Uveitis is an inflammation of the uvea (middle skin of the eye), an intermediate layer surrounding the eye consisting of the iris (iris skin), the ciliary body (radiation body) and the choroid (choroid).
The uvea plays the most important role in the blood supply to the retina.
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Classification of uveitis
The disease can be divided into several types:
Anatomical classification
Anterior uveitis refers to inflammation of the iris skin.
Depending on the structures involved, it can also be referred to as:
- iridocyclitis (iris + inclusion of the ciliary body);
- Anterior cyclitis (the anterior region of the ciliary body is affected).
Intermedia uveitis affects the vitreous and posterior part of the ciliary body; it can also be called chronic cyclitis, peripheral uveitis, pars planitis, the latter refers to the anterior vitreous area.
Posterior uveitis describes inflammation of the choroid called choroiditis or chorioretinitis when the retina is also involved.
The blood vessels of the retina can also be affected, leading to retinal vasculitis.
Posterior uveitis is also divided into focal, multifocal or diffuse, depending on the type of inflammation visible at the back of the eye.
Total or panuveitis indicates inflammation in all areas of the uvea and represents a serious condition.
Another classification divides uveitis into two categories:
- Granulomatous
- Non-granulomatous
This is a descriptive classification based on clinical examination and on the damage that is caused, and not on histology; it can be used to limit the possibilities of differential diagnosis.
Uveitis is called granulomatous when busacca nodules appear in the intercellular space (stroma) of the iris and fatty deposits.
Granulomatous uveitis has a gradual onset and a long course.
Another characteristic of granulomatous uveitis is the Koeppe nodules at the edge of the pupil, which are smaller than the Busacca nodules.
Non-granulomatous uveitis does not have these formations.
The presence of Koeppe nodules does not always mean that uveitis is of the granulomatous type.
Onset, duration and course of uveitis
The disease can occur gradually or suddenly, and the duration is defined as acute if it lasts less than three months and chronic if three months are exceeded.
Possible course:
- Recurrent (repeated single episodes after at least 3 months of inactivity)
- Chronic (recurrences occur less than three months after interruption of therapy)
Causes of uveitis
The causes depend on the type of uveitis:
Inflammatory – due to an autoimmune and rheumatic disease.
It is believed that the cause of uveitis is an immune reaction. The triggering factor varies depending on genetic and environmental factors.
There are special diseases associated with a subcategory of uveitis (anterior, intermedia, posterior, panuveitis).
Non-granulomatous disease may be associated with:
- rheumatoid arthritis,
- systemic lupus erythematosus,
- multiple sclerosis,
- Vogt-Koyanagi-Harada syndrome,
- sacroiliitis,
- Ankylosing spondylitis
- Reiter’s syndrome,
- psoriasis,
- inflammatory bowel diseases (for example, ulcerative colitis and Crohn’s disease),
- Sarcoidosis
- Behçet’s disease,
- autoimmune vasculitis
- juvenile idiopathic arthritis
The only group of patients currently undergoing screening for uveitis are children with juvenile idiopathic arthritis.
Infectious – caused by known ocular and systemic pathogens.
Some infections are related to anterior uveitis and the cause is probably an immune reaction of the organism.
Anterior and posterior granulomatous uveitis is associated with:
- toxoplasmosis – the most common cause of posterior uveitis,
- cytomegalovirus,
- Herpes simplex Virus
- Herpes zoster Virus
- Tuberculosis
- Syphilis
- Human Syncytial Virus,
- Cryptococcosis
- Candidiasis.
Infiltrative – secondary after invasive neoplasms, such as lymphoma.
Traumatic.
Iatrogenic – caused by surgery, accidental injuries or medications (for example, rifabutin, cidofovir). When uveitis occurs a few weeks or months after surgery, it is called phaco-anaphylactic.
Hereditary – secondary due to metabolic disease or dystrophy.
Ischemic – caused by blockage of the bloodstream.
Idiopathic – a category used when, despite thorough research, no underlying cause can be identified. About 50% of uveitis cases are idiopathic.
