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  Uveitis  
 
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Signs, symptoms and indicators | Conditions that suggest it | Contributing risk factors | Other conditions that may be present | Recommendations

 

Uveitis is a general medical term for inflammation affecting the middle layer of the eye which is called the uvea. The uvea consists of 3 distinct structures: iris, ciliary body, and the choroid. The iris is the colored ring around the pupil of the eye; the choroid is a thin layer of blood vessels covering both the back and sides of the eye; and the ciliary body is a ring shaped structure between the iris and choroid that joins the iris with the retina, the inner layer of the eye. The ciliary body has two main functions: its muscles serve to focus the lens, and it also produces the aqueous humor, a nourishing liquid that bathes the front of the eye. Uveitis may affect any or all of these 3 parts of the eye.

The primary symptom of uveitis affecting the choroid, known as posterior uveitis, is a vague feeling of hazy or fading vision. Some people see black spots that seem to float before their eyes. Iritis, also known as anterior uveitis, is a type of uveitis that affects the iris, although the term is sometimes used for inflammation that includes the ciliary body as well. Iritis can cause redness, pain, blurred vision, an intolerance to light, and, sometimes, headaches.

Uveitis is often linked to an autoimmune disorder such as rheumatoid arthritis and other conditions which may have an autoimmune cause, but it can also be the result of infection. More often than not, there is no obvious cause. Uveitis can be a precursor of other eye problems, including glaucoma and detached retina. If you suspect you may have uveitis, then you should consult an ophthalmologist for a complete eye examination.
 

 
 

Signs, symptoms & indicators of Uveitis:
 
 
Symptoms - Head - Eyes/Ocular  Unilateral/bilateral eye pain
  Vision disturbances
  (High) sensitivity to bright light
  Bloodshot eyes

Symptoms - Metabolic

  Current atypical recent headaches
 
 

Conditions that suggest Uveitis:
 
 
Symptoms - Head - Eyes/Ocular  Uveitis
 
 

Risk factors for Uveitis:
 
 
Symptoms - Head - Eyes/Ocular  History of uveitis
  Past episodes of bloodshot eyes

Counter-indicators:
  Absence of uveitis
 
 

Uveitis suggests the following may be present:
 
 
Autoimmune  Autoimmune Tendency
 
 

Recommendations for Uveitis:
 
 
Drug  Conventional Drugs / Information
 Many uveitis specialists treat intermediate uveitis according to the method outlined by Kaplan. Patients whose visual acuity is better than 20/40 are generally not treated, unless they have CME, extensive neovascularization of the peripheral retina, extensive vasculitis, or if they complain of severe floaters. Patients whose visual acuity is 20/40 or worse usually are treated. As with most forms of uveitis, corticosteroids are the mainstay of therapy.

Topical therapy with prednisolone acetate 1% or prednisolone sodium phosphate 1% is only helpful in the treatment of the anterior segment inflammation. The intravitreal concentration of drugs administered topically is too low to be efficacious in the face of moderate-to-severe vitritis, especially in the phakic patient.

Periocular injections of corticosteroids are preferentially given in unilateral cases and occasionally in bilateral cases. Triamcinolone acetonide can be administered superotemporally into the sub-Tenon space or through the inferior eyelid into the retroseptal space. If the disease is not controlled after 2-3 injections given over an 8-week period, systemic prednisone should be considered. Some authorities advocate the use of a combination of betamethasone and depot methylprednisolone in an effort to achieve early onset and prolonged duration of action.

Oral prednisone may be the preferred treatment in patients with bilateral intermediate uveitis or in cases resistant to topical or periocular steroids. A purified protein derivative (PPD) test is imperative prior to starting any patient on systemic corticosteroids if there are any risk factors for TB. Once the inflammation stabilizes, the oral dose is tapered according to disease activity. An H2 blocker (Tagamet or Zantac) or a proton pump inhibitor (Prilosec or Prevacid) can be prescribed adjunctively to oral steroids.

Finally, intravitreal triamcinolone acetonide injections have been used to treat CME. In a small series by Androudi et al of 16 patients (20 eyes) with noninfectious uveitis and CME, of which 3 had intermediate uveitis, visual acuity improved in 11 eyes and improved but returned to baseline levels in another 5 eyes, respectively.

For recalcitrant cases with high corticosteroid requirements to control the inflammation, the surgical implantation of a device releasing fluocinolone acetonide in the vitreous can be considered (see Surgical Care).

In the event that corticosteroids cannot control the intermediate uveitis or in those whose disease invariably flares when steroids are discontinued, immunosuppressive therapy often is attempted. Immunosuppression or immune-modulation is also used as part of the concept of steroid-sparing therapy in an effort to reduce the patient's requirement for systemic corticosteroids and, therefore, to diminish the adverse effects of systemic corticosteroid therapy.

Cyclosporine, tacrolimus, azathioprine, and methotrexate are the most commonly used agents with documented efficacy in many uveitic conditions. Chlorambucil can be considered for intractable cases. They can be used concurrently with corticosteroids as steroid sparing agents or alone.

Murphy et al prospectively evaluated the efficacy and the safety of cyclosporine and tacrolimus in patients with posterior and intermediate uveitis. The 2 agents did show a similar response rate (approximately 67%), but cyclosporine was associated with a higher incidence of adverse effects.

The use of infliximab, an anti-tumor necrosis factor (anti-TNF) monoclonal antibody, has been shown to be effective in improving macular thickness and visual acuity in patients with uveitic refractory CME due to intermediate uveitis or other noninfectious uveitis. Initial successful reports by Markomichelakis et al were duplicated by Rajaraman et al in a pediatric population in which infliximab achieved reduction in intraocular inflammation with concurrent elimination or decrease in steroid requirements.

More recently, daclizumab, an interleukin-2 receptor blocking antibody, has been shown to be effective in noninfectious uveitis in a multicenter nonrandomized interventional case series. It allowed control of ocular inflammation with stability in visual acuity with reduction of concomitant immunosuppression by at least 50%.

Finally, interferon-beta (INF-beta), which has an established value in the treatment of MS, appears to have a positive effect in terms of visual acuity, CME, and aqueous and vitreous inflammation in intermediate uveitis associated with MS. This information was taken from emedicine.com.
 
 


KEY
Weak or unproven link
Strong or generally accepted link
Proven definite or direct link
Very strongly or absolutely counter-indicative
Highly recommended