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Uveitis

Overview

Uveitis refers to inflammation of the uvea (the middle layer of the eye). The uvea comprises the iris (the coloured part of the eye), ciliary body (a thin, ring-shaped membrane behind the iris), and choroid (a vascular tissue layer supporting the retina).

While uveitis may be idiopathic (autoimmune or unknown causes) or arise as a consequence of an underlying systemic disease or infection, it can also result from an injury or in rare cases, from ocular surgery. If left untreated, uveitis can cause serious damage to the eye and severely affect eyesight.

Uveitis has also been associated with further ocular complications, including glaucoma and cataract development. However, in most cases, patients recover well after treatment. Diagnosing uveitis early is critical as the timely diagnosis and treatment of this condition markedly improves the patient outcomes.

Uveitis can affect anyone. However, uveitis most commonly affects people of working age, especially in the aged group of 20–59 years, and can occur in children.

Based on the affected part of the eye, uveitis may be categorised as follows:

  • Anterior uveitis: Inflammation of the iris (iritis) or the collective inflammation of the iris and the ciliary body (iridocyclitis). It affects the front of the eye (usually the iris). Depending on the cause, one or both eyes are affected. It is most common type, accounting for 75% of all uveitis cases in adults.
  • Intermediate uveitis: The vitreous humour is affected. This occurs in children, teenagers, and young adults and is the second most common type of ocular inflammation.
  • Posterior uveitis: A severe form of uveitis that affects the choroid and the retina (back layers of the eye). It can seriously damage visual acuity.
  • Panuveitis: Affects the entire uveal tract (the simultaneous inflammation of the front and the back of the eye). This condition seriously threatens vision and requires immediate medical attention.

Based on the duration for which it lasts, uveitis may also be categorised as follows:

  • Acute uveitis: Lasts for 2–3 weeks and can recur.
  • Chronic uveitis: Lasts for three or more months, with symptoms varying over the course of the disease.

Repeated episodes of inflammation in the eye may also occur at intervals of a few months between each episode. This is termed as recurrent uveitis.

Uveitis is broadly categorised into the infectious and non-infectious types. Often, the exact cause of uveitis is unclear. After clinical investigation, no specific cause can be pinpointed for roughly 40% of patients. In many cases, uveitis is linked to an increased degree of immune responses in the eye (occurring due to unknown reasons). In rare cases, uveitis has been reported to be caused by injuries or infections or as a complication of surgical procedures.

The following health conditions have been reported as risk factors for uveitis:

  • Inflammatory or autoimmune conditions (when the body attacks its own organs), such as rheumatoid arthritis (autoimmune joint inflammation), ankylosing spondylitis (also known as lumbar (lower back) arthritis), inflammatory bowel disease, or psoriasis, or other systemic conditions, including sarcoidosis (formation of lumps (granulomas) in various body parts), Behçet’s disease (inflammation and damage of blood vessels), and Reiter’s disease (inflammatory arthritis triggered by bacterial infections).
  • Bacterial (tuberculosis, Lyme disease, etc.), viral (herpes simplex virus infection, herpes zoster infection (shingles), etc.), fungal infections (candidiasis, aspergillosis, etc.), and parasitic infections (toxoplasmosis, filariasis, etc.). The development of immunodeficiency or an immunocompromised state, which are commonly observed in patients with known underlying conditions, such as lymphoma, leukaemia, and/or HIV/AIDS may increase the susceptibility of these patients to opportunistic eye infections, such as cytomegalovirus retinitis.
  • Juvenile idiopathic arthritis (JIA). In children, JIA has been identified as the most common cause of uveitis.

The symptoms of uveitis may vary in intensity from mild to severe depending on the type of the disease.

  • Anterior uveitis symptoms may progress over several hours or days. Their severity may gradually increase. They include:
    • An aching, painful, red eye, ranging from mild eye pain to intense discomfort
    • Cloudy or blurry vision
    • Decreased pupil size or distortion of pupil shape
    • Slight alterations in iris colour
    • Sensitivity to light (photophobia)
    • Headaches
  • Intermediate uveitis is usually painless and affect both eyes. The symptoms of this condition include:
    • Floaters (dots that move across the field of vision)
    • Blurry vision due to the leakage of proteins and cells from the blood vessels into the vitreous humour because of retinal vasculitis (inflammation of retinal blood vessel walls) or pars planitis (the formation of deposits behind the ciliary body)
    • Mild redness (despite the symptoms, the inflamed eye may appear completely normal)
  • Posterior uveitis is usually painless and affects one or both eyes. Its symptoms develop slower, and often last longer, than those of anterior uveitis. This condition can cause a greater degree of ocular damage than other types of uveitis. Its symptoms include:
    • Decreased vision and floaters
    • Retinal detachment
    • In some cases, loss of vision

As uveitis is predominantly diagnosed based on clinical examinations, meticulous collection of patient history (ocular and systemic history) is vital. Further tests to confirm or exclude certain eye and/or systemic conditions may be recommended based on the symptoms, presentation, and severity of the condition. These include:

  • Comprehensive eye examinations that include the collection and assessment of a complete, detailed medical history (overall ocular health and general health).
  • Assessment of eye scans and/or photographs, especially using the slit-lamp examination.
  • Blood tests to detect the causative pathogen (for cases of infectious uveitis).
  • Chest radiography (X-ray) to identify any underlying condition that may be the cause of uveitis.
  • Tests for rheumatoid arthritis (RA) factor, serum uric acid tests, the purified protein derivative (PPD) skin test or Mantoux test (skin tests for detecting tuberculosis in which a PPD is injected into the forearm, and the diameter of the resulting swelling is measured after 48–72 hours), tests for the levels of HLA B-27, acetylcholine esterase (ACE) inhibitors, and C-reactive protein, fluorescent treponemal antibody absorption (FTA-ABS) test, perinuclear anti-neutrophil cytoplasmic antibody (P-ANCA) and cytoplasmic ANCA (C-ANCA) level measurements, and serum IgG and serum IgM antibody tests are usually recommended in cases of suspected uveitis.

Based on the results of the aforementioned analyses, ophthalmologists recommend further tests to be conducted.

The type and underlying cause of uveitis usually determine the recommended course of action and treatment. However, an exact cause cannot always be identified. The methods used for treating uveitis include:

  • Steroid medications, which are the most common uveitis treatment modality, help reduce inflammation. While steroid-based eyedrops are usually administered for treating anterior uveitis, steroid-based tablets or injections (administered as systemic medications) may be required for treating severe cases of anterior uveitis and several types of non-infectious posterior uveitis.
  • Additional treatment, usually in the form of eye drops, may be prescribed for pain relief or dilation of the pupils.
  • In rare instances, such as uveitis cases in which cataract or glaucoma development is observed (eye drops are unable to mitigate the increase in intraocular pressure), surgery may be needed.

In most cases, patients with uveitis, especially, those with anterior uveitis, respond quickly to treatment without any long-lasting eye damage or further complications. However, the risk of complications is markedly high among patients with intermediate or posterior uveitis or those with recurrent uveitis. These complications include retinal damage, glaucoma, cataract development, macular oedema, and the permanent deterioration of vision.

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