There are also some ocular symptoms caused by anterior uveitis (for example, Posner-Schlossman syndrome, Fuchs heterochromia cyclitis and Schwartz syndrome).
Sympathetic ophthalmia (sometimes called sympathetic ophthalmitis) is a rare form of bilateral panuveitis. It is a special type of uveitis in response to an eye injury.
Symptoms of uveitis
Signs, symptoms and characteristics of uveitis include:
- reddened eyes,
- eye pain,
- photophobia (hypersensitivity to light),
- blurred vision,
- dots or dark and trembling spots in the visual field (myodesopsia),
- loss of vision,
- whitish area (hypopyon) inside the eye in front of the lower iris (coloured area of the eye),
- watery eyes,
- Headache
- Fever
- Dizziness.
Possible complications of uveitis
Complications of uveitis include adhesions between the iris and lens or other structures of the front eye.
In the anterior area, they can form between the iris and cornea and cause the following disorders:
- clouding of the cornea,
- high eye pressure.
Posterior adhesions occur between the iris and the lens, the consequences are:
Other complications include:
- retinal detachment,
- loss of vision,
- macular degeneration,
- Macular edema.
Diagnosis, examinations and tests for uveitis
To diagnose uveitis, a complete eye examination should be performed; This includes:
- examination with the slit lamp,
- Control with the ophthalmoscope after pupil dilation.
The doctor analyzes the patient’s medical history.
Laboratory tests can be done to rule out infection or autoimmune disease.
The doctor may prescribe imaging tests, such as:
- fluorescence angiography,
- optical coherence tomography (OCT)
- Magnetic resonance imaging to rule out systemic diseases such as multiple sclerosis.
Therapy of uveitis and iritis
The doctor will probably prescribe corticosteroids to reduce inflammation in the eye.
The administration of cortisone can be in the form of:
- Eye drops
- Tablets
- Injections.
This depends on the type of uveitis.
Since anterior uveitis affects the front area of the eye, it can easily be treated with eye drops.
As a rule, posterior uveitis is treated with tablets or injections.
Depending on the symptoms, one of these forms of treatment could be used for intermedial uveitis.
Corticosteroids and other immunosuppressants can cause very serious side effects, for example:
- kidney damage,
- high blood sugar levels,
- arterial hypertension,
- osteoporosis,
- Glaucoma.
This occurs especially with cortisone in tablet form, as the dose must be relatively high to reach the back of the eye.
It is therefore important to strictly follow the doctor’s instructions regarding the dose and to attend the regular check-ups to monitor the progress of the treatment.
In the case of anterior uveitis, in addition to corticosteroids, the doctor prescribes pupil-dilating and pain-relieving eye drops based on atropine and homotropin.
One can also use eye drops to reduce eye pressure if increased eye pressure has developed due to uveitis.
Anyone who suffers from a systemic disease that causes uveitis should also be treated for this by the doctor.
If uveitis is provoked by bacterial infectious diseases, the doctor may prescribe antibiotics.
In severe or chronic cases, surgical treatment may be required, such as:
- laser or photocoagulation,
- cold treatment (cryotherapy) of the peripheral retina,
- surgical removal of the vitreous body (vitrectomy).
Natural remedies
Natural remedies are unable to treat the more serious conditions that cause uveitis, especially if there is an autoimmune disease behind it.
There are some products that can help with:
- Infectious
- Traumatic
- ischemic uveitis.
For example, propolis, blueberries and echinacea help boost the immune system and improve circulation.
Natural remedies work better when the patient eats healthy.
Until complete recovery, contact lenses should not be used.
Prognosis and recovery times of uveitis
If left untreated, uveitis can lead to loss of vision.
With fast and effective treatment, one usually achieves a good result of vision (one study has shown that 91% of these patients maintain their normal vision).
Recurrence after a first episode of acute anterior uveitis is common; a recent study found an occurrence in 24% of cases per year.
Recurrences occur with an increased frequency in:
- younger patients (18-35 years),
- Cases when anterior uveitis occurs in connection with autoimmune diseases and chronic inflammation.
The prognosis of chronic granulomatous uveitis depends on the cause, underlying disease, and early detection and treatment.
