Frequently Asked Questions
What is uveitis?
How common is uveitis?
Uveitis classifications
Signs and symptoms
Causes
Visiting an eye specialist
Treatment
What to expect
Prevention
Answers
What is uveitis?
Uveitis is swelling and irritation in the middle portion of the eye which is called the uveal tract. The uveal tract is made up of three structures: iris, ciliary body and choroid. Each of these three structures has a function. The iris is the coloured portion of the eye that controls the amount of light entering into it. The ciliary body forms a clear liquid which fills the front part of the eye and provides nutrients to the eye. The choroid supplies blood to the eye so that we are able to see images. Sometimes the term “uveitis” is loosely used to describe irritation and swelling in parts of the eye that are located near these structures as well, such as the retina. Swelling and irritation in any of these structures can lead to the eye not being able to function normally.
Uveitis is not one specific condition, rather it is a group of disorders that are characterized by irritation and swelling in any portion of the uveal tract. It can begin and continue due to various causes such as trauma, infection, malignancies, and autoimmune disorders. But most cases of uveitis don’t have any cause that we can find. Although most people with uveitis are treated with great success, uveitis remains an important group of disorders because it can create scars in the eye and lead to vision loss in a minority of patients.
Image 1 Uveal tracts
How common is uveitis?
It is estimated that approximately 200 out of 10 000 people are newly diagnosed with uveitis each year. Although this makes uveitis a relatively uncommon disease, it is an important cause of visual loss. Uveitis causes 20% of all legal blindness. Unlike many eye conditions which occur in the elderly population, uveitis most often causes vision loss in young adults. In the developed world, it is the fifth most common cause of visual loss for people between the ages of 20 to 60 years.
Uveitis was previously believed to be uncommon in the elderly. But recent studies have found it to increase in the elderly population as well.
Uveitis classifications
Uveitis is commonly referred to by the location where the swelling and irritation is occurring. When it occurs in the front portion of the uveal tract, it is called anterior uveitis (or iritis). Anterior uveitis affects the iris, the ciliary body or both. When it occurs in the rear portion of the uveal tract it is called posterior uveitis. Posterior uveitis affects the choroid and the retina. Another category is called intermediate uveitis. This form of uveitis affects a clear gel that is found within the eye called the vitreous humour. Panuveitis is a term used to describe uveitis of all structures of the uveal tract. Anterior uveitis is 4 times more common than posterior uveitis.
Uveitis can also be classified by its duration. Acute uveitis is of short duration and lasts for a few weeks to months before it resolves. Chronic uveitis is of longer duration and lasts from months to years. Some cases of chronic uveitis never completely resolves.
Signs and symptoms
Living with uveitis can be different for different people. Some people (especially children and young adults) may not experience any symptoms at all. Others may have significant and severe symptoms. An individual’s experience with uveitis can depend upon the cause, location and duration of uveitis, as well as upon an individual’s overall health status.
These are common signs and symptoms that people experience:
-aching eye pain
-red eye
- sensitivity to light
- tearing
- blurry, hazy vision
- moving dark spots called “floaters”
- flashing lights
- narrowing of the pupil
The symptoms that people experience can depend upon the location of the uveitis. Patients with anterior uveitis generally experience pain, sensitivity to light and blurry vision. Intermediate uveitis generally leads to seeing floaters and blurry vision. Posterior uveitis commonly causes one to see floaters and reduced or lost vision.
Causes
Uveitis is a group of disorders and can have numerous causes. This section includes information on common disorders associated with anterior, intermediate and posterior uveitis. Most often, the exact cause of uveitis is unknown. Doctors refer to this as “idiopathic.”
