What is Uveitis?
Uveitis is an inflammatory condition associated with visual impairment, blindness, and reduced quality of life. The condition often affects patients in their most active and economically productive years. Uveitis has been demonstrated to cause between 5% and 20% of cases of legal blindness in the United States. The eye is composed of three basic layers. The outermost layer is the sclera or “white” of the eye and the cornea-the curved dome in the front of the eye. The innermost layer is the retina, and the middle layer is the Uvea. The Uvea or Uveal tract includes the iris, the ciliary body and the choroid which provide most of the blood supply to the retina. Inflammation in any of the parts of the Uveal tract is called Uveitis.
Types of Uveitis
There are different types of uveitis depending on what parts of the eye are affected.
- Anterior Uveitis is inflammation in the front of the Uveal tract of eye, and called Iritis or Iridocyclitis.
- Intermediate Uveitis is inflammation in the middle part of the Uveal tract of eye, and called Pars Planitis or Vitritis.
- Posterior Uveitis is inflammation of the back of the Uveal tract of eye, such as Choroiditis, Retinal Vasculitis, Retinitis, Neuroretinitis, Retinochoroiditis, or Chorioretinitis.
Inflammation inside the eye is a medical emergency and left untreated will almost certainly lead to vision loss.
Symptoms of Uveitis
The common symptoms of uveitis include redness, blurry vision, pain, light sensitivity and even flashes & floaters. Any or all of these can occur in one or both eyes. There are even some types of uveitis that can occur without any symptoms at all, such as uveitis associated with juvenile idiopathic arthritis.
Causes of Uveitis
Uveitis can have a number of different causes and associations:
- Viruses such as Herpes Simplex (Cold Sores), Varicella Zoster (Chicken Pox or Shingles)
- Bacteria such as Tuberculosis, Borrelia burgdorferi (Lyme Disease), Treponema Pallidum (Syphilis)
- Parasites such as Toxoplasma gondi
- Autoimmune disorders such as Rheumatoid Arthritis, Ankylosing Spondylitis, Psoriatic Arthritis, Reactive Arthritis, Sarcoidosis, Crohn’s Disease, Systemic Lupus Erythematosus (SLE), Multiple Sclerosis and Inflammatory Bowel Disease.
- Masquerade Syndromes such as Lymphoma
How is Uveitis Diagnosed?
It is very important to get a prompt and careful examination by an ophthalmologist upon the onset of eye inflammation symptoms as there will often, but not always be clear signs of inflammation inside the eye. Besides a dilated exam of the inside of the eye it may be necessary to have multiple types of photography and/or imaging. Further, a thorough determination of whether or not an underlying systemic disease or infection is causing or is associated with your Uveitis is a key step in the evaluation process. This may require radiologic or other imaging such as x-rays, CAT or MRI scans as well as laboratory blood work. Finally, it may be necessary to take fluid samples from inside the eye to identify a particular type of infection or cause, but then gives us the ability to effectively target your treatment options.
Treatment of Uveitis
The primary goal of treating uveitis is getting rid of inflammation as fast as possible.
Corticosteroids are the mainstay of therapy for acute uveitis of non-infectious causes, and can be used along with antibiotics in some cases of infectious uveitis. They can be given by drops, injection around or inside the eye, by mouth, or by intravenous infusion, depending on location and severity of inflammation. Unfortunately, they can never be depended upon for long term control of uveitis as they inevitably cause their own complications, such as cataract and glaucoma.
In addition, if the inflammation is not controlled with steroids alone, or if the dose & frequency of steroid treatment increases systemic or ocular risks, treatment regimens may require the use of “steroid sparing immunosuppressive medications” which can treat the inflammation and may eliminate the need for steroids. There are several classes of medications that can be used to control chronic or recurrent uveitis and in some cases will require assistance of a rheumatologist.
These can include:
- Antimetabolites such as Mycophenolate mofetil, Methotrexate and Azathioprine
- T-Cell Inhibitors such as Cyclosporine and Tacrolimus
- Biologics such as Adalimumab (Humira®) and Infliximab (Remicade®)
Other drops used in uveitis include cycloplegic drops (dilating drops), which are used to help limit light sensitivity, pain, and scarring of the iris to the lens, called synechiae.
Also, glaucoma from uveitis can be treated with drops that lower pressure in the eye.
Sometimes systemic therapy, by mouth, injection, or intravenous infusion, is necessary to treat stubborn cases of uveitis that recur after being treated acutely with steroids. Antibiotic or antiviral medication can be used, sometimes long term, to achieve remission.
A step-ladder approach to therapy has been adopted by most uveitis specialists to treat patients with stubborn or severe forms of non-infectious uveitis, with therapy again based on type and severity, as well as the extent of complications already suffered. This can include chemotherapy-style medications which require regular examinations and blood work monitoring. Side effects of medication can generally be avoided.
Surgery can be useful both for diagnosis and treatment of uveitis. Cataracts can be removed to improve vision as well as the uveitis specialist’s view inside the eye. Vitrectomy, removal of the gel center of the eye, can be used to perform biopsy as well as rid bothersome cells and debris to improve vision. Sometimes medication releasing implants or laser therapy with or without surgery can also be used to treat active inflammation.
When disease is caught early enough, prior to complications, inflammation can usually be treated successfully with appropriate therapy. However, when disease is not detected early enough, or when providers who are unfamiliar or uncomfortable dealing with uveitis fail to refer to a specialist, complications are much more prevalent and prognosis usually worse. Occasionally uveitis is severe and may lead to complications despite aggressive and timely therapy.
Is Uveitis Hereditary?
Generally speaking, Uveitis is not hereditary however there are certain systemic inflammatory diseases and conditions that are inherited and thus may affect the eyes but generally not passed to offspring.
Will Uveitis Just Go Away On Its Own?
Most often Uveitis tends to affect both eyes-not necessarily symmetrically-and require chronic treatment. Any amount of persistent untreated intraocular inflammation has the potential to cause irreversible vision loss and structural damage to one’s eyes. Therefore, close follow up, at the very least, is warranted in most cases. Lifelong treatment may be required in some cases in which withdrawal of treatment results in recurrence of potentially damaging inflammation.