Uveitis- a photoessay 

  John G. O'Shea MD,  David A. Infeld FRCSEd, Robert B. Harvey FRCSEd.

Uveitis can be defined as inflammation of the uvea, the middle, vascular coat of the eye (Greek uva- grape) The uvea consists of the iris, ciliary body and the choroid. The International Uveitis Study Group classification separates uveitis anatomically by location of observed disease according to visible signs- anterior posterior or intermediate. Iritis is a synonym for anterior uveitis. (1,2,3,4,5,6,7)

Additionally, uveitis is described in relation to specific disease syndromes, for example Fuchs Heterochromic Cyclitis or occurring in relation to systemic disease such as sarcoidosis or toxoplasmosis. (1,2,3,4,5,6,7)

Uveitis may affect not only the uvea but also the optic nerve retina and vitreous. Uveitis is a major cause of visual impairment and may account for 10-15% of blindness in the USA. Of people aged under 65 who are registered legally blind, 10% are visually compromised because of uveitis and its complications, very nearly the same number affected by diabetic retinopathy.  This paper will embrace uveitis and also other inflammatory ocular manifestations of systemic diseases commonly encountered by physicians. (1,2,3,4,5,6,7)

International  Classification of Uveitis

________________________________________________________________

Table- International Classification of Uveitis

 

Temporal- Acute versus Chronic ( >3 months)

In acute uveitis symptoms and signs occur suddenly and typically lasts up to 6 weeks. In chronic uveitis the onset is usually  gradual and the inflammation lasts longer than three months.

 

Anatomical

  • Anterior Uveitis ( Iris and anterior ciliary body )
  • Intermediate Uveitis ( posterior ciliary body- pars plana )   
  • Posterior Uveitis ( predominantly choroid)   

____________________________________________________(1,2,3)______________

 

The above classification attempts to characterize uveitis appropriately based upon anatomical description of the major clinical signs. Once the type of uveitis has been identified, the process of meshing can be used to determine the appropriate etiology or syndrome. Even if an etiology cannot be established, a prognosis and suitable treatment regimen can often be formulated.  (5,6,7)

Overview of the Investigation and Management of Uveitis

The management of the patient with uveitis may involve the following,

  •             History taking  (ocular and general) 
  •             Complete ocular examination
  •             General physical examination
  •             Investigations
  •             Specialist medical referral ( for further evaluation )

Following history-taking and examination a short differential diagnostic list is compiled, taking into consideration the clinical features and the causes of uveitis seen in the patientís age group. The most practical approach with regard to the type of investigations to be arranged is one which is tailored to the individual patient.   (1,2,3)

Epidemiology of uveitis in the United Kingdom

A uveitis register at the Leicester Royal Infirmary consisted of data collected on all uveitis patients except minor easily resolved, anterior uveitis cases. The diagnoses of these patients were classified by the aetiological method. A total of 712 patients was entered into the register over a period of 10 years starting from January 1985. In the study, 73.0% of the cases fit into named clinical syndromes while 27.0% of the cases were diagnosed as idiopathic or uncategorised. The commonest definable cause of anterior uveitis was HLA-B27-related acute anterior uveitis, comprising 15.2% of all uveitis cases ( in some series up to 50% of uveitis is related to HLA B27 antigen ). Intermediate uveitis accounted for 7.9% of all cases while the commonest definable cause of posterior uveitis was toxoplasmosis, forming 4.6% of all uveitis cases.  (8)

The annual incidence in Western countries is approximately 17/100,000 while the prevalence of uveitis is estimated as about 38/100,000.  (1,3)

 

Ethnicity

Ethnicity affects uveitis, for example- HLAB27 antigen is the commonest factor responsible for uveitis in Caucasians, in the Afro-Caribbean community  sarcoid is common whist Bechetís disease affects those of Asian and Middle Eastern origins (HLA B5 ). (1,2,3,4,5,6,7)

