Uveitis

Uveitis
Classification and external resources
Hypopyon in anterior uveitis, seen as yellowish exudate in lower part of anterior chamber of eye
ICD-10	H20
ICD-9	364
DiseasesDB	13676
eMedicine	oph/580 emerg/284
MeSH	D014605

Uveitis specifically refers to inflammation of the middle layer of the eye, termed the "uvea" but in common usage may refer to any inflammatory process involving the interior of the eye.

Uveitis is estimated to be responsible for approximately 10% of the blindness in the United States.^[1] Uveitis requires an urgent referral and thorough examination by an optometrist or ophthalmologist along with urgent treatment to control the inflammation.

Anatomical classification

Uveitis may be classified anatomically into anterior, intermediate, posterior and panuveitic forms, based on which part of the eye is primarily affected by the inflammation.

• "Anterior uveitis" (or iridocyclitis) is the inflammation of the iris and anterior chamber. Anywhere from two-thirds to 90% of uveitis cases are anterior in location. This condition can occur as a single episode and subside with proper treatment or may take on a recurrent or chronic nature. Symptoms include red eye, injected conjunctiva, pain and decreased vision. Signs include dilated ciliary vessels, presence of cells and flare in the anterior chamber, and keratic precipitates ("KP") on the posterior surface of the cornea.
• "Intermediate uveitis" (pars planitis) consists of vitritis - inflammatory cells in the vitreous cavity, sometimes with snowbanking, or deposition of inflammatory material on the pars plana.
• "Posterior uveitis" (or chorioretinitis) is the inflammation of the retina and choroid.
• "Pan-uveitis" is the inflammation of all the layers of the uvea.

In 2004, a group of international uveitis specialists convened in Baltimore, MD, to standardize the method of reporting data in uveitis clinical trials, including anatomical classification. The results of this meeting were published in the American Journal of Ophthalmology in 2005.^[2]

Conditions associated with uveitis and uveitis syndromes

Myriad conditions can be associated with uveitis, including diseases with major extra-ocular involvement, as well as syndromes confined to the eye. In anterior uveitis, no associated condition or syndrome is found in approximately one-half of cases. However, anterior uveitis is often one of the syndromes associated with HLA-B27. Presence this type of HLA allele has a relative risk of evolving this disease by approximately 15%.^[3]

Systemic disorders associated with uveitis

Systemic disorders that can be associated with uveitis include:^[4]

• Ankylosing spondylitis
• Behçet's disease
• Chronic granulomatous disease
• Enthesitis
• Inflammatory bowel disease
• Juvenile rheumatoid arthritis
• Kawasaki's disease
• Multiple sclerosis
• Polyarteritis nodosa
• Psoriatic arthritis
• Reactive arthritis
• Sarcoidosis
• Systemic lupus erythematosus
• Vogt-Koyanagi-Harada syndrome
• Whipple's disease
• Lyme disease
• HLA-B27
• A wide range of autoimmune and autoinflammatory disease^[5]

Infectious causes

Uveitis may be a (normal) immune response to fight an infection inside the eye. While representing the minority of patients with uveitis, such possible infections include:

• Brucellosis
• Herpes simplex
• Herpes zoster
• Leptospirosis
• Lyme disease
• Presumed ocular histoplasmosis syndrome
• Syphilis
• Toxocariasis
• Toxoplasmosis
• Tuberculosis

Uveitis Syndromes

In many cases, uveitis is not associated with a systemic (i.e. extraocular) condition: the inflammation is confined to the eye. In some of these cases, the presentation in the eye is characteristic of a described syndrome, and include the following diagnoses:

• Acute posterior multifocal placoid pigment epitheliopathy (APMPPE)
• Birdshot retinochoroidopathy
• Fuchs Heterochromic Iridocyclitis
• Multifocal Choroiditis and Panuveitis Syndrome
• Multiple Evanescent White Dot Syndrome (MEWDS)
• Punctate Inner Choroidopathy (PIC)
• Serpiginous Choroiditis

Masquerade syndromes

Masquerade syndromes are ophthalmic disorders that clinically present as either an anterior or posterior uveitis, but are not primarily inflammatory. The following are some of the most common:

• Anterior segment

• Intraocular foreign body
• Juvenile xanthogranuloma
• Leukemia
• Malignant melanoma
• Retinal detachment
• Retinoblastoma

• Posterior segment

• Lymphoma
• Malignant melanoma
• Multiple sclerosis
• Reticulum cell sarcoma
• Retinitis pigmentosa
• Retinoblastoma

Symptoms

• Redness of the eye
• Blurred vision
• Sensitivity to light (photophobia)
• Dark, floating spots along the visual field
• Eye pain

Treatment

The prognosis is generally good for those who receive prompt diagnosis and treatment, but serious complication (including cataracts, glaucoma, band keratopathy, retinal edema and permanent vision loss) may result if left untreated. The type of uveitis, as well as its severity, duration, and responsiveness to treatment or any associated illnesses, all factor in to the outlook.[1]

Uveitis is typically treated with glucocorticoid steroids, either as topical eye drops (prednisolone acetate) or oral therapy with corticosteroids. But before administration of corticosteroids, corneal ulcers are ruled out, typically by a Florescence Dye test. In addition to corticosteroids, topical cycloplegics, such as atropine or homatropine, may be used. In some cases an injection of PSTTA (posterior subtenon triamcinolone acetate) may also be given to reduce the swelling of the eye. ^[6]

Antimetabolite medications, such as methotrexate are often used for recalcitrant or more aggressive cases of uveitis. Experimental treatments with Infliximab or other anti-TNFs' infusions may prove helpful.

See also

• List of eye diseases and disorders
• List of systemic diseases with ocular manifestations
• Intermediate uveitis

Footnotes

1. ^ Sergio Schwartzman. Inflammatory eye disease: an expert interview with Sergio Schwartzman,MD Medscape Rheumatology 2007.
2. ^ Jabs DA, Nussenblatt RB, Rosenbaum JT. Standardization of Uveitis Nomenclature (SUN) Working Group. Standardization of uveitis nomenclature for reporting clinical data. Results of the First International Workshop. Am J Ophthalmol 2005;140:509-516.
3. ^ Table 5-7 in: Mitchell, Richard Sheppard; Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson. Robbins Basic Pathology. Philadelphia: Saunders. ISBN 1-4160-2973-7.  8th edition.
4. ^ White G. "Uveitis." AllAboutVision.com. Retrieved August 20, 2006.
5. ^ McGonagle D, McDermott MF (2006) A proposed classifi cation of the immunological diseases. PLoS Med 3(8): e297. DOI: 10.1371/journal. pmed.0030297
6. ^ BNF 45 March 2003

External links

• Uveitis Information Group, UK based information site and support group
• Uveitis at the Open Directory Project
• The Ocular Immunology and Uveitis Foundation