Anterior uveitis
-Arthritis syndromes (ankylosing spondylitis, reactive arthritis, juvenile idiopathic arthritis)
-Lens-induced uveitis
-Gastrointestinal diseases (Ulcerative colitis, Crohn’s disease, Whipple’s disease)
-Sarcoidosis
-Syphilis
-Tuberculosis
-Cancers
-Fuchs’ heterochromic iridocyclitis
-Sympathetic ophthalmia
Intermediate uveitis
-Pars planitis
-Gastrointestinal diseases (Ulcerative colitis, Crohn’s disease, Whipple’s disease)
-Syphilis
-Sarcoidosis
Posterior uveitis
-Toxoplasmosis
-Toxocariasis
-Cytomegalovirus
-Candida
-Tuberculosis
-Presumed ocular histoplasmosis Syndrome
-Behcet’s disease
-Vogt-Koyanagi-Harada syndrome
-Sacroidosis
-Birdshot retinochoroidopathy
-Acute Multifocal Placoid Pigment Epitheliopathy
-Cancers
Visiting an eye specialist
Uveitis is managed and treated by an ophthalmologist (eye specialist). When uveitis is suspected, a referral is made by a family physician or an optometrist to an ophthalmologist. Optometrists are specialized eye care practitioners who examine eyes, prescribe glasses and take care of some medical eye problems. An ophthalmologist is a medically and surgically trained medical doctor (MD) who treats eye diseases. Ophthalmologists consider the medical history, signs and symptoms and results of eye exams to determine the severity and extent of uveitis. Ophthalmologists may use specialized equipments to carry out complete eye exams. If the ophthalmologist feels that it is necessary, you may be asked to complete specific blood tests as well.
Image 1 Slit-lamp
Image 2 Drops
Image 3 Testing vision
Treatment
General information
Uveitis treatment is a complex topic since there are numerous causes of uveitis. The ultimate goals when treating uveitis are to prevent vision loss, to provide pain relief and to reduce or prevent new and harmful changes in the eye.
Ophthalmologists work with patients to recommend the best possible treatment options on an individual basis. The decision of whether to treat uveitis and how to do so is a result of the careful assessment of various factors. Factors taken into account include: eye structures being affected by uveitis, whether or not the uveitis appears to be reversible, the extent to which vision is affected, if one or both eyes are involved and the patient’s age and overall health.
In some situations there may not be any recommended treatment. This is because medications may have the potential to cause side effects, allergies or lead to complications. If the harmful effects of treatment outweigh the benefits, then treatment will not be suggested.
Numerous medications are used to effectively treat uveitis today. With new medical advancements, Ophthalmologists are better able to manage and treat uveitis. In the absence of these medications, uveitis can lead to vision loss and to permanent damages within the eye.
How medications are administered
Medications to treat uveitis are taken in 3 main ways:
1. Drops
2. Pills
3. Injections into the eye
Types of medications
The most commonly used medications to treat uveitis are: cycloplegic medications, corticosteroids, immunosuppressive agents and non-steroidal anti-inflammatory drugs. There are also other medications, such as antibiotics and antiviral medications, which are only used for specific causes of uveitis.
1. Cycloplegic medications
Cycloplegic medications are amongst the most commonly used medications to treat uveitis. These medications are given as drops and help to reduce some of the symptoms experienced in uveitis, such as sensitivity to light. They also help to prevent further complications.
Examples of commonly used cycloplegic medications are: homatropine, atropine, cyclopentolate and mydriacyl.
2. Corticosteroids
Corticosteroids are the most commonly used medications to treat uveitis. This group of medications is used extensively in many areas of medicine and is extremely effective at reducing the irritation and swelling that occurs in uveitis. Corticosteroids have been used for decades and play a critical role in uveitis treatment. Without treatment by corticosteroids uveitis can lead to complete vision loss in some situations.
Nonetheless, corticosteroids do have important and potentially harmful side effects. The dosage, strength, duration of usage and route of medication all play an important role in whether or not side-effects develop.
Examples of commonly used corticosteroids are: prednisolone acetate, prednisolone phosphate and rimexolone. The most commonly used oral (by mouth) steroid is prednisone.
Side-effects of corticosteroids drops can include:
- Cataract
- Glaucoma
- Droopy eyelid (ptosis)
Side-effects of corticosteroids pills can include:
- Muscle weakness
- Osteoporosis
- Nausea
- Increased appetite
- Stomach ulcers
- Poor wound healing
- Tendency to bruise
- Increased sweating
- Headaches
- Moodiness
- Menstrual irregularities
- Diabetes
- Weight gain
- Clot formation
- Serious eye complications such as cataracts and glaucoma
- Hirsutism
3. Immunosuppressive agents
Immunosuppressive medications reduce the irritation and swelling that is characteristic of uveitis. They have been used to treat uveitis for decades and play a particularly important role for patients who are unable to tolerate corticosteroid treatment. There are many different immunosuppressive medications and ophthalmologists recommend those that are best suited to an individual. They are usually taken by mouth.