 ________________________________________________________________________

Table- Aetiology of Anterior uveitis

  • HLA-B27 Positive or Seronegative Group
  • Ankylosing spondylitis
  • Reiterís syndrome
  • Inflammatory bowel disease (Ulcerative colitis, Crohnís disease)
  • Psoriatic arthritis
  • Intraocular lens related
  • Herpes simplex
  • Herpes zoster
  • Trauma
  • Juvenile rheumatoid arthritis
  • Fuchsí Heterochromic iridocyclitis
  • Behcetís disease
  • Sarcoidosis
  • Tuberculosis
  • Syphilis
  • Glaucomatocyclitic crisis
  • Lens-induced uveitis
  • Idiopathic

Intermediate uveitis

  •             Pars planitis

           

Aetiology of Posterior uveitis

 

  • Infection                       Toxoplasma
  •                                     Histoplasmosis
  •                                     Cytomegalovirus
  •                                     Toxocara                                
  • Herpes simplex
  • Syphilis
  • Tuberculosis
  • Candida           
  •  
  • Retinal vasculitis
  • Sarcoidosis
    Sympathetic ophthalmia
  • Behcetís disease
  • Idiopathic                                          (1,2,3,4,5,6,7)

                                                                        

 


 

Clinical features of Anterior Uveitis

In acute uveitis symptoms and signs occur suddenly and last up to 6 weeks. Typically the patient has pain, ocular redness, blurred vision, photophobia and epiphora. The redness tends to be perilimbal with a violaceous hue.

 

Keratic precipitates

Occasionally the eye may be white with minimal pain. Examination of  the anterior chamber with the slit lamp microscope reveals the presence of white cells and flare. There may be small collections of white cells on the corneal endothelium (keratic precipitates). Mononuclear cells may collect to form iris nodules. The pupil may be irregular due to the presence of adhesions between the pupil margin and the anterior lens surface (posterior synechiae). Cells in the vitreous and occasionally oedema of the central retina (i.e. macular oedema) may be noted. (1,2,3)

 

Keratic precipitates (retroilumination )

Hypopyon

Clinical features of Intermediate and  Posterior Uveitis

 

Disturbance of the central retina (macula) may cause blurred or distorted vision.

Cellular debris in the vitreous may cause floaters. The retina may appear cloudy and  white from oedema. Choroidal or retinal lesions may appear yellow or white, sometimes with black pigmented borders. Neovascularisation of the retina or optic nerve may be seen. Occasionally there may be swelling or pallor of the optic nerve head  

Debris in vitreous

The retinal vessels may be cuffed with inflammatory exudate. (1,2,3)

 

Retinal scarring from past toxoplasma.

Histopathology of Uveitis

 

The time course and the anatomical site of the inflammation can be determined in almost every case. Thus, at least these two aspects can be considered for every patient with uveitis (e.g., chronic iridocyclitis, acute retinitis). Acute disease usually starts abruptly and lasts 2 to 6 weeks, while chronic disease begins insidiously and has no defined endpoint, often lasting longer than 6 weeks.

 

Ocular inflammation involves vessel dilatation and increased vessel permeability with fluid extravasation and leucocyte migration. The ocular inflammation has acute and chronic phases. During the acute phase chemical mediators are elaborated, including prostaglandinís, histamine, serotonin, kinins, complement and leukotriene.

 

The chronic inflammatory phase can be granulomatous or non-granulomatous. Granulomatous inflammation  is characterized by infiltration with epithelioid cells, giant cells, plasma cells and lymphocytes. In non-granulomatous inflammation there is infiltration mainly with plasma cells and lymphocytes. Protein may leak from inflamed blood vessels and leucocytes may migrate from inflamed vessels, giving rise to so-called aqueous flare and cells. (1,2,3)

   

Investigations and Differential Diagnosis

 

The most practical approach is one which is tailored to the individual patient. and determine an appropriate management scheme can be aided by this system. It is not possible to review the many investigations routinely ordered for ocular inflammation individually but the following are worth stressing.

(1,2,3)

 

HLA-B27 Antigen

 

The test can be useful in cases of recurrent anterior uveitis. HLA-B27 denotes a genotype located on chromosome 6. It is present in 4% of the general population and up to 50% of patients with acute iritis. Many  patients with acute iritis therefore have a genetic predisposition. Factors which may trigger the occurrence of acute iritis are often unknown. In general, the importance of tissue tying for HLA B27 is under appreciated, the investigation has a high yield, is inexpensive, and gives patients an explanation of an often recurrent problem. (9)

 

Ankylosing spondylitis, Reiterís syndrome, psoriatic arthritis and inflammatory bowel disease are all associated with iritis, spondylitis and the presence of HLA-B27 positivity.         

