Diagnosis

Uveitis (Intraocular Inflammation)

Uveitis is not one specific disease, but a broad category of diseases that share some characteristics.  The term uveitis refers to inflammation of the uvea, which is an internal layer of the eye. This includes the iris, or the-colored part of the eye surrounding the pupil, and the choroid, which is a layer of vascular tissue that lies between the sclera, the outer white coat over the eye, and the retina, the inner layer of nerve tissue lining the inside wall of the eye.

Inflammation refers to activation of the immune system which causes certain changes in the tissues of the body that can result in damage in these tissues.  Inflammation can develop as a result of an infection via microaneurysm, such as a bacteria, virus, or parasite.  It can also develop as a result of an autoimmune process, which can result when the immune system mistakenly attacks its own tissues and organs. It can also result from trauma, either due to an injury or surgery.

 

So, the term uveitis refers to inflammation that involves some or all of the uvea of the eye.

Terminology

Uveitis is generally divided into several different categories.

  1. Anterior uveitis.  This is also commonly called iritis.  This is inflammation that involves only the iris, or the-colored part of the eye.

  2. Intermediate uveitis.  This is inflammation that involves the part of the uvea immediately behind the iris, known as the pars plana.  For this reason intermediate uveitis is also sometimes referred to as pars planitis.

  3. Posterior uveitis.  This involves all of the uveal tissue underneath the retina, which lies behind the iris and pars plana.

  4. Panuveitis.  This refers to inflammation involving all of the uvea.

Diagnosis

Uveitis has a large spectrum of severity.  Some cases of anterior uveitis, or iritis, can be relatively mild and self-limited.  These cases and can oftentimes be successfully treated with a limited course of anti-inflammatory eyedrops.  More severe uveitis can be very difficult to treat and can result in blindness.

In addition to the anatomic location of the inflammation, this condition is also generally categorize based on the cause of the inflammation.

  1. Infectious uveitis.  This refers to uveitis that is caused by an infectious organism such as a bacteria, virus, or parasite.

  2. Noninfectious uveitis.  This refers to any form of uveitis that is not associated with an infectious organism.

Etiology

Uveitis has a large spectrum of severity.  Some cases of anterior uveitis, or iritis, can be relatively mild and self-limited.  These cases and can oftentimes be successfully treated with a limited course of anti-inflammatory eyedrops.  More severe uveitis can be very difficult to treat and can result in blindness.

In addition to the anatomic location of the inflammation, this condition is also generally categorize based on the cause of the inflammation.​

Infectious uveitis

One of the first steps that an ophthalmologist will take in diagnosing uveitis is to test for microorganisms which can be treated with various antibiotics or antiviral agents.  There are many microorganisms that can infect the eye, a list of the most common infectious diseases causing uveitis is listed below:

  • Syphilis

  • Tuberculosis

  • Toxoplasmosis

  • Cat scratch disease

  • Lyme disease

  • Toxocariasis

  • Candidiasis

  • Cysticercosis

  • Leptospirosis  

  • Herpes simplex

  • Herpes zoster

  • Cytomegalovirus​

Noninfectious uveitis

These conditions are treated not with antibiotics or antivirals, but with drugs that suppress the immune response. Below is a list of some of the most common noninfectious uveitis syndromes.

  • Sarcoidosis

  • Serpiginous choroiditis

  • Vogt-Koyanagi-Harada Syndrome (VKH)

  • Systemic Lupus Erythematosis

  • Rheumatoid arthritis

  • Multifocal choroiditis

  • HLA B 27 positive iritis

  • Birdshot Choroidopathy

  • Sympathetic ophthalmia

Workup

Except in cases of relatively mild anterior uveitis, especially the first episode, the physician will frequently order laboratory tests and possibly imaging studies to determine whether the uveitis is most likely infectious or noninfectious.  This is very important since it is necessary to treat infectious uveitis with the appropriate antibiotics or antiviral medication.  Once an infection has been ruled out, there are a large number of treatments that can be used for noninfectious uveitis.

Treatment

Corticosteroids

For many years the standard treatments for uveitis were medications within the corticosteroid class. These medications are still usually used as the initial treatment to quickly quell the acute inflammation. In some cases these are the only treatment necessary to successfully resolve the inflammation. Steroid medication can be administered in several ways.

 

  1. Topical. There are several different steroid eye drop preparations that can be used.

  2. Periocular. This refers to the injection of steroids, usually in a long acting, slow release formulation, such as triamcinolone. These injections are given around the eye, but not inside the eye itself. This is done in the office using local anesthesia.

  3. Intraocular or intravitreal steroids. This refers to the injection of steroid medication into the inside cavity of the eye. This is frequently done either with dexamethasone or preservative free triamcinolone, but there are other longer acting steroid implants and pellets that can be injected or surgically implanted into the eye.

  4. Systemic steroids. This refers to steroid medication taken orally or given by way of intravenous or intramuscular injection.

The choice of the type of steroid and the mode of delivery depends on many factors including the duration, severity and the cause of the inflammation. These are all factors that an ophthalmologist takes into consideration when choosing the type of steroid treatment.

Nonsteroidal medications

These medications can be used in conjunction with, or in place of steroids.

  1. Nonsteroidal anti-inflammatories (NSAIDs). These can be used in drop form, or more uncommonly in oral form. Nonsteroidal anti-inflammatory eye drops are frequently used with steroid eye drops because they tend to have an additive effect, increasing the potency of the steroid eye drops. Sometimes they are used in place of steroid eye drops when an inflammation is mild or when there are unacceptable side effects from steroid eye drops.

  2. Immune modulatory drugs. There are now a large number of anti-inflammatory drugs that can be used to modulate the immune system without the severe, long term side effects that systemic steroids have when taken for long periods of time (usually weeks or months). Some of these medications may also have the risk of significant side effects themselves, so the ophthalmologist may enlist the assistance of an internist or rheumatologist when using one of these medications. The most recent addition to this class of medications is the “biologicals”. These are medications which are manufactured by genetically engineering bacteria to produce a chemical that targets a specific site in the immune system rather than indiscriminately disabling all or large parts of the system, which can cause severe side effects.

Immune modulatory drugs are most often used when it is anticipated that the patient may require long term treatment, as is the case in chronic uveitis (uvetis which can last from months to years or that tends to be recurrent).

The choice of medication is complex and depends upon multiple factors. Often the choice is made in consultation between the ophthalmologist and the rheumatologist or internist.

In some cases of chronic uveitis patients may require treatment for years, or possibly even for life, but if the inflammation can be kept completely under control for a period of 3 years or longer, some patients can be successfully weaned off of medication without a recurrence.

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