UVEITIS

Uveitis is an inflammation of the eye that affects one or more than three parts from which the middle eye membrane – uvea – consists.

We can perceive the eye as a bowl composed of three layers: the outer layer is the sclera with the cornea, the inner layer is the retina, and in the middle is located the uvea. The uvea consists of three parts:

–      iris (the colored part of the eye)

–      ciliary or radially body (responsible for creating the aqueous humor and for accommodation of the eye)

–      choroids (the tissue with many blood vessels, it is located beneath the retina, and it has a nutritional role)

Uvea supplies nutrients to the eye through blood vessels; therefore, its disease endangers nutrition of the whole eye. Uveitis may be life threatening and it is more dangerous than many other eye diseases. Problems with uveitis are generally underestimated in general population as well as with ophthalmologists, eye doctors. Very few people know that uveitis is the third leading cause of blindness.

Autoimmune uveitis is the most common one. Uveitis tends to reoccur.

Causes:

Approximately 60 different causes can be responsible for the development of uveitis and therefore ‘detective work’ to uncover the causes of uveitis at patients is an arduous and expensive process. This detective work is more like the diagnostic process in internal medicine than in ophthalmology. This exactly is the reason why so few ophthalmologists are specialized for uveitis. Except that, the treatment of some forms of uveitis requires systemic therapy (non-steroidal anti-inflammatory drugs, steroids and/or immuno-modulators, chemotherapy) which also rejects many ophthalmologists from this area.

Types of uveitis:

According to the causes uveitis is divided into the following groups:

1. 1.Infectious

–      Bacterial (tuberculosis, syphilis, leprosy, borreliosis …)

–      Viral (varicella virus, herpes simplex virus, HIV, cytomegalovirus …)

–      Fungi (candidiasis, aspergillosis, histoplasmosis)

–      Protozoa (toxoplasmosis)

–      Parasites (toksokaroza, cysticercosis)

2. Non-infectious uveitis caused by the associated systemic disease

–      Ankylosing spondylitis

–      Reiter’s syndrome

–      Psoriatic arthritis

–      Juvenile chronic arthritis

–      Behcet’s disease

–      Sarcoidosis

–      Vogt-Koyanogi-Haradin syndrome

3. Specific idiopathic (unknown cause) entities

–      Fuchs’ uveitis, pars planitis

–      Idiopathic vasculitis, vitritis

–      Sympathetic ophthalmia

4. Non-specific entities of unknown cause – uveitis which cannot be counted into the first three groups

Except according to causes, uveitis can also be divided by:

–      Anatomical location: the front (anterior), middle (intermediate), rear (posterior), complete (panuveitis), peripheral (pars planitis)

–      Clinical course (duration): acute, sub-acute and chronic

–      Pathological-histological result: granulomatous and non-granulomatous

Symptoms:

Anterior uveitis

Anterior uveitis is an inflammation of the iris and/or the radially body (iritis, cyclitis, iridocyclitis). It may be acute if it lasts for a short period of time or it may be chronic if it lasts longer than three months. Symptoms of acute anterior uveitis are pain, redness of the eye, sensitivity to light or photophobia (the patient is bothered by light), lacrimation, decreased vision.                                                             At chronic uveitis the eye is white and placid. The signs that the doctor notices during the examination are redness of the conjunctiva, cornea and aqueous humor blurring due to the deposition of inflammatory cells and proteins, blood in the anterior chamber (hyphema), adhesions (synechia) of the iris and lens, increased supply of the iris because of what the iris changes color into dirty-greenish or dirty-grey-greenish.

Intermediate uveitis

The main symptoms are “ants’ eggs” in front of the eye (due to inflammatory elements in the vitreous body of the eye) and decreased vision.

Posterior uveitis

Posterior uveitis is more often painless, but more dangerous when it comes to vision loss. “Ants’ eggs” and decreased vision are also its characteristics.

Treatment:

In treating uveitis it is attempted to achieve the following:

–      to relieve the pain and discomfort

–      to prevent vision loss because of the disease and its complications

–      to cure the cause when it is known and when the treatment is possible

As the causes of uveitis considerably differ, so does the treatment of various types. The treatment is, therefore, symptomatic and causal.

Symptomatic treatment

– The prevention and/or pain relief is carried out by dripping analgesic drops into the eye and by warm compresses, and if necessary by taking analgesic pills                                                                                       – Prevention of the creation of adhesions between the rear edge of the iris and the lens: dripping atropine sulfate solution and placing atropine fat because atropine expands the pupil                                                        – If adhesions already began to create the injection is given to the eye, a so called mydriatic cocktail (1% solution of Cocaini hydrocloridi + 1% solution of Adrenalini hydrocloridi). After the application of this cocktail which expands the pupil, complete or partial disruption of adhesions occurs, which leads to transient severe pain. Therefore, it is recommended to inject strong analgesics before injecting the cocktail into the eye.              – Anti-inflammatory treatment: corticosteroids in the form of drops, ointments or injections into the eye each day or every 2-3 days. Corticosteroids also have an anti-allergic effect so they often, especially with acute iridocyclitis, need to be taken orally as a systemic therapy for several weeks. The dosage is reduced each week. This therapy is not carried out if there are distinct reasons against it: stomach or intestinal ulcers, herpes diseases, pregnancy. During therapy it is necessary to control the blood count and liver function.                                                – To reduce the permeability of capillaries daily injections or tablets of calcium and vitamin C are needed.

Causal treatment implies treating the underlying disease, i.e. cause of uveitis. Bacterial diseases are treated with appropriate antibiotics. Tuberculosis is treated by tuberculostatics, corticosteroids and staying in high-altitude climate. Syphilis: penicillin or other antibiotics. Etc…           Iridocyclitis caused by hypertension is treated with dilation of the pupil with mydriatics, if there are adhesions created – mydriatic cocktail, pilocarpine is not applied because of pupil constriction and subsequent glaucoma.

Surgical treatment

Surgical procedures are performed only when complications occur. When the iris completely sticks to the lens the flow of aqueous humor from posterior to anterior chamber stops, so there are openings made in the iris or the iris is cut. Openings in the iris can be made by laser. If due to uveitis cataract occurs, it is also treated by surgery. If a purulent inflammation of the iris and ciliary body affects the whole eye, it might be needed to remove the whole eye. This is sometimes carried out with sore eyes, which are already blind.