(1,2,9)

 

________________________________________________________________________

 

Differential Diagnosis Of Uveitis- It is of paramount importance to note that uveitis can be caused or mimicked by the following-

 

ďMasquerade SyndromesĒ- neoplasms mimicking uveitis

Ocular malignant melanoma

Retinoblastoma

Reticulum Cell Sarcoma ( Primary Intraocular Lymphoma )

Leukaemia

Lymphoma

Ocular Metastasis

 

Other-

Endophthalmitis

Retinal detachment

Intraocular foreign body

                                                                                   (1,2,3,4,5,6,7)

   

 

_____________________________________________________________________

 

Table Uveitis - Investigations

 

General Investigations

 

ESR / Plasma Viscosity/ C Reactive Protein

CXR

FBC

Syphilis Serology- TPHA, VDRL

Urine analysis ( Diabetes Mellitus )

 

Specific Investigations

 

HLA B27 Ag;   HLA B29 ( birdshot retinochoroidopathy )

Angiotensin Converting Enzyme

Rheumatoid Factor , Lupus Group Autoantibodies including anti-neutrophil cytopasmic antibody ( Wegenerís Granulomatosis ) Anticardiolipin Antibody- ( the yield of these investigations is actually low except in children with Juvenile Chronic Arthritis )

Toxoplasma Serology / IgG antibodies ( if negative on undiluted serum to exclude congenital toxoplasmosis )

Toxocara ELISA

HIV

Pathergy Test

Mantoux Test, Sputum Acid Fast Bacilli

X Ray Hands and SI Joints

B Scan for Masquerade Leisions or Posterior Scleritis

Kveim Test

Immune Complexes -Polyethylene Glycol Method

DNA Polymerase Chain Reaction ( Herpes virus, Propionebacter )

CT scan of chest ( sarcoidosis)

MRI( non Hodgkins lymphoma, neurosarcoid, demyelination )

Choroidal biopsy ( Non Hodgkinís Lymphoma )

 

 

Physician Referral

 

Rheumatological Referral

Broncho-alveolar lavage ( Sarcoid)

CSF studies ( non Hodgkins lymphoma, neurosarcoid, VKH )

Venereological Referral   HIV, Reiter's, Syphilis

 

A recent retrospective review showed the following abnormal results, plasma viscosity/ esr 34.2%, VDRL/TPHA (4.3%) Angiotensin converting enzyme (10.8%) Chest X ray ( 14.6%)

                                                                   (1,2,3,4,5,6,7)


_______________________________________________________________________

 


 Some Systemic Diseases Commonly Associated with Uveitis

 

Ankylosing Spondylitis  

About 30% of patients with Ankylosing spondylitis develop iritis. The iritis may precede the onset of back stiffness and pain. Rarely there may be retinal vasculitis and vitritis. (9,10,11)

------------------------------------------------------------------------------------------------

Table Ankylosing Spondylitis

 

30% of AS patients develop iritis, especially if male; iritis may precede arthritis

rarely retinal vasculitis / vitritis.

Acute anterior uveitis lasting 2-6 weeks, good prognosis

 

Investigations in suspected ankylosing spondylitis

X-ray sacroiliac joints ( 2 yearly Sacroiliac joint X rays in males if initial X ray normal.)

ESR

Rheumatoid factor

HLA B27 (positive in more than 90% )

Need 2 yearly Sacroiliac joint X rays in males if initial X ray normal  (9,10,11)

 

Arthritis associated with uveitis

 Reiter's syndrome

This syndrome is characterised by the triad of arthritis, urethritis and conjunctivitis or less commonly, iritis. ( Conjunctivitis and iritis affect 60% and 20% of patients respectively.)

There may be also be associated episcleritis and keratitis.

_________________________________________________________________________

 

Table- Reiter's Syndrome

triad of:  arthritis (weight bearing joints, sacroiliitis),

conjunctivitis or  iritis

urethritis (cervicitis).                         (9,10,11)

 

________________________________________________________________________

________________________________________________________________________

 

Table- Associations of Reiter's Syndrome

 

Occurs if genetically predisposed (HLA B27);  60 - 90% association

M>F

Exposure to certain urethritis / dysentery organisms: e.g.

