Uveitis
Uveitides
Uveitis refers to the inflammation of the uveal tract of the eye.
Presentation
The symptoms of anterior uveitis are as below.
- Photophobia
- Ocular pain
- Tenderness of the globe
- Decreased visual acuity
- Lacrimation
Photophobia is due to the reactive spasm of the inflamed muscles of the iris; whereas spasm of the ciliary muscles leads to brow pain. Visual acuity is only decreased in severe cases associated with hypopyon.
The signs of anterior uveitis include the following.
- Miosis
- Ciliary flush
- Anterior chamber cells and flare
- Hypopyon
- Keratic precipitates
- Reduced intraocular pressure (IOP)
Ciliary flush results from perilimbal conjunctival injection. Spasm of the ocular sphincter muscle causes miosis. Anterior chamber cells are infact white blood cells that are seen in the anterior chamber; whereas anterior chamber flare refers to the presence of protein precipitates in the anterior chamber. Both of these manifestations are secondary to inflammation. Hypopyon results from the collection of neutrophilic exudates inferiorly in the anterior chamber. Keratic precipitates are only occasionally present and are seen as clumps of cells on the corneal epithelium. Iritis typically reduces the intraocular pressure because the inflammation of the ciliary body causes decreased production of the aqueous humor. However, there is an exception to this rule in which severe iritis, or iritis resulting from herpes simplex and herpes zoster may cause an inflammatory glaucoma.
Intermediate uveitis usually has an insidious onset. Blurred vision accompanied by vitreous floaters are usually present. Initially, the symptoms are usually unilateral but inflammatory changes are often bilateral and asymmetric. Vitreous cells, condensations and “snowballs” are often seen on examination, the latter being vitreous aggregates of inflammatory cells. Posterior segment snowbanking is also seen.
Posterior uveitis is usually painless. This is because the choroid has no sensory innervation. Conjunctival or scleral injection is often not present. Visual acuity may be decreased. Floaters (due to debris and inflammatory cells) are present. Vitreous cells and opacities may also be seen. In certain cases, hypopyon may also form.
Entire Body System
Reiter's Syndrome
- Autoimmune inflammation of iris and ciliary muscle Isolated or part of systemic autoimmune condition such as ankylosing spondylitis, juvenile rheumatoid arthritis, Reiter syndrome, sarcoidosis, herpes simplex, herpes zoster, or Behçet disease Delayed[kellogg.umich.edu]
- syndrome sarcoidosis syphilis systemic lupus erythematosus toxocariasis toxoplasmosis tuberculosis Vogt-Koyanagi-Harada syndrome Research has shown smoking is a risk factor for uveitis.[allaboutvision.com]
- It is an autoimmune reaction that may be either isolated or part of a systemic condition such as psoriatic arthritis, ankylosing spondylitis, inflammatory bowel disease, juvenile rheumatoid arthritis, Reiter’s syndrome, sarcoidosis, tuberculosis, brucellosis[sanantonioeyeinstitute.com]
- syndrome sarcoidosis syphilis systemic lupus erythematosus toxocariasis toxoplasmosis tuberculosis Vogt-Koyanagi-Harada syndrome New evidence shows that smoking also appears linked to development of uveitis, according to a study reported in the March[web.archive.org]
- Common known causes include: autoimmune disease – such as arthritis, Reiter’s syndrome, sarcoidosis and ankylosing spondylitis infection – such as herpes virus infection, syphilis, tuberculosis and Lyme disease eye problems – such as an eye infection,[betterhealth.vic.gov.au]
Whipple Disease
- disease Rifabutin, a derivative of Rifampin, has been shown to cause uveitis.[en.wikipedia.org]
Eyes
Photophobia
- Pupillary examination may reveal direct photophobia when the light is directed into the affected eye, as well as consensual photophobia when light is directed into the uninvolved eye; consensual photophobia is typical of iritis, whereas photophobia due[emedicine.com]
- RESULTS: A 30-year-old man presented with headaches, ocular pain, photophobia, and blurred vision. He was found to have significant skin inflammation, predominantly involving areas of tattoos.[ncbi.nlm.nih.gov]