Common immunosuppressive medications include:
Azathioprine
Methotrexate
Cyclophosphamide
Cyclosporine
Mycophenolate
TNF alpha antagonists
Other biologic agents
While they are very effective, immunosuppressive medications can also cause a variety of side-effects. These will vary from drug to drug and can include:
-Reduced number of blood cells
-Increasing numbers of infections
-Scarring of lungs
-Kidney dysfunction
-Liver dysfunction
-Visual disturbances
-Birth defects
-Cancers
-Nausea
-Vomiting
-Diarrhea
4. Non-steroidal Anti-inflammatory drugs (NSAIDs)
NSAIDs is a group of medications that is used widely in different areas of medicine. NSAIDs help to reduce the irritation and swelling within the eye that is the hallmark of uveitis. NSAIDs are not always as effective as corticosteroids; however, the associated side-effects are less severe as well. The non-steroidal property of this class of drugs means that it lacks many of the potentially harmful side-effects of corticosteroids. The most common side-effects of NSAIDs that are taken orally include nausea, vomiting, diarrhea, constipation, decreased appetite, dizziness and headaches.
Commonly used NSAIDs in Canada are:
Taken as drops-
Voltaren, acular, nevanac
Taken orally-
Celebrex, naproxen, indocid
Following medication guidelines
Uveitis can lead to serious damages to eye structures and can cause complete vision loss. Therefore, it is extremely important to take prescribed medications as advised. In many situations, medications help to completely cure uveitis. Delaying treatment might mean that the damage done to the eye cannot be reversed. At times, uveitis treatment may also require antibiotic medications-when the uveitis is caused by an infection. Taking antibiotics improperly or irregularly can lead to antibiotic resistance. This means that the medications may no longer be effective against the organisms causing the disease.
Along with taking medications, it is equally important to attend all follow-up appointments with your ophthalmologist. This will allow your ophthalmologist to determine whether the prescribed medication is helping. Different medications are most effect in different people, which is why changes may need to be made to an individual’s prescription or to its dosage.
Patients should also have contact information for whom to notify in the event that any severe or unusual symptoms appear.
Surgery
Medications can control the irritation and swelling that occurs in uveitis. However, at times there may be physical damage caused to structures within the eye that can only be corrected surgically. Although surgeries within the eye can be risky, advancements in technology have made it easier and safer to operate in various parts of the eye.
What to expect
People with uveitis naturally worry about the outcome of their disease. The outcome for a patient with uveitis depends upon many factors including: eye structures involved, duration of symptoms, age, cause and the individual’s overall health. Rarely, anterior uveitis may resolves on its own without treatment. However, any form of uveitis may occur again or last for weeks to months. Uveitis may also spread within the eye and lead to additional structures becoming affected. This can lead to the worsening of symptoms and to the development of other complications within the eye. Complications that can result from uveitis include, but are not limited to: vision loss, glaucoma, cataract formation and various other serious eye diseases. Poorer outcomes are often observed in:
- Intermediate or posterior uveitis
- Chronic uveitis
- Individuals with repeated episodes of uveitis
Regular visits to your ophthalmologist and following treatment guidelines can help to avoid poorer outcomes. However, the complications may not be preventable in all situations.
Prevention
Unfortunately, uveitis cannot directly be avoided since most often the cause is unknown or not modifiable. However, individuals with uveitis can take measures to reduce symptoms and to prevent it from spreading or repeating.
These measures include:
- Prompt medical care by an ophthalmologist
- Follow treatment guidelines accurately
- Pay careful attention to any new symptoms
- Ensure hand hygiene. Some causes of uveitis, such as toxoplasmosis and toxocariasis, may be caused by infections that can spread through contaminated hands
- Take preventative measures to avoid infections such as syphilis and tuberculosis which cause uveitis
- Maintain overall good health by trying to: treat pre-existing diseases that might be weakening your immune system, maintain a well-balanced diet, exercise regularly and quit smoking