Chlamydia, Yersinia, Shigella, Salmonella, Campylobacter.

The order of manifestation is normally: Ć urethritis ć conjunctivitis é arthritis.

Ocular

20% anterior uveitis,

60% conjunctivitis,

episcleritis, keratitis, post-uveitis.

Reiterís disease can sometimes result in hypopyon formation    (9,10,11)

________________________________________________________________________


Juvenile Chronic Arthritis  

 

In juvenile chronic arthritis, a seronegative inflammatory arthritis affecting children, the patient often suffers from chronic anterior uveitis. The uveitis is most commonly seen in girls who are ANF positive and have pauciarticular disease. The uveitis is usually bilateral and may be complicated by the development of cataract, band keratopathy and glaucoma.

(12,13)

________________________________________________________________________

 

Table- Juvenile Chronic Arthritis

 

Chronic AAU , usually bilateral Commoner in female patients, the young, ANF positive. Pauciarticular disease <5 joints.

 

Complications

Glaucoma (20%)

Cataract (40%)

Band Keratopathy (40%)      (12,13)

________________________________________________________________________

The anterior uveitis is typically initially asymptomatic; the eyes are white rather than red

The visual prognosis may be adversely affected by a delay in diagnosis. Screening of affected children is therefore regarded as mandatory

________________________________________________________________________

Table- Monitoring Children with Juvenile Chronic Arthritis

 

High Risk

 

Early Onset , < 6 years, Pauciarticular Disease , ANA Positive

 

3 months for first year , then 6 months for five years , then annually

 

Medium Risk

 

polyarticular disease ANA positive , pauciarticular -disease ANA negative

 

6 monthly intervals for 5 years then annually

 

Low Risk

 

Systemic JCA , B27 associated arthritis , disease starting after age 11

 

Duration

 

For ten years after onset of JCA or until age 12, whichever is shorter.

 

Source RCOphth (UK),  British Paediatric Association (1994) (12)

_____________________________________________________________________

 


Treatment includes topical corticosteroids, mydriatics, NSAID's and oral prednisolone  Chlorambucil may occasionally be required in severe cases. Reading glasses may be helpful if mydriatics are being used for both eyes as accommodation is paralysed by cycloplegics. Surgical treatment of cataract, glaucoma and band keratopathy may also be required. (12,13)

 

Toxoplasmosis

Toxoplasmosis gondii is an obligate intracellular protozoa causing up to 50% of cases of posterior uveitis .Ocular infection is characterised by focal necrotising retinochoroiditis with vitritis.In congenital infection the eye may also be affected by cataract, microphthalmos, and optic atrophy. (1,2,3)

_________________________________________________________________________

Table- Congenital Toxoplasmosis

 

Highest transmission occurs in the IIIrd trimester

90% of congenital infections have no clinical signs

Earlier infection occurs in pregnancy - worse potential outcome

Triad:-   convulsions,

cerebral calcification

and chorioretinitis

Eye - chorioretinitis, cataracts, microphthalmos, panuveitis, optic atrophy  (1,2,3)

 

Toxoplasma focus

 

Complications include direct involvement of the fovea, papillomacular bundle, or optic disc. Cystoid macular oedema, subretinal neovascular membrane formation, tractional and rhegmatogenous detachment and retinal neovascularisation may also occur.   (1,2,3)

 

________________________________________________________________________

 

Table- Investigation of Toxoplasmosis

 

ELISA IgM in neonates, rising IgG in adults (although not that helpful in adults).

Fluorescein angiography (hypofluorescence in the early stages and then progressive leakage).

Indocyanine angiography - multiple small dark spots may be seen around the visible lesions implying the affected retina is greater than apparent initially. This sign may be useful in assessing the effect of treatment.  (5,6,7)

_________________________________________________________________________

 

Some authorities argue that any active chorio-retinal lesion should be treated in order to decrease the risk of  macular traction, secondary retinal detachment and cystoid macular oedema. Medications used for treatment include pyramethamine, clindamycin,  sulfadiazine and  prednisolone.  Rarely, vitrectomy may be indicated for the removal of vitreous opacities and  haemorrhage and for the release of vitreoretinal traction.