- This may be accompanied by pain, photophobia, erythropsia, anterior uveitis, hyphaema along with raised intraocular pressure. A careful history and examination, as well as appropriate investigations can confirm the diagnostic.[ncbi.nlm.nih.gov]
- Pupils There may be direct photophobia There may be consensual photophobia (typical of iritis: photophobia due to more superficial causes is typically direct but not consensual). Miosis is common.[patient.info]
Eye Pain
- When to get medical advice Contact your GP as soon as possible if you have persistent eye pain or an unusual change in your vision, particularly if you've had previous episodes of uveitis.[nhs.uk]
- If you're having significant eye pain and unexpected vision problems, seek immediate medical attention. Causes In about half of all cases, the specific cause of uveitis isn't clear.[mayoclinic.org]
- The most common side effects noted during those studies were cataract progression, increased intraocular pressure, procedural complications and eye pain.[web.archive.org]
- Signs of the condition include: blurred vision, floaters, eye pain, redness, and extreme sensitivity to light. If left untreated, intermediate uveitis can cause permanent damage to the eye and vision loss.[rebuildyourvision.com]
- Common symptoms include: Blurred vision Eye pain Sensitivity to light Redness of the eye Floaters Treatment Uveitis needs to be treated as soon as possible to reduce scar tissue development in the eye Treatment may include eye drops, intraocular injection[baretina.com]
Red Eye
- If you have chronically red eyes—this is likely not caused by an infection. Optometrist sometimes attempt to treat these patients with antibiotics, steroids and allergy drops with no improvement.[sanantonioeyeinstitute.com]
- […] by · Published October 6, 2017 · Updated October 5, 2017 The “ Pediatric Red Eye ” is a commonly encountered presentation that we are all accustomed to evaluating.[pedemmorsels.com]
- Iritis symptoms typically begin suddenly and can include a red eye, eye pain, light sensitivity, blurred vision and a small or distorted pupil. Attacks typically only involve one eye at a time.[betterhealth.vic.gov.au]
- The condition causes painful red eye with lightsensitivity and watering. The condition when seen through slit lamp shows inflammatory cells in anterior chamber known as flare and cells.[myeyeworld.com]
- It is very important that you see your ophthalmologist for a complete eye examination if you develop these symptoms, especially if a painful, red eye does not clear up quickly. If it is not treated, uveitis can damage your vision permanently.[my.clevelandclinic.org]
Miosis
- Miosis Ciliary flush Anterior chamber cells and flare Hypopyon Keratic precipitates Reduced intraocular pressure (IOP) Ciliary flush results from perilimbal conjunctival injection. Spasm of the ocular sphincter muscle causes miosis.[symptoma.com]
- Pupillary miosis is common. Slit-lamp examination This is the most important aspect of the examination. Examine the cornea via direct illumination with a broad beam at a 30 -40 angle between the viewing microscope and the light source.[emedicine.com]
- […] lacrimation and some loss of vision because of exudation of cells (aqueous flare), protein-rich fluid and fibrin into either the anterior chamber or vitreous body, as well as ciliary injection, adhesion between the iris and lens (posterior synechia), miosis[medical-dictionary.thefreedictionary.com]
- Miosis is common. Epithelium and stroma Look for abrasions, oedema, ulcers, foreign bodies. Cornea Look for: KPs - inflammatory cells clumped together on the posterior (endothelial) part of the cornea as little white spots.[patient.info]
Ciliary Injection
- Clinical Signs of Anterior Uveitis Ciliary Injection In iritis or iridocyclitis the enlargement of episcleral vessels around the limbus is seen in dark red color.[touchophthalmology.com]
- Acute anterior uveitis is accompanied by pain, photophobia and lacrimation and some loss of vision because of exudation of cells (aqueous flare), protein-rich fluid and fibrin into either the anterior chamber or vitreous body, as well as ciliary injection[medical-dictionary.thefreedictionary.com]
