UVEITIS

Types of uveitis

The types of uveitis will depend on which part of the eye is affected:

• anterior uveitis – the most common type of uveitis involving the iris (iritis), or the iris and the ciliary body (iridocyclitis); accounting for about three out of four cases, tends to come on quickly, and can be recurrent, causing pain and redness
• intermediate uveitis – inflammation of the area behind the ciliary body and the vitreous jelly; this can cause floaters and blurred vision
• posterior uveitis – inflammation involving the uveal tract at the back of the eye, the choroid and the retina; this can cause problems with vision

In some cases, uveitis can affect the front and back of the eye. This is known as panuveitis.

Symptoms of uveitis include:

• a painful red eye – ranging from a mild ache to a intense pain, and focusing your eye can make the pain worse; the eye can feel tender or bruised
• blurred or cloudy vision – this may come after other symptoms
• sensitivity to light (photophobia)
• marked increase or new floaters – shadows, webs, dots or veils that move across the field of vision
• loss of peripheral vision
• a pupil shaped differently or that doesn’t get smaller when reacting to light
• headaches

One or both eyes may be affected by uveitis. The symptoms can develop suddenly or gradually over a few days.

People with long-term uveitis tend to have more visual symptoms and their eyes may look normal. Patients with sudden onset uveitis usually have more pain and tenderness.

When to seek medical advice

If persistent eye pain occurs or there is an unusual change in your vision, immediate consult with your doctor should be done especially if with previous episodes of uveitis.The earlier it is managed, the more successful treatment will be.

Referral to an ophthalmologist, an eye specialist, is done. An ophthalmologist will examine your eye in more detail with the use of a slit-lamp, and may suggest further tests if uveitis is diagnosed.

This may include imaging procedures, X-rays and blood tests. Knowing the cause of uveitis will help determine the treatment needed.

Treating uveitis 

Treatment for uveitis will depend on the areas of the eye affected and what caused the condition.

Medication is the main treatment, but surgery can be used in particularly severe cases.

Steroid medication

Steroid medication (corticosteroids) are used to treat most cases of uveitis. A medicine called prednisolone is usually used.

Corticosteroids work by suppressing the immune system so it no longer releases the mediators that cause inflammation.

Corticosteroids are available in numerous forms, and the type used will often depend on the areas affected by uveitis.

Corticosteroid eye drops

Corticosteroid eye drops are the first choice of treatment for anterior uveitis not caused by an infection.

Depending on the severity of symptoms, the recommended dose can range from using eye drops every hour to once every two days.

Vision may be temporarily blurred after using corticosteroid eye drops. Precautionary measures should be implemented if this occurs, such as avoiding driving or operating machinery until vision returns to normal. In some cases, steroid eye drops can increase intraocular pressure (pressure in the eye). Regular check-ups should be done to monitor improvement and adverse events.

Eye drops should not be stopped even if symptoms disappear, until the ophthalmologist advises you to do so. Stopping treatment too soon could lead to recurrence. The frequency of drops is usually slowly tapered over a matter of weeks.

Corticosteroid injections

If the middle or back of the eye is affected (intermediate or posterior uveitis) or corticosteroid eye drops haven’t worked, corticosteroid injections will be recommended.

The injection can be given to the side of the eye (subconjunctival) or around the eye (periocular). Local anaesthetic eye drops are used to numb the eye.

Corticosteroid injections rarely cause significant side effects, but may increase intraocular pressure. The ophthalmologist will check for this and advise you if this happens.

Oral corticosteroids

Oral corticosteroids are the strongest form of corticosteroids. They are usually used if steroid eye drops and injections haven’t worked or are unsuitable, or for posterior uveitis.

Corticosteroids tablets can cause a wide range of side effects, and are only recommended if there is a hig risk of permanent damage without treatment.

The period of time of corticosteroid use will depend on the response to treatment and the presence of an underlying autoimmune condition. Course of treatment lasts for at least three- to six-weeks to months or even years.

Short-term side effects of oral corticosteroids can include weight gain, increased appetite, behavioral changes such as irritability, anxiety, and insomnia. In the long-term they can cause osteoporosis (fragile bones), thinning of the skin, and an increased risk of infection.

To minimize the impact of side effects, the lowest possible effective dose is given to control symptoms.

Oral corticosteroids should not be stopped abruptly especially if taking it for more than two weeks. If the decision to stop treatment is made by the ophthalmologist, corticosteroids will be tapered gradually.

Mydriatic eye drops

Mydriatics or dilating eye drops may be given in addition to steroids, in cases of anterior uveitis. These drops dilate the pupils and relieve pain by relaxing the muscles in your eye. They can also reduce the risk of anterior synechiae (condition where the iris, the coloured part of the eye, adheres to the lens). This can result in a condition called glaucoma, which affects vision.

However, these drops can cause some temporary blurring of your vision and problems focusing your eyes.

Treating infection

If the cause of your uveitis is known to be an underlying infection, the infection may also need to be treated.

Viruses can be treated with antiviral medication, bacterial infections can be treated with antibiotics, and fungal infections can be treated with antifungal medication.

The medications will usually be used alongside appropriate steroid medication and cycloplegic or mydriatic eye drops.

Immunosuppressants

A small number of people fail to respond to the mentioned treatment options. In such circumstances, a type of medication called an immunosuppressant may be recommended.

Immunosuppressants are a type of medication that suppress (control) the immune system and disrupt the process of inflammation.

If steroid treatment causes significant side effects, immunosuppressants can also be used to allow your dose of steroids to be reduced.

Possible side effects of immunosuppressants include:

• skin rash
• numbness or tingling in different parts of your body
• loss of appetite
• nausea and vomiting
• high blood pressure
• headaches
• hair loss

Immunosuppressants increase the susceptibility to infections, precautionary measures should be observed, such as avoiding close contact with anyone who has a known infection.

Symptoms of infection should also be reported, such as a high temperature, cough or inflammation in other parts of the body.

Surgery

In rare cases, surgery may be needed to treat uveitis. However, this is usually only recommended if repeated or severe uveitis occurs, or if the condition is caused by certain infections.

An operation called a vitrectomy can be used to treat uveitis. This involves gently sucking out the jelly-like substance that fills the inside of the eye (the vitreous humour). It can be carried out either using general anesthesia or local anaesthesia.

The fluid inside the eye will be temporarily replaced during the operation with either a bubble of air or gas (or a mixture of the two), or a liquid substitute. Eventually, the eye will naturally replace the vitreous humour with a slightly different clear fluid called aqueous humour.

Like all operations, a vitrectomy carries a risk of complications. These include needing further surgery and an increased risk of developingcataracts (opacification of the lens).

The following may help your symptoms:

• wear dark glasses if your eye becomes sensitive to light
• place a warm flannel over the eye to soothe it
• relieve pain by taking painkillers, such as ibuprofen