________________________________________________________________________

 

Table- Some indications for active treatment of toxoplasmosis

 

Lesions that involve  the macula, papillomacular bundle or optic disc

and large, active lesions should be treated.

Immunocompromised patients should be treated.    

___________________________________________________(1,2,3)_________________

 

Behcetís Disease

 

This idiopathic systemic disease consists of an obliterative vasculitis and usually effects young males of Japanese and eastern Mediterranean origin. The eye may be involved with conjunctivitis, episcleritis, keratitis and uveitis. The anterior uveitis is usually acute with recurrent episodes. Severe disease may be indicated by the presence of a hypopyon. The eye may be white. Chronic uveitis is less common.  (1,14,15)

_________________________________________________________________________

Table - Behcetís Disease

 

Idiopathic, systemic disease consisting of an obliterative vasculitis possibly due to circulating immune complexes

 

Young males, Japanese and eastern Mediterranean, HLA-B5 associated

 

Clinical

Oral ulceration-100%, may pre-date eye disease, painful, recurrent

Genital ulceration- 90%, may be asymptomatic in females

Skin- erythema nodosum, pustules, ulceration, cutaneous hypersensitivity

Arthritis- non-destructive, wrists and ankles

CNS- palsies, brainstem syndrome, meningoencephalitis, affects 25% and major cause of mortality        (1,14,15)

_________________________________________________________________________

 

Posterior uveitis is  more common than anterior uveitis. There may be vitritis; this is usually associated with anterior uveitis. Diffuse vascular leakage may lead to retinal oedema, cystoid macular oedema and optic disc oedema. Retinal vasculitis, predominantly periphlebitis, can lead to branch retinal vein occlusion and retinal neovascularization. Retinitis may be manifest as transient white necrotic infiltrates and intraretinal haemorrhages.     (1,14,15)

 

Aphthous ulcers

 

Anterior uveitis is treated with topical corticosteroids and mydriatics. Posterior uveitis is treated with oral prednisolone, usually with immunosuppression suc as azothiaprine chlorambucil and cyclophosphamide. The visual prognosis is often  poor.  (16)

 


Sarcoidosis

 

This chronic non-caseating granulomatous systemic disease of unknown aetiology affects women more commonly than men and is more common in individuals of Afro-Caribbean ethnicity. (16,17,18)

 

Ocular Manifestations

 

About 30% of patients with sarcoidosis have ocular involvement.

Iritis  may be acute or chronic; it may be unilateral or bilateral. Patients with posterior uveitis usually have anterior uveitis as well. Vitritis is also common and tends to occur in older patients.

 

"Mutton fat" KPs

There may be retinal periphlebitis; the vessels may display an exudative cuff

(so called Ďcandle wax drippingsí). Inflammation of the retina may lead to macular oedema, retinal granuloma, preretinal nodules and retinal haemorrhage. Inflammation of the optic nerve may cause optic disc oedema, granuloma and neovascularization.

 

Branch retinal vein occlusion and retinal neovascularisation are uncommon. (16,17,18)

__________________________________________________________________

 

Table- Sarciodosis - Investigations

 

Chest X-ray

 

Serum ACE (angiotensin converting enzyme)- this is elevated in active disease

urine and serum calcium levels- hypercalciuria is common; hypercalcaemia is less common

 

Conjunctival biopsy may show granulomata

 

Broncho-Alveolar Lavage       (7,8,19)

_________________________________________________________________________

 

Treatment

 

Anterior uveitis is treated with topical corticosteroids and mydriatics. Orbital floor steroids, such as Depomedrone,  dexamethasone 40mg, can be given for unilateral posterior uveitis. Oral prednisolone may be given for bilateral posterior uveitis. Some patients may require immuno-suppression. (1,20,21,22,23)

 


Tuberculosis ( Ocular Manifestations )

 

The eyelids may be affected by lupus vulgaris with skin nodules surrounded by erythema.The orbit may be affected by cellulitis, dacryoadenitis, dacryocystitis, osteomyelitis and abscess formation.There may be  chronic conjunctivitis, episcleritis or scleritis.The cornea may be affected by keratoconjunctivitis or interstitial keratitis.

