UVEITIS

Inflammation inside the eye is called uveitis. There are several different types of uveitis.

Contents WHAT IS A UVEITIS? TYPES OF UVEITIS OFFICE EVALUATION OF UVEITIS SYSTEMIC EVALUATION OF UVEITIS

PIC with macular scarring

Uveitis is the term used for inflammation on the inside of the eye. There are several ways to organize subtypes of uveitis.

Inflammation can be caused by either an infection or from auto-immunity.  Most cases of uveitis are auto-immune.  Secondarily uveitis is characterized by where the inflammation affects the eye.  Inflammation in the front of the eye is called iritis; in the middle of the eye, intermediate uveitis; in the back of the eye, posterior uveitis; and throughout the eye, panuveitis. The image associated with this text shows scarring the macula of a patient from multifocal choroiditis and panuveitis.

Our practice treats all forms of uveitis, but predominantly sees patients with intermediate, posterior, and panuveitis.

posterior anterior synechia

Types of Uveitis: Anterior, Intermediate, Posterior, and Panuveitis

Uveitis is a term that encompasses a group of inflammatory conditions affecting the uvea, the middle layer of the eye. The classification is based on the specific part of the uvea that is inflamed. Understanding the different types of uveitis is crucial for appropriate diagnosis and treatment. Here are the four main types:

  1. Anterior Uveitis:
    • Location of Inflammation: Anterior uveitis, also known as iritis, primarily involves inflammation of the iris, the front portion of the uvea.
    • Characteristics: This type is the most common form of uveitis, and it often presents with symptoms such as eye redness, pain, sensitivity to light (photophobia), and blurred vision.
    • Associated Conditions: Anterior uveitis is frequently associated with autoimmune diseases, such as ankylosing spondylitis and reactive arthritis.
  2. Intermediate Uveitis:
    • Location of Inflammation: Intermediate uveitis involves inflammation of the ciliary body and vitreous humor, the middle portion of the uvea.
    • Characteristics: Symptoms may include floaters (small specks or clouds moving in the field of vision), blurred vision, and occasionally, mild eye pain. Intermediate uveitis is less common than anterior uveitis.
    • Associated Conditions: It is often associated with systemic inflammatory conditions like sarcoidosis or multiple sclerosis.
  3. Posterior Uveitis:
    • Location of Inflammation: Posterior uveitis affects the choroid and retina, the back portion of the uvea.
    • Characteristics: Symptoms may include floaters, blurred or distorted vision, and, in severe cases, vision loss. Posterior uveitis is less common than anterior uveitis but can be more severe.
    • Associated Conditions: Infections, such as toxoplasmosis or cytomegalovirus, are common causes of posterior uveitis.
  4. Panuveitis:
    • Location of Inflammation: Panuveitis involves inflammation of all three parts of the uvea: the iris, ciliary body, and choroid.
    • Characteristics: This is a more widespread and severe form of uveitis that can affect the entire eye. Symptoms may include redness, pain, light sensitivity, floaters, and vision changes.
    • Associated Conditions: Panuveitis can be associated with systemic autoimmune diseases, such as Behçet’s disease or systemic lupus erythematosus.

 

sarcoid uveitis

Diagnosing uveitis requires a comprehensive eye examination:

  1. Visual Acuity Test:
    • Changes in visual acuity may indicate the presence and severity of uveitis.
  2. Slit-Lamp Examination:
    • A slit-lamp examination is a detailed microscopic inspection of the eye’s anterior and posterior segments. This microscope allows the eye care professional to examine under magnification the cornea, iris, lens, and vitreous humor. It aids in identifying signs of inflammation, such as cells or flare in the anterior chamber.
  3. Ocular Pressure Measurement:
    • Most forms of uveitis cause the intraocular pressure to decline but some forms cause an elevated intraocular pressure.
  4. Dilated Fundus Examination:
    • Dilation of the pupils allows for a thorough examination of the retina and the optic nerve. A complete eye examination is necessary to properly characterize the uveitis.
  5. Fluorescein and Indocyanine green Angiography:
    • In some cases, a fluorescein and indocyanine green angiogram may be performed to better characterize the uveitis.  Some forms of uveitis cause inflammation of the retinal vessels which is visible on fluoresceine angiography.  Some forms of posterior uveitis have very specific findings on indocyanine green angiography.
  6. Optical Coherence Tomography (OCT):
    • OCT is a non-invasive imaging technique that provides cross-sectional images of the retina. It helps in visualizing retinal layers and identifying swelling or fluid accumulation, aiding in the assessment of macular edema and other structural changes associated with uveitis.
  7. Ultrasound Imaging:
    • Certain forms of posterior uveitis cause fluid build up around the back of the eye which is evident on ultrasound imaging.

These diagnostic tests collectively contribute to a comprehensive evaluation of uveitis.  It is helpful to properly characterize the uveitis prior to developing a treatment plan.

syphilis

A systemic evaluation for uveitis involves assessing the patient for underlying systemic conditions that may contribute to or be associated with the inflammation in the eye. It is particularly important to rule out infectious uveitis prior to starting immunosuppressive therapy for uveitis.  Most patients with uveitis are tested for syphilis.  The image with this text shows a typical image of an eye of a patient with syphilitic chorioretinitis. Also, since sarcoidosis is a common cause of uveitis and can have systemic implications, many providers perform systemic testing for sarcoidosis.

  1. Syphilis Testing:
    • Rationale: Syphilis is a sexually transmitted infection caused by the bacterium Treponema pallidum. Ocular syphilis can manifest as uveitis and may lead to severe vision impairment if left untreated.
    • Recommended Tests: Blood tests for syphilis typically include:
      • Rapid Plasma Reagin (RPR): This non-specific test detects antibodies that the body produces in response to syphilis infection.
      • Treponemal Tests (e.g., TP-PA, FTA-ABS): These tests confirm the presence of syphilis antibodies and help differentiate between current and past infections.
  2. Sarcoidosis Screening:
    • Rationale: Sarcoidosis is a systemic inflammatory disease that can affect various organs, including the eyes. Ocular involvement may present as uveitis, granulomatous inflammation, or other eye manifestations.
    • Recommended Tests: Blood tests and imaging studies may be used to assess for sarcoidosis, including:
      • Angiotensin-Converting Enzyme (ACE) levels: Elevated levels may indicate sarcoidosis, although it is not specific to the disease.
      • Chest X-ray or Chest CT Scan: These imaging studies help identify granulomas in the lungs, a characteristic feature of sarcoidosis.
      • Sarcoidosis-specific blood tests: These may include angiotensin converting enzyme and serum lysozyme.

It’s important to note that the specific tests conducted in a systemic evaluation may vary based on the clinical presentation, medical history, and physical examination findings. Some patients with uveitis may have a rash, joint pain, gastrointestinal problems, oral ulcers, fevers or weight change.  All of these problems are associated with different specific diseases that are associated with uveitis.