- Manifestations of this disorder include ciliary injection, exudation into the anterior chamber, iris changes, and adhesions between the iris and lens (posterior synechiae). Intraocular pressure may be increased or reduced.[fpnotebook.com]
Neurologic
Headache
- RESULTS: A 30-year-old man presented with headaches, ocular pain, photophobia, and blurred vision. He was found to have significant skin inflammation, predominantly involving areas of tattoos.[ncbi.nlm.nih.gov]
- Symptoms can vary slightly depending on where the uveitis is in your eye, but they can include: Pain Blurred/cloudy vision Loss of peripheral vision Sensitivity to light Redness of the eye Headaches Floating spots in field of vision How is uveitis diagnosed[ibdrelief.com]
- General vision problems, including blurred or cloudy vision Floaters, spots in the eye that look like tiny rods or chains of transparent bubbles floating around in the field of vision Eye pain and redness Photophobia, an abnormal sensitivity to light Headaches[medicalnewstoday.com]
- Critical review questions include, but are not limited to, asking about arthritis, rashes, shortness of breath, swollen lymph nodes, recent headaches, hearing difficulties, hair loss, pigment changes in the skin, a history of ocular trauma, recent insect[web.archive.org]
Workup
The diagnosis of uveitis is usually clinical and no specific tests are needed. Intraocular pressure measurement may be required to rule out glaucoma. Tests may be performed to determine the underlying cause of uveitis (e.g. infections, autoimmune causes and malignancies).
Microbiology
Treponema Pallidum
- Etiologies of the infections were Herpes simplex virus-type 1, Varicela-Zoster virus, Treponema pallidum, Brucella mellitensis, Borrelia burgdorferi, Toxoplasma gondii, and cytomegalovirus.[ncbi.nlm.nih.gov]
Treatment
The treatment of anterior uveitis consists of the following components.
- Mydriatics: Mydriatics are given to counter the severe miosis. Dilation of the pupil prevents the formation of the posterior synechiae and also decreases the pain resulting from ciliary spasm.
- Steroids: Steroids are given to reduce inflammation. Depending upon the severity, steroids may be administered topically, subconjunctivally or systemically.
- Systemic analgesia: This is necessary to reduce pain.
- Treatment of the cause: The cause of anterior uveitis should also be promptly treated.
The treatment strategies for intermediate uveitis include the following.
- Systemic steroids are given to reduce inflammation.
- Immunosuppressive agents are also given in severe cases [9].
- Surgical options included in the treatment of intermediate uveitis include vitrectomy, cryotherapy and laser photocoagulation [10].
Posterior uveitis is treated with steroids which may be given through retrobulbar or systemic route.
Prognosis
With proper treatment, the prognosis of uveitis is usually good.
Untreated anterior uveitis may lead to inflammatory glaucoma and the formation of posterior synechiae and peripheral anterior synechiae. The former refers to adhesions of posterior iris to anterior lens capsule whereas the latter refers to adhesions of the iris to the cornea. Cataracts and band keratopathy may also occur.
Untreated intermediate uveitis can lead to cystoid and macular edema in up to 30% of the cases. Cataract and glaucoma may also develop in some cases.
Temporary or permanent visual impairment or even blindness may occur from uveitis in severe cases [8].
Etiology
The etiological factors depend upon the type of uveitis.
Anterior uveitis is usually idiopathic. It may be the result of several connective tissue diseases. Several causes of anterior uveitis are related to HLA-B27 and include reactive arthritis, ankylosing spondylitis, psoriatic arthritis and inflammatory bowel disease [2]. Causes unrelated to HLA-B27 include juvenile idiopathic arthritis, sarcoidosis, ocular trauma, ocular surgery and infections (such as toxoplasmosis, syphilis, Lyme’s disease, herpes simplex virus, herpes zoster virus and tuberculosis) [3].