TB Vasculitis

 

Uveitis is the most common ocular manifestation. There may be chronic granulomatous anterior uveitis, multifocal choroiditis, exudative retinitis, vasculitis and optic nerve oedema.  Anti-tuberculous medications -isoniazid, ethambutol and rifampicin are given for at least 6 months. The use of prednisolone in ocular disease  is controversial. (16,17,18)

 

 

Table- Ocular Manifestations of Tuberculosis

 

Affects 2% of sufferers of active tuberculosis , uveitis is commonest manifestation.  Systemic disease is often apparent.

 

Eyelids- lupus vulgaris (nodules surrounded by erythema)

Orbit- cellulitis, dacryoadenitis, dacryocystitis, osteomyelitis, abscess

Conjunctiva- rarely affected, chronic conjunctivitis

Cornea- phlyctenular keratoconjunctivitis, interstitial keratitis (unilateral, sectorial, superficial vascularisation)

Sclera- episcleritis, nodular scleritis

Uveitis- chronic granulomatous anterior uveitis, multifocal choroiditis, exudative retinitis, vasculitis, optic nerve oedema, papilloedema       (16,17,18)

 

_________________________________________________________________________

 

Herpes Zoster Ophthalmicus   

Herpes Zoster Ophthalmicus is commonly seen in the elderly. A vesicular rash is seen affecting the ophthalmic trigeminal distribution. The presence of vesicles on side of tip of nose (Hutchinsonís sign) indicates involvement of  the external nasal branch of nasociliary nerve and is associated with a high rate of ocular disease. Immunosuppression is  a risk factor for development of the disease.

 

There is often chronic anterior uveitis. Complications include sectoral iris atrophy, glaucoma, cataract, hypotony and phthisis bulbi. Posterior segment inflammation is seen including vitritis, retinal vasculitis and optic neuritis.

 

Therapy includes the following. Acyclovir ointment  (5 X day) is given. Topical corticosteroids  and mydriatrics are given for anterior uveitis. Anti-glaucoma medications are required occasionally. Prednisolone may be given if neurological, orbital or optic nerve involvement occurs. (1,2,3)


_________________________________________________________________________

 

Table- Herpes Zoster Ophthalmicus

 

50% of varicella infected patients will develop zoster by 80yrs

15% trigeminal, 50% thoracic

Age is the most common predisposing factor, immunosuppression occurs in 1-2 % only.

 

Pathology is related to ischaemic vasculitis caused by viral invasion.

 

#10% will have ophthalmic involvement and of these 50% will develop complications

3-5 days of pain in trigeminal distribution maculopapular rash - vesicular (may not develop rash - zoster sine herpete)

 

Hutchinsonís sign- involvement of external nasal branch of nasociliary nerve - vesicles on side of tip of nose ř 93% will develop ocular disease

Lid margin vesicles ř 100% ocular involvement)

________________________________________________________(2)_______________

 

Ocular Manifestations Of  Acquired Syphilis

Uveitis may be acute or chronic, unilateral or bilateral. Interstitial keratitis affects a small percentage of acquired cases and is often unilateral. Chorioretinitis is bilateral in 50% of cases; multifocal or diffuse yellow exudate is seen.  (25,26)

 

The chorioretinitis may resolve, leaving extensive bone spicule pigmentation. The appearance may resemble retinitis pigmentosa. There may be retinal oedema, haemorrhages, exudates, cotton wool spots and vascular sheathing. Optic disc oedema may also be seen.

 

Investigations for suspected syphilitic uveitis include VDRL and FTA-ABS tests.

The VDRL test is useful for screening; false positive results may occur. The FTA-ABS test remains positive for life, even after treatment. (7,8)

 

Treatment- Syphilitic may be cured with treatment, in other types of uveitis, the condition is usually suppressed  by topical steroids.  Medications that may be considered include penicillin, erythromycin, doxycycline and ceftriaxone. (25,26)

 

Guidelines for the Treatment of Uveitis

 

The exact nature of the clinical features, their severity and their time course will vary between individual patients. Appropriate treatment requires knowledge of the patientís type of uveitis and awareness of the details of the individualís clinical features. In addition, the risks and benefits of various treatment options need to be considered.

