Uveitis Disease
DESCRIPTION
Uveitis is a nonspecific term used to describe any intraocular inflammatory disorder. Symptoms vary depending on depth of involvement and associated conditions.
- Anterior uveitis - refers to ocular inflammation limited to the iris (iritis) alone or iris and ciliary body (iridocyclitis)
- Intermediate uveitis - refers to inflammation of the structures just posterior to the lens (pars planitis or peripheral uveitis)
- Posterior uveitis - refers to inflammation of the choroid (choroiditis), retina (retinitis), or vitreous near the optic nerve and macula
- System(s) affected: Nervous
- Genetics: No specific pattern for uveitis in general; iritis: 50-70% of patients are HLA-B27 positive
- Incidence/Prevalence in USA:
- Anterior uveitis most common (8.2 cases/100,000 annual incidence)
- Iritis is 4 times more prevalent than posterior uveitis
- Predominant age: All ages
- Predominant sex: Male = Female (except for HLA-B27 anterior uveitis male > female (2.5:1)
SIGNS AND SYMPTOMS
- Anterior uveitis (approximately 80% of patients with uveitis)
- Decreased visual acuity
- Generally acute in onset
- Deep eye pain
- Photophobia (consensual)
- Conjunctival vessel dilation
- Perilimbal (circumcorneal) dilation of episcleral and scleral vessels (ciliary flush)
- Small pupillary size of affected eye
- Frequently unilateral (95% of HLA-B27 associated cases)
- Bilateral involvement and systemic symptoms (fever, fatigue, abdominal pain) may be associated with interstitial nephritis
- Systemic disease is most likely to be associated with anterior uveitis (53% of patients found to have systemic disease in one study)
- Intermediate and posterior uveitis
- Decreased visual acuity
- Generally insidious in onset
- More commonly bilateral
- Posterior inflammation will generally cause minimal pain or redness unless associated with an iritis
CAUSES
- Infectious - may result from viral, bacterial, parasitic, or fungal etiologies
- Suspected immune-mediated - possible autoimmune or immune-complex mediated mechanism postulated in association with systemic (especially rheumatologic) disorders
- Isolated eye disease
- Idiopathic (approximately 25%)
- Masquerade syndromes - diseases such as malignancies that may be mistaken for inflammation of the eye
RISK FACTORS
No specific risk factors. Higher incidence seen with specific associated conditions.
LABORATORY
- No specific test for the diagnosis of uveitis. Tests for etiologic factors or associated conditions should be based on history and physical examination.
- CBC, BUN, creatinine (to evaluate for interstitial nephritis)
- HLA-B27 typing (associated with ankylosing spondylitis, Reiter's syndrome)
- ANA, ESR (to evaluate for SLE, Sjögren's syndrome)
- VDRL, FTA (to evaluate for syphilis)
- PPD (to evaluate for tuberculosis)
- Lyme serology (to evaluate for Lyme disease)
PATHOLOGICAL FINDINGS
Keratic precipitates, inflammatory cells in anterior chamber or vitreous, synechiae (fibrous tissue scarring between iris and lens), macular edema, perivasculitis of retinal vessels
SPECIAL TESTS
Slit lamp examination and indirect ophthalmoscopy are necessary for precise diagnosis
IMAGING
- Chest x-ray (to evaluate for sarcoidosis, histoplasmosis, tuberculosis, lymphoma)
- Sacroiliac x-ray (to evaluate for ankylosing spondylitis)
DIAGNOSTIC PROCEDURES
Slit lamp examination
APPROPRIATE HEALTH CARE
Outpatient with urgent ophthalmologic consultation
GENERAL MEASURES
- Medical therapy best initiated following full ophthalmologic evaluation
- Treatment of underlying cause, if identified
- Cycloplegia
- Anti-inflammatory therapy
SURGICAL MEASURES
N/A
ACTIVITY
Full activity
DIET
No special diet
PATIENT EDUCATION
- Instructions on proper method for instilling eye drops
- Wear dark glasses if photophobia is a problem
- Medication side effects to watch for and report
PREVENTION/AVOIDANCE
N/A
POSSIBLE COMPLICATIONS
- Loss of vision as a result of the following:
- Keratic precipitate deposition on the corneal or lens surfaces
- Increased intraocular pressure, acute angle-closure glaucoma
- Formation of synechiae
- Cataract formation
- Vasculitis with vascular occlusion, retinal infarction
- Macular edema
- Optic nerve damage
EXPECTED COURSE AND PROGNOSIS
- Dependent upon the presence of causal diseases or associated conditions
- Uveitis resulting from infections (systemic or local) tends to resolve with eradication of the underlying infection
- Uveitis associated with seronegative arthropathies tends to be acute (lasting less than 3 months) and frequently recurrent
ASSOCIATED CONDITIONS
- Viral infections: HIV, herpes simplex, herpes zoster, cytomegalovirus
- Bacterial infections: Tuberculosis, leprosy, Propionibacterium, syphilis, leptospirosis, brucellosis, Lyme disease, Whipple's disease
- Parasitic infections: Toxoplasmosis, acanthamebiasis, toxocariasis, cysticercosis, onchocerciasis
- Fungal infections: Histoplasmosis, coccidioidomycosis, candidiasis, aspergillosis, sporotrichosis, blastomycosis, cryptococcosis
- Suspected immune-mediated: Ankylosing spondylitis, Behçet's disease, Crohn's disease, drug or hypersensitivity reaction, interstitial nephritis, juvenile rheumatoid arthritis, Kawasaki disease, multiple sclerosis, psoriatic arthritis, Reiter's syndrome, relapsing polychondritis, sarcoidosis, Sjögren's syndrome, systemic lupus erythematosus, ulcerative colitis, vasculitis, vitiligo, Vogt-Koyanagi (Harada's) syndrome
- Isolated eye disease: Acute multifocal placoid pigmentary epitheliopathy, acute retinal necrosis, bird-shot choroidopathy, Fuch's heterochromatic cyclitis, glaucomatocyclitic crisis, lens-induced uveitis, multifocal choroiditis, pars planitis, serpiginous choroiditis, sympathetic ophthalmia, trauma
- Masquerade syndromes: Leukemia, lymphoma, retinitis pigmentosa, retinoblastoma
AGE-RELATED FACTORS
Pediatric: Infection should be the primary consideration. Allergies and psychological factors (depression, stress) may serve as a trigger factor.
Geriatric: The inflammatory response to systemic disease may be suppressed
Others: N/A
PREGNANCY
May be of importance in the selection of medications
OTHER NOTES
- Synonyms: Anatomic descriptions of the focus of the uveal inflammation
- Severe or unresponsive uveitis may require therapy including periocular injection of corticosteroids, systemic corticosteroids, cytotoxic agents (azathioprine, cyclophosphamide, chlorambucil and methotrexate), or immunosuppressive agents (cyclosporine)
ABBREVIATIONS
gtt = drop
Clinical Investigations
- Cardiology
- Dermatology
- General Destistry
- Cardiology
- Dermatology
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