Intermediate uveitis is mostly idiopathic. Secondary causes such as sarcoidosis, Lyme’s disease and multiple sclerosis may also cause intermediate uveitis [4] [5]. Intermediate uveitis is often associated with anterior uveitis.
Posterior uveitis results from infections, autoimmune mechanisms and malignancies. The infection may be bacterial, viral, fungal or parasitic. The most common cause of posterior uveitis is parasitic infection (toxoplasmosis). Bacterial causes include syphilis and tuberculosis whereas viral causes are herpes simplex virus, cytomegalovirus (in acquired immunodeficiency syndrome). Fungal infections leading to posterior uveitis include histoplasmosis and candidiasis. Behcet’s disease is an autoimmune cause of posterior uveitis. It includes a triad of oral ulcers, genital ulcers and posterior uveitis [6]. Malignant melanoma and metastatic lesions can also cause posterior uveitis.
Epidemiology
Uveitis is affects around 1 in 4500 people worldwide. Adults of age 20 to 60 years are usually affected whereas children are relatively spared. Anterior uveitis is the most common type of uveitis and accounts for 50 to 90% of the cases in the United States and around 30 to 50% in Asia [7].
Pathophysiology
The clinical features and manifestations of the disease result from the infection of the various parts of the uveal tract.
Prevention
Uveitis results from multifactorial causes and there are no specific preventive measures against it.
If any causal infection has developed, prompt treatment is mandatory to prevent the progression of the disease and involvement of the eye(s).
Summary
Uvetis refers to the inflammation of the uveal tract of the eye. Depending upon the regions involved, may be classified into 3 types; namely anterior uveitis, intermediate uveitis and posterior uveitis [1].
Anterior uveitis is usually unilateral and can be defined as the inflammation of the iris (iritis). Iritis is usually accompanied by cyclitis (inflammation of the ciliary body). When both the iris and the ciliary body are involved, the condition is called iridocyclitis.
Intermediate uveitis refers to the inflammation of the vitreous; while inflammation of the choroid is known as posterior uveitis.
Patient Information
References
Article
- Lowder CY, Char DH. Uveitis. A review. The Western journal of medicine. Mar 1984;140(3):421-432.
- Wakefield D, Abi-Hanna D. HLA antigens and their significance in the pathogenesis of anterior uveitis: a mini review. Current eye research. Jun 1986;5(6):465-473.
- Tabbara KF. Infectious uveitis: a review. Archivos de la Sociedad Espanola de Oftalmologia. Apr 2000;75(4):215-259.
- Jamilloux Y, Kodjikian L, Broussolle C, Seve P. Sarcoidosis and uveitis. Autoimmunity reviews. Aug 2014;13(8):840-849.
- Sun SM. [Clinical analysis of sarcoidosis uveitis]. [Zhonghua yan ke za zhi] Chinese journal of ophthalmology. Mar 1988;24(2):83-85.
- van Dongen CM, Gijselhart JP, van Gijn J. [Behcet and his triad]. Nederlands tijdschrift voor geneeskunde. 2012;156(41):A5230.
- Chang JH, Wakefield D. Uveitis: a global perspective. Ocular immunology and inflammation. Dec 2002;10(4):263-279.
- Silva LM, Muccioli C, Oliveira F, Arantes TE, Gonzaga LR, Nakanami CR. Visual impairment from uveitis in a reference hospital of Southeast Brazil: a retrospective review over a twenty years period. Arquivos brasileiros de oftalmologia. Nov-Dec 2013;76(6):366-369.
- Kulkarni P. Review: uveitis and immunosuppressive drugs. Journal of ocular pharmacology and therapeutics : the official journal of the Association for Ocular Pharmacology and Therapeutics. Apr 2001;17(2):181-187.
- Franklin RM. Laser photocoagulation of retinal neovascularization in intermediate uveitis. Developments in ophthalmology. 1992;23:251-260.