The nature of the uveitis and any limitations of treatment should be outlined to the patient. (1,3)


________________________________________________

Table Treatment of Uveitis

 

Specific vs. Nonspecific

Local Ocular vs. Systemic

Medical vs. Surgical

Specialist referral, for example to a rheumatologist, paediatrician or infectious disease specialist, may be helpful in many cases. A useful specialist report is more likely to be obtained if one indicates to the specialist the diagnostic possibilities that are being considered (e.g. juvenile rheumatoid arthritis, sarcoidosis).          (27)

 

 

Specific treatment, such as antimicrobial medication for infectious uveitis, should be given when appropriate. Examples include uveitis due to toxoplasma, syphilis or tuberculosis.

 

Ocular medication (such as eye drops or subconjunctival injection) is generally preferred to systemic medication (such as oral or intravenous therapy) in view of the much lower incidence of systemic side effects from ocular medication. (1,2,3)

 

Corticosteroids

Routes of administration of corticosteroid for uveitis include eye drops, ointment, periocular injection, oral and intravenous. The initial dose should be proportional to the severity of the inflammation. The dose is tapered gradually in order to minimize the risk of recurrence; the dose is correlated with the severity of the inflammation. Systemic corticosteroids can be given for certain types of posterior uveitis and for severe anterior uveitis unresponsive to intensive topical therapy. Eye drops are effective for anterior segment inflammation. Various strengths are available (table 3). Possible side effects from topical therapy are glaucoma, posterior subcapsular cataract and exacerbation of infection (particularly herpes simplex).  (1,3)

_______________________________________________________________________

 

Table Corticosteroid eye drops  (in order of decreasing strength)

Dexamethasone           

Betamethasone

Prednisolone    

Fluorometholone   (1,3)

________________________________________________________________________


Mydriatic eye drops

Mydriatic eye drops (see table 4) produce pupil dilatation (mydriasis) and paralysis of the ciliary body (cycloplegia). It is important for mydriatic eye drops to be used in anterior uveitis as they provide pain relief, prevent posterior synechiae formation and also break any posterior synechiae that have already formed. Posterior synechiae can cause permanent pupil irregularity and can, if extensive, cause glaucoma. Short acting mydriatic eye drops allow the dilated pupil to remain mobile and possibly less likely to develop posterior synechiae if the inflammation is mild.

_______________________________________________________________________

 

Table             Mydriatic eye drops (in decreasing order of  strength)

Tropicamide

Cyclopentolate

Homatropine

Atropine                               (2)

_______________________________________________________________________

 

Cytotoxic medication and Immunosupression

 

These medications are commonly used as steroid sparing agents, patients will usually not be able to tolerate doses of prednisolone above 20 milligrams per day for long periods. Cytotoxic medication can cause serious side effects, such as bone marrow suppression, and is therefore reserved for patients with potentially blinding uveitis in whom the use of corticosteroid therapy is effective, poorly tolerated or contraindicated. Cyclosporin, an anti-T-cell immunosupressive agent, is occasionally used in severe uveitis when corticosteroids and cytotoxic medication are ineffective. (1)

 

Table             Cytotoxic and Immunosuppressive medication used in Uveitis Therapy

Cyclosporin- selectively depresses CD4+ lymphocytes

Azathioprine-  interferes with purine synthesis

Chlorambucil- alklating agent, used for Bechetís Diease 

Cyclophosphamide- alkylating agent used for uveitis in combination with life threatening systemic disease such as Wegenerís Granulomoatosis

Methotrexate  (seldom used) folic acid antagonist

FK 506 ( Tacrolimus), Rapamycin- alkylating agents, originally derived from streptococcus species     (1)

   

Summary

Uveitis may be an important consequence of systemic disease with profound implications for patient morbidity and quality of life. In many cases the morphology of ocular inflammation may be an important guide to the nature of the underlying disease under investigation. (1,3,23) The review encompasses  common types of uveitis encountered  in assocation with systemic disease in clinical practice and has outlined practical clinical approaches to investigate and treat uveitis .

