Uveitis Inflammatory Eye Disease & Infectious Diseases
What is Uveitis?
Uveitis is an inflammatory condition that affects the Uvea, part of the eye. The uvea is the middle of the 3 principle layers that make up the eye ball. It is pigmented and vascular (full of blood vessels). The name derives from Latin for a grape, which early anatomists thought it resembled. It lies between the tough white sclera and the light sensitive retina. (Strictly speaking the retina is not part of the uvea, but nearly all of the diseases that affect the uvea affect the retina to some degree - so uveitis doctors are all experts in medical retina, as much of their work is managing retinal involvement).
Like any tissue in the body it can become inflamed. Why the uvea becomes inflamed can remain unclear. This happens quite often - especially in the most common type of uveitis, Acute Anterior Uveitis (AAU). Fortunately this common form of uveitis is the easiest to manage, normally subsiding with a course of steroid eye drops. ￼ However other types of uveitis and some types of AAU can be shown to be the result of an infection, an auto-immune disease or other disease process and can be more troublesome.
How do I know if I have Uveitis?
Uveitis frequently causes a light sensitive (photophobic) and painful eye. The eye can go red and vision can be affected - sometimes severely. insert inflammed eye picture Not uncommonly, mild Acute Anterior Uveitis (AAU) is mistaken for the more common and normally self limiting superficial eye infection called conjunctivitis. Only when it fails to clear resolve or respond to antibiotics are patients referred to an ophthalmologist (eye doctor) who can correctly diagnose the condition. If your eye is red and sensitive to light and there is no significant discharge (pus) from the eye you should make an urgent appointment with an ophthalmologist for review. At the Moreton Eye Group we will be able to examine you carefully and if necessary instigate treatment. Dr Hay-Smith at the Morton Eye Group is specifically and fellowship trained in managing Uveitis and he, or one of his colleagues, will be able to help manage the condition.
What causes Uveitis?
In general terms the causes of uveitis can be split into 3 broad classes: Idiopathic,Infectious and Auto-Immune.
The most common is idiopathic. Idiopathic is a medical term that means the underlying cause remains obscure. Fortunately Idiopathic Acute Anterior Uveitis usually responds well to simple management with a course of steroid eye drops. You will probably be asked to use the drops intensively to start with and to tail them off over a matter of some weeks. Many people have a single attack of AAU and that is it - but for some people it can be a recurring problem.
Infections can cause Uveitis. These can be difficult to diagnose and treat and so it is important that all cases of suspected infectious uveitis are seen by an ophthalmologist experienced in their diagnosis and management. Often the management of these infections is carried out in partnership with another doctor, such as a chest physician. At Morton Eye Group we can arrange for the best care with both an expert specialist eye doctor and an expert specialist physician.
Auto-immune diseases are the third cause of Uveitis. Immunology is an area of medicine that is yielding up its secrets and is an area of fast moving change. New drugs have helped and the genetics of these diverse conditions is becoming better understood. In Australia the most common auto-immune association is with a particular blood marker known as HLA B27 (a type 1 major histocompatibility complex molecule). This can be linked with back pain and a condition called ankylosing spondylitis.
Genetics has an important part to play in auto-immune Uveitis. For example patients of Middle Eastern or Eastern Mediterranean origin have a higher risk of Behcet’s disease (a systemic autoimmune disease which causes eye inflammation). In Japan and in pigmented people ￼generally VKH is a much more common cause of severe uveitis than in those of European Origin (VKH or Vogt–Koyanagi–Harada syndrome is an autoimmune syndrome that targets melanocytes, which are the cells containing pigment in the skin and elsewhere). Then there are a range of other auto-immune diseases that again can be difficult to diagnose and can involve other parts of the body, such as joints, chest, bowels or nerves.￼ Don’t be surprised if the Uveitis doctor wants to ask about your general health and is interested in the rest of your body - not just your eyes.
Uveitis can also be caused some other systemic diseases, often called masquerade syndromes - but these are not common, and by trauma. Juvenile arthritis (Juvenile Ideopathic Arthritis, or JIA) can cause low grade but very damaging uveitis and it is essential that any child with arthritis is seen by an experienced ophthalmologist in addition to a rheumatologist, even if they have no eye symptoms.
How is Uveitis managed?
Uveitis is an inflammatory disease. Central to its management is the control of inflammation, normally with steroids. It is important to exclude infections before starting steroids as suppressing the immune system can make infections much worse very quickly. In most cases steroids can be given as simple eye drops. These are usually very effective and lack the systemic side effects of steroid tablets or injections.
In more severe (and rarer) cases it can be necessary to control the inflammation with high doses of steroid. This is usually done with tablets. Sometimes the doctor may decide to give a steroid injection, either into a vein as an infusion or occasionally directly into or around the eye.￼
Steroids are normally very effective at controlling uveitis. Their use is, however, associated with a range of side effects. As a result some patients with intermediate or posterior uveitis (the rarer types not normally controlled with simple drops) may require other immune modulation with drugs know as steroid sparing agents. The use of these drugs is a specialist area of ophthalmology and only ophthalmologists with specific training and experience in the use of these drugs are normally prepared to prescribe them. Dr Hay-Smith at the Moreton Eye Group has gained considerable experience with these conditions during his ophthalmic training at Moorfields Eye Hospital in London and as a Fellow to Professor Miles Stanford at the Western Eye Hospital in London. He also has gained specific experience in uveitis in immuno-suppressed patients on the world famous Ron Johnson (HIV) ward as a Fellow at the Chelsea and Westminster Hospital, also in London.
Apart from the inflammation are there any other problems associated with uveitis?
Yes there are. Uveitis can be associated with raised intra-ocular pressure (IOP). This is called glaucoma and can also require treatment, normally with IOP lowering drops. Steroids - the mainstay treatment of uveitis - can also cause the pressure to rise in the eyes in around 15% of the population. These people are known as “steroid responders”. Their uveitis can be more difficult to manage as a result.
Steroids can also hasten the development of cataract (clouding of the lens of the eye). The repeated episodes of inflammation cause the tissues in the eye to change and in particular the iris often sticks to the lens, known as synechiae. These, and other changes, can make cataract surgery more difficult. However the skilled use of immunosuppressant or immunomodulating drugs has made this difficult area much easier in recent years. In skilled and experienced hands the results of cataract extraction in patients with uveitis can be as good as in any other patient - though the surgery nearly always takes a bit longer to do and the recovery can be slower.
Is there anything I can do to prevent myself from getting Uveitis?
Unfortunately there is little that can be done to prevent uveitis. What is important is to see an ophthalmologist at the first signs of trouble. It really is a case of a “stitch in time saves nine” when managing uveitis. Early intervention can prevent some of the hard to manage complications of uveitis and so help preserve good vision.