Uveitis

Uveitis: Excerpt from Professional Guide to Diseases (Eighth Edition)

Uveitis is inflammation of the uveal tract. It occurs as anterior uveitis, which affects the iris (iritis) or both the iris and the ciliary body (iridocyclitis); as posterior uveitis, which affects the choroid (choroiditis) or both the choroid and the retina (chorioretinitis); or as panuveitis, which affects the entire uveal tract. Although clinical distinction isn’t always possible, anterior uveitis occurs in two forms — granulomatous and nongranulomatous.

Granulomatous uveitis was once thought to be caused by tuberculosis bacilli; nongranulomatous uveitis, by streptococci. Although this isn’t true, the terms are still used. (See Granulomatous and nongranulomatous uveitis.) Untreated anterior uveitis may result in elevated intraocular pressure (IOP), leading to vision loss. With immediate treatment, anterior uveitis usually subsides after a few days to several weeks; however, recurrence can occur. Posterior uveitis may lead to vision loss if the macula is involved.

Causes and incidence

Typically, uveitis is idiopathic. However, it can result from allergy, bacteria, viruses, fungi, chemicals, trauma, or surgery; or it may be associated with systemic diseases, such as rheumatoid arthritis, ankylosing spondylitis, and toxoplasmosis.

Uveitis occurs in 15 of every 100,000 people.

Signs and symptoms

Anterior uveitis produces moderate to severe unilateral eye pain; severe ciliary injection; photophobia; tearing; a small, nonreactive pupil; and blurred vision (due to the increased number of cells in the aqueous humor). It sometimes produces deposits called keratic precipitates on the back of the cornea, which may be seen in the anterior chamber. The iris may adhere to the lens, causing posterior synechiae and pupillary distortion; pain and photophobia may occur. Onset may be acute or insidious.

Posterior uveitis begins insidiously, with complaints of slightly decreased or blurred vision or floating spots. Posterior uveitis may be acute or chronic, and it may affect one or both eyes. Retinal damage caused by lesions from toxoplasmosis and retinal detachments may occur. Refer the patient to an ophthalmologist for dilated fundus examination and treatment for local systemic diseases.

Diagnosis

Confirming diagnosis  In anterior and posterior uveitis, a slit-lamp examination shows a “flare and cell” pattern, which looks like particles dancing in a sunbeam. With a special lens, slit-lamp and ophthalmoscopic examination can also identify active inflammatory fundus lesions involving the retina and choroid, although a hazy vitreous may obscure the view.

In posterior uveitis, serologic tests may be used to rule out toxoplasmosis.

Treatment

Uveitis requires vigorous and prompt management, which includes treatment for any known underlying cause — corticosteroids with antibiotic therapy for infectious diseases and suppression therapy for autoimmune diseases — and application of a topical cycloplegic, such as 1% atropine sulfate, and of topical corticosteroids applied three to four times daily. For severe uveitis, therapy includes oral systemic corticosteroids.

Alert  Long-term steroid therapy can cause a rise in IOP or cataracts. Carefully monitor IOP during acute inflammation. If IOP rises, therapy should include an antiglaucoma medication, such as brimonidine (Alphagan), an alpha₂-adrenergic agonist, or dorzolamide (Trusopt), a sulfonamide.

Occasionally, posterior uveitis requires systemic immunosuppression with azathioprine or cyclosporine.

Special considerations

❑ Encourage rest during the acute phase.

❑ Teach the patient the proper method of instilling eyedrops.

❑ Suggest the use of dark glasses to ease the discomfort of photophobia.

❑ Instruct the patient to watch for and report adverse effects of systemic corticosteroid therapy (for example, edema or muscle weakness).

❑ Stress the importance of follow-up care for IOP checks while the patient is taking steroids. Tell the patient to seek treatment immediately at the first sign of iritis.

Pictures

Book Source Details

• Book Title: Professional Guide to Diseases (Eighth Edition)
• Author(s): Springhouse
• Year of Publication: 2005
• Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Professional Guide to Diseases (Eighth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2005 ISBN: 1-58255-370-X

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