blood cells at the vitreous base (inferior portion of the vitreous cavity)
  • Retinitis – The presence of inflammation within the retina
  • Choroiditis – The presence of inflammation within the choroid
  • Endophthalmitis - The presence of inflammation in the anterior and posterior segments of the eye secondary in infection.
  • Panuveitis is defined as simultaneous inflammation in the anterior chamber, vitreous humor, and retina or choroid.

Causes

There are a variety of conditions which cause uveitis including the following:

  • Genetic Disorders
    • HLA-B27 (Psoriasis, Ankylosing Spondylitis, Ulcerative Cholitis, Reiter’s syndrome)
    • HLA-DR15 (Multiple Sclerosis, Optic Neuritis, Intermediate Uveitis)
    • HLA-Dw51 & HLA-D5 (Bechet’s disease)
    • HLA-A29 (Birdshot Chorioretinopathy)
  • Autoimmune Disorders
    • Sarcoidosis
    • Rheumatoid arthritis
    • Juvenile Rheumatoid Arthritis
    • Systemic Lupus Erythematosis
    • Sympathetic Ophthalmia
    • Vogt-Koyanagi-Harada Syndrome (VKH)
  • Infections
    • Bacterial infections
      • Toxoplasmosis
      • Tuberculosis
      • Lyme disease
      • Syphillis
      • Toxocariasis
      • Bartonella
      • Babesia
      • Rocky Mountain Spotted Fever
      • Ehrlichia
    • Viral infections
      • Herpes virus (HSV1 & HSV2)
      • Cytomegalovirus
      • HIV
      • Zika virus
      • West nile virus
      • White dot syndromes
    • Fungal infections
      • Cryptococcus
      • Aspergillosis
      • Candida
  • Cancer
    • Leukemia
    • Lymphoma

When uveitis is recognized by a physician, depending on its location and/or characteristic appearance, a focused systemic work up may be ordered.

Symptoms

A patient with ocular inflammation can have a range of different symptoms including the following:

  • Blurred vision
  • Difficulty focusing/reading
  • Eye ache
  • Eye pain
  • Redness/injection of the sclera (white part of eye)
  • Sensitivity to bright lights (photophobia)
  • Dilated pupil
  • Irregular pupil

Complications of uveitis

The complications of uveitis include the following:

  • Band Keratopathy - deposition of calcium below the epithelium of the cornea causing blurred vision.
  • Posterior Synechiae – scar tissue that forms between the iris and lens leading to irregular pupil
  • Cataract – clouding of the lens inside the eye leading to blurred vision (resulting from inflammation, or as a side effect of steroid medication used to treat the inflammation)
  • Glaucoma – high pressure in the eye leading to damage to the optic nerve (due to direct effects of inflammation or as a consequence of scarring, the ability of the eye to maintain its optimal pressure can be compromised, resulting in dangerously high intraocular pressure levels)
  • Cystoid macular edema - the accumulation of fluid and swelling in the central retina, or macula, that causes blurred and decreased vision

Diagnostic Testing

A patient with uveitis may need a complete ocular and systemic work-up. Diagnostic testing includes (but is not limited to) the following:

  • Dilated Fundoscopic Exam – evaluation of posterior segment of the eye (including the vitreous, retina & choroid)
  • OCT imaging – evaluation of retina, retinal pigment epithelium & choroid
  • Fluorescein Angiography
  • ICG Angiography
  • Visual Fields Testing
  • Bloodwork – to rule out infectious, inflammatory & genetic disorders
  • Chest X-rays
  • CT Scans or MRI
  • Rheumatology Consult

Treatment

Treatment of ocular inflammation depends entirely on the severity and on the underlying cause and include the following:

  • Steroid Eye Drops
    • Durazol
    • Pred Forte
    • Prednisolone
    • Lotemax
    • Pred Mild
    • FML
  • Dilating Eye Drops
    • Cyclogyl
    • Homatropine
    • Atropine
  • Non-Steroidal Anti-Inflammatory Drops (NSAID’s)
    • Bromsite
    • Prolensa
    • Ilevro
    • Flurbiprofen
    • Ketorolac
    • Voltaren
  • Sub-Tenon’s Steroid Injection
    • Triamcinolone
    • Dexamethasone
  • Intraocular Steroid Injection
    • Ozurdex
    • Iluvien
    • Triamcinolone
  • Oral Steroids
    • Prednisone
  • Systemic Steroids
    • Solumedrol
    • Solucortef
    • Dexamethasone
  • Systemic Anti-Metabolite Medication
    • Humera
    • Remicade
    • Embril
    • Interferon
    • Methotrexate
  • Surgery
    • Vitreous Biopsy