 


References

 

1. Jones NP, Uveitis an illustrated manual Oxford ; Butterworth ; Heinemann 1998 1-93

 

2. Harvey RB, Practical Ophthalmology- CD ROM 2002 Birmingham; Palmtrees Publishing

 

3. Nussenblatt RB, Whitcup SM, Palestine AG, Uveitis- Fundamentals and Clinical Practice 2nd Edition ;  St Louis ;  Mosby 1996 3-151

 

4. Marr JE, Stavrou P, Murray PI, Should we investigate uveitis ? Invest Ophthalmol Vis Sci 1998 ; 39: S608

 

5. Murray  P, Serum Autoantibodies and Uveitis  Br J Ophthalmol 1986; 70 :266-8

 

6. Murray  PI, Stavrou P, Marr JE, Moradi P, Pattern of visual loss in patients with uveitis Invest Ophthalmol Vis Sci 1998 : 39 : S607

 

7. Murray PI, Uveitis, When to Investigate ? Focus- Occasional Update from the Royal College of Ophthalmologists 1998 ; 8 : 1-2

 

8. Thean LH, Thompson J,  Rosenthal AR. A uveitis register at the Leicester Royal Infirmary Ophthalmic Epidemiology 1996  3(3):151-8,

 

9. Feltkamp TEW. HLA-B27, acute anterior uveitis, and ankylosing spondylitis. Adv Inflamm Res. 1991;9:211-16.

 

10. Brewerton DA, Caffrey M, Nicholls A, Walter D, James DCO. Acute anterior uveitis and HLA-B27. Lancet. 1973;ii:994-6.

 

11. D'Alessandro LP, Forster DJ, Rao NA. Anterior uveitis and hypopyon. Am J Ophthalmol. 1991;112:317-21.

 

12. Evan-Jones G, Ophthalmic Services for Children; Report of a Joint Working Party  Royal College of Ophthalmologists

 

13. Kanski JJ. Juvenile arthritis and uveitis. Surv Ophthalmol. 1990;34:253-67.

 

14. International Study Group for BehÁet's disease. Criteria for diagnosis of BehÁet's disease. Lancet. 1990;335:1078-80.

 

15.  Michelson JB, Chisari FV. BehÁet's disease. Surv Ophthalmol. 1982;26:190-203.

Barlie GR, Flynn TE Syphilis exposure in patients with uveitis Ophthalmology 1997 ; 104 1605-9


References

 

16. Yazici H, Pazarli H, Barnes CG, et al. A controlled trial of azathioprine in BehÁet's syndrome. N Engl J Med. 1990;322:281-5.

 

17. Karma A, Hukti E, Poukkula A. Course and outcome of ocular sarcoidosis. Am J Ophthalmol. 1988;106:467-72.

 

18. Rothova A, Alberts C, Glasius E, Kijlstra A, Buitenhuis HJ, Breebaart AC. Risk  factors for ocular sarcoidosis. Doc Ophthalmol. 1989;72:287-96.

 

19.  Bienfait MF, Hoogstenden HC, Baarsma GS, Adraiaansen HJ, Verheijen-Breemhaar L. Diagnostic value of bronchoalveolar lavage in ocular sarcoidosis. Acta Ophthalmol. 1987;65:745-8.

 

20. Selroos O. Treatment of sarcoidosis. Sarcoidosis. 1994;11:80-3.

 

21. Lower EE, Baughman RP. Prolonged use of methotrexate for sarcoidosis. Arch Intern Med. 1995;155: 846-51.

 

22. O'Callaghan CA, Wells AU, Lalvani A, Dhillon PD, Hansell DM, Mitchell DN. Effective use of cyclosporine in sarcoidosis: A treatment strategy based on computed tomography scanning. Eur Respir J. 1994;7:2255-6.

 

23. McCluskey PJ
,
Towler HM
,
Susan Lightman, S
Management of chronic uveitis BMJ 2000;320:555-558

 

24. Rosenbaum JT, Wernick R. The utility of routine screening of patients with uveitis for systemic lupus and tuberculosis: A Bayesian analysis. Arch Ophthalmol. 1990;108:1291-3.

 

25. Margo CE, Hamed LM. Ocular syphilis. Surv Ophthalmol. 1992;37:203-20.

 

26. Tamesis RR, Foster CS. Ocular syphilis. Ophthalmology. 1990;97:1281-7.

 

27. Rosenbaum JT. Characterization of uveitis associated with spondyloarthritis. J Rheum. 